Dramatic Improvement in Blood Pressure Management among Veterans with Diabetes, with Potential Over-Treatment

BACKGROUND:
Current performance measures suggest that a majority of patients with diabetes should be treated to a target blood pressure (BP) <140/90, but these dichotomous measures do not account for individual patient factors, nor do they follow closely the evidence from treatment trials. As a result, such measures may contribute to over-treatment which may result in worse outcomes. "Tightly linked" clinical action measures, which reward clinical actions that are strongly tied to evidence, might better capture the complexity of clinical decision making. Investigators in this study collaborated with VA clinical and Operations leaders to specify a clinical action measure for BP management in diabetes. Investigators further specified a marker of potential over-treatment for high blood pressure to assess the proportion of Veterans who may be receiving overly aggressive, and thus potentially risky, treatment. This study examined performance on the measure and on the marker of potential overtreatment among 977,282 Veterans with diabetes receiving primary care in VA during 2009-2010. Using VA data, investigators specifically assessed the proportion of patients meeting appropriate quality for hypertension, the degree of potential hypertension overtreatment, and the relationship between meeting current threshold measures and potential overtreatment. The clinical action measure specified that quality of care was appropriate if: an index systolic BP (SBP) was <140 and diastolic BP (DBP) was <90; or if the index SBP was <150 and the DBP was <65; or if the index SBP was <150 and the patient was on 3 or more moderate-dose antihypertensive medications; or if appropriate action had occurred within 90 days. A patient was considered to have received possible over-treatment if their index SBP was <130 and DBP <65 and they were receiving 3 or more BP medications, and/or active medication intensification.

FINDINGS:

• 713,790 Veterans were eligible for the clinical action measure. Of these, 94% (n=668,210) met the clinical action measure for BP measurement (82% had a BP <140/90; an additional 12% had BP >=140/90 but appropriate management). This represents a dramatic improvement in BP management over the past decade.
• Among all Veterans in this study, 197,291 (20%) had a BP <130/65; of these, 80,903 (41% - or slightly more than 8% of the cohort) had potential over-treatment. Facility rates of potential over-treatment varied from 3% to 20%. Facilities with higher rates of meeting the current threshold measure (<140/90) had higher rates of potential over-treatment.
• Veterans with potential over-treatment were older, had lower mean index BP, and were more likely to be men and have ischemic heart disease.

LIMITATIONS:
Investigators were unable to assess medications prescribed outside VA, nor contraindications to treatment other than low diastolic levels.

IMPLICATION:

• The rate of BP over-treatment is approaching, or even exceeding, that of under-treatment.
• The authors suggest that implementing a clinical action measure for hypertension management may result in more appropriate care and less over-treatment. VA is planning to implement such measures for internal tracking.

AUTHOR/FUNDING INFORMATION:
This study was funded through VA/HSR&D's Quality Enhancement Research Initiative (QUERI: RRP 09-111). Drs. Kerr and Hofer are part of Diabetes-QUERI. All authors (except Dr. Lucatorto) are part of HSR&D's Center for Clinical Management Research, Ann Arbor, MI.

Kerr E, Lucatorto M, Holleman R, Hogan M, Klamerus M, and Hofer T. Monitoring Performance for Blood Pressure Management among Diabetic Patients: Too Much of a Good Thing? Archives of Internal Medicine 2012 Jun 25;172(12):938-45.