Quality Improvement Initiatives Improve Hypertension Care Among Veterans

Trends in Initial Antihypertensive Medication Prescribing Among >2.8 Million Veterans Newly Diagnosed With Hypertension, 2000 to 2019

BACKGROUND

Among patients diagnosed with high blood pressure (BP), initial dual therapy has been recommended for patients with high pretreatment systolic BP (≥160 mm Hg) since 2003, and first-line β-blocker use without a compelling condition has fallen out of favor in US guidelines.

METHODS AND RESULTS

This serial cross-sectional study of national Veterans Health Administration data included adult Veterans with incident hypertension initiating antihypertensive medication between January 1, 2000, and December 31, 2019. We assessed annual trends in initial regimens dispensed (index date: first antihypertensive dispense date) by number of classes and unique class combinations used overall and by pretreatment systolic BP (<140, 140 to <160, and ≥160 mm Hg), as well as trends in subgroups (age, sex, race and ethnicity, and comorbidities warranting β-blocker use). Among 2 832 684 eligible Veterans (average age 61 years, 95% men, 65% non-Hispanic White, and 8% with cardiovascular disease), from 2000-2004 to 2015-2019, initial monotherapy increased across all pretreatment systolic BP levels (<140 mm Hg: 62.1% to 66.4%; 140 to <160 mm Hg: 70.7% to 76.8%; ≥160 mm Hg: 64.2% to 69.7%). Initiation of dual therapy decreased across all pretreatment systolic BP levels (<140 mm Hg: 25.0% to 24.2%; 140 to <160 mm Hg: 20.4% to 17.6%; ≥160 mm Hg: 22.7% to 22.0%). Among 2 521 696 Veterans (89% of overall) without a β-blocker-indicated condition in 2015 to 2019, 20% initiated a β-blocker, most commonly as monotherapy.

CONCLUSIONS

More than half of US Veterans diagnosed with hypertension with a pretreatment systolic BP ≥160 mm Hg were started on antihypertensive monotherapy. There are disparities between guideline-recommended first-line treatments and the actual regimens initiated for newly diagnosed Veterans with hypertension.

Achieving 70% Hypertension Control: How Hard Can It Be?

BACKGROUND

Although decades of research support hypertension treatment, studies guiding the successful implementation of programs to control blood pressure (BP) in real-world primary care settings are sparse.

METHODS

In this study a multicomponent intervention was implemented, with the following goals: (1) achieve 70% control of hypertension within 18 months, (2) use the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework to evaluate the implementation of the program, and (3) assess additional actions that could have been undertaken to achieve control among those who remained uncontrolled.

RESULTS

Of 786 patients, 597 achieved BP control (75.9%; improvement of 20.9 percentage points). For RE-AIM outcomes, (1) staff performed outreach for all uncontrolled patients, with 75.3% making follow-up appointments, and 61.3% attending at least one appointment; (2) the proportion of faculty with at least 70% control increased from 26.7% to 87.5%, indicating significant physician adoption; (3) implementation outcomes were mixed, with four of six medical assistant BP training sessions completed, outreach calls performed in 16 of 18 months, but only 24 patients referred to the patient counseling and medication management program. For maintenance, 70% control was maintained for a 7-month observation period. The research team determined that 16.8% of those uncontrolled could have had additional actions taken to achieve control.

CONCLUSION

The goal of 70% control was achieved, improving control by 20.9 percentage points over 18 months. The RE-AIM framework evaluation demonstrated successful implementation and likely contributed to achievement of the target. The chart review findings revealed that a minority of patients could have additional interventions provided by the primary care practice.

2014 Hypertension Guideline: Recommendation for a Change in Goal Systolic Blood Pressure

The 2014 Kaiser Permanente Care Management Institute National Hypertension Guideline was developed to assist primary care physicians and other health care professionals in the outpatient treatment of uncomplicated hypertension in adult men and nonpregnant women aged 18 years and older. A major practice change is the recommendation for goal systolic blood pressure less than 150 mmHg in patients aged 60 years and older who are treated for hypertension in the absence of diabetes or chronic kidney disease. This article describes the reasons for, evidence for, and consequences of the change, and includes the guideline.

Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.

The Ethics of External Peer Review

External peer review can be a useful part of a quality improvement program. However, it can also be used for political and punitive purposes. The distinction between potentially useful and damaging review is largely an issue of the ethics of how it is done. The ethics of external peer review lie not only in the process itself, but also in the role of the pathologists performing the review. While there are many ethical issues involved in external peer review, the most important may be a dedication to due process, allowing the pathologist under review to respond to allegations, and an insistence on complete information prior to drawing conclusions. Well established criteria for external peer review may provide protection both for the pathologist under review against allegations of negligence or incompetence, but also for the reviewers against accusations of bad faith.

Improved blood pressure control associated with a large-scale hypertension program

IMPORTANCE

Hypertension control for large populations remains a major challenge.

OBJECTIVE

To describe a large-scale hypertension program in Northern California and to compare rates of hypertension control in that program with statewide and national estimates.

DESIGN, SETTING, AND PATIENTS

The Kaiser Permanente Northern California (KPNC) hypertension program included a multifaceted approach to blood pressure control. Patients identified as having hypertension within an integrated health care delivery system in Northern California from 2001-2009 were included. The comparison group comprised insured patients in California between 2006-2009 who were included in the Healthcare Effectiveness Data and Information Set (HEDIS) commercial measurement by California health insurance plans participating in the National Committee for Quality Assurance (NCQA) quality measure reporting process. A secondary comparison group was included to obtain the reported national mean NCQA HEDIS commercial rates of hypertension control between 2001-2009 from health plans that participated in the NCQA HEDIS quality measure reporting process.

MAIN OUTCOMES AND MEASURES

Hypertension control as defined by NCQA HEDIS.

RESULTS

The KPNC hypertension registry included 349,937 patients when established in 2001 and increased to 652,763 by 2009. The NCQA HEDIS commercial measurement for hypertension control within KPNC increased from 43.6% (95% CI, 39.4%-48.6%) to 80.4% (95% CI, 75.6%-84.4%) during the study period (P < .001 for trend). In contrast, the national mean NCQA HEDIS commercial measurement increased from 55.4% to 64.1%. California mean NCQA HEDIS commercial rates of hypertension were similar to those reported nationally from 2006-2009 (63.4% to 69.4%).

CONCLUSIONS AND RELEVANCE

Among adults diagnosed with hypertension, implementation of a large-scale hypertension program was associated with a significant increase in hypertension control compared with state and national control rates. Key elements of the program included a comprehensive hypertension registry, development and sharing of performance metrics, evidence-based guidelines, medical assistant visits for blood pressure measurement, and single-pill combination pharmacotherapy.

Psychoactive drugs in seven nursing homes

AIMS

We wanted to pinpoint any differences in treatment between participating nursing homes, investigate which drugs are currently prescribed most frequently for long-term patients in nursing homes, estimate prevalence of administration for the following drug groups: neuroleptics, antidepressants, antidementia agents, opioids and the neuroleptics/anti-Parkinson's drug combination, and study comorbidity correlations. We also wanted to study differences in the administration of medications to patients with reduced cognitive functions in relation to those with normal cognition.

METHODS

Information about 513 patients was collected from seven nursing homes in the city of Bergen, Norway, during the period March-April 2008. This consisted of copying personal medication records, weighing, recording the previous weight from records, electrocardiography, anamnestic particulars of any stroke suffered, recording if there is cognitive impairment or not and analyzing a standardized set of blood samples.

