Despite some recent improvements in blood pressure control, the number of patients with inadequate control remains high and contributes to excess morbidity and mortality, especially among patients at high risk from complications of hypertension. Several studies have suggested that "clinical inertia" - the failure by providers to initiate or intensify therapy (medication intensification) in the face of apparent need to do so - is a main contributor to poor control. Factors underlying failure to intensify therapy in response to elevated blood pressure have not been systematically studied.
We examined the process of care for diabetic patients with elevated triage blood pressure during routine primary care visits to assess 1) whether a treatment change occurred; 2) and to what degree specific patient, provider, and organizational factors correlated with the likelihood of treatment change.
This study was conducted as a prospective cohort study of patients with scheduled primary care visits at 9 VA facilities. We enrolled 92 primary care providers and 1169 of their diabetic patients. Patients were enrolled if their lowest triage blood pressure was >=140/90. Principal sources of data included a baseline primary care clinician survey, a baseline patient survey, a clinician brief visit survey, patient semi-structured interviews, medical record data, automated data, and information on organizational structure.
A cross-sectional analysis examined whether or not there was a treatment change at the visit by the provider in response to the elevated triage blood pressure. Data were analyzed using three-level logistic regression models, with the first level addressing patient variables, the second level the primary care provider and the third level the site.
Overall, 573 (49%) patients had a blood pressure treatment change at the visit. We found that the following factors made treatment change less likely: repeat blood pressure by provider recorded as < 140/90 (13% vs. 61%, p<0.001); patient report of home blood pressure < 140/90 (18% vs. 52%, p<0.001); provider systolic blood pressure goal >130 (33% vs. 52%, p=0.002); discussion at the visit of conditions unrelated to hypertension and diabetes (44% vs. 55%, p= 0.008); and discussion of medication issues (23% vs. 52%, p<0.001).
Rather than simply failing to act (inertia), providers were often confronted with the inherent clinical uncertainty about blood pressure values and document actions to incorporate additional information (e.g., repeating measurements or eliciting home blood pressure values), which in turn had an enormous effect on decisions to change treatment. Unfortunately, they are relying on these additional measures without a systematic approach. Such an ambiguous approach to BP measurement could easily undermine performance improvement initiatives and may well be a major obstacle to optimizing management of hypertension and improving outcomes for high risk populations. We need to promote more systematic approaches to the use of clinic and home blood pressure measurements in the treatment of hypertension.
- Meddings J, Kerr EA, Heisler M, Hofer TP. Physician assessments of medication adherence and decisions to intensify medications for patients with uncontrolled blood pressure: still no better than a coin toss. BMC health services research. 2012 Aug 21; 12(1):270.
- Zulman DM, Kerr EA, Hofer TP, Heisler M, Zikmund-Fisher BJ. Patient-provider concordance in the prioritization of health conditions among hypertensive diabetes patients. Journal of general internal medicine. 2010 May 1; 25(5):408-14.
- Zikmund-Fisher BJ, Hofer TP, Klamerus ML, Kerr EA. First Things First: Difficulty with Current Medications Is Associated With Patient Willingness to Add New Ones. The patient. 2009 Dec 1; 2(4):221-231.
- Krein SL, Hofer TP, Holleman R, Piette JD, Klamerus ML, Kerr EA. More than a pain in the neck: how discussing chronic pain affects hypertension medication intensification. Journal of general internal medicine. 2009 Aug 1; 24(8):911-6.
- Subramanian U, Kerr EA, Klamerus ML, Zikmund-Fisher BJ, Holleman RG, Hofer TP. Treatment decisions for complex patients: differences between primary care physicians and midlevel providers. The American journal of managed care. 2009 Jun 1; 15(6):373-80.
- Kerr EA, Zikmund-Fisher BJ, Klamerus ML, Subramanian U, Hogan MM, Hofer TP. The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Annals of internal medicine. 2008 May 20; 148(10):717-27.
- Watts B, Lawrence R, Litaker D, Aron DC, Neuhauser D. Quality of care by a hypertension expert: a cautionary tale for pay-for-performance approaches. Quality management in health care. 2008 Jan 1; 17(1):35-46.
