improving hypertension quality measurement using electronic health records s persell, an kho, ja...
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Improving Hypertension Quality Measurement Using
Electronic Health Records
S Persell, AN Kho, JA Thompson, DW Baker
Feinberg School of Medicine
Northwestern University
Chicago, Illinois
Supported by award 1 K08 HS015647-01 from the Agency for Healthcare Research and Quality
Problems with Current Quality Measures
Simple intermediate outcome measures (e.g., blood pressure at last visit <140/90) may not reliably indicate who is truly receiving poor care
– A pt with controlled blood pressure runs out of meds and comes to clinic with BP 150/100
– A pt with coronary disease had an LDL cholesterol of 220 mg/dl, which decreased to 110 on a maximal dose of a statin but did not reach the goal of LDL < 100
Adverse Consequences
These limitations problematic as incentives based on performance measures increase
When used for internal quality improvement, measurement errors such as these may cause physicians to reject measure validity
…and the Solution?
Develop quality measures that more accurately capture what would be defined as poor care– i.e. higher specificity of failures
Electronic health records can help facilitate implementation of more complicated measures
Study Aims
To develop and apply increasingly more sophisticated measures of hypertension quality utilizing data available within an EHR
To compare the results of measured quality using simple outcome measures and more sophisticated measures
Methods
Design: retrospective observational cohort study
Setting: urban Internal Medicine practice with a commercial EHR (Epic)
Eligibility
– Hypertensive adults with 3 or more clinic visits between 7/05 and 12/06
Baseline Quality Measure
Baseline:
– Patients with hypertension recorded on their problem list, past medical history, or encounter diagnosis codes
– Blood pressure at last visit <140/90
– Blood pressure <130/80 if comorbid diabetes
Quality Measure 2:Relax Cutoff
Include last BP ≤ goal as satisfying measure
≤ 140/90
≤ 130/80 if diabetes
Quality Measure 3:Incorporate Average BP
If either the last or mean of last three BPs
are at goal, the patient is considered to
satisfy the measure
Quality Measure 4:Account for Aggressive Management
Include patients prescribed 3 or more different antihypertensive drug classes including a diuretic as satisfying the measure
– Beta blocker, calcium channel blocker, ACE or ARB, peripheral alpha blocker, centrally acting anti-adrenergic drug, or direct vasodilator
– AND diuretic
Quality Measure 5Account for Low Diastolic Blood
Pressure, A Safety Concern Studies suggest that for pts with coronary
artery disease and diabetes, lowering the diastolic BP below 70 mmHg may be harmful
Therefore, if patients with uncontrolled systolic blood pressure had diastolic pressure < 70 mmHg, they were consider to satisfy measure
Quality Measure 6:Include Patients with
Undiagnosed Hypertension Include in denominator patients with a mean
blood pressure ≥140/90 mmHg or ≥130/80
mmHg if the patient has comorbid diabetes
even if they do not have hypertension
recorded as a diagnosis
Study Population
N Age, mean (SD)
Female, %
Diagnosed hypertension
No diabetes
Diabetes
3933
1526
60 (14)
61 (12)
65
59
Undiagnosed hypertension
No diabetes
Diabetes
284
143
48 (15)
51 (12)
44
46
Variation Across Measures (no DM)
0
10
20
30
40
50
60
70
80
90
100
Per
cen
t co
ntr
olle
d
Last BP < 140/9058%
Last BP ≤ 140/9067%
Last or mean ≤ 140/90: 76%
≤ 140/90 or 3 drugs with diuretic: 83%
≤ 140/90 or 3 drugs w/ diuretic or low DBP: 84%
Include undiagnosed hypertension: 81%
0
10
20
30
40
50
60
70
80
90
100P
erce
nt c
ontr
olle
d
Last BP < 130/8030%
Last BP ≤ 130/8039%
Last or mean ≤ 130/80: 47%
≤ 130/80 or 3 drugs with diuretic: 73%
≤ 130/80 or 3 drugs w/ diuretic or low DBP: 76%
Include undiagnosed hypertension: 73%
Variation Across Measures (DM)
Results of Standard vs. Advanced Hypertension Quality Measures
58
30
8173
0102030405060708090
100
No diabetes Diabetes
Perc
en
t co
ntr
olled
Baseline Final
} Δ 23%
}Δ 43%
Limitations We used hypothetical quality measures to
demonstrate concept
Single site; generalizability not known
– Would be difficult, but not impossible, to apply measures at sites without an EHR
Data within EHRs may be incomplete
Still may miss important exceptions
– Home blood pressure controlled
Conclusions
Small changes in measure criteria produce large changes in measured quality
Many patients who did not satisfy the simple measure were receiving aggressive care
More sophisticated measures may better align external measurement with internal quality improvement
Implications More sophisticated measures may:
– Improve detection of true quality problems that need attention by MDs and other staff
– Remove incentives to stop caring for patients with resistant hypertension
– Remove incentives to unsafely or unnecessarily over treat some patients