Assessing Hypertension Care for Aged Veterans: Balancing Risks and Benefits

评估老年退伍军人的高血压护理：平衡风险和收益

• 批准号: 8978569
• 负责人: Lillian Chiang Min
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-10-01 至 2019-12-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8978569
• 关键词: Adherence; Adherence; Affect; Affect; Age; Age; Aging; Aging; Algorithms; Algorithms; Award; Award; Benefits and Risks; Benefits and Risks; Blood Pressure; Blood Pressure; Cardiac; Cardiac; Cardiovascular Diseases; Cardiovascular Diseases; Cardiovascular system; Cardiovascular system; Caring; Caring; Characteristics; Characteristics; Chronic; Chronic; Clinic; Clinic; Data; Data; Data Element; Data Element; Data Reporting; Data Reporting; Data Set; Data Set; Databases; Databases; Development; Development; Diabetes Mellitus; Diabetes Mellitus; Diagnostic; Diagnostic; Disputes; Disputes; Early identification; Early identification; Elderly; Elderly; Electronic Health Record; Electronic Health Record; Equilibrium; Equilibrium; Event; Event; Fright; Fright; Health; Health; Health and Retirement Study; Healthcare; Healthcare; Hip Fractures; Hip Fractures; Hypertension; Hypertension; Hypotension; Hypotension; Individual; Individual; Injury; Injury; Interview; Interview; Lead; Lead; Link; Link; Measures; Measures; Medical Records; Medical Records; Medical center; Medical center; Medicare; Medicare; Methods; Methods; Myocardial Infarction; Myocardial Infarction; Outcome; Outcome; Patients; Patients; Performance; Performance; Pharmaceutical Preparations; Pharmaceutical Preparations; Polypharmacy; Polypharmacy; Predisposing Factor; Predisposing Factor; Provider; Provider; Quality of Care; Quality of Care; Reporting; Reporting; Research; Research; Retirement; Risk; Risk; STEM research; Sampling; Sampling; Severities; Severities; Site; Site; Stroke; Stroke; Structure; Structure; Subgroup; System; System; Taxonomy; Taxonomy; Testing; Testing; Translational Research; Translational Research; Variant; Variant; Veterans; Veterans; Work; Work; acute stroke; acute stroke; age group; age group; aged; aged; aggressive therapy; base; base; blood pressure medication; blood pressure reduction; blood pressure regulation; blood pressure regulation; cardiovascular disorder risk; cardiovascular disorder risk; cardiovascular risk factor; cardiovascular risk factor; comorbidity; comorbidity; control trial; design; design; diabetic; diabetic; electronic data; electronic data; fall injury; fall risk; fall risk; falls; falls; health administration; health administration; human old age (65+); hypertension control; hypertension control; improved; improved; meetings; novel; novel; older patient; older patient; overtreatment; patient oriented; patient oriented; patient subsets; primary outcome; primary outcome; research to practice; research to practice; response; response; stem; success; success

 DESCRIPTION (provided by applicant): Hypertension, the most commonly-treated condition in the VHA, affects more than 80% of older Veterans. With continuing improvements in quality of VHA care, more older Veterans meet blood pressure (BP) targets than older patients in Medicare. Despite known benefits of BP control, one concern as Veterans age and accumulate multiple conditions is that overly-aggressive control may result in unintended outcomes such as falls. We propose to better understand both cardiovascular benefits and fall injury risks associated with overly-aggressive hypertension care. This work will lead to a development of a novel measure of harmful or wasteful BP treatment for > 1.6 million Veterans. The VHA has been highly successful at improving BP control, exceeding performance on existing BP measures by 79% versus only 62% in Medicare. Older individuals stand to benefit from good BP control, especially in stroke reduction. However, older individuals are at risk of falls due to polypharmacy. One concern is that our existing dichotomous BP targets result in inadvertently-low BPs, especially as aging Veterans develop geriatric conditions such as falls. We have previously found that nearly one-third of older Veterans with diabetes are potentially-over-treated. Whether or not VHA providers should consider de-intensifying BP care in older Veterans has not been well-studied. We aim to define Aggressive Hypertension Care (AHC) in Veterans age 65 and older using national VHA databases. First, we will validate data elements of AHC using medical record review. Next, we will test whether AHC (in comparison to adequate care) is associated with falls injury, and whether the risks outweigh reduction in strokes and cardiac events. Last, we will measure inter-facility variation in AHC. We will involve VHA providers throughout these Aims to review results, guide analytic decisions and provide early identification of potential barriers to implementation. By the end of the award, we aim to develop a novel measure of appropriate hypertension care of relevance to older Veterans specific to age group, co-morbidity burden, and baseline risk for cardiovascular and fall events. Aim 1 (Validating data elements of AHC): Working with our provider panels and steering committee, we will review data elements of AHC (BP < 130/65 mmHg in combination with continuing 3+ or escalating 1+ BP medications) for appropriateness in older Veterans age 65 and older. Then, in a small subsample, we will validate the data elements by full review of the electronic health record. Aim 2 (Harms and Benefits of AHC): In Sub-Aim 2A, We will use the Health and Retirement Study which captures both interview-based fall injury and diagnostic injury data from Medicare, thus facilitating development of a fall injur severity algorithm that we can apply to the VHA-Medicare data. Then, in Sub-Aim 2B, we will use two years of VHA data merged with Medicare to test whether AHC (compared to adequate care) is linked with increased risk of severe falls injury, and if so, whether the risks exceed the cardiovascular benefits (acute strokes and myocardial infarction). We will consider refinement of the AHC as guided by our provider panels and steering committee. We will consider subgroups of patients depending on baseline cardiovascular or falls risk. Aim 3: We will identify site/facilty characteristics that predict AHC using 2 years of national VHA data and measure the factors associated with the most variation between sites. We will consider results with provider panels and steering committee to implement potential ways to reduce AHC. Aim 4: Throughout Aims 1-3, we will convene a panel of VA providers across medical centers and clinics to provide input on how to define AHC, structure the measure of modest/appropriate AHC, identify barriers to implementation, and best prepare the new indicator for dissemination.

