Blood Pressure Control Among US Veterans

Fletcher, Ross D.; Amdur, Richard L.; Kolodner, Robert M.; McManus, Chris; Jones, Rodney W.; Faselis, Charles; Kokkinos, Peter; Singh, Steven; Papademetriou, Vasilios

doi:10.1161/circulationaha.111.029983

Cited by 90 publications

(52 citation statements)

References 12 publications

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“…Patient registries, population health management tools, and EHRs meeting the objectives of the meaningful use certification criteria11, 12, 13 include functions to generate lists of patients by specific conditions, send patient reminders, prompt offers of patient education material, provide embedded clinical content, and chart and report out changes in BP. More specifically, ambulatory practices can apply data query capabilities to select subgroups of underserved or at‐risk hypertensive patients and pair those patients with targeted interventions, such as a follow‐up visit to confirm an elevated BP reading, initiate treatment, or intensify treatment 15, 18, 19, 28…”

Section: Discussionmentioning

confidence: 99%

“…Increasing the frequency of visits for this population could lead to improved BP control 19, 31. Providers might target these patients by employing follow‐up visit reminders15 or automated outreach call services aimed at increasing visit adherence 14.…”

Section: Discussionmentioning

confidence: 99%

“…There are several common reasons for therapeutic ineffectiveness in these groups that might be remedied by changing improvement targets 40. For instance, failure to change or increase therapy for patients who are not at goal (“therapeutic inertia”)41, 42 can be addressed by leveraging EHRs to implement treatment algorithms and protocols,16, 28, 38 utilizing clinical decision support tools embedded within EHRs including a 2‐week follow‐up process and patient reminders,19 and changes in team care 43, 44, 45, 46. Treatment‐resistant hypertension is related to age, patient factors, and medical causes of secondary hypertension47 and can be explored by implementing streamlined referral pathways35 and pushing EHR alerts to providers when the BP is elevated 30…”

Section: Discussionmentioning

confidence: 99%

“…If discrete patient populations experience lack of control for different reasons, patient panels should be stratified to reflect that variation in barriers to awareness, treatment, or control and then paired with targeted evidence‐based interventions. We illustrate how functions embedded within population health management tools, EHRs, or data registries are available to support this strategy 14, 15, 16, 17, 18, 19…”

mentioning

confidence: 99%

See 3 more Smart Citations

Hypertension Control Cascade: A Framework to Improve Hypertension Awareness, Treatment, and Control

Wozniak

Khan

Gillespie

et al. 2015

J of Clinical Hypertension

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Evidence‐based interventions differ for increasing hypertension awareness, treatment, and control and should be targeted for specific patient panels. This study developed a hypertension control cascade to identify patients with a usual source of care represented at each level of the cascade using the 2007–2012 National Health and Nutrition Examination Survey. Overall, 10.7 million adults in the United States were unaware of their condition, 3.8 million were aware but untreated, and 15.8 million were treated but uncontrolled. The results also suggest that failure to attain hypertension control because of lack of awareness or lack of treatment despite awareness occurs mainly among younger individuals and those with no annual healthcare visits, while the elderly and minorities are more likely to remain uncontrolled when aware and treated. Opportunities to leverage population health management functions in electronic health information systems to align the specific patient subgroups facing barriers to hypertension control at each level of the cascade with targeted hypertension management interventions are discussed.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

See 2 more Smart Citations

Hypertension Control Cascade: A Framework to Improve Hypertension Awareness, Treatment, and Control

Wozniak

Khan

Gillespie

et al. 2015

J of Clinical Hypertension

View full text Add to dashboard Cite

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“…Acquisition, storage, and analysis of the data have been previously described 14. In brief, the Department of Veterans Affairs first deployed electronic data in 1982 as the Decentralized Hospital Computer Program.…”

Section: Methodsmentioning

confidence: 99%

Time in Therapeutic Range, as a Determinant of All‐Cause Mortality in Patients With Hypertension

Doumas

Tsioufis

Fletcher

et al. 2017

JAHA

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BackgroundAccumulating evidence indicates that reducing systolic blood pressure (BP) to <140 mm Hg improves health outcomes; however, an optimal level has not yet been determined. Many population studies or post hoc analyses suggest a target systolic BP between 120 and 140 mm Hg with increased risk above and below that range. We tested the hypothesis that consistent control of systolic BP between 120 and 140 mm Hg—time in therapeutic range—is a strong determinant of all‐cause mortality among US veterans.Methods and ResultsA total of 689 051 individuals from 15 Veterans Administration Medical Centers were followed over a 10‐year period. Participants were classified as hypertensive, intermediate hypertensive, and normotensive according to the number of elevated BP recordings (>3, 1 or 2, and none, respectively). Time within, above, or below therapeutic range (120–140 mm Hg) was considered in quartiles and related to all‐cause mortality. The study population consisted of 54% hypertensive, 19.9% intermediate, and 26.1% normotensive participants; the corresponding mortality rates for the 3 groups were 11.5%, 8%, and 1.9%, respectively (P<0.0001 for all comparisons). Mortality rates for hypertensive participants with BP consistently within, above, or below the therapeutic range were 6.5%, 21.9%, and 33.1%, respectively (P<0.0001 for all comparisons). Mortality rates in hypertensive participants increased from 6.5% in the most consistently controlled quartile (>75%) to 8.9%, 15.6%, and 23.5% towards the less consistently controlled quartiles (50–75%, 25–50%, and <25%, respectively; P<0.0001 for all comparisons).ConclusionsAn inverse and gradual association between time in therapeutic range and all‐cause mortality was observed in this large veteran cohort. Consistency of BP control over time is a strong determinant of all‐cause mortality, and consistency of BP control should be monitored in everyday clinical practice.

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Effects of Individual Physician-Level and Practice-Level Financial Incentives on Hypertension Care

Petersen

Simpson

Pietz

et al. 2013

JAMA

102

143

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IMPORTANCE Pay for performance is intended to align incentives to promote high-quality care, but results have been contradictory.OBJECTIVE To test the effect of explicit financial incentives to reward guidelinerecommended hypertension care. DESIGN, SETTING, AND PARTICIPANTSCluster randomized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel (eg, nurses, pharmacists).INTERVENTIONS Physician-level (individual) incentives, practice-level incentives, both, or none. Intervention participants received up to 5 payments every 4 months; all participants could access feedback reports.MAIN OUTCOMES AND MEASURES Among a random sample, number of patients achieving guideline-recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure, number of patients prescribed guideline-recommended medications, and number who developed hypotension.

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Blood Pressure Control Among US Veterans

Cited by 90 publications

References 12 publications

Hypertension Control Cascade: A Framework to Improve Hypertension Awareness, Treatment, and Control

Hypertension Control Cascade: A Framework to Improve Hypertension Awareness, Treatment, and Control

Time in Therapeutic Range, as a Determinant of All‐Cause Mortality in Patients With Hypertension

Effects of Individual Physician-Level and Practice-Level Financial Incentives on Hypertension Care

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