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Overtreatment rates for monitoring BP in vets with diabetes similar to undertreatment rates
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The Department of Veterans Affairs and other health systems are overtreating veterans with diabetes and hypertension, according to a study that examined treatment rates.
“While there is no doubt that appropriate management of hypertension among patients with diabetes is of critical importance, our data suggest that the VA and other high-performing health systems may have reached the point when threshold measures for BP control have the potential to do more harm than good,” researchers wrote.
Eve A. Kerr, MD, MPH, professor of internal medicine at the University of Michigan, director of the Center for Clinical Management Research, and research director of the VA Quality Enhancement Research Initiative for Diabetes Mellitus, and colleagues conducted a retrospective cohort study in 879 VA medical centers and community-based outpatient clinics.
The cohort included patients aged 18 to 75 years or with a diabetes diagnosis in the 24 months before eligibility to participate in the study. Measurements took place between July 1, 2009, and June 30, 2010. The threshold was set at less than 140/90 mm Hg.
Of the 977,282 patients measured, 713,790 were eligible for the “action measure,” in which 94% passed. Eighty-two percent had an index BP lower than 140/90 mm Hg, and another 8% met the measure with medication intensification, researchers wrote.
In an accompanying editorial, Eileen Handberg, PhD, of the department of CV medicine at the University of Florida, Gainesville, said reporting performance measures is important, and the study by Kerr and colleagues is a substantial step toward understanding the complex nature of hypertension management.
“However, reporting and evaluating performance measures must ensure that performance is linked to guidelines at the time of performance,” Handberg wrote.
Of all patients with diabetes, 197,291 (20%) had BP lower than 130/65 mm Hg, and 80,903 (8%) of those patients had overtreatment, researchers concluded.
Additionally, VA and other health systems with higher rates meeting the threshold measure (<140/90 mm Hg) had an increased rate for possible overtreatment, they said.
“This represents a dramatic improvement in BP control over the past decade, during which there has also been an intense focus on performance measures, guidelines, and quality improvement initiatives related to BP control,” researchers wrote.
For more information:
Handberg E. Arch Intern Med. 2012;doi:10.1001/archinternmed.2012.2261.
Kerr EA. Arch Intern Med. 2012;doi:10.1001/archinternmed.2012.2253.
Disclosure: Drs. Kerr and Handberg report no relevant financial disclosures.
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David S.H. Bell, MD, FACE, FACP
For years, we have been concerned with undertreatment of diabetic hypertension. To my knowledge, this is the first study to record an overtreatment (3% to 20%). Certainly, there is no advantage and potential harm to treating to levels below 130/65 mm Hg. Now, we should probably ‘curb our enthusiasm.’
If you overtreat systolic hypertension, especially in older people, it can have adverse renal consequences. It can actually worsen kidney disease instead of improving it. Lowering diastolic pressure below 70 mm Hg in the same group may also decrease filling of coronary arteries and, therefore, have adverse cardiac effect.
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