Monitoring Performance for Blood Pressure Management Among Patients With Diabetes Mellitus: Too Much of a Good Thing?

Jun 25, 2012
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Authors:
Kerr EA, Lucatorto MA, Holleman R, Hogan MM, Klamerus ML, Hofer TP, on behalf of the VA Diabetes Quality Enhancement Research Initiative (QUERI) Workgroup on Clinical Action Measures.
Citation:
Arch Intern Med 2012;172:938-945.
Summary By:
Debabrata Mukherjee, MD, FACC

Study Questions:

What is 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?

Methods:

The investigators conducted a retrospective cohort study in 879 Department of Veterans Affairs (VA) medical centers and smaller community-based outpatient clinics. The clinical action measure for hypertension was met if the patient had a passing index blood pressure (BP) at the visit or had an appropriate action. They further examined the rate of passing the action measure and of potential overtreatment in the Veterans Health Administration during 2009-2010. The authors divided the 879 sites into quartiles based on meeting the current dichotomous threshold performance measure of BP lower than 140/90 mm Hg, and examined the association between facility quartile and potential overtreatment using a multilevel logistic model.

Results:

There were 977,282 established VA patients, 18 years and older, with diabetes mellitus (DM). A total of 713,790 patients were eligible for the action measure; 94% passed the measure (82% because they had a BP <140/90 mm Hg at the visit and an additional 12% with a BP ≥140/90 mm Hg and appropriate clinical actions). Facility pass rates varied from 77-99% (p < 0.001). Among all patients with DM, 197,291 (20%) had a BP lower than 130/65 mm Hg; of these, 80,903 (8% of all patients with DM) had potential overtreatment. Facility rates of potential overtreatment varied from 3% to 20% (p < 0.001). Facilities with higher rates of meeting the current threshold measure (<140/90 mm Hg) had higher rates of potential overtreatment (p < 0.001).

Conclusions:

The authors concluded that rates of potential BP overtreatment are currently approaching the rate of undertreatment, and high rates of achieving current threshold measures are directly associated with overtreatment.

Perspective:

The study reports that nearly 94% of patients with DM met the clinical action measure for BP measurement, which represents a dramatic improvement in BP control over the past decade. However, rates of potential overtreatment are currently approaching, and perhaps even exceeding, the rate of undertreatment and that high rates of achieving current performance measurement targets are directly associated with medication escalation that may increase risk for patients. Implementing a clinical action measure for hypertension management may result, over time, in more appropriate care and more net benefit for patients avoiding both under- and overtreatment.

Keywords: Veterans Health, Cardiology, Blood Pressure Monitoring, Ambulatory, Cardiovascular Diseases, Disease Management, Blood Pressure, United States Department of Veterans Affairs, Hypertension, Diabetes Mellitus, United States


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