The Quandary of Improving Hypertension Control in Diabetes

STUDY

Kerr EA, Zikmund-Fisher BJ, Klamerus ML, Subramanian U, Hogan MM, Hofer TP: The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure.

SUMMARY

Design. A prospective cohort study examining what proportion of diabetic patients with a triage blood pressure > 140 mmHg systolic or 90 mmHg diastolic received a treatment change during a single routine visit and to what extent certain provider and patient factors influenced the likelihood of change.

Subjects. The study included 1,169 diabetic patients with elevated blood pressure treated by 92 primary care providers at nine Veterans Affairs facilities in three Midwestern states over 13 months. Patients were older (mean age 66 years) and were primarily male (97%) and white (80%). The mean systolic blood pressure was 154 mmHg (standard deviation: 113-228).

Methods. The main outcome was the proportion of patients who had either intensification of blood pressure medication or a planned follow-up visit within 4 weeks. Data were obtained from patient surveys, provider surveys, medical records, and VA automated sources. Factors hypothesized to influence the likelihood of change were analyzed in a logistic regression model that assessed four categories of variables: clinical uncertainty; competing demands and prioritization of comorbid conditions; medication issues; and practice organizational characteristics.

Results. A total of 573 (49%) patients with a triage blood pressure > 140 mmHg systolic or 90 mmHg diastolic had a treatment change: 511 had medications changes, and 62 had a plan for follow-up blood pressure measurement within 4 weeks. The likelihood of treatment change increased markedly as systolic and diastolic blood pressure increased. Providers were less likely to change medication if repeat blood pressure measurement was < 140/90 mmHg (13 vs. 61%, P < 0.001) or if the patient reported a home …