Quality Improvement Initiative for Rapid Induction of Hypertension Control in Primary Care

Abstract

Hypertension affects 1 of every 4 adults, including two thirds of those over 60 years of age in the United States.1,2 Despite improvements in hypertension awareness and access to care, rates of blood pressure (BP) control remain below 50% in most population studies.1,3,–,5 The Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC) in Houston, Texas, is one of the largest regional health centers within the national VA system, handling more than 900 000 outpatient visits in 2006, including 50 000 patients enrolled in primary care. MEDVAMC serves as the main referral center for specialized care for veterans in Southeast Texas and Louisiana. From October 1, 2004, to May 31, 2005, 21 794 patients were treated for chronic hypertension within primary care at the MEDVAMC. Rates of control were 54% in 2005 for all hypertensive patients without diabetes receiving primary care at the MEDVAMC and 30% among patients with comorbid diabetes.6 Under the guidance of the primary care clinic director (J.K.) and nurse manager (D.T.), selected clinicians and staff of the primary care clinic initiated a quality improvement (QI) program to specifically address the quality issues related to the care of patients with persistent, uncontrolled hypertension despite regular follow-up and treatment. The persistence of uncontrolled hypertension among patients with access to health insurance and treatment from a regular provider has been well characterized.7 The cause of treated but uncontrolled hypertension is often attributed to clinical inertia, the failure to initiate or intensify therapy.8,9 Clinical inertia in hypertension care may reflect uncertainty about whether the BP measurement merits intensification (clinical uncertainty) and/or preoccupation with the patient's other problems (competing demands).10,11 The primary care providers (PCPs) at the MEDVAMC adapted a model of frequent, shared …