RESULTS

Considerable treatment differences existed between nursing homes, both percentage patients and Defined Daily Dosages. Patients with reduced cognitive functions were prescribed less drugs in general, except neuroleptics. Of all patients, 41.5% were given antidepressants, 24.4% neuroleptics, 22.0% benzodiazepines, 8.0% anticholinesterases and 5.0% memantine. The ratio of traditional to atypical neuroleptics was 122:23. In all, 30.0% of the patients taking neuroleptics were on more than one drug and 35.0% of the patients had opioids by way of regular or as-needed drugs, ratio 14.6%:28.7%. Of 146 patients on neuroleptics, five patients had anti-Parkinson's drugs too. The average use of regular drugs for patient with intact cognition was 7.1 drugs, and for patients with reduced cognitive functions 5.7 drugs.

CONCLUSIONS

There are differences in treatment with psychoactive drugs between nursing homes. Patients with reduced cognitive functions receive less cardiovascular drugs than patients with normal cognition. The reason for this still remains unclear. Improvement strategies are needed. The proportion of patients per institution on selected drugs can serve as a feedback parameter in quality systems.

A 10 year (2000-2010) systematic review of interventions to improve quality of care in hospitals

BACKGROUND

Against a backdrop of rising healthcare costs, variability in care provision and an increased emphasis on patient satisfaction, the need for effective interventions to improve quality of care has come to the fore. This is the first ten year (2000-2010) systematic review of interventions which sought to improve quality of care in a hospital setting. This review moves beyond a broad assessment of outcome significance levels and makes recommendations for future effective and accessible interventions.

METHODS

Two researchers independently screened a total of 13,195 English language articles from the databases PsychInfo, Medline, PubMed, EmBase and CinNahl. There were 120 potentially relevant full text articles examined and 20 of those articles met the inclusion criteria.

RESULTS

Included studies were heterogeneous in terms of approach and scientific rigour and varied in scope from small scale improvements for specific patient groups to large scale quality improvement programmes across multiple settings. Interventions were broadly categorised as either technical (n = 11) or interpersonal (n = 9). Technical interventions were in the main implemented by physicians and concentrated on improving care for patients with heart disease or pneumonia. Interpersonal interventions focused on patient satisfaction and tended to be implemented by nursing staff. Technical interventions had a tendency to achieve more substantial improvements in quality of care.

CONCLUSIONS

The rigorous application of inclusion criteria to studies established that despite the very large volume of literature on quality of care improvements, there is a paucity of hospital interventions with a theoretically based design or implementation. The screening process established that intervention studies to date have largely failed to identify their position along the quality of care spectrum. It is suggested that this lack of theoretical grounding may partly explain the minimal transfer of health research to date into policy. It is recommended that future interventions are established within a theoretical framework and that selected quality of care outcomes are assessed using this framework. Future interventions to improve quality of care will be most effective when they use a collaborative approach, involve multidisciplinary teams, utilise available resources, involve physicians and recognise the unique requirements of each patient group.

Adherence behavior in the prevention and treatment of cardiovascular disease

Adherence is critical to the overall management of individuals at risk for and with cardiovascular disease. It forms an interplay between the patient, provider, and health care system and includes barriers that have been encountered within all 3 domains. Improving adherence to exercise, diet, and medication as well as focusing on addictive disorders such as smoking cessation requires patient, provider, and health care system approaches. The use of the cognitive/behavioral elements of health behavior change and communication strategies such as motivational interviewing and coaching serve to enhance overall adherence. Continuous quality improvement initiatives at the system level of change also increase the likelihood that teams will succeed in helping individuals change their behavior. Cardiac rehabilitation programs offer a unique opportunity for health care professionals to play a key role in supporting individuals through the health behavior change process.