- Subramanian U, Hofer TP, Klamerus ML, Zikmund-Fisher BJ, Heisler M, Kerr EA. Knowledge of blood pressure targets among patients with diabetes. Primary Care Diabetes. 2007 Dec 1; 1(4):195-8.
- Rodondi N, Peng T, Karter AJ, Bauer DC, Vittinghoff E, Tang S, Pettitt D, Kerr EA, Selby JV. Therapy modifications in response to poorly controlled hypertension, dyslipidemia, and diabetes mellitus. Annals of internal medicine. 2006 Apr 4; 144(7):475-84.
- Kerr EA, Sussman JB, Klamerus ML, Min L, Holleman R, Saini SD, Vijan S, Hofer TP. Failing to Choose Wisely: Lack of Treatment De-intensification in Older Patients with Diabetes. Paper presented at: AcademyHealth Annual Research Meeting; 2014 Jun 9; San Diego, CA.
- Kerr EA, Holleman R, Klamerus ML, Saini SD, Min L, Vijan S, Sussman JB, Hofer TP. Failing to Choose Wisely: Lack of Treatment De-intensification in Older Patients with Diabetes. Paper presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 24; San Diego, CA.
- Kerr EA. Management of Hypertension in the ABATe Study. Paper presented at: VA Battle Creek Health System Primary Care Grand Rounds; 2010 Aug 21; Battle Creek, MI.
- Kerr EA, Holleman R, Piette JD, Krein SL, Hofer TP. Achievement of blood pressure control targets at a single visit does not adequately reflect quality of antihypertensive care. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2009 May 14; Miami, FL.
- Keirns C, Frankel R, Frankel RM, Robinson CH, Kerr EA, Forman JH. The role of discordant and Concordant Comorbidities in Hypertension Self-Management. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD.
- Zulman DM, Kerr EA, Hofer TP, Zikmund-Fisher BJ. Patient-Provider Concordance in Prioritization of Health Conditions: The Role of Competing Demands for Patients with Complex Chronic Conditions. Paper presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD.
- Krein SL, Hofer TP, Holleman, Piette JD, Standiford CJ, Klamerus ML, Kerr EA. More Than a Pain in the Neck: How Discussing Chronic Pain Affects Medication Intensification for Hypertension. Paper presented at: VA QUERI National Meeting; 2008 Dec 11; Phoenix, AZ.
- Subramanian, Kerr EA, Klamerus, Zikmund-Fisher BJ, Hofer. Treatment decisions for complex patients: differences between primary care physicians and mid-level providers. Paper presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 10; Pittsburgh, PA.
- Frankel RM. Role of Discordant and Concordant Comorbidities in Hypertension Self-management: A Mixed Methods Study. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 8; Pittsburgh, PA.
- Klamerus, Kerr EA, Zikmund-Fisher BJ. Treatment decisions for complex patients: Differences between primary care physicians and mid-level providers. Paper presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD.
- Heisler M, Hogan MM, Hofer T, Kerr EA. When More is Not Better: Treatment Intensification among Hypertensive Patients with Poor Medication Adherence. Paper presented at: Society of General Internal Medicine Annual Meeting; 2007 Apr 28; Toronto, Canada.
- Butchart A, Kerr EA, Hofer TP, Heisler M. Are Providers Looking at Adherence before Leaping to Intensify Medications. Paper presented at: VA HSR&D National Meeting; 2007 Feb 25; Arlington, VA.
- Hogan MM, Heisler M, Kerr EA, Hofer TP. Identifying Medication Adherence for Hypertension. Paper presented at: VA HSR&D National Meeting; 2007 Feb 25; Arlington, VA.
- Klamerus ML, Hofer TP, Zikmund-Fisher BJ, Heisler M, Kerr EA. Knowledge of blood pressure targets and blood pressure self-monitoring among patients with diabetes. Paper presented at: VA HSR&D National Meeting; 2006 Feb 16; Arlington, VA.
- Hofer TP, Klamerus ML, Zikmund-Fisher BJ, Kerr E. Providers Vary Substantially in their Propensity to Intensify Blood Pressure Treatment. Paper presented at: VA HSR&D National Meeting; 2006 Feb 15; Arlington, VA.
Aging, Older Veterans' Health and Care, Health Systems
Epidemiology, Treatment - Observational
Cardiovasc’r disease, Diabetes, Quality assessment