Circ: EHR helps VA control patients hypertension
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The Department of Veterans Affairs has implemented a number of system-wide initiatives to improve the awareness, treatment and control of hypertension, wrote Ross D. Fletcher, MD, chief of staff at the VA Medical Center in Washington, D.C., and colleagues. Among the approaches are several that took advantage of the department EHR’s Computerized Patient Record System, which in 1998 added performance measures to monitor and control care.
The system allowed physicians to enter data on vital signs, including blood pressure. It also provided reminders about previous blood pressure readings; prompts for treating elevated blood pressure with medication and lifestyle modifications; helped establish frequent visits until blood pressure control was achieved; and helped identify difficult-to-control patients for referral to specialized clinics.
Fletcher and colleagues wanted to assess improvement in blood pressure control within the VA system. For their study, they identified 582,881 patients as hypertensive and 260,924 as normotensive who were treated at one of 15 VA medical centers between 2000 and 2010. To be considered hypertensive, the patient had at least three days with elevated blood pressure readings (systolic blood pressure greater than 140 and diastolic blood pressure of greater than 90). Normotensive patients included those with at least three days of blood pressure readings with no elevation recorded.
Based on readings taken in November 2000, 43 percent of the patients with hypertension had their blood pressure under control. Mean age for the hypertensives was 61.9 years. Ninety-six percent were male; among those who provided racial information, 52.3 percent were white, 25.1 percent were African American and 21.1 percent were Hispanic. Compared with patients with normal blood pressure, they were more likely to be older, male and African American.
Between 2000 and 2001, the control rate averaged 46.8 percent. Between 2009 and 2010, that jumped to an average of 74.2 percent, for an improvement rate of 3 percent annually. By August 2010, 76.3 percent of patients with hypertension were controlled. The researchers noted improvement rates across all age and racial groups in both genders.
The average systolic and diastolic blood pressure decreased in the hypertensive group from 142.6/77.1 in 2000 to 131.2/74.8 mmHg in 2010. Patients with normal blood pressure saw a slight increase over the 10-year span.
“Although no single intervention can be credited for this impressive improvement in control rates a number of interventions probably contributed substantially,” Fletcher and colleagues wrote. They said that the department implemented many changes over the decade. “Among the changes that influence hypertension control a prominent role is attributable to electronic health records, the ability to provide feedback to patients and healthcare professionals regarding patient appointments, prescription refills, regimen adjustment and the need to meet existing national performance measures.”
They added that the EHR provides automatic reminders when blood pressure is elevated and facilitates with ensuring patients get frequent appointments until their blood pressure is under control. Other factors included involving patients in the process, the VA’s efforts to address issues such as clinician inertia and clinician education, and at many centers in the study the inclusion of healthcare professionals such as nurses, pharmacists and nutritionists in patient management.
They noted that recent National Health and Nutritional Survey (NHANES) data showed a much lower improvement rate of 50 percent for hypertension. “The difference in control rates can be partially explained by the number of patients treated rather than ability to reduce blood pressure to normal in individual patients,” they wrote. “In the NHANES surveys, even under the best circumstances, only 73 percent of patients received antihypertensive medication.”
Among the study's limitations, they said they did not have data on compliance to medication, beyond asking patients if they take their pills. Nonetheless, they reported that data from the Veterans Affairs Medical Center indicate that more than 90 percent of patients with hypertension are under treatment. “Thus identifying and treating patients with hypertension in the community may be the most efficient way to improve control rates,” they suggested.