Monitoring Performance for Blood Pressure Management Among Patients With Diabetes Mellitus

Abstract

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 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 (CBOCs). 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 (VHA) during 2009-2010. Results There were 977,282 established VA patients, ages 18 years and older, with diabetes. 713,790 patients were eligible for the action measure. 94% passed the measure: 82% because they had a BP<140/90 at the visit; and an additional 12% with BP>140/90 and appropriate clinical actions. Facility pass rates varied from 77% to 99% (p<0.001). Among all diabetics, 197,291 (20%) had a BP<130/65; of these, 80,903 (8% of all diabetics) 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 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 VHA is planning to do, may result in more appropriate care and less overtreatment.

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