*219. Use of the VISTA Vitals Package to Evaluate Pharmacological Treatment of Hypertension in Veterans With Diabetes
G Hawley, VA Healthcare Analysis Information Group; LPogach, VA New Jersey Healthcare System
Objectives: The percentage of veterans with diabetes achieving a blood pressure of <140/90 showed minimal improvement (40% to 44%) between 1997 and 1999 based upon chart abstraction. The objective of this analysis was to use the vitals package of VISTA to explore patterns of pharmacological treatment of hypertension among veterans with diabetes receiving oral agents or insulin therapy.
Methods: Using linked FY99 pharmacy and administrative databases obtained by the VA Healthcare Analysis Information Group, veterans with diabetes were identified if they had >0 inpatient or >1 outpatient 250.xx ICD9-CM codes, or were prescribed an oral agent or insulin; hypertension was diagnosed based upon outpatient or inpatient ICD9-CM codes. The routine also identified the prescription of beta-blockers, angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), calcium channel blockers (CCB), and diuretics. A previously validated software routine was utilized to obtain the last three associated blood pressures from the vital signs package on patients receiving insulin or oral agents. 140 stations contributed vital sign data on 291,871 patients. Aggregate BP data on diabetic patients with hypertension was available from the External Peer Review Program (EPRP).
Results: The prevalence of hypertension among veterans with diabetes was 65.6% (330,257/503,607). 83.4% of patients were followed by one facility and 14.6% by two facilities. Age, (64 years), gender (98% male); race was available on 79% of patients, of whom 71.4%% were white and 20.3% non-Hispanic black. Demographics were comparable to the complete diabetes cohort. 86% of the diabetic hypertension cohort received at least one antihypertensive agent; of those on medications, 32% received 3 or more. 79.4% received ACEI or ARB; 34.1% received beta-blockers, and 45% CCB. 9% of patients were on CCB alone or in combination with a diuretic. BP measurements were available on 189,581 veterans with diabetes and hypertension. 44.8% had a last value >139/89 (EPRP=45%); 26.9% had a BP >159/89%; and 21.7% had a BP >159/99 (EPRP=17%). The percentage of patients on 3 or more medications varied from 36.7% for patients with one BP>159/89 (n=51,060); 39.3% for 2 BP>159/89 (n=21,524); and 43.6% for 3 BP >159/89 (n=8,556).
Conclusions: The aggregate data from the vitals package are comparable to aggregate EPRP data with respect to the proportion of patients achieving specific blood pressure thresholds. Compliance with prescribing guidelines is suggested by the finding that ACEI and ARB are prescribed for nearly 80% of patients receiving medications, and that only 9% of veterans were on CCB without ACEI, ARB or beta blocker. Conversely, three or more antihypertensive agents were prescribed for between 36% and 43% of patients with one to three BP >159/89, consistent with under treatment.
Impact: These findings suggest that the vitals package can be used to profile facility level patterns of pharmacological treatment of hypertension for data feedback and quality improvement. Furthermore, evaluation of the agreement of individual electronic blood pressure entries with chart abstraction of progress notes is warranted.