A Clinically Guided Approach for Improving Performance Measurement for Hypertension

Abstract

Background Performance measures often fail to account for legitimate reasons why patients do not achieve recommended treatment targets. Methods We tested a novel performance measurement system for blood pressure control that was designed to mimic clinical reasoning. This clinically-guided approach focuses on (1) exempting patients for whom tight blood pressure control may not be appropriate or feasible, and (2) assessing blood pressure over time. Trained abstractors conducted structured chart reviews of 201 adults with hypertension in 2 VA healthcare systems. Results were compared with traditional methods of performance measurement. Results Among 201 veterans, 183 (91%) were male, and mean age was 71 +/− 11 years. Using the clinically-guided approach, 61 patients (30%) were exempted from performance measurement. The most common reasons for exemption were inadequate opportunity to manage blood pressure (35 patients, 17%) and use of 4 or more antihypertensive medications (19 patients, 9%). Among patients eligible for performance measurement, there was little agreement on the presence of controlled vs. uncontrolled blood pressure when comparing the most recent blood pressure (the traditional approach) with an integrated assessment of control (kappa 0.14). After accounting for clinically-guided exemptions and methods of blood pressure assessment, only 15 of 72 patients (21%) whose last blood pressure was ≥140/90 mm Hg were classified as problematic by the clinically-guided approach. Conclusions Many patients have legitimate reasons for not achieving tight blood pressure control, and methods of blood pressure assessment have marked effects on whether a patient is classified as having adequate or inadequate blood pressure control.