Cardiac Risk Is Not Associated With Hypertension Treatment Intensification

Preventing cardiovascular disease efficiently and effectively should be a primary goal of healthcare organizations, but clinical focus on non–patient-centered end points can limit efficiency. Clinical decision making and organizational guidance for prevention of cardiovascular (CV) disease has often focused on reduction of individual risk factors, such as hyperlipidemia and hypertension. Care could be more efficient and effective if decision making focused more on processes that reduce overall CV risk, which can be measured by the UK Prospective Diabetes Study (UKPDS)¹ Risk Engine or Framingham Heart Score.² Overall risk is a better indicator of treatment benefit because those with a higher likelihood of having an event have a higher absolute benefit from treatment.^3,4 Even among patients with diabetes there exist large variations of potential benefit.^3-5 For example, a patient with diabetes and hypertension in the lowest decile of risk has one-eighth the benefit from a treatment to reduce CV events as a patient in the highest decile of risk.⁶ However, given the current focus of guidelines on discrete risk factors, clinicians may be less likely to take CV risk into account when making decisions about modifying individual CV risk factors.

One way to assess how clinicians prioritize overall CV risk in patients with a known CV risk factor is by assessing hypertension treatment intensification (TI) decisions in those with elevated blood pressure (BP). While failure of TI has been considered an indicator of poor clinical quality,⁷ more recent research^5,8 has shown that it often occurs due to clinical circumstances that make the potential benefits of TI less clear, such as clinical uncertainty about the validity of a BP measurement or the presence of comorbidities. Given the variation in benefit as a function of CV risk, if clinicians think about CV risk in decision making, patients at higher CV risk should have more consistent, reliable TI than those of lower CV risk and treatment benefit. This strategy of individually tailored care would maximize benefits and minimize risks for patients.

In this study we examined if clinicians account for overall CV risk when making TI decisions in response to an elevated BP. Using data from a study of veterans with diabetes and an elevated measured BP, we assessed whether patients with higher CV risk are more likely to have TI than those with lower CV risk. We also examined whether individual clinical risk factors predict clinical action. We then developed a decision analysis to estimate the potential benefit of making treatment more risk focused.

METHODS

Setting and Participants

The Addressing Barriers to Treatment for Hypertension (ABAT e) study was a prospective cohort study of patients with diabetes from 9 Veterans Health Administration (VHA) facilities in 3 Midwestern states. The study conducted a detailed examination of the factors that influence BP management. As has been described elsewhere,^5,9 the study enrolled 1169 US veterans with diabetes who were found to have elevated triage BP (>140 mm Hg systolic or >90 mm Hg diastolic) before an index primary care visit. Participants were patients of 96 attending-level primary care providers with at least 2 half-days per week of clinic at the involved sites. 87% of all approached and eligible patients and 83% of approached and eligible clinicians participated. Data were obtained from baseline provider and patient surveys, brief post-visit provider and patient surveys, an electronic medical record review, and data from automated VHA data sources. Because of the very small number of women in the population, they were excluded from analysis. We have removed from our analyses patients whose measurements were <140/90 mm Hg when repeated by the clinician that day, because of the clinical uncertainty about the appropriate clinical action in these circumstances. The original study examined patients with diabetes because of their greater cardiac risk and benefit from hypertension treatment. The VA electronic health record (EHR) does not have an automated Framingham or UKPDS risk calculator, although they are available on many websites.

Institutional review boards of all participating facilities approved the study protocol, and all patients and providers gave written informed consent before participating.

Outcome Variable: Intensification of Hypertension Treatment

Our dependent variable was whether a provider intensified a patient’s BP medication within 3 months after the index visit in response to the elevated measured BP. We considered a treatment intensified if the dosage was increased on any antihypertensive medication or if any antihypertensive medications were started or switched. We included any actions taken within 3 months after the initial visit to allow time for laboratory work and BP reassessments.

CV Risk Variable

We defined 3 mutually exclusive categories of CV risk: 1) the highest risk group, which consisted of those in need of secondary prevention (individuals with a history of myocardial infarction [MI] or congestive heart failure [CHF]); 2) the high-risk primary prevention group, which consisted of those with a UKPDS¹ 10- year event risk of >20% but without a history of MI or CHF; and 3) the low/medium risk primary prevention group, which included those with a UKPDS 10-year event risk of <20% and no history of MI or CHF. We could not estimate an overall risk for secondary prevention patients or create an overall continuous risk score because we know of no validated risk predictor that integrates primary and secondary prevention. We also examined a continuous measure of CV risk in a secondary analysis. For this analysis, we excluded patients with a history of MI or CHF. The UKPDS risk score has better discrimination than the Framingham scores for patients with diabetes.^10,11

Covariates for the Primary Model