BACKGROUND/RATIONALE:
Hypertension affects over 20 percent of adults, with most patients poorly controlled, resulting in excess morbidity. Thus, improving hypertension care is critical. While many processes of care are important in delivering high quality hypertension care, the critical process in achieving good blood pressure (BP) control is likely to be clinician management of anti-hypertensives. We recently developed a novel approach for measuring intensity of anti-hypertensive therapy and applied it to the problem of BP control. Those receiving more intensive therapy had better BP control. This measure could be used in profiling clinician practices and promoting practice improvements. However, our work was limited since it was based on paper medical records and included only 800 patients. Clinical information available from VA databases has increased in recent years. These data could be used in our therapy intensity measure.

OBJECTIVE(S):
Objectives are: 1) to examine availability, reliability, and validity of key data elements used in modeling clinician practices with anti-hypertensives; 2) to validate our previous model for predicting changes in anti-hypertensives using information in existing VA databases.

METHODS:
At each of 10 VA sites, we randomly selected approximately 100 patients with a diagnosis of hypertension receiving regular medical care. We undertook a retrospective chart review for the period January 1 to December 31, 1999, abstracting data on visit type, BP, medications and diagnoses. We will compare BP measurements, diagnoses, and prescribed anti-hypertensives described in VISTA databases and the OPC with information derived from clinicians’ notes. We will evaluate whether BPs from outpatient medical visits are recorded in the database, whether hypertension-related diagnoses are accurately captured, and whether changes in anti-hypertensives described in the database can be accurately assigned to a clinic visit. Next, we will validate our model predicting therapy changes in this new study sample and with this new data source. We will determine whether the model continues to discriminate among patients at different probability of having a therapy increase and whether simple model modifications improve its performance.

FINDINGS/RESULTS:
Objective 1: data collection and chart abstractions have been completed at all 10 sites. Preliminary analyses suggest that detailed information on BP control is available at these sites; of 4620 visits, 71 percent had at least one BP in VISTA; only 38 percent had a BP in clinicians’ notes and only 27 percent had a BP from both sources. Data analysis for objective 1 is nearing completion. Objective 2: data collection is nearing completion.

IMPACT:
This project represents an important intermediate step in our plans for developing a quality measurement and improvement program for hypertension care in the VA. Specifically, we will learn whether necessary data are available and whether these data can be used to model the decision to change anti-hypertensive medication therapy. Subsequent studies will then be able to profile hypertension care in the VA using readily available data sources.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Borzecki AM, Oliveria SA, Berlowitz DR. Barriers to hypertension control. American heart journal. 2005 May 1; 149(5):785-94. [view]
2. Borzecki AM, Wong AT, Hickey EC, Ash AS, Berlowitz DR. Can we use automated data to assess quality of hypertension care? The American journal of managed care. 2004 Jul 1; 10(7 Pt 2):473-9. [view]
3. Borzecki AM, Wong AT, Hickey EC, Ash AS, Berlowitz DR. Hypertension control: how well are we doing? Archives of internal medicine. 2003 Dec 8; 163(22):2705-11. [view]
4. Berlowitz DR, Ash AS, Hickey EC, Glickman M, Friedman R, Kader B. Hypertension management in patients with diabetes: the need for more aggressive therapy. Diabetes Care. 2003 Feb 1; 26(2):355-9. [view]
5. Borzecki AM, Wong AT, Hickey EC, Ash AS, Berlowitz DR. Identifying hypertension-related comorbidities from administrative data: what's the optimal approach? American journal of medical quality : the official journal of the American College of Medical Quality. 2004 Sep 1; 19(5):201-6. [view]
6. Borzecki AM, Berlowitz DR. Management of hypertension and diabetes: treatment goals, drug choices, current practice, and strategies for improving care. Current Hypertension Reports. 2005 Dec 1; 7(6):439-49. [view]
7. Borzecki AM, Glickman ME, Kader B, Berlowitz DR. The effect of age on hypertension control and management. American journal of hypertension. 2006 May 1; 19(5):520-7. [view]

VA Cyberseminars

1. Berlowitz D. Blood Pressure Control Within the VA. [Cyberseminar]. 2004 Sep 2. [view]

Conference Presentations

1. Berlowitz D. Assessing the Quality of Hypertension Care. Paper presented at: Harvard School of Public Health Quality of Care Research Annual Seminar; 2002 Feb 1; Boston, MA. [view]
2. Berlowitz D. Assessing the Risk: From Clinical Evaluation to Large Databases. Paper presented at: National Pressure Ulcer Advisory Panel Biennial Conference; 2001 Feb 23; Washington, DC. [view]
3. Oates DJ, Berlowitz DR, Glickman ME, Silliman RA, Borzecki AM. Blood Pressure and Survival in a Cohort of Very Old Hypertensive Veterans. Paper presented at: American Geriatrics Society Annual Meeting; 2006 May 5; Seattle, WA. [view]
4. Berlowitz DR. Current Trends in Controlling Blood Pressure. Paper presented at: Partnership for a Heart Healthy Stroke Free Massachusetts Annual Conference; 2007 Jan 26; Shrewsbury, MA. [view]
5. Borzecki A, Wong A, Ash A, Berlowitz D. Hypertension Control: How Well are we Doing. Paper presented at: VA HSR&D National Meeting; 2002 Feb 23; Washington, DC. [view]
6. Borzecki A, Wong A, Hickey E, Ash A, Berlowitz D. Identifying hypertension-related comorbidities from administrative data: what's the optimal approach? Paper presented at: VA HSR&D National Meeting; 2004 Mar 17; Washington, DC. [view]
7. Berlowitz D. Outcomes Measurements for Controlling Blood Pressure in Patients with Diabetes. Paper presented at: Top Healthcare Industry Leaders Clinical Outcomes Exclusive Annual Forum; 2003 Dec 2; Orlando, FL. [view]
8. Bokhour BG, Solomon J, Cohn EC, Cortes DE, Haidet P, Elwy AR, Katz L, Borzecki AM, Green AR, Kressin NR. Patient Perspectives on Managing Hypertension: Developing a New Conceptual Model of Patient Behavior. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD. [view]
9. Borzecki AM, Glickman ME, Kader B, Berlowitz DR. The effect of age on hypertension control and management. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA. [view]
10. Borzecki AM, Kader B, Berlowitz DR. The Epidemiology of Severe Hypertension. Presented at: European Hypertension Annual Meeting; 2007 Jun 6; Milan, Italy. [view]
11. Borzecki AM, Kader B, Berlowitz DR. The Management of Severe Hypertension. Presented at: European Hypertension Annual Meeting; 2007 Jun 6; Milan, Italy. [view]

DRA: Health Systems
DRE: Technology Development and Assessment
Keywords: Cardiovasc’r disease, Pharmaceuticals, Quality assessment
MeSH Terms: none