2009 Southern Regional Meeting Abstracts
Session: SSGIM Research Abstract Oral Plenary Session
MULTIPLE UNCONTROLLED COMORBID CONDITIONS AND MEDICATION INTENSIFICATION
Salanitro AH1,3, Funkhouser E1,3, Allison JJ1,3, Halanych JH3, Houston TK1,3, Litaker MS1,3, Levine DA2, Safford MM3. 1Birmingham VA Medical Center, Birmingham, AL; 2Ohio State University, Columbus, OH and 3University of Alabama at Birmingham, Birmingham, AL.
Purpose of Study: Multiple uncontrolled comorbid medical conditions (MUCC) in the same patient may act as competing demands for clinical decision-making. We hypothesized that MUCC decreases the likelihood of blood pressure (BP) medication intensification among uncontrolled hypertensive patients.
Methods Used: After each encounter made by 946 patients in a VA Medical Center primary care clinic, clinicians recorded whether BP medications (meds) were intensified (new med added or existing med titrated). Research assistants recorded patient age, sex, BP, and last HbA1c and low density lipoprotein cholesterol (LDL-C) levels. “Uncontrolled” was defined for BP as >140/90 mmHg or >130/80 if diabetic; for diabetes as HbA1c>7%; and for lipids as LDL-C >130 mg/dl or >100 if diabetic. Hierarchical regression models examined factors associated with BP med intensification, accounting for clustering.
Summary of Results: Patients had mean age 62+SD13, 3.1% were female, 424 (45%) presented with uncontrolled BP, 158 (17%) with uncontrolled diabetes, and 210 (22%) with uncontrolled lipids; intensification rates for the 424 patients with uncontrolled BP are in the Table. Among the 424 patients, adjusting for patient age, BP level, and clustering by clinician, odds of BP med intensification increased as MUCC rose (odds ratio of med intensification for BP+1 was 1.40 (95%CI: 0.97, 2.02) and for BP+2 was 2.72 (1.32, 5.58), compared with BP+0). Stratifying on median SBP revealed similar MUCC effects in both groups.
Conclusions: Providers appropriately managed hypertension more aggressively in patients with MUCC. Contrary to our hypothesis, MUCC actually enhanced guideline-concordant hypertension care. Performance measures must advance beyond simple dichotomous thresholds to examine appropriate decision-making, especially among complex patients.
Table. BP med intensification rates by number of MUCC and SBP
| Uncontrolled conditions | Patients, n | Intensification rates (all)* | Intensification rates, SBP >142^ | Intensification rates, SBP<142† | | BP+0 (BP only) | 245 | 30% | 46% | 10% | | BP+1 (BP + [DM or lipids]) | 148 | 34% | 55% | 18% | | BP+2 (all 3) | 31 | 45% | 75% | 26% |
*p for trend=0.11. ^p=0.04; 142 mm Hg was the median SBP. †p=0.03.
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