There has been substantial progress toward better quality of diabetes care for veterans; however, improvement in risk factor levels, specifically, HbA1c, lipids (LDL), and blood pressure (BP), have not kept the same pace. Control of these risk factors is critical to improving diabetes outcomes. Current quality measures focus mainly on assessment. A logical next step is to focus on clinical actions, e.g., medication intensification, that should lead to risk factor control.
Ascertaining the following: 1) whether the presence of multiple uncontrolled comorbid conditions (MUCC) affect blood pressure intensification rate among diabetics with uncontrolled hypertension, 2) whether the lack of intensification is clinical inertia or appropriate clinical inaction, and 3) whether administrative data can be used to determine if physicians recognize non-adherent patients and appropriately do not intensify medications.
There were 3 separate study designs for each objective. For #1 we observed 946 consecutive patients of 13 clinicians in 2 primary care clinics in 2006; we analyzed the 387 patients who presented with uncontrolled BP. At each visit, the patient's BP was recorded as was the value and date of the most recent HbA1c and LDL levels; clinicians recorded whether BP medications were intensified, and if not, reason. Patients were categorized into one of four clinical scenarios: uncontrolled hypertension AND 1) no diabetes or hyperlipidemia; 2) controlled diabetes and/or hyperlipidemia; 3) either uncontrolled diabetes or hyperlipidemia; or 4) both UNcontrolled diabetes and hyperlipidemia. Independent associations with BP medication intensification were ascertained. For #2: an external survey of 138 primary care providers was conducted in 2009 based on reasons given for not intensifying BP medications by the 13 VA clinicians to ascertain appropriateness of reasons for not intensifying. For #3: all veterans with diabetes seen in primary care clinics at one VAMC 2001-2005 who had uncontrolled BP (>140/90 mmHg) on two consecutive visits were studied. Nonadherence was defined as being off/out of all BP medications for at least 7 days immediately prior to the second visit.
Overall, 34.9% (135/387) of directly observed patients with UNcontrolled BP had their BP medications intensified at the visit. We observed a U-shaped relationship between the clinical scenarios and intensification: the lowest intensification rates were among those with controlled diabetes or hyperlipidemia, slightly higher for patients without either condition, and increased as the number of uncontrolled conditions rose. Intensification rates reached 80% for patients with MUCC who were at least 10 mmHg above systolic BP goal. The provider survey suggests that only 12% of patients were who not intensified represents clinical inertia, and this may be lower, namely, 3-6%. Of 4,711 black and white diabetic men with uncontrolled BP seen at one VAMC 2001-05, the overall BP intensification rate was 55.5%. A total of 244 were nonadherent, of whom 33.6% were intensified; all had a change in class of BP medications, none had a dose increase.
Quality indicators that capture medication intensification and permit the monitoring of both appropriate clinical actions and inactions are needed to maximize high quality, patient-centered care.
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Chronic heart failure, Cost effectiveness, Diabetes, Quality assurance, improvement, Telemedicine