Department of Veterans Affairs Geriatric Research, Education and Clinical Centers: translating aging research into clinical geriatrics

Department of Veterans Affairs (VA) Geriatric Research, Education and Clinical Centers (GRECCs) originated in 1975 in response to the rapidly aging veteran population. Since its inception, the GRECC program has made major contributions to the advancement of aging research, geriatric training, and clinical care within and outside the VA. GRECCs were created to conduct translational research to enhance the clinical care of future aging generations. GRECC training programs also provide leadership in educating healthcare providers about the special needs of older persons. GRECC programs are also instrumental in establishing robust clinical geriatric and aging research programs at their affiliated university schools of medicine. This report identifies how the GRECC program has successfully adapted to changes that have occurred in VA since 1994, when the program's influence on U.S. geriatrics was last reported, focusing on its effect on advancing clinical geriatrics in the last 10 years. This evidence supports the conclusion that, after more than 30 years, the GRECC program remains a vibrant "jewel in the crown of the VA" and is poised to make contributions to aging research and clinical geriatrics well into the future.

Factors associated with screening or treatment initiation among male United States veterans at risk for osteoporosis fracture

Male osteoporosis continues to be under-recognized and undertreated in men. An understanding of which factors cue clinicians about osteoporosis risk in men, and which do not, is needed to identify areas for improvement. This study sought to measure the association of a provider's recognition of osteoporosis with patient information constructs that are available at the time of each encounter. Using clinical and administrative data from the Veterans Health Administration system, we used a stepwise procedure to construct prognostic models for a combined outcome of osteoporosis diagnosis, treatment, or a bone mineral density (BMD) test order using time-varying covariates and Cox regression. We ran separate models for patients with at least one primary care visit and patients with only secondary care visits in the pre-index period. Some of the strongest predictors of clinical osteoporosis identification were history of gonadotropin-releasing hormone (GnRH) agonist exposure, fragility fractures, and diagnosis of rheumatoid arthritis. Other characteristics associated with a higher likelihood of having osteoporosis risk recognized were underweight or normal body mass index, cancer, fall history, and thyroid disease. Medication exposures associated with osteoporosis risk recognition included opioids, glucocorticoids, and antidepressants. Several known clinical risk factors for fracture were not correlated with osteoporosis risk including smoking and alcohol abuse. Results suggest that clinicians are relying on some, but not all, clinical risk factors when assessing osteoporosis risk.

Prevalence of inadequate blood pressure control among veterans after acute ischemic stroke hospitalization: a retrospective cohort

BACKGROUND

Reducing blood pressure (BP) after stroke reduces risk for recurrent events. Our aim was to describe hypertension care among veterans with ischemic stroke including BP control by discharge and over the 6 months after the stroke event.

METHODS AND RESULTS

The Office of Quality and Performance Stroke Special Study included a systematic sample of veterans hospitalized for ischemic stroke in 2007. We examined BP control (<140/90 mm Hg) at discharge excluding those who died, enrolled in hospice, or had unknown discharge disposition (n=3640, n=3382 adjusted analysis). The second outcome was BP control (<140/90 mm Hg) within 6-months after stroke, excluding patients who died/readmitted within 30 days, were lost to follow-up, or did not have a BP recorded (n=2054, n=1915 adjusted analysis). The population was 62.7% white and 97.7% men; 46.9% were <65 years of age; and 29% and 37% had a history of cerebrovascular or cardiovascular disease, respectively. Among the 3640 stroke patients, 1573 (43%) had their last documented BP before discharge as >140/90 mm Hg. Black race (adjusted odds ratio, 0.77; 95% confidence interval, 0.65 to 0.91), diabetes (odds ratio, 0.73; 95% confidence interval, 0.62 to 0.86), and hypertension history (odds ratio, 0.51; 95% confidence interval, 0.42 to 0.63) were associated with lower odds for controlled BP at discharge. Of the 2054 stroke patients seen within 6 months from their index event, 673 (32.8%) remained uncontrolled. By 6 months after the event, neither race nor diabetes was associated with BP control, whereas history of hypertension continued to have lower odds of BP control. For each 10-point increase in systolic BP >140 mm Hg at discharge, odds of BP control within 6 months after discharge decreased by 12% (95% confidence interval [8%, 18%]).

CONCLUSIONS

BP values in excess of national guidelines are common after stroke. Forty-three percent of patients were discharged with an elevated BP, and 33% remained uncontrolled by 6 months.