Guidelines for Hypertension: Are Quality-Assurance Measures on Target?

Abstract

Abstract-Guideline committees recommend targets of treatment based on trial data on efficacy and effectiveness.Quality-assurance initiatives apply these parameters in the general practice setting. Therefore, targets must be feasible and achievable by the practicing physicians who are judged by these targets as goals for care. We evaluated 437 patients in the Rush University Hypertension Clinic using the Health Employer Data Information Set (HEDIS) measures for 2000 to assess goal achievement in a practice-based setting. We compared guideline achievement of uncomplicated hypertensive and diabetic subjects to standards dictated by HEDIS, the 6th Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI), and the American Diabetic Association (ADA)/National Kidney Foundation (NKF). Overall, 276 (63%) patients achieved SBP goal, with 376 (86%) achieving DBP goal and 358 (59%) achieving both goals. However, in the 20% of patients who were diabetic, only 52% had a BP of Ͻ140 mm Hg and Ͻ90 mm Hg, whereas only 22% achieved the more stringent goals of JNC VI of Ͻ130 mm Hg systolic and Ͻ85 mm Hg diastolic and only 15% achieved the ADA/NKF goals of Ͻ130 mm Hg systolic and Ͻ80 mm Hg diastolic. Although goal was achievable in most uncomplicated hypertension, hypertension in diabetes was more difficult to control, despite being more likely to receive enhanced benefit from effective management. Goal-oriented strategy, especially in diabetic subjects, should be aggressively sought rather than relaxing goals to promote achievement.

Effects of Noncardiovascular Comorbidities on Antihypertensive Use in Elderly Hypertensives

“…57,58 Expanding drug coverage may be needed to ease financial barriers faced by patients with multiple conditions. 46,47 Drug utilization review programs could alert physicians to instances of suboptimal antihypertensive use 45 and performance standards 59 or "report cards" (eg, National Committee for Quality Assurance standards 60 ) could help monitor the impact of interventions on antihypertensive use in patients with comorbidities. A combination of all of these may be needed if the quality of hypertension care and the clinical outcomes of vulnerable elderly with comorbidities are to be improved.…”

Epidemiology of Uncontrolled Hypertension in the United States

“…42,47,48 The proportion of diabetic, hypertensive patients treated and controlled in recent studies has been 20% to 25% using contemporary blood pressure criteria. 32,40,42,48,49 Chronic kidney disease represents another comorbidity associated with both difficult blood pressure control and high cardiovascular risk. Coresh et al 50 found that only 27% of hypertensive individuals with elevated serum creatinine in NHANES III had blood pressure Ͻ140/90 mm Hg.…”

The paradigm has shifted to systolic blood pressure

“…12,23,24 Even in our Hypertension Specialist Clinic in which 'goal-oriented management' has enabled us to successfully reduce DBP to o90 mmHg in uncomplicated hypertensives and to o85 mmHg in those with renal disease and/or diabetes mellitus in nearly 90% of our patients, we are only able to get SBP to goal in less than 60% of those patients. This finding that controlling DBP to goal is considerably easier than controlling SBP to goal has also been demonstrated in clinical trials which follow forcedtitration protocols.…”