Action or Inaction? Decision Making in Patients With Diabetes and Elevated Blood Pressure in Primary Care

Abstract

OBJECTIVE -Hypertension increases micro-and macrovascular complications of diabetes. The goal for blood pressure is Ͻ130/80 mmHg. In primary care, however, blood pressure in many patients exceeds this goal. In this study, we evaluated the clinical decision-making process when a patient with diabetes presents with elevated blood pressure.RESEARCH DESIGN AND METHODS -Twenty-six primary care practices in two practice-based research networks in Colorado participated. Questionnaires were completed after each encounter with an adult with type 2 diabetes. Data obtained from the survey included 1) demographic information, 2) blood pressure results, 3) action taken, 4) type of action if action was taken, and 5) reasons for inaction if action was not taken. Bivariate and multivariate analyses were performed to identify predictors of action.RESULTS -Completed surveys totaled 778. Blood pressure was 130/74 Ϯ 18.8/12.0 mmHg (mean Ϯ SD). Sixty-two percent of patients exceeded goals. Action was taken to lower blood pressure in 34.9% of those. Predictors of action were 1) blood pressure level, 2) total number of medicines the patient was taking, and 3) patient already taking medicines for blood pressure. As blood pressure rose, providers attributed inaction more often to "competing demands" and reasons other than "blood pressure being at or near goal." CONCLUSIONS -No evidence was found for patterns of poor care among primary care physicians. Providers balance the clinical circumstances, including how elevated the blood pressure is, and issues of polypharmacy, medication side effects, and costs when determining the best course of action. Knowledge deficit is not a common cause of inaction. Diabetes Care 29:2580 -2585, 2006T here is extensive clinical evidence linking hypertension with microand macrovascular complications of diabetes, including randomized controlled trials and a meta-analysis (1-6). Until 2000, the target blood pressure for individuals with diabetes was the same as that for individuals without diabetes (Ͻ140/90 mmHg). However, because of the demonstrated clinical benefit of lower blood pressure specifically for diabetes, national guidelines, established by the American Diabetes Association and the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), call for more intensive management, with a target of Ͻ130/80 mmHg (7,8).Of the care provided to patients with type 2 diabetes, ϳ90% takes place in primary care practices (9). Unfortunately, blood pressure control in these settings is frequently suboptimal (10 -12) and may be even worse in those with diabetes and hypertension compared with those with hypertension alone (13).An essential component of lowering blood pressures to goal is the clinical decision made by the primary care provider at the visit in which blood pressure is elevated. Multiple factors may influence this decision. For example, it has been found that optimal blood pressure control often requires three or more medications (8), leading to increas...

Influence of Elevated Cardiometabolic Risk Factor Levels on Treatment Changes in Type 2 Diabetes

“…Regarding blood pressure management, we confirmed previous findings that treatment changes are less likely in moderately controlled than in poorly controlled patients and that there is more reluctance to start than to intensify treatment (10). For lipid management, action remained low even at high cholesterol levels.…”

“…Although accepting higher risk-factor levels than indicated by guidelines has been reported as a reason for not changing treatment, few studies have examined differences in treatment intervention rates for moderately and poorly controlled patients (8 -11). Results from two provider survey studies suggest that physicians treat near-goal A1C levels more aggressively than neargoal blood pressure levels (10,12). Our aim was to assess the influence of moderately and highly elevated levels of cardiometabolic risk factors on the decision to change antihypertensive, lipid-lowering, and glucose-lowering treatment in primary care.…”

Patients’ Future Expectations for Diabetes and Hypertension Treatments: “Through the Diet… I Think This is Going to Go Away.”

“…6,7 However, many patients experience delays in medication intensification. [8][9][10][11][12][13] Delays in treatment initiation and intensification may be partially due to patient beliefs about their chronic diseases. Prior studies have found that patients hold inaccurate beliefs about diabetes and hypertension, which negatively impact decision-making.…”

Treatment Intensification in a Hypertension Telemanagement Trial

“…4 Others have attempted to evaluate underlying causes for clinical inertia. [5][6][7][8] One such study used a conceptual model to systematically identify provider factors associated with a lower likelihood of medication intensification in hypertensive patients with diabetes mellitus. 9 These factors included reported clinical uncertainty regarding BP measurements, competing demands during clinic appointments, inappropriate physician BP goals, lack of timely follow-up of elevated BP, and concern for patient treatment nonadherence.…”