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Rapid Responses to:
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Electronic letters published:
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Quality of Care for Hypertension
What are the statistical factors inducing the reduction of uncontrolled hypertension?
Measuring the impact of comorbid conditions: cautionary notes
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Barbara J Turner, MD, MSED University of Pennsylvania, David St. Michel MPH, Drexel University and Simon Tang MPH, Pfizer, Inc.
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bturner{at}mail.med.upenn.edu Barbara J Turner, et al.
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This letter raises concerns about evaluating quality of care for uncontrolled hypertension at only one visit, just as we do in our paper. We concur that a physician should not intensify treatment when a patient has been poorly adherent. Recommendations about lifestyle changes may also be reasonable depending on the blood pressure. Because of these short-term factors, Kerr and colleagues suggested that quality of care should be evaluated only after two consecutive visits with an elevated blood pressure (1). In light of this recommendation, we examined hypertension management in two urban primary care practices for patients aged 18 or older with moderately elevated blood pressure at two consecutive visits (i.e., at least 10 mmHg systolic or 5 mmHg diastolic) (2). We considered only patients whose treatment was not intensified at the first visit and withover one month between visits. We selected the first pair of eligible visits for patients with multiple sets. Our sample of 239 patients was primarily female (67%) and African-American (86%) with an average age of 66.7 years. Treatment was not intensified at the second visit or at any time until the third visit in 50.1%. Among the 120 patients without intensification, chart review revealed that, for 37 of these second visits (31%), a legitimate excuse was recorded such as the patient ran out of medication. Thus, even in a pair of visits with uncontrolled hypertension, an analysis of medication intensification alone overestimates poor quality of care. So we agree with the observation in this letter and suggest that future work could consider a longer window to assess management of uncontrolled hypertension such as 6 months to a year to allow the physician to address patient factors. In regard to the second point , our ‘related’ conditions are those included in most studies of hypertension management (i.e., coronary artery disease, stroke, and peripheral vascular disease). Physicians would not immediately think of hypertension as a key factor affecting collagen vascular disease or pulmonary circulation disorders. Therefore, we considered these to be “unrelated” diseases along with others occurring more commonly in the outpatient setting (e.g., gastroesophageal reflux, arthritis). Given that most studies consider only ‘related’ comorbidities, we believe that our attempt to look at other unrelated competing comorbidities is a major advance. Again, future work needs to consider how to deal with diabetes and chronic renal insufficiency where the blood pressure standard is stricter. 1. Kerr EA, Krein SL, Vijan S, Hofer TP, Hayward RA. Avoiding pitfalls in chronic disease quality measurement: a case for the next generation of technical quality measures. Am J Manag Care. 2001 Nov;7(11):1033-43 2. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560-72 Conflict of Interest:Dr Turner has received unrestricted research funding from Pfizer, Inc. Mr Tang is employed by Pfizer, and Mr. St. Michel has no conflicts to declare |
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Liu Hong, Ph.D. Institute of Digestive Disease, Xijing Hospital, Fourth Military Medical University, Xi¡¯an, China, Kaichun Wu, Daiming Fan
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hlhyhj{at}126.com Liu Hong, et al.
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To the editor: We read with interest the article by Turner BJ and colleagues [1]. They clearly show that patients with more unrelated comorbid conditions are less likely to have uncontrolled hypertension addressed at a visit. The study is based on the data from electronic medical records. However, the authors don't evaluate the compliance of patients by follow up. Patients may have not adhered to the antihypertensive medication as the electronic medical records described. Furthermore, the patients with more unrelated comorbid conditions may receive other medication, which may affect blood presure or enhance (or weaken) the effect of antihypertensive medication. In our opinions, the reduction in the rate of uncontrolled hypertension may result from other factors except for antihypertensive treatment intensification. Could the authors comment on the statistical factors which induce the differences observed? In addition, this study is based on the participants living in the United States, so the results may not be applicable for Asians. Could the authors comment on the effect of racial diversify on hypertension management? References: 1. Turner BJ, Hollenbeak CS, Weiner M, Ten Have T, Tang SS. Effect of unrelated comorbid conditions on hypertension management. Ann Intern Med. 2008 Apr 15;148(8):578-86. Conflict of Interest:None declared |
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Jose M Valderas, MD, PhD, MPH NIHR School of Primary Care Research. University of Manchester
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jose.valderas{at}manchester.ac.uk Jose M Valderas
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In their study on the “Effect of unrelated comorbid conditions on Hypertension Management”, Tuner et al. conclude that patients with more unrelated comorbidities were less likely to have their hypertension addressed. Two relevant limitations of the study make it necessary to handle this statement with due caution. Firstly, Turner et al. equate intensification with “better quality of care” and non intensification with “poor performance” (p.584). The authors fail to acknowledge that raised blood pressure measurements may be due to reasons other than non response to medical treatment, making other approaches available to the clinician more appropriate than treatment intensification. Patients may have not adhered to the drug regime, or they may have made minimal temporary adjustments to their lifestyles (diet, exercise), making an emphasis on adherence to current management rather intensification a better approach. Alternatively, there may be an intercurrent problem explaining a the apparently uncontrolled hypertension, and again treating that problem may prove a better approach than intensification (incidentally, this may very well explain, at least in part, the negative association observed for some non related diseases associated with chronic-recurrent pain). Even if the patient is compliant, the physician may use the raised figure to stress the need for lifestyle changes. This may be particularly the case if the patient is on maximal dose of a number of drugs and pharmacological interactions and possibly medical contraindications that not allow for additional drugs. Although it is not possible to determine it from the data presented by the authors, some of these situations may occur more frequently among patients with non related comorbidities and may at least in part explain the differences observed. Secondly, the concept of related disease is intuitive, but difficult to generalize. The lack of an explicit definition in this study makes it difficult to understand why some vascular diseases were considered related and some other not (e.g., collagen vascular disease, or pulmonary circulation disorders). As a matter of fact, although related diseases were expected to show a positive association with treatment intensification, one did not (chronic renal insufficiency) and another one even showed a strong reverse association (diabetes). Even those showing a positive association correspond to disease groups (single vs multiple vascular disease) that have not previously defined in relation to the related diseases. The interactions between comorbid conditions in terms of diagnosis, prognosis, and treatment and their impact on health care seems far too complicated to accomodate in these two categories. Conflict of Interest:None declared |
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