 描述（由申请人提供）： 高血压是VHA中最常见的治疗疾病，影响了80%以上的老年退伍军人。随着VHA护理质量的不断提高，达到血压（BP）目标的老年退伍军人比医疗保险中的老年患者要多。尽管已知BP控制的益处，但随着退伍军人年龄的增长和多种疾病的积累，一个令人担忧的问题是过度积极的控制可能会导致意外的结果，如福尔斯。我们建议更好地了解与过度积极的高血压护理相关的心血管益处和跌倒损伤风险。这项工作将导致为超过160万退伍军人开发一种新的有害或浪费的BP治疗措施。 VHA在改善BP控制方面非常成功，超过现有BP措施的79%，而Medicare仅为62%。老年人从良好的血压控制中受益，特别是在减少中风方面。然而，老年人由于多种药物治疗而面临福尔斯跌倒的风险。一个令人担忧的问题是，我们现有的二分血压目标导致血压过低，特别是当年老的退伍军人发展成老年病时，如福尔斯。我们之前发现，近三分之一患有糖尿病的老年退伍军人可能接受了过度治疗。VHA提供者是否应该考虑在老年退伍军人中减少BP护理还没有得到很好的研究。 我们的目标是使用国家VHA数据库定义65岁及以上退伍军人的积极高血压护理（AHC）。首先，我们将使用病历审查来验证AHC的数据元素。接下来，我们将测试AHC（与适当护理相比）是否与福尔斯损伤相关，以及风险是否超过中风和心脏事件的减少。最后，我们将测量AHC的设施间变化。我们将让VHA提供商参与这些目标，以审查结果，指导分析决策，并及早识别实施的潜在障碍。在该奖项结束时，我们的目标是开发一种新的措施，适当的高血压护理的相关性，老年退伍军人特定的年龄组，共病负担，心血管和跌倒事件的基线风险。 目标1（验证AHC的数据元素）：与我们的提供者小组和指导委员会合作，我们将审查AHC的数据元素（BP < 130/65 mmHg，结合持续3+或递增1+ BP药物）是否适用于65岁及以上的老年退伍军人。然后，在一个小的子样本中，我们将通过全面审查电子健康记录来验证数据元素。 目标2（AHC的危害和益处）：在子目标2A中，我们将使用健康和退休研究，该研究从Medicare获取基于访谈的跌倒伤害和诊断伤害数据，从而促进我们可以应用于VHA-Medicare数据的跌倒伤害严重程度算法的开发。然后，在子目标2B中，我们将使用两年的VHA数据与Medicare合并，以测试AHC（与适当护理相比）是否与严重福尔斯损伤风险增加有关，如果是，风险是否超过 心血管益处（急性中风和心肌梗死）。我们将在供应商小组和指导委员会的指导下考虑完善AHC。我们将根据基线心血管或福尔斯风险考虑患者亚组。 目标三：我们将使用2年的国家VHA数据确定预测AHC的研究中心/设施特征，并测量与研究中心之间最大变化相关的因素。我们将与供应商小组和指导委员会一起考虑结果，以实施减少AHC的潜在方法。 目标4：在目标1-3中，我们将召集医疗中心和诊所的VA提供者小组，就如何定义AHC提供意见，构建适度/适当AHC的衡量标准，确定实施障碍，并为传播新指标做好最好的准备。