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Publication Briefs

Study Offers Clinically-Guided Approach for Improving Performance Measurement for Hypertension

Hypertension is a central focus of many performance measurement systems; however, despite the ubiquity of measures that evaluate blood pressure (BP) control, substantial debate remains over the best ways to evaluate quality. Many performance measures use a relatively straightforward approach — assessing whether the most recent reading is above or below 140/90 mm Hg. But this approach does not differentiate between patients for whom tight BP control is strongly indicated, or patients in whom such treatment may yield limited benefits or even harms. In addition, reliance on the most recent BP reading does not account for temporary fluctuations that can result from acute infection, pain, or disease. This study tested a novel performance measurement system for BP control that was designed by a multi-disciplinary expert panel to mimic clinical reasoning. Using an algorithm that replicates clinical decision-making, this approach focuses on: 1) exempting Veterans for whom tight BP control may not be appropriate or feasible, and 2) assessing BP over time. This BP measurement algorithm also distinguishes visits associated with acute illness from non-acute visits. Using the clinically-guided algorithm, investigators conducted structured chart reviews for 201 randomly selected Veterans who were treated at two VAMCs in 2009, and who had been diagnosed with hypertension in the previous two years. Results were compared with traditional methods of performance measurement.


  • Nearly one in three Veterans with hypertension would be exempted from BP performance measurement based on clinically-guided criteria. The most common reasons for exemption were inadequate opportunity for clinicians to manage Veterans' BP, and the patient's use of four or more anti-hypertensive medications.
  • After accounting for clinically-guided exemptions and methods of BP assessment, only 15 of 72 Veterans (21%) whose last BP was >140/90 mm Hg were classified as problematic by the clinically-guided approach, i.e., eligible for performance assessment and defined as having uncontrolled BP.


  • While pilot testing suggests study methods were robust, the chart review protocol may have missed some exemptions.
  • Data were collected from only two VAMCs.


  • These findings highlight a major discordance between clinically sensible approaches to measuring BP control and the relatively simplistic measures commonly employed in practice. The findings also emphasize the promise of clinically-guided approaches to increase the credibility of performance measures and to better align incentives to improve quality of care.

This study was partly funded by HSR&D. Drs. Steinman and Lee, and Ms. Peterson and Ms. Fung are part of HSR&D's Program to Improve Care for Veterans with Complex Comorbid Conditions, San Francisco, CA. Dr. Goldstein is part of HSR&D's Center for Health Care Evaluation, Palo Alto, CA.

PubMed Logo Steinman M, Lee S, Peterson C, Fung K, and Goldstein M. A Clinically-Guided Approach to Improving Performance Measurement for Hypertension. Medical Care May 2012;50(5):399-405.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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