Treatment Intensification Does Not Always Lead to Better Quality of Care in Patients with Hypertension

IN RESPONSE:

Dr. Valderas raises concerns about evaluating the quality of care for uncontrolled hypertension at only 1 visit, as we do in our article. 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 patient's blood pressure. Because of these short-term factors, Kerr and colleagues (1) suggested that quality of care should be evaluated only after 2 consecutive visits with an elevated blood pressure. In light of this recommendation, we examined hypertension management in 2 urban primary care practices for patients age 18 years or older with moderately elevated blood pressure at 2 consecutive visits (that is, systolic blood pressure ≥10 mm Hg or diastolic blood pressure ≥5 mm Hg) (2). We considered only patients whose treatment was not intensified at the first visit and whose visits were more than 1 month apart. We selected the first pair of eligible visits for patients with multiple sets. Our sample of 239 patients was primarily female (67%) and black (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% of participants. 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 running 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 by Dr. Valderas and suggest that future work could consider a longer window to assess management of uncontrolled hypertension, such as 6 months to 1 year, to allow the physician to address patient factors.

With regard to the second point, our “related” conditions are those included in most studies of hypertension management (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 (for example, gastroesophageal reflux disease or arthritis). Given that most studies consider only “related” comorbid conditions, we believe that our attempt to look at other unrelated, competing comorbid conditions is a major advance. Again, future studies need to consider how to deal with diabetes and chronic renal insufficiency because the blood pressure standard is more strict.