Related Experiment Video
Updated: Sep 3, 2025
Measuring the Carotid to Femoral Pulse Wave Velocity Cf-PWV to Evaluate Arterial Stiffness
Published on: May 3, 2018
Adjusting for Patient Economic/Access Issues in a Hypertension Quality Measure
Jenna Donovan1, Erika K Cottrell2, Megan Hoopes1
1OCHIN, Inc., Portland, Oregon.
Insights
Adjusting hypertension quality measures by excluding patients with economic barriers had varied effects on control rates. Excluding these patients removed a large proportion, questioning the measure's clinical performance value.
Area of Science:
- Health Services Research
- Quality Improvement
- Health Equity
Background:
- Professional organizations recommend adjusting hypertension quality measures.
- Exclusions target patients facing economic or access barriers to care.
- Methods for operationalizing these exclusions remain underexplored.
Purpose of the Study:
- To apply and compare different methods for populating denominator exceptions in hypertension quality measures.
- To assess the impact of excluding patients with economic/access issues on hypertension control rates.
- To evaluate the feasibility and implications of these adjustments in community health centers.
Main Methods:
- Utilized electronic health record data from 84 community health centers (2019 data, analyzed in 2021).
- Applied 10 distinct indicators of patient economic/access barriers as denominator exclusions.
- Calculated and compared adjusted hypertension control rates across different exclusion approaches.
Main Results:
- Five of ten measures showed increased adjusted hypertension control rates in over 50% of clinics (0.7-3.71 pp increase).
- Three of ten measures showed decreased adjusted rates in over 50% of clinics (1.33-13.82 pp decrease).
- Five measures resulted in excluding over 50% of the patient population from assessments.
Conclusions:
- The impact of adjusting hypertension quality measures varied significantly based on the exclusion criteria used.
- Adjustments resulted in small changes to clinic-level rates but excluded substantial patient proportions.
- Excluding large patient groups raises concerns about the meaningfulness of these adjusted quality measures for clinical performance evaluation.
Introduction:
The American Heart Association and American College of Cardiology have proposed adjusting hypertension-related care quality measures by excluding patients with economic/access issues from the denominator of rate calculations. No research to date has explored the methods to operationalize this recommendation or how to measure economic/access issues. This study applied and compared different approaches to populating these denominator exceptions.
Methods:
Electronic health record data from 2019 were used in 2021 to calculate hypertension control rates in 84 community health centers. A total of 10 different indicators of patient economic/access barriers to care were used as denominator exclusions to calculate and then compare adjusted quality measure performance. Data came from a nonprofit health center‒controlled network that hosts a shared electronic health record for community health centers located in 22 states.
Results:
A total of 5 of 10 measures yielded an increase in adjusted hypertension control rates in ≥50% of clinics (average rate increases of 0.7-3.71 percentage points). A total of 3 of 10 measures yielded a decrease in adjusted hypertension control rates in >50% of clinics (average rate decreases of 1.33-13.82 percentage points). A total of 5 measures resulted in excluding >50% of the clinic's patient population from quality measure assessments.
Conclusions:
Changes in clinic-level hypertension control rates after adjustment differed depending on the measure of economic/access issue. Regardless of the exclusion method, changes between baseline and adjusted rates were small. Removing community health center patients experiencing economic/access barriers from a hypertension control quality measure resulted in excluding a large proportion of patients, raising concerns about whether this calculation can be a meaningful measure of clinical performance.
Related Concept Videos
01:25Errors occurring during blood pressure monitoring
Several factors...
01:28Special considerations while measuring blood pressure
Monitoring Both Arms:
Monitoring BP in both arms during the initial assessment is advisable, as the systolic value may differ by five to ten mm Hg between arms. For subsequent BP assessments, use the arm with the higher reading.
01:10Pre-Procedural Guidelines for Assessing Blood Pressure
01:23Hypertension V: Nursing Management
01:17Measurement of Blood Pressure
01:30Hypertension III: Clinical Manifestations and Diagnostic Studies