title: A clinically guided approach for improving performance measurement for hypertension.
abstract: BACKGROUND
  Performance measures often fail to account for legitimate reasons why patients do not achieve recommended treatment targets.
  
  
  METHODS
  We tested a novel performance measurement system for blood pressure (BP) control that was designed to mimic clinical reasoning. This clinically guided approach focuses on (1) exempting patients for whom tight BP control may not be appropriate or feasible and (2) assessing BP over time. Trained abstractors conducted structured chart reviews of 201 adults with hypertension in 2 VA health care systems. Results were compared with traditional methods of performance measurement.
  
  
  RESULTS
  Among 201 veterans, 183 (91%) were male, and the mean age was 71±11 years. Using the clinically guided approach, 61 patients (30%) were exempted from performance measurement. The most common reasons for exemption were inadequate opportunity to manage BP (35 patients, 17%) and the use of 4 or more antihypertensive medications (19 patients, 9%). Among patients eligible for performance measurement, there was little agreement on the presence of controlled versus uncontrolled BP when comparing the most recent BP (the traditional approach) with an integrated assessment of BP control (κ 0.14). After accounting for clinically guided exemptions and methods of BP assessment, only 15 of 72 patients (21%) whose last BP was ≥140/90 mm Hg were classified as problematic by the clinically guided approach.
  
  
  CONCLUSIONS
  Many patients have legitimate reasons for not achieving tight BP control, and the methods used for BP assessment have marked effects on whether a patient is classified as having adequate or inadequate BP control.
authors.affiliation: Health Services Research and Development Research Enhancement Award Program, San Francisco VA Medical Center, San Francisco, CA 94121, USA. mike.steinman@ucsf.edu
authors.forename: Michael A
authors.initials: MA
authors.lastname: Steinman
authors.forename: Sei J
authors.initials: SJ
authors.lastname: Lee
authors.forename: Carolyn A
authors.initials: CA
authors.lastname: Peterson
authors.forename: Kathy Z
authors.initials: KZ
authors.lastname: Fung
authors.forename: Mary K
authors.initials: MK
authors.lastname: Goldstein
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000959:Antihypertensive Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D001794:Blood Pressure; D001795:Blood Pressure Determination; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D006973:Hypertension / Q000188:drug therapy*; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D010353:Patient Education as Topic; D019984:Quality Indicators, Health Care; D012959:Socioeconomic Factors; D014481:United States; D014493:United States Department of Veterans Affairs / Q000706:statistics & numerical data
chemical_list: D000959:Antihypertensive Agents