title: Action or inaction? Decision making in patients with diabetes and elevated blood pressure in primary care.
abstract: OBJECTIVE
  Hypertension increases micro- and macrovascular complications of diabetes. The goal for blood pressure is <130/80 mmHg. In primary care, however, blood pressure in many patients exceeds this goal. In this study, we evaluated the clinical decision-making process when a patient with diabetes presents with elevated blood pressure.
  
  
  METHODS
  Twenty-six primary care practices in two practice-based research networks in Colorado participated. Questionnaires were completed after each encounter with an adult with type 2 diabetes. Data obtained from the survey included 1) demographic information, 2) blood pressure results, 3) action taken, 4) type of action if action was taken, and 5) reasons for inaction if action was not taken. Bivariate and multivariate analyses were performed to identify predictors of action.
  
  
  RESULTS
  Completed surveys totaled 778. Blood pressure was 130/74 +/- 18.8/12.0 mmHg (mean +/- SD). Sixty-two percent of patients exceeded goals. Action was taken to lower blood pressure in 34.9% of those. Predictors of action were 1) blood pressure level, 2) total number of medicines the patient was taking, and 3) patient already taking medicines for blood pressure. As blood pressure rose, providers attributed inaction more often to "competing demands" and reasons other than "blood pressure being at or near goal."
  
  
  CONCLUSIONS
  No evidence was found for patterns of poor care among primary care physicians. Providers balance the clinical circumstances, including how elevated the blood pressure is, and issues of polypharmacy, medication side effects, and costs when determining the best course of action. Knowledge deficit is not a common cause of inaction.
authors.affiliation: Salud Family Health Center, 1115 Second St., Fort Lupton, CO 80621, USA. phicks@saludclinic.org
authors.forename: Paul C
authors.initials: PC
authors.lastname: Hicks
authors.forename: John M
authors.initials: JM
authors.lastname: Westfall
authors.forename: Rebecca F
authors.initials: RF
authors.lastname: Van Vorst
authors.forename: Caroline
authors.initials: C
authors.lastname: Bublitz Emsermann
authors.forename: L Miriam
authors.initials: LM
authors.lastname: Dickinson
authors.forename: Wilson
authors.initials: W
authors.lastname: Pace
authors.forename: Bennett
authors.initials: B
authors.lastname: Parnes
mesh_terms: D003925:Diabetic Angiopathies / Q000175:diagnosis*; D003937:Diagnosis, Differential; D005194:Family Practice; D005260:Female; D006801:Humans; D006973:Hypertension / Q000150:complications*; D007341:Insurance; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D044469:Racial Groups; D011795:Surveys and Questionnaires