Another 197,291 (20%) of the DM patients had a BP lower than 130/65 mm Hg, and, of those, 80,903 had potential overtreatment. That represented 8% of all patients with DM.

The authors noted that facility pass rates varied from 77% to 99%, with facility rates of potential overtreatment ranging from 3% to 20%. Interestingly, facilities with higher rates of meeting the current threshold measure (<140/90 mm Hg) also had higher rates of potential overtreatment.

Figure 1. The tightly linked clinical action measure and the marker of potential overtreatment among patients with diabetes mellitus. A, Clinical action measure for patients aged 18 to 75 years; B, marker of potential overtreatment for patients 18 years and older. *Associated with a primary care visit. †With prescription refills of all 4 classes in the 120 days following the index BP. ‡With no dropping of a medication within 120 days following the index BP (existing medications had a fill in the 120 days following the index BP). BP indicates blood pressure; DBP, diastolic blood pressure; and SBP, systolic blood pressure. Source: Kerr EA, Lucatorto MA, Holleman R, Hogan MM, Klamerus ML, Hofer TP, VA Diabetes Quality Enhancement Research Initiative Queri Workgroup On Clinical Action Measures FT. Monitoring Performance for Blood Pressure Management Among Patients With Diabetes

“While 94% of diabetic veterans met the action measure, rates of potential overtreatment are currently approaching the rate of undertreatment, and high rates of achieving current threshold measures are directly associated with overtreatment,” the authors report.

”While there is no doubt that appropriate management of hypertension among patients with diabetes is of critical importance,” they explain, “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.”

Lack of data on a “particular threshold risk-factor level,” means performance measures have the potential to “promote overtreatment and diastolic hypotension, which has been shown in multiple studies to be associated with worse cardiovascular outcomes,” they warned.

Instead, study authors say they favor “tightly linked” clinical action measures strongly tied to the evidence, pointing out that the VA is instituting new clinical action measures for hypertension management that take into account the complexity of clinical decisions, credit facilities for delivering the right evidence-based treatment, even if a specific risk-factor threshold is not achieved, and reduce potential for overtreatment.

In an accompanying editorial, Eileen Handberg PhD, ARNP, of the University of Florida’s Department of Cardiovascular Medicine, points out that the VA’s, “attainment of such a large percentage of patients who achieved performance measures is an outstanding accomplishment.”

She also argues the study’s definition of “overtreatment” is based on their critique of current hypertension management research and not guidelines that were available to the VA clinicians evaluated by the study.²

“With no guidance as to a lower threshold other than epidemiological (for BP) and other risk-factor (for LDL-cholesterol) data that ‘lower is better,’ one could argue that lower BPs were an indicator of better care, not ‘overtreatment,’” Handberg states. The study presents no evidence of increased risk for allegedly overtreated patients, she adds, so “a blanket statement that 10% of the VA population may be overtreated creates a negative impression of care that might not be true.”

In her editorial, however, Handberg agrees that, “reporting of performance measures is important, and the development of tightly linked clinical measures … are an important step forward in evaluating the complexities of management for hypertension and serve as a model for other measures.”

Kerr noted that one-goal-for-all benchmarks were set years ago, when blood pressure control for people with diabetes was poor across the board. The situation has changed, however, with blood pressure under 140/90 mm Hg for 82% of VA patients with diabetes, and a more sophisticated approach is now required, she said.

1: Kerr EA, Lucatorto MA, Holleman R, Hogan MM, Klamerus ML, Hofer TP, VA
Diabetes Quality Enhancement Research Initiative Queri Workgroup On Clinical
Action Measures FT. Monitoring Performance for Blood Pressure Management Among
Patients With Diabetes

2. Handberg E. How Do Guidelines Impact Measures of Performance?: Comment on
“Monitoring Performance for Blood Pressure Management Among Patients With
Diabetes Mellitus” How Do Guidelines Impact Measures of Performance? Arch Intern
Med. 2012 May 28:8-9. doi: 10.1001/archinternmed.2012.2261. [Epub ahead of print]
PubMed PMID: 22641271.

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