VA Ann Arbor Medical Center, Geriatric Research, Education, and Clinical Center, Ann Arbor, Michigan.
Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor.
JAMA Netw Open. 2020 Jul 1;3(7):e205417. doi: 10.1001/jamanetworkopen.2020.5417.
Blood pressure (BP) targets are the main measure of high-quality hypertension care in health systems. However, BP alone does not reflect intensity of pharmacological treatment, which should be carefully managed in older patients.
To develop and validate an electronic health record (EHR) data-only algorithm using pharmacy and BP data to capture intensive hypertension care (IHC), defined as 3 or more BP medications and BP less than 120 mm Hg, and to identify conditions associated with greater IHC, either through greater algorithm false-positive IHC, or by contributing clinically to delivering more IHC.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study was conducted among 319 randomly selected patients aged 65 years or older receiving IHC from the Veterans Health Administration (VHA) from July 1, 2011, to June 30, 2013. Data were collected from a total of 3625 primary care visits. Data were analyzed from January 2017 to March 2020.
Calibration and measurement of the algorithm for IHC (algorithm IHC).
For each primary care visit, the reference standard, clinical IHC, was determined by detailed review of free-text clinical notes. The correlation in BP medication count between the EHR-only algorithm vs the reference standard and the sensitivity and specificity of the algorithm IHC were calculated. In addition, presence vs absence of contributing conditions acting in combination with hypertension management were measured to examine incidence of IHC associated with contributing conditions, including an acute condition that lowered BP (eg, dehydration), another condition requiring a BP target lower than the standard 140 mm Hg (eg, diabetes), or the patient needing a BP-lowering medication for a nonhypertension condition (eg, β-blocker for atrial fibrillation) resulting in low BP.
Among 319 patients with 3625 visits (mean [SD] age, 75.6 [7.2] years; 3592 [99.1%] men), 911 visits (25.1%) had clinical IHC by the reference standard. The algorithm for determining medication count was highly correlated with the reference standard (r = 0.84). Sensitivity of detecting clinical IHC was 92.2% (95% CI, 89.3%-95.1%), and specificity was 97.2% (95% CI, 96.1%-98.3%), suggesting that clinical IHC can be identified from routinely collected data. Only 75 visits (2.1%) were algorithm IHC false positives, 55 visits (1.5%) involved IHC with contributing conditions, and 125 visits (3.5%) involved either false-positive or IHC with contributing conditions. Among select contributing conditions, congestive heart failure (37 patients [5.2%]) was most associated with a prespecified combined false-positive or IHC with contributing conditions rate higher than 5%.
These findings suggest that health system data can be used reliably to estimate IHC.
血压（BP）目标是衡量医疗系统中高质量高血压护理的主要指标。然而，仅 BP 并不能反映药物治疗的强度，而在老年患者中应仔细管理这种强度。
使用药房和 BP 数据开发和验证一种电子健康记录（EHR）数据算法，以捕捉强化高血压护理（IHC），定义为使用 3 种或更多种 BP 药物和 BP 低于 120mmHg，并确定与更高强度的 IHC 相关的条件，无论是通过更大的算法假阳性 IHC，还是通过临床提供更多的 IHC 来做出贡献。
设计、设置和参与者：这项横断面研究在 2011 年 7 月 1 日至 2013 年 6 月 30 日期间，从退伍军人健康管理局（VHA）中随机选择了 319 名年龄在 65 岁或以上接受 IHC 的患者进行。共收集了 3625 次初级保健就诊的数据。数据分析于 2017 年 1 月至 2020 年 3 月进行。
IHC（算法 IHC）算法的校准和测量。
对于每次初级保健就诊，参考标准为临床 IHC，通过详细审查自由文本临床记录确定。计算了 EHR 仅算法与参考标准之间的 BP 药物计数相关性，以及算法 IHC 的敏感性和特异性。此外，还测量了与高血压管理相结合的合并症的存在与否，以检查与合并症相关的 IHC 发生率，包括降低 BP 的急性疾病（例如脱水）、需要低于标准 140mmHg 的 BP 目标的另一种疾病（例如糖尿病）或患者需要降压药物治疗非高血压疾病（例如用于心房颤动的β受体阻滞剂）导致 BP 降低。
在 319 名患者的 3625 次就诊中（平均[SD]年龄，75.6[7.2]岁；3592[99.1%]名男性），911 次就诊（25.1%）符合参考标准的临床 IHC。用于确定药物计数的算法与参考标准高度相关（r=0.84）。检测临床 IHC 的敏感性为 92.2%（95%CI，89.3%-95.1%），特异性为 97.2%（95%CI，96.1%-98.3%），这表明可以从常规收集的数据中识别临床 IHC。只有 75 次就诊（2.1%）为算法 IHC 假阳性，55 次就诊（1.5%）涉及合并症的 IHC，125 次就诊（3.5%）涉及假阳性或合并症的 IHC。在选定的合并症中，充血性心力衰竭（37 名患者[5.2%]）与预先指定的假阳性或合并症 IHC 发生率高于 5%的组合关联度最高。
这些发现表明，可以可靠地使用健康系统数据来估计 IHC。
