BACKGROUND/RATIONALE:
Despite some recent improvements in blood pressure control, the number of patients with inadequate control remains high and contributes to excess morbidity and mortality, especially among patients at high risk from complications of hypertension. Several studies have suggested that "clinical inertia" - the failure by providers to initiate or intensify therapy (medication intensification) in the face of apparent need to do so - is a main contributor to poor control. Factors underlying failure to intensify therapy in response to elevated blood pressure have not been systematically studied.
OBJECTIVE(S):
We examined the process of care for diabetic patients with elevated triage blood pressure during routine primary care visits to assess 1) whether a treatment change occurred; 2) and to what degree specific patient, provider, and organizational factors correlated with the likelihood of treatment change.
METHODS:
This study was conducted as a prospective cohort study of patients with scheduled primary care visits at 9 VA facilities. We enrolled 92 primary care providers and 1169 of their diabetic patients. Patients were enrolled if their lowest triage blood pressure was >=140/90. Principal sources of data included a baseline primary care clinician survey, a baseline patient survey, a clinician brief visit survey, patient semi-structured interviews, medical record data, automated data, and information on organizational structure.
A cross-sectional analysis examined whether or not there was a treatment change at the visit by the provider in response to the elevated triage blood pressure. Data were analyzed using three-level logistic regression models, with the first level addressing patient variables, the second level the primary care provider and the third level the site.
FINDINGS/RESULTS:
Overall, 573 (49%) patients had a blood pressure treatment change at the visit. We found that the following factors made treatment change less likely: repeat blood pressure by provider recorded as < 140/90 (13% vs. 61%, p<0.001); patient report of home blood pressure < 140/90 (18% vs. 52%, p<0.001); provider systolic blood pressure goal >130 (33% vs. 52%, p=0.002); discussion at the visit of conditions unrelated to hypertension and diabetes (44% vs. 55%, p= 0.008); and discussion of medication issues (23% vs. 52%, p<0.001).
IMPACT:
Rather than simply failing to act (inertia), providers were often confronted with the inherent clinical uncertainty about blood pressure values and document actions to incorporate additional information (e.g., repeating measurements or eliciting home blood pressure values), which in turn had an enormous effect on decisions to change treatment. Unfortunately, they are relying on these additional measures without a systematic approach. Such an ambiguous approach to BP measurement could easily undermine performance improvement initiatives and may well be a major obstacle to optimizing management of hypertension and improving outcomes for high risk populations. We need to promote more systematic approaches to the use of clinic and home blood pressure measurements in the treatment of hypertension.
PUBLICATIONS:
Journal Articles
- Watts B, Lawrence R, Litaker D, Aron DC, Neuhauser D. Quality of care by a hypertension expert: a cautionary tale for pay-for-performance approaches. Quality Management in Health Care. 2008; 17(1): 35-46.
