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Development and testing of a clinically detailed system to assess quality of care in hypertension

Asch S, Kerr E, McGlynn B. Development and testing of a clinically detailed system to assess quality of care in hypertension. Paper presented at: VA HSR&D National Meeting; 2000 Mar 1; Washington, DC.


Title: Development and testing of a clinically-detailed system to assess quality of care in hypertension. Objective: Guidelines for care of hypertensive patients have proliferated recently, yet quality assessment remains difficult in the absence of well-defined measurement systems. As part of a larger effort, we developed indicators for measuring process quality in hypertension. We tested this system on hypertensive women in one site of a large group model health plan. Methods: We selected indicators based on the explicit a priori criteria of clinical importance, outcome link, evidence strength, operational ease, provider accountability, reliability and adaptability. A 1996 expert panel rated the indicators using the modified Delphi method. 1 screening, 11 diagnostic, 5 treatment, and 2 follow-up indicators (including subparts) survived this process. Patients were eligible if they had a visit in 1996-97, were continuously enrolled for at least 13 months, and were under 65. Trained nurses used a laptop-based tool to abstract data from medical and administrative records for a two-year period. We sampled 467 out of 15004 eligibles, oversampling patients with hypertensive and other chronic disease administrative codes; all these patients were eligible for the screening indicator. 234 women with average blood pressure > = 140/90 or a documented diagnosis of hypertension were evaluated for the remaining indicators. Results: We analyzed 19 indicators and calculated weighted adherence proportions for each. indicator. 97% of hypertensive patients were eligible for at least 1 non-screening indicator. From 0% to 93% of eligible patients received the indicated care. 84% of all patients presenting for care had at least an annual blood pressure. Among hypertensives, only 7% had an adequate history as defined by documentation of at least 2 of the following elements: family or personal history of premature CAD, VA, diabetes or hyperlipidemia. Only 30% had annual urinalysis, 29% annual potassium, while 86% had annual cholesterol. Just 3% of prevalent and 33% of new mild to moderate hypertensives had chart evidence of being offered lifestyle modification before pharmacotherapy. While 93% had an annual visit, only 37% of hypertensives noted to have persistent elevations > 160/90 had changes in therapy or lifestyle recommended. We also calculated overall adherence proportions (number of indicators passed/ number of indicators eligible) for each person. The average adherence proportion was lower in patients with poor control (average BP > 140/90) than those with good control (54% vs. 73% p < .001) Conclusion: Quality of hypertensive care falls far short of indicators based on national guidelines. Poor performance in essential care processes is associated with poor blood pressure control. Future research should examine patient and system level predictors of adherence and extend measurement to older women, men and other delivery systems. Impact Statements: We have developed and tested an evidence-based system for measuring process quality in hypertension and validated it against blood pressure outcomes.

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