Goldstein MK (Palo Alto VAHCS)
Many patients with hypertension have legitimate reasons to forego standard blood pressure treatment goals yet are nonetheless included in VA’s performance measurement system. Traditionally, performance measurement programs have dealt with over-selection by setting performance goals below 100%. However, there is little data about what the correct performance goal should be, or if current systems promote overtreatment of patients who may suffer more harm than benefit from tight blood pressure management.
As preliminary work to a study, we convened an 11-member multispecialty panel to refine a taxonomy of situations in which the balance of benefits and harms do not mandate control of blood pressure to < 140/90. We used semi-structured methods to obtain panelists’ opinions about which situations should merit a patient being exempted from performance measurement that defines “success” as a blood pressure < 140/90.
The panel identified several categories of reasons that could reasonably exempt a patient from performance measurement systems based on controlling blood pressure to < 140/90. These included (1) patients who suffer adverse effects from multiple classes of antihypertensive medications; (2) patients already taking > =4 antihypertensive medications; (3) patients with terminal disease, moderate to severe dementia, or conditions that overwhelmingly dominate the patient’s clinical status; and (4) other patient factors, including comfort care orientation, patient refusal to take medications despite adequate education, and poor medication adherence despite attempts to remedy adherence difficulties. Several general principles also emerged. First, performance measurement should focus only on patients for whom the ratio of benefits to harms from treatment clearly favors treatment. Second, performance measurement for hypertension should incorporate a longitudinal approach, whereby clinicians should be given an opportunity to intervene on their patients with high blood pressure. Third, the patient’s risk of adverse events from hypertension should be a key consideration in how strict the criteria should be for exempting that patient from performance measurement.
It is possible to develop a method of performance measurement for hypertension that incorporates “real world” clinical principles and judgment.
This method will be used to validate current approaches to performance measurement for hypertension, and to determine whether performance goals are being appropriately set.