Kerr Eve A, Lucatorto Michelle A, Holleman Rob, Hogan Mary M, Klamerus Mandi L, Hofer Timothy P
Center for Clinical Management Research, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan 48113-0170, USA.
Arch Intern Med. 2012 Jun 25;172(12):938-45. doi: 10.1001/archinternmed.2012.2253.
Performance measures that reward achieving blood pressure (BP) thresholds may contribute to overtreatment. We developed a tightly linked clinical action measure designed to encourage appropriate medical management and a marker of potential overtreatment, designed to monitor overly aggressive treatment of hypertension in the face of low diastolic BP.
We conducted a retrospective cohort study in 879 Department of Veterans Affairs (VA) medical centers and smaller community-based outpatient clinics. The clinical action measure for hypertension was met if the patient had a passing index BP at the visit or had an appropriate action. We examined the rate of passing the action measure and of potential overtreatment in the Veterans Health Administration during 2009-2010.
There were 977,282 established VA patients, 18 years and older, with diabetes mellitus (DM). A total of 713,790 patients were eligible for the action measure; 94% passed the measure (82% because they had a BP <140/90 mm Hg at the visit and an additional 12% with a BP ≥140/90 mm Hg and appropriate clinical actions). Facility pass rates varied from 77% to 99% (P < .001). Among all patients with DM, 197,291 (20%) had a BP lower than 130/65 mm Hg; of these, 80 903 (8% of all patients with DM) had potential overtreatment. Facility rates of potential overtreatment varied from 3% to 20% (P < .001). Facilities with higher rates of meeting the current threshold measure (<140/90 mm Hg) had higher rates of potential overtreatment (P < .001).
While 94% of diabetic veterans met the action measure, rates of potential overtreatment are currently approaching the rate of undertreatment, and high rates of achieving current threshold measures are directly associated with overtreatment. Implementing a clinical action measure for hypertension management, as the Veterans Health Administration is planning to do, may result in more appropriate care and less overtreatment.
奖励达到血压（BP）阈值的绩效指标可能导致过度治疗。我们制定了一项紧密关联的临床行动指标，旨在鼓励适当的医疗管理，并制定了一个潜在过度治疗的标志物，用于监测在舒张压较低情况下对高血压的过度积极治疗。
我们在879个退伍军人事务部（VA）医疗中心和较小的社区门诊诊所进行了一项回顾性队列研究。如果患者在就诊时有合格的索引血压或采取了适当的行动，则高血压的临床行动指标达标。我们检查了2009 - 2010年退伍军人健康管理局中行动指标达标的比率以及潜在过度治疗的比率。
有977,282名18岁及以上患有糖尿病（DM）的VA在册患者。共有713,790名患者符合行动指标；94%的患者达标（82%是因为他们在就诊时血压<140/90 mmHg，另外12%的患者血压≥140/90 mmHg且有适当的临床行动）。各医疗机构的达标率从77%到99%不等（P <.001）。在所有糖尿病患者中，197,291名（20%）的血压低于130/65 mmHg；其中，80,903名（占所有糖尿病患者的8%）存在潜在过度治疗。各医疗机构的潜在过度治疗率从3%到20%不等（P <.001）。达到当前阈值指标（<140/90 mmHg）比率较高的医疗机构，其潜在过度治疗率也较高（P <.001）。
虽然94%的糖尿病退伍军人达到了行动指标，但目前潜在过度治疗率正接近治疗不足率，并且达到当前阈值指标的高比率与过度治疗直接相关。正如退伍军人健康管理局计划实施的那样，实施高血压管理的临床行动指标可能会带来更适当的治疗并减少过度治疗。
