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When tight blood pressure control is not for everyone: a new model for performance measurement in hypertension
Michael A Steinman1, Mary K Goldstein
1San Francisco Veterans Affairs Medical Center, USA. mike.steinman@ucsf.edu
Insights
Performance measures for hypertension should exclude patients with valid reasons for not meeting strict blood pressure targets. Clinical judgment is key to accurately assessing patient care and improving institutional comparisons.
Area of Science:
- Cardiovascular Medicine
- Health Services Research
- Clinical Performance Measurement
Background:
- Many hypertension patients have valid reasons to deviate from standard blood pressure targets.
- Current performance measurement systems often fail to account for these clinical nuances.
- This can lead to inaccurate assessments of care quality.
Purpose of the Study:
- To develop an approach for performance measurement that incorporates clinical reasoning.
- To identify specific patient groups that should be considered for exemption from standard blood pressure control targets.
- To refine criteria for performance measurement in hypertension management.
Main Methods:
- A 10-member multispecialty advisory panel was convened.
- The panel refined a taxonomy of situations where tight blood pressure control (< 140/90 mm Hg) is not clearly beneficial.
- Clinical judgment and real-world principles guided the refinement process.
Main Results:
- Several categories for exempting patients from performance measurement were identified.
- Exemptions include patients with medication side effects, those on multiple antihypertensives, individuals with terminal illness or severe cognitive impairment, and those with complex adherence issues.
- Principles for performance measurement emphasize focusing on patients benefiting from treatment and adopting a longitudinal approach.
Conclusions:
- Incorporating clinical judgment into performance measurement improves care targeting.
- Accounting for patient case mix allows for more accurate comparisons between healthcare institutions.
- This approach enhances the relevance and fairness of hypertension performance measures.
Background:
Many patients with hypertension have legitimate reasons to forego standard blood pressure targets yet are nonetheless included in performance measurement systems. An approach to performance measurement incorporating clinical reasoning was developed to determine which patients to include in a performance measure.
Design:
A 10-member multispecialty advisory panel refined a taxonomy of situations in which the balance of benefits and harms of anti-hypertensive treatment does not clearly favor tight blood pressure control (< 140/90 mm Hg).
Findings:
The panel identified several broad categories of reasons for exempting a patient from performance measurement for blood pressure control. These included (1) patients who have suffered adverse effects from multiple classes of antihypertensive medications; (2) patients already taking four or more antihypertensive medications; (3) patients with terminal disease, moderate to severe dementia, or other conditions that overwhelmingly dominate the patient's clinical status; and (4) other patient factors, including comfort care orientation and poor medication adherence despite attempts to remedy adherence difficulties. Several general principles also emerged. Performance measurement should focus on patients for whom the benefits of treatment clearly outweigh the harms and should incorporate a longitudinal approach. In addition, the criteria for exempting a patient from performance measurement should be more strict in patients at higher risk of adverse health outcomes from hypertension and more lenient for patients at lower risk.
Conclusions:
Incorporating "real world" clinical principles and judgment into performance measurement systems may improve targeting of care and, by accounting for patient case mix, allow for better comparison of performance between institutions.
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