Monitoring performance for blood pressure management among patients with diabetes mellitus: too much of a good thing?
Monitoring performance for blood pressure management among patients with diabetes mellitus: too much of a good thing?
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DOI：
10.1001/archinternmed.2012.2253
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发表时间：
2012-06-25
影响因子：
--
通讯作者：
Hofer, Timothy P.
中科院分区：
文献类型：
--
作者：
Kerr, Eve A.;Lucatorto, Michelle A.;Holleman, Rob;Hogan, Mary M.;Klamerus, Mandi L.;Hofer, Timothy P.
奖励达到血压 (BP) 阈值的绩效衡量标准可能会导致过度治疗。我们制定了一项紧密相连的临床行动措施，旨在鼓励适当的医疗管理；以及潜在过度治疗的标志，旨在监测低舒张压时过度积极的治疗。我们在 879 个退伍军人事务部 (VA) 医疗中心和小型社区门诊诊所 (CBOC) 中进行了一项回顾性队列研究。如果患者在就诊时血压指数通过或采取了适当的行动，则满足高血压的临床行动措施。我们调查了 2009 年至 2010 年退伍军人健康管理局 (VHA) 行动措施的通过率和潜在的过度治疗情况。有 977,282 名 VA 患者年龄在 18 岁及以上，患有糖尿病。 713,790 名患者符合该行动措施的资格。 94% 通过了该措施：82% 是因为他们就诊时血压<140/90；另外 12% 的患者血压>140/90，并采取适当的临床措施。设施合格率从 77% 到 99% 不等 (p<0.001)。在所有糖尿病患者中，197,291 人（20%）的血压<130/65；其中，80,903 人（占所有糖尿病患者的 8%）有可能过度治疗。潜在过度治疗的设施比率从 3% 到 20% 不等（p<0.001）。达到当前阈值测量 (<140/90 mm Hg) 的比率较高的机构潜在过度治疗的比率较高 (p<0.001)。虽然 94% 的糖尿病退伍军人达到了行动措施，但潜在过度治疗的比率目前接近治疗不足的比率，并且实现当前阈值措施的高比率与过度治疗直接相关。正如 VHA 计划的那样，实施高血压管理的临床行动措施可能会带来更适当的护理并减少过度治疗。
Performance measures that reward achieving blood pressure (BP) thresholds may contribute to overtreatment. We developed a tightly-linked clinical action measure designed to encourage appropriate medical management; and a marker of potential overtreatment, designed to monitor overly aggressive treatment in the face of low diastolic BP. We conducted a retrospective cohort study in 879 Department of Veterans Affairs (VA) medical centers and smaller community based outpatient clinics (CBOCs). The clinical action measure for hypertension was met if the patient had a passing index BP at the visit or had an appropriate action. We examined the rate of passing the action measure and of potential overtreatment in the Veterans Health Administration (VHA) during 2009-2010. There were 977,282 established VA patients, ages 18 years and older, with diabetes. 713,790 patients were eligible for the action measure. 94% passed the measure: 82% because they had a BP<140/90 at the visit; and an additional 12% with BP>140/90 and appropriate clinical actions. Facility pass rates varied from 77% to 99% (p<0.001). Among all diabetics, 197,291 (20%) had a BP<130/65; of these, 80,903 (8% of all diabetics) had potential overtreatment. Facility rates of potential overtreatment varied from 3% to 20% (p<0.001). Facilities with higher rates of meeting the current threshold measure (<140/90 mm Hg) had higher rates of potential overtreatment (p<0.001). While 94% of diabetic Veterans met the action measure, rates of potential overtreatment are currently approaching the rate of undertreatment and high rates of achieving current threshold measures are directly associated with overtreatment. Implementing a clinical action measure for hypertension management, as VHA is planning to do, may result in more appropriate care and less overtreatment.
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影响因子：
120.7
作者：
Cooper-DeHoff, Rhonda M.;Gong, Yan;Handberg, Eileen M.;Bavry, Anthony A.;Denardo, Scott J.;Bakris, George L.;Pepine, Carl J.
通讯作者：
Pepine, Carl J.
影响因子：
39.2
作者：
Asch, SM;McGlynn, EA;Kerr, EA
通讯作者：
Kerr, EA
影响因子：
168.9
作者：
Hansson, L;Zanchetti, A;Westerling, S
通讯作者：
Westerling, S
影响因子：
39.2
作者：
Kerr, EA;Gerzoff, RB;Mangione, CM
通讯作者：
Mangione, CM
影响因子：
120.7
作者：
Egan, Brent M.;Zhao, Yumin;Axon, R. Neal
通讯作者：
Axon, R. Neal