The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure.
BACKGROUND
Factors underlying failure to intensify therapy in response to elevated blood pressure have not been systematically studied.


OBJECTIVE
To examine the process of care for diabetic patients with elevated triage blood pressure (> or =140/90 mm Hg) during routine primary care visits to assess whether a treatment change occurred and to what degree specific patient and provider factors correlated with the likelihood of treatment change.


METHODS
Prospective cohort study.


METHODS
9 Veterans Affairs facilities in 3 midwestern states.


METHODS
1169 diabetic patients with scheduled visits to 92 primary care providers from February 2005 to March 2006.


METHODS
Proportion of patients who had a change in a blood pressure treatment (medication intensification or planned follow-up within 4 weeks). Predicted probability of treatment change was calculated from a multilevel logistic model that included variables assessing clinical uncertainty, competing demands and prioritization, and medication-related factors (controlling for blood pressure).


RESULTS
Overall, 573 (49%) patients had a blood pressure treatment change at the visit. The following factors made treatment change less likely: repeated blood pressure by provider recorded as less than 140/90 mm Hg versus 140/90 mm Hg or greater or no recorded repeated blood pressure (13% vs. 61%; P < 0.001); home blood pressure reported by patients as less than 140/90 mm Hg versus 140/90 mm Hg or greater or no recorded home blood pressure (18% vs. 52%; P < 0.001); provider systolic blood pressure goal greater than 130 mm Hg versus 130 mm Hg or less (33% vs. 52%; P = 0.002); discussion of conditions unrelated to hypertension and diabetes versus no discussion (44% vs. 55%; P = 0.008); and discussion of medication issues versus no discussion (23% vs. 52%; P < 0.001).


CONCLUSIONS
Providers knew that the study pertained to diabetes and hypertension, and treatment change was assessed for 1 visit per patient.


CONCLUSIONS
Approximately 50% of diabetic patients presenting with a substantially elevated triage blood pressure received treatment change at the visit. Clinical uncertainty about the true blood pressure value was a prominent reason that providers did not intensify therapy.
Kerr
Eve A
EA
Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System and the University of Michigan Department of Internal Medicine, Ann Arbor, Michigan 48113-0170, USA. ekerr@umich.edu
Zikmund-Fisher
Brian J
BJ
Klamerus
Mandi L
ML
Subramanian
Usha
U
Hogan
Mary M
MM
Hofer
Timothy P
TP
D000959:Antihypertensive Agents / Q000008:administration & dosage*; D001795:Blood Pressure Determination; D019091:Critical Pathways / Q000592:standards; D003657:Decision Making; D048909:Diabetes Complications; D005500:Follow-Up Studies; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000188:drug therapy*; D016014:Linear Models; D011320:Primary Health Care / Q000379:methods / Q000592:standards*; D011446:Prospective Studies
D000959:Antihypertensive Agents