1044 — Developing Clinically Meaningful Performance Measures for Hypertension: Are We Overtreating?
Kerr EA (Ann Arbor VA HSR&D Center for Clinical Management Research and Diabetes QUERI), Lucatorto M
(Office of Quality and Performance), Holleman R
(Ann Arbor VA HSR&D Center for Clinical Management Research and Diabetes QUERI), Pogach L
(Center for Healthcare Knowledge Management for Chronic Complex Illness and Diabetes QUERI), Hogan MM
(Ann Arbor VA HSR&D Center for Clinical Management Research and Diabetes QUERI), Krein SL
(Ann Arbor VA HSR&D Center for Clinical Management Research and Diabetes QUERI), Bermstein S
(Ann Arbor VA HSR&D Center for Clinical Management Research and Diabetes QUERI), Hofer TP
(Ann Arbor VA HSR&D Center for Clinical Management Research and Diabetes QUERI)
In response to performance measurement, VA has seen dramatic improvements over the past decade in the proportion of diabetic patients whose blood pressure (BP) is less than 140/90 mm Hg. However there is increasing concern that performance measures may also be motivating overtreatment of hypertension, resulting in dangerously low diastolic levels. In collaboration with experts from VA Patient Care Services, the Office of Quality and Performance (OQP) and Diabetes Mellitus QUERI have developed tightly-linked clinical action measures, which are designed to encourage appropriate clinical action while minimizing unintended consequences like overtreatment. We applied these measures to examine what proportion of VA diabetic patients are meeting appropriate quality for hypertension and the degree of potential overtreatment.
Using data from the national corporate data warehouse (CDW), we examined the proportion of diabetic Veterans passing a linked clinical action measure for hypertension, defined as: having an adequate BP at the visit (BP < 140/90, SBP < 150 with a low diastolic ( < 65), on > = 3 moderate dose BP medications) or having an appropriate action within 90 days (BP medication intensification, repeat BP < 140/90). We also examined overtreatment, defined as having a BP < 140/65 and BP medication intensification within 90 days or being on > = 4 BP medications at moderate or high dose. Variability across facilities was assessed using multilevel logistic models.
177,407 diabetic Veterans in 129 facilities had a BP recorded at a primary care visit in October, 2009. Overall, 93% passed the linked action measure: 78% because they had a BP < 140/90 at the visit; and an additional 15% with BP > 140/90 who passed on the basis of BP < 150/65 (1%), SBP < 150 on > = 3 medications (3%), medication intensification (9%) and repeat BP < 140/90 (2%). Facility pass rates varied significantly but over a limited range from 88% to 95% (p < .001). 35,501 (20%) had a BP < 140/65. Of these, 33% had potential overtreatment (24% were intensified, 7% were on > = 4 medications, and 2% both). Facility rates of potential overtreatment varied from 28% to 39% (p < 0.001).
Over 90% of diabetic Veterans are receiving appropriate hypertension care, as indicated by linked clinical action measures, with moderate variation across facilities. However, 10% or more may be experiencing overtreatment, and rates of potential overtreatment varied widely across facilities.
We have demonstrated the feasibility of constructing tightly linked action measures and are currently working with OQP to prepare 1-2 of these measures for national testing in FY11. However, our results show that because appropriate BP treatment has reached very high levels, monitoring and addressing potential overtreatment may be equally important for improving quality of care for Veterans.