Addressing Barriers to Translation for Treatment of Hypertension
Eve A. Kerr MD MPH
VA Ann Arbor Healthcare System
Ann Arbor, MI
Funding Period: March 2004 - February 2008

BACKGROUND/RATIONALE:
Type 2 diabetes mellitus affects nearly 20 million people in the United States (over 800,000 veterans receiving care through the Veterans Health Administration). The prevalence of hypertension among individuals with diabetes is extremely high and the inadequate control of this high blood pressure results in many cases of preventable stroke, myocardial infarction, end-stage renal disease, visual impairment/blindness, and premature death. Yet, clinicians often fail to act (by increasing medication dosages or starting new medications) even when faced with an elevated blood pressure for a patient with diabetes. Such failure to act has been termed clinical inertia. We know little about the causes of clinical inertia for treatment of elevated blood pressure.

OBJECTIVE(S):
Our short-term research objectives are to define important clinician, organizational and patient factors that contribute to clinical inertia in the treatment of hypertension. The long-term objectives of this study are to design appropriate quality improvement (QI) interventions that address the most important barriers and facilitators to translation for high-risk patients with hypertension. To achieve our objectives, we will answer the following research questions for patients with diabetes and hypertension: 1. What role do competing demands, such as number and type of patient comorbidities, play in facilitating or hindering treatment for patients with blood pressure elevations? 2. How does the priority that clinicians and patients place on treatment for uncontrolled hypertension relative to other factors facilitate or hinder adequate treatment? 3. How does the organization of care influence medication intensification and follow-up for patients with blood pressure elevations? 4. To what extent are some patients with hypertension not eligible for intensification of medication treatment because of medication related problems and uncertainty in blood pressure measurement?

METHODS:
This study employs a cross-sectional design to examine factors that influence the decision to initiate treatment change in response to an elevated blood pressure at a single visit and a prospective cohort design to identify important clinician, organizational and patient factors that contribute to inadequate treatment of elevated blood pressure over time among patients with diabetes. We will enroll about 80 primary care clinicians at about 5 VAMCs, and about 880 of their diabetic patients who have an elevated blood pressure. Principal sources of data will include a baseline primary care clinician survey, a baseline patient survey, a clinician enrollment visit survey, patient semi-structured interviews, medical record data, automated data, and information on organizational structure. Our quantitative analyses will be both cross-sectional and longitudinal in nature, involving 2-level modeling of patients nested within clinicians. Qualitative analyses of the interviews will enhance our understanding of the results.

FINDINGS/RESULTS:
Accomplishments to date - Both the baseline clinician survey and the baseline patient survey have been successfully pilot tested. Institutional review boards, at each study site, have reviewed and approved the study protocol and several of the data collection instruments. Providers have been recruited at all study sites.

IMPACT:
Appropriate and sustainable translation policies begin with a firm understanding of why some patients, even with a clearly identified stimulus for action, do not get adequate treatment. This study is the first multi-site, systematic evaluation of such barriers to translation of research into action for hypertension. Our study will allow researchers to design and test new, theoretically based QI approaches, and policy makers to adopt effective approaches to blood pressure control. Equally important, our study can serve as a model for understanding barriers to translation in other conditions, both within and outside of the VA.

PUBLICATIONS:
None at this time.

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DRA: Chronic Diseases, Health Services and Systems
DRE: Communication and Decision Making, Treatment
Keywords: Cardiovasc’r disease, Diabetes, Quality assessment
MeSH Terms: