Background Performance measures that reward achieving blood pressure (BP) thresholds may contribute to overtreatment. We developed a tightly linked clinical action measure designed to encourage appropriate medical management and a marker of potential overtreatment, designed to monitor overly aggressive treatment of hypertension in the face of low diastolic BP.
Methods We 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 BP at the visit or had an appropriate action. We examined the rate of passing the action measure and of potential overtreatment in the Veterans Health Administration during 2009-2010.
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% to 99% (P < .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 < .001). Facilities with higher rates of meeting the current threshold measure (<140/90 mm Hg) had higher rates of potential overtreatment (P < .001).
Conclusions While 94% of diabetic veterans met the action measure, rates of potential overtreatment are currently approaching the rate of undertreatment, and high rates of achieving current threshold measures are directly associated with overtreatment. Implementing a clinical action measure for hypertension management, as the Veterans Health Administration is planning to do, may result in more appropriate care and less overtreatment.
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Figure 1. The tightly linked clinical action measure and the marker of potential overtreatment among patients with diabetes mellitus. A, Clinical action measure for patients aged 18 to 75 years; B, marker of potential overtreatment for patients 18 years and older. *Associated with a primary care visit. †With prescription refills of all 4 classes in the 120 days following the index BP. ‡With no dropping of a medication within 120 days following the index BP (existing medications had a fill in the 120 days following the index BP). BP indicates blood pressure; DBP, diastolic blood pressure; and SBP, systolic blood pressure.
Figure 2. Patients meeting the clinical action measure or the marker of potential overtreatment. A, Quality of care by the linked action measure is met in 94% of patients; B, 8% of patients with diabetes mellitus have potential hypertension overtreatment. BP indicates blood pressure.
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