Health Services Research & Development

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2007 HSR&D National Meeting Abstract

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National Meeting 2007

1051 — Clinical Inertia or Appropriate Care Plan? Effect of Using a Follow-Up Interval on Performance Measures for Hypertension with Co-Existing Conditions

Petersen LA (Houston Center for Quality of Care and Utilization Studies) , Woodard LD (Houston Center for Quality of Care and Utilization Studies), Henderson L (Houston Center for Quality of Care and Utilization Studies), Urech TH (Houston Center for Quality of Care and Utilization Studies)

Objectives:
Clinical inertia is defined as failure to initiate or intensify therapy when indicated. How much of the apparent clinical inertia revealed in performance measures for hypertension would be remedied if appropriate therapy in a follow-up window after an index visit was incorporated? What is the impact of a follow-up period when there is co-existing diabetes and ischemic heart disease (IHD)?

Methods:
We studied 237,202 patients who had a primary care visit in FY 2004 in one of 8 VAMCs. Using both clinical data (e.g. blood pressure [BP], medications, labs) and ICD-9 codes, we identified patients with hypertension and the subset with both diabetes and IHD. Of those with BP >140/90 mm Hg at index, we determined the proportion who received appropriate care (e.g. medication change) in a 6-month follow-up period.

Results:
154,444 (65%) had hypertension and 18,167 (12%) of these had both IHD and diabetes. 66% of those with hypertension alone and 71% of those with both IHD and diabetes had BP < 140/90 at index (P<0.0001). 11% of patients with hypertension alone and 10% of those with both IHD and diabetes had either a BP of >=160/100 mm Hg or none recorded at index. 57% of patients with hypertension alone and 75% of the patients with both IHD and diabetes who did not meet the goal at index received appropriate care in the 6-month follow-up period (P<0.0001). Of those with a BP of >=160/100 mm Hg or no BP recorded, 52% of those with hypertension alone and 79% of those with diabetes and IHD had appropriate care in follow-up (P<0.0001).

Implications:
Over half of patients with hypertension alone and over three-quarters of those with comorbid diabetes and IHD who did not have controlled BP at an index visit subsequently received appropriate care.

Impacts:
Performance measures that do not include a follow-up window to assess therapeutic responses may produce bias in performance assessments, particularly for patients with co-existing diseases. This could lead to false attribution of clinical inertia. Performance measures must be improved in order to ensure that providers who care for complex patients are not penalized under pay-for-performance and other quality reporting efforts.