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A Clinically Guided Approach for Improving Performance Measurement for Hypertension

Steinman, Michael A. MD*,†; Lee, Sei J. MD, MAS*,†; Peterson, Carolyn A. MA*,†; Fung, Kathy Z. MS*,†; Goldstein, Mary K. MD‡,§

doi: 10.1097/MLR.0b013e318245a147
Original Articles

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.

Supplemental Digital Content is available in the text.

*Health Services Research and Development Research Enhancement Award Program, San Francisco VA Medical Center

Division of Geriatrics, University of California, San Francisco

Geriatrics Research, Education, and Clinical Center, VA Palo Alto Health Care System

§Department of Medicine, Stanford University School of Medicine, Palo Alto, CA

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

Supported by the Department of Veterans Affairs (VA) Health Services Research & Development Service (CDTA 01-013 and related to IAF 06-080-02, CPI 99-275, and IMV 04-062) and by the National Institutes on Aging and the American Federation for Aging Research (K23 AG030999), and further supported with resources of the San Francisco Veterans Affairs Medical Center Health Services Research and Development Research Enhancement Award Program. Dr Lee was supported by NIH/NCRR/OD UCSF-CTSI Grant number KL2 RR024130.

These sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Views expressed are those of the authors and not necessarily those of the Department of Veterans Affairs.

Research stewardship: Dr Steinman had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Presented at the Society of General Internal Medicine Annual Meeting, Minneapolis, May 2010.

The authors declare no conflict of interest.

Reprints: Michael A. Steinman, MD, Health Services Research and Development Research Enhancement Award Program, San Francisco VA Medical Center, 4150 Clement St, Box 181G, San Francisco, CA 94121. E-mail:

© 2012 Lippincott Williams & Wilkins, Inc.