Treatment Intensification for Hypertension Not Significantly More Likely to Occur in Veterans with Diabetes and at Higher CV Risk
Clinical decision-making and organizational guidance for the prevention of cardiovascular (CV) disease has often focused on the reduction of individual risk factors (i.e., hypertension). However, overall risk is a better indicator of treatment benefit because those with a higher likelihood of having an event have a higher absolute benefit from treatment. One way to assess how clinicians prioritize overall risk in patients with a known CV risk factor is by assessing hypertension treatment intensification (TI). This prospective cohort study examined whether or not hypertension TI was more likely for those with elevated CV risk among 856 Veterans with diabetes and elevated BP (>140/90), who were treated at nine VAMCs in three Midwestern states. Of these Veterans, 159 (19%) were classified as low/medium CV risk; 324 (38%) were high-risk, but with no history of myocardial infarction (MI) or heart failure (HF); and 373 (44%) had a history of MI or HF. The dependent variable measured in this study was whether or not a VA provider intensified a patient's BP medication within three months after an index primary care visit in response to an elevated measured BP. Investigators also developed a decision analysis to estimate the potential benefit of making treatment more risk-focused.
- Treatment intensification for hypertension was not significantly more likely to occur in Veterans with diabetes and at higher CV risk, compared with patients at low to medium risk. However, physicians were more likely to advance therapy in patients with higher and more consistently elevated blood pressures.
- Several individual risk factors were associated with higher rates of treatment intensification: systolic BP, mean BP in the prior year, and higher hemoglobin A1c, while self-reported home BP <140/90 was associated with lower rates of TI.
- The authors suggest that incorporating CV risk into TI decision algorithms could prevent an estimated 38% cardiac events without increasing the number of patients being treated.
- The investigators were unaware of any risk assessment score applicable to both primary and secondary prevention, thus were unable to use a single, continuous variable of CV risk, which would have been considerably more statistically efficient.
This study was funded through VA/HSR&D's Diabetes Quality Enhancement Research Initiative (Diabetes-QUERI). Drs. Sussman, Hayward, Hofer, and Kerr are part of HSR&D's Center for Clinical Management Research, Ann Arbor, MI. Dr. Kerr also is Director of Diabetes-QUERI. Dr. Zulman is part of HSR&D's Center for Health Care Evaluation, Palo Alto, CA.
Sussman J, Zulman D, Hayward R, Hofer T, and Kerr E. Cardiac Risk is not Associated with Hypertension Treatment Intensification. American Journal of Managed Care August 2012;18(8):414-20.