Multiple uncontrolled conditions and blood pressure medication intensification: an observational study
1 VA National Quality Scholars Program, Department of Veterans Affairs Medical Center, Birmingham, AL, USA
2 Center for Surgical, Medical Acute care Research and Transitions (C-SMART), Department of Veterans Affairs Medical Center, Birmingham, AL, USA
3 Division of General Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
4 Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
5 Department of Quantitative Health Sciences and Medicine, University of Massachusetts Medical School, Worcester, MA, USA
6 Center for Health Quality, Outcomes & Economic Research (CHQOER), Department of Veterans Affairs Medical Center, Bedford, MA, USA
7 Department of General Dental Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
8 Ann Arbor VA Medical Center/University of Michigan Health System Patient Safety Enhancement Program, Department of Veterans Affairs Medical Center, Ann Arbor, MI, USA
9 Division of General Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
Implementation Science 2010, 5:55 doi:10.1186/1748-5908-5-55Published: 19 July 2010
Multiple uncontrolled medical conditions may act as competing demands for clinical decision making. We hypothesized that multiple uncontrolled cardiovascular risk factors would decrease blood pressure (BP) medication intensification among uncontrolled hypertensive patients.
We observed 946 encounters at two VA primary care clinics from May through August 2006. After each encounter, clinicians recorded BP medication intensification (BP medication was added or titrated). Demographic, clinical, and laboratory information were collected from the medical record. We examined BP medication intensification by presence and control of diabetes and/or hyperlipidemia. 'Uncontrolled' was defined as hemoglobin A1c ≥ for diabetes, BP ≥ 140/90 mmHg (≥ 130/80 mmHg if diabetes present) for hypertension, and low density lipoprotein cholesterol (LDL-c) ≥ 130 mg/dl (≥ 100 mg/dl if diabetes present) for hyperlipidemia. Hierarchical regression models accounted for patient clustering and adjusted medication intensification for age, systolic BP, and number of medications.
Among 387 patients with uncontrolled hypertension, 51.4% had diabetes (25.3% were uncontrolled) and 73.4% had hyperlipidemia (22.7% were uncontrolled). The BP medication intensification rate was 34.9% overall, but higher in individuals with uncontrolled diabetes and uncontrolled hyperlipidemia: 52.8% overall and 70.6% if systolic BP ≥ 10 mmHg above goal. Intensification rates were lowest if diabetes or hyperlipidemia were controlled, lower than if diabetes or hyperlipidemia were not present. Multivariable adjustment yielded similar results.
The presence of uncontrolled diabetes and hyperlipidemia was associated with more guideline-concordant hypertension care, particularly if BP was far from goal. Efforts to understand and improve BP medication intensification in patients with controlled diabetes and/or hyperlipidemia are warranted.