When Tight Blood Pressure Control Is Not for Everyone: A New Model for Performance Measurement in Hypertension

Abstract

Background Many patients with hypertension have legitimate reasons to forego standard blood pressure targets yet are nonetheless included in performance measurement systems. An approach to performance measurement that incorporates clinical reasoning was developed to determine which patients to include in a performance measure for blood pressure control. Design A 10-member multispecialty advisory panel refined a taxonomy of situations in which the balance of benefits and harms of anti-hypertensive treatment do not clearly favor tight blood pressure control (blood pressure < 140/90). Results The panel identified several broad categories of reasons that could reasonably exempt a patient from performance measurement for blood pressure control. These included (1) patients who have suffered adverse effects from multiple classes of antihypertensive medications;(2) patients already taking ≥ 4 antihypertensive medications; (3) patients with terminal disease, moderate to severe dementia, or other conditions that overwhelmingly dominate the patient’s clinical status; and (4) other patient factors, including comfort care orientation and poor medication adherence despite attempts to remedy adherence difficulties. Several general principles also emerged. Performance measurement should focus on patients for whom the benefits of treatment clearly outweigh the harms and incorporate a longitudinal approach whereby clinicians are given a reasonable period of time to intervene on their patients with high blood pressure. In addition, the criteria for exempting a patient from performance measurement should be more strict in patients at higher risk of adverse health outcomes from hypertension, and more lenient for patients at lower risk. Conclusions Incorporating “real world” clinical principles and judgment into performance measurement systems may improve targeting of care and, by accounting for patient case-mix, allow for better comparison of performance between institutions.

Quality of Care for Patients with Multiple Chronic Conditions: The Role of Comorbidity Interrelatedness

“…For example, an advisory panel on hypertension performance measures recommended accounting for control of severe psychiatric or addictive illness, as achieving control of these conditions is frequently necessary before hypertension can be appropriately addressed. 66 Building on such measures to incorporate comorbidity interrelatedness may offer an opportunity to reward especially clinically challenging and time-consuming care. 34,53,60 One method for incorporating comorbidity interrelatedness into performance measurement would be to weight clinical care based on the complexity of management decisions and/or the clinical benefit to an individual patient.…”

A Clinically Guided Approach for Improving Performance Measurement for Hypertension

“…The resulting approach, which we term the “clinically-guided approach,” has been described elsewhere and has two key foci. 5 First, it employs an algorithm that replicates clinical decision-making to exclude patients for whom aggressive treatment to standard blood pressure targets may not be strongly indicated (see Box). The model does not suggest that excluded patients should not be treated, but rather than there is enough uncertainty about the net benefit of treatment that physicians should not be penalized for failing to maintain their patients’ blood pressure below 140/90 mm Hg.…”

Diabetes Mellitus Performance Measures in Individuals with Limited Life Expectancy

“…Paradoxically, to improve care, performance measures must influence individual‐level decisions by changing the practice of individual clinicians who must maintain a patient‐level perspective. Often these two perspectives align, with the performance measure encouraging an intervention that the clinician recognizes is likely to help an individual, but because no intervention is beneficial for all individuals with a specific disease, there are many instances in which performance measures encourage an intervention that the clinician believes is unlikely to help an individual . In today's healthcare environment, with financial incentives tied to performance measures, it is critical to understand how clinicians reconcile this tension between performance measures and their clinical judgment.…”