Central Texas Veterans Affairs Health System, Austin, Texas, USA
Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA.
BMJ Open Qual. 2024 May 27;13(2):e002611. doi: 10.1136/bmjoq-2023-002611.
Clinical practice guidelines recommend screening for primary hyperaldosteronism (PH) in patients with resistant hypertension. However, screening rates are low in the outpatient setting. We sought to increase screening rates for PH in patients with resistant hypertension in our Veterans Affairs (VA) outpatient resident physician clinic, with the goal of improving blood pressure control. Patients with possible resistant hypertension were identified through a VA Primary Care Almanac Metric query, with subsequent chart review for resistant hypertension criteria. Three sequential patient-directed cycles were implemented using rapid cycle improvement methodology during a weekly dedicated resident quality improvement half-day. In the first cycle, patients with resistant hypertension had preclinic PH screening labs ordered and were scheduled in the clinic for hypertension follow-up. In the second cycle, patients without screening labs completed were called to confirm medication adherence and counselled to screen for PH. In the third cycle, patients with positive screening labs were called to discuss mineralocorticoid receptor antagonist (MRA) initiation and possible endocrinology referral. Of 97 patients initially identified, 58 (60%) were found to have resistant hypertension while 39 had pseudoresistant hypertension from medication non-adherence. Of the 58 with resistant hypertension, 44 had not previously been screened for PH while 14 (24%) had already been screened or were already taking an MRA. Our screening rate for PH in resistant hypertension patients increased from 24% at the start of the project to 84% (37/44) after two cycles. Of the 37 tested, 24% (9/37) screened positive for PH, and 5 patients were started on MRAs. This resident-led quality improvement project demonstrated that a focused intervention process can improve PH identification and treatment.
临床实践指南建议对耐药性高血压患者进行原发性醛固酮增多症（PH）筛查。然而，在门诊环境下，筛查率较低。我们试图通过退伍军人事务部（VA）门诊住院医师诊所提高耐药性高血压患者的 PH 筛查率，以改善血压控制。通过 VA 初级保健年鉴指标查询确定可能患有耐药性高血压的患者，随后对耐药性高血压标准进行图表审查。在每周一次的专门住院医师质量改进半天中，使用快速循环改进方法实施了三个连续的以患者为导向的循环。在第一个循环中，对患有耐药性高血压的患者进行 PH 筛查前的实验室检查，并在诊所安排高血压随访。在第二个循环中，对未完成筛查实验室检查的患者进行电话联系以确认药物依从性，并进行 PH 筛查咨询。在第三个循环中，对阳性筛查实验室的患者进行电话联系，讨论醛固酮受体拮抗剂（MRA）的启动和可能的内分泌科转介。最初确定的 97 名患者中，有 58 名（60%）被发现患有耐药性高血压，而 39 名因药物不依从而患有假性耐药性高血压。在 58 名患有耐药性高血压的患者中，有 44 名之前未接受过 PH 筛查，而 14 名（24%）已经接受过筛查或正在服用 MRA。我们对耐药性高血压患者进行 PH 筛查的比率从项目开始时的 24%提高到两轮后（37/44）的 84%。在 37 名接受测试的患者中，有 24%（9/37）PH 筛查阳性，有 5 名患者开始服用 MRA。这个由住院医师主导的质量改进项目表明，集中干预过程可以提高 PH 的识别和治疗效果。
