Effect of Unrelated Comorbid Conditions on Hypertension Management

15 April 2008 | Volume 148 Issue 8 | Pages 578-586

Background: Quality-of-care assessment at a single visit can be affected by whether a patient's comorbid conditions are related or unrelated to a specific measure.

Objective: To examine the association of unrelated comorbid conditions with treatment of uncontrolled hypertension in primary care visits.

Design: Examination of a database derived from electronic medical records collected during routine care of a cohort of primary care patients.

Setting: 6 primary care practices in Philadelphia, Pennsylvania.

Patients: 15 459 patients with uncontrolled hypertension who made 70 557 visits to 200 clinicians from January 2004 through December 2006.

Measurements: Intensification of any antihypertensive treatment before the next visit was assessed. Patient and clinician information were obtained from electronic medical records and administrative data. Unrelated comorbid conditions included 28 conditions, such as arthritis and emphysema, whereas related comorbid conditions included vascular diseases. Generalized estimating equation logistic regression models were used to adjust for patient, health care, and provider characteristics and for clustering. Variation in the effect of unrelated comorbid conditions was examined at the visit, patient, and provider level.

Results: At study visits, patients had a mean of 2.2 (SD, 1.8) unrelated comorbid conditions. The adjusted odds of treatment intensification decreased with the number of unrelated comorbid conditions, from 0.85 (95% CI, 0.80 to 0.90) for 1 to 0.59 (CI, 0.51 to 0.69) for 7 or more versus none. The relationship between treatment intensification and unrelated comorbid conditions persisted at the visit, patient, and provider levels (P < 0.001).

Limitations: The reasons for not intensifying treatments are unknown. The recorded blood pressure may be inaccurate. Physicians may vary in their recording of comorbid conditions.

Conclusion: Patients with more unrelated comorbid conditions were less likely to have uncontrolled hypertension addressed at a visit. The effect of different types of comorbid conditions on meeting quality-of-care measures merits further investigation.

Editors' Notes Context Little is known about the quality of care received by patients with multiple unrelated conditions. Contribution This study examined the electronic medical records of 15 459 patients who were seen at 6 primary care practices with uncontrolled hypertension. Most patients had 2 or more comorbid conditions that were not related to hypertension, such as arthritis, gastroesophageal reflux, or thyroid disease. At clinic visits, the odds that treatment for uncontrolled hypertension would be intensified decreased as the number of unrelated comorbid conditions increased. Caution Electronic medical record data may be inaccurate or incomplete. Implication Patients with multiple unrelated conditions are less likely to have uncontrolled hypertension addressed at a clinic visit. —The Editors

 

Author and Article Information

From the University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Penn State College of Medicine, Hershey, Pennsylvania; and Pfizer, New York, New York.

Presented in part at the 26th Annual Meeting of the Society of General Internal Medicine, New Orleans, Louisiana, 12–14 May 2005.

Reproducible Research Statement: Study protocol: Not available. Statistical code: Available from Dr. Hollenbeak (e-mail, chollenbeak{at}psu.edu). Data set: Access to the database is completely restricted but could be made available if approved by the University of Pennsylvania institutional review board.

Grant Support: From Pfizer to the University of Pennsylvania.

Potential Financial Conflicts of Interest: Employment: S.S.K. Tang (Pfizer). Stock ownership or options (other than mutual funds): S.S.K. Tang (Pfizer). Grants received: B.J. Turner (Pfizer), C.S. Hollenbeak (Pfizer), M. Weiner (Pfizer). Receipt of payment for manuscript preparation: B.J. Turner (Pfizer), C.S. Hollenbeak (Pfizer), M. Weiner (Pfizer).

Requests for Single Reprints: Barbara J. Turner, MD, MSEd, University of Pennsylvania School of Medicine, 1123 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021; e-mail, bturner{at}mail.med.upenn.edu.

Current Author Addresses: Dr. Turner: University of Pennsylvania School of Medicine, 1123 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021.

Dr. Hollenbeak: Department of Public Health Sciences, Penn State College of Medicine, 600 Centerview Drive, A210, Hershey, PA 17033.

Dr. Ten Have: Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Blockley Hall, 6th Floor, 423 Guardian Drive, Philadelphia, PA 19104-6021.

Dr. Weiner: University of Pennsylvania School of Medicine, 1116 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021.

Mr. Tang: Pfizer, 235 East 42nd Street, New York, NY 10017.

Author Contributions: Conception and design: B.J. Turner, M. Weiner, S.S.K. Tang.

Analysis and interpretation of the data: B.J. Turner, C.S. Hollenbeak, M. Weiner, T. Ten Have.

Drafting of the article: B.J. Turner, C.S. Hollenbeak.

Critical revision of the article for important intellectual content: B.J. Turner, C.S. Hollenbeak, M. Weiner, T. Ten Have, S.S.K. Tang.

Final approval of the article: B.J. Turner, C.S. Hollenbeak, M. Weiner, T. Ten Have, S.S.K. Tang.

Provision of study materials or patients: B.J. Turner.

Statistical expertise: B.J. Turner, C.S. Hollenbeak, T. Ten Have.

Obtaining of funding: B.J. Turner, S.S.K. Tang.

Administrative, technical, or logistic support: B.J. Turner, M. Weiner.

Collection and assembly of data: M. Weiner.

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