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Health Services Research & Development

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2009 HSR&D National Meeting Abstract

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National Meeting 2009

1056 — Multiple Uncontrolled Comorbid Conditions and Medication Intensification

Salanitro AH (Birmingham VA Medical Center), Funkhouser E (Birmingham VA Medical Center), Allison JJ (Birmingham VA Medical Center), Halanych JH (University of Alabama at Birmingham), Houston TK (Birmingham VA Medical Center), Litaker MS (Birmingham VA Medical Center), Levine DA (Ohio State University), Safford MM (University of Alabama at Birmingham)

Objectives:
Multiple medical conditions in the same patient act as competing demands for clinical decision-making, especially when more than one condition is uncontrolled. We hypothesized that the presence of multiple uncontrolled comorbid conditions (MUCC) decreases the likelihood of blood pressure (BP) medication intensification among uncontrolled hypertensive patients.

Methods:
We observed one visit for each of 946 patients made to 13 clinicians at a VA Medical Center primary care clinic over 6 months in 2006. After each encounter, clinicians recorded whether BP medications were intensified (new medication added or existing medication titrated). Research assistants recorded patient age, sex, BP, and last HbA1c and low density lipoprotein cholesterol (LDL-C) levels. “Uncontrolled” was defined for BP as > 140/90 mmHg or > 130/80 if diabetic; for diabetes as HbA1c > 7%; and for lipids as LDL-C > 130 mg/dl or > 100 if diabetic. Hierarchical regression models examined factors associated with BP medication intensification, accounting for clustering.

Results:
Patients had mean age 62 [SD+/-13], 3.1% were female, and 424 (45%) presented with uncontrolled BP, 158 (17%) with uncontrolled diabetes, and 210 (22%) with uncontrolled lipids. 245 patients had only BP uncontrolled (BP+0), 148 had BP plus either diabetes or lipids uncontrolled (BP+1), and 31 had all three uncontrolled (BP+2). BP medication intensification rates were: BP+0 = 30%, BP+1 = 34%, and BP+2 = 45% (trend p = 0.11). Rates differed by degree of high BP: among the 206 patients with systolic BP (SBP) > 142 (median uncontrolled BP), rates for BP+0 = 46%, BP+1 = 55%, BP+2 = 75% (p = 0.04), while for the 218 with SBP < 142, rates for BP+0 = 10%, BP+1 = 18%, BP+2 = 26% (p = 0.03). Among all 424 patients with uncontrolled BP, adjusting for patient age, BP level, and clustering by clinician, the odds of BP medication intensification increased as MUCC rose (odds ratio of medication intensification for BP+1 was 1.40 (95%CI: 0.97, 2.02) and 2.72 (95%CI: 1.32, 5.58) for BP+2, compared with BP+0). Stratifying the analysis on SBP = 142 demonstrates similar MUCC effects in both groups.

Implications:
Providers appropriately managed hypertension more aggressively in patients with MUCC. Contrary to our hypothesis, MUCC actually enhanced guideline-concordant hypertension care.

Impacts:
Performance measures must advance beyond simple dichotomous thresholds to examine appropriate decision-making, especially among complex patients.


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