Study highlights:

• High blood pressure patients with related and non-related co-existing medical conditions were more likely to receive overall good quality care than patients with high blood pressure alone in the Veteran’s Affairs health system.
• This is one of the first studies assessing the impact of co-existing conditions on quality of care while also assessing patients’ perception of the quality of the care they receive.
• Patient satisfaction remained positive among those patients being treated for more complex health issues.
• These results indicate “pay-for-performance” measures may not penalize physicians who treat patients with more complicated medical needs.

DALLAS, June 1, 2009 — Contrary to some previous indications, sicker high blood pressure patients are more likely to receive high-quality care than those with fewer medical needs, researchers report in Circulation: Journal of the American Heart Association.

Researchers looked at data on 141,609 high blood pressure (HBP) patients at eight Veterans Affairs (VA) medical centers in three states. Overall, 90 percent of the HBP patients treated for additional medical conditions received high-quality care. That held true whether the conditions were those typically related to HBP, such as diabetes and heart disease, or those less likely to be related to HBP, such as arthritis and chronic lung disease. Patient perception of the care they received remained positive overall, regardless of the number of medical conditions for which they were being treated.

The study is one of the first to assess the impact of co-existing conditions on quality of care while also assessing patients’ perception of the quality of the care they receive.

The findings are reassuring for physicians concerned that quality initiatives and performance measures (sometimes known as “pay-for-performance”) could penalize those caring for medically complex patients, researchers said.

“Many clinicians are concerned that when they care for patients with multiple medical conditions, their performance on measures of health care quality is going to suffer due to that complexity,” said Laura A. Petersen, M.D., M.P.H., lead author of the study and director of the VA Health Services Research and Development Center of Excellence and Associate Professor of Medicine at Baylor College of Medicine, in Houston, Texas. “The concern is that the time spent treating other unrelated conditions would take away time from treating high blood pressure, causing performance on measures of quality to suffer.
 
However, we did not find that to be the case. In fact, the sicker patients were more likely to receive high quality health care, even after statistically controlling for number of visits and other issues.”

In addition, evidence-based guidelines focus upon treating a single disease. If a patient has multiple diseases, evidence-based guidelines might dictate that a patient take many medications, she said.

“We wondered whether patients’ satisfaction may be negatively affected, despite receiving high quality care, when they are being treated for multiple conditions that may require a lot of medications or other interventions,” Petersen said. However, in the study, patient satisfaction remained positive across all groups, whether patients were being treated just for high blood pressure or for additional conditions.

Researchers defined “overall good quality care” as having blood pressure controlled to under 140/90 millimeters of mercury (mm Hg) at the initial visit analyzed and within the six-month follow-up period, or evidence that the medical team was actively trying to achieve HBP control.

“So, even if the patient fell short of the treatment goal, they were classified as getting good overall quality of care if there was evidence of intensified treatment during follow-up, such as a change in medication,” said Petersen, who is also chief of Health Services Research at Baylor College of Medicine in Houston.

Among key differences between the VA system and civilian care, the VA system has a nationwide, computerized medical records system structured to provide complete medical information and to prompt clinicians with clinical reminders and alerts about medication interactions and allergies.
 
“However, even with the caveat that this is a health care system with excellent electronic medical records and an emphasis on health care quality, doctors who are concerned that they might be penalized for taking care of complex patients should be reassured by these findings,” she said.

An accompanying editorial by Thomas H. Lee, M.D., M.Sc. and Timothy G. Ferris, M.D., M.P.H., notes that this study provides welcome, but inconclusive data on the pay-for-performance issue. It says physicians should not shy away from payment systems that introduce accountability for clinical outcomes.

Co-authors are LeChauncy D. Woodard, M.D., M.P.H.; Louise M. Henderson, Ph.D., M.S.P.H.; Tracy H. Urech, M.P.H.; and Kenneth Pietz, Ph.D. Author disclosures can be found on the manuscript.

The research was partially funded by the Department of Veterans Affairs, the National Institutes of Health and an American Heart Association Established Investigator Award grant to Petersen.

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NR09-1061 (Circ/Petersen)