When tight blood pressure control is not for everyone: a new model for performance measurement in hypertension

Abstract

Background: Many patients with hypertension have legitimate reasons to forego standard blood pressure targets yet are nonetheless included in performance measurement systems. An approach to performance measurement incorporating clinical reasoning was developed to determine which patients to include in a performance measure.

Design: A 10-member multispecialty advisory panel refined a taxonomy of situations in which the balance of benefits and harms of anti-hypertensive treatment does not clearly favor tight blood pressure control (< 140/90 mm Hg).

Findings: The panel identified several broad categories of reasons for exempting a patient from performance measurement for blood pressure control. These included (1) patients who have suffered adverse effects from multiple classes of antihypertensive medications; (2) patients already taking four or more antihypertensive medications; (3) patients with terminal disease, moderate to severe dementia, or other conditions that overwhelmingly dominate the patient's clinical status; and (4) other patient factors, including comfort care orientation and poor medication adherence despite attempts to remedy adherence difficulties. Several general principles also emerged. Performance measurement should focus on patients for whom the benefits of treatment clearly outweigh the harms and should incorporate a longitudinal approach. In addition, the criteria for exempting a patient from performance measurement should be more strict in patients at higher risk of adverse health outcomes from hypertension and more lenient for patients at lower risk.

Conclusions: Incorporating "real world" clinical principles and judgment into performance measurement systems may improve targeting of care and, by accounting for patient case mix, allow for better comparison of performance between institutions.

Figure 1. Traditional and New Approaches to Performance Measurement for Blood Pressure

Figure 1a shows a traditional approach, in which all patients with hypertension (represented as circles in the box) as included in the performance measure, whether tight blood pressure control is clearly appropriate (white circles) or not (colored circles). Figure 1b shows the new approach, in which patients for whom tight blood pressure control is not clearly appropriate, are excluded from the denominator of the performance measure.

Figure 2. Algorithm for Performance Measurement for Blood Pressure Control

The algorithm for performance measurement for blood pressure control includes several steps, each of which is explained in the text. BP, blood pressure.