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Ann Intern Med. 2008 May 20;148(10):717-27.

The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure.

Author information

1
Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System and the University of Michigan Department of Internal Medicine, Ann Arbor, Michigan 48113-0170, USA. ekerr@umich.edu

Abstract

BACKGROUND:

Factors underlying failure to intensify therapy in response to elevated blood pressure have not been systematically studied.

OBJECTIVE:

To examine the process of care for diabetic patients with elevated triage blood pressure (> or =140/90 mm Hg) during routine primary care visits to assess whether a treatment change occurred and to what degree specific patient and provider factors correlated with the likelihood of treatment change.

DESIGN:

Prospective cohort study.

SETTING:

9 Veterans Affairs facilities in 3 midwestern states.

PARTICIPANTS:

1169 diabetic patients with scheduled visits to 92 primary care providers from February 2005 to March 2006.

MEASUREMENTS:

Proportion of patients who had a change in a blood pressure treatment (medication intensification or planned follow-up within 4 weeks). Predicted probability of treatment change was calculated from a multilevel logistic model that included variables assessing clinical uncertainty, competing demands and prioritization, and medication-related factors (controlling for blood pressure).

RESULTS:

Overall, 573 (49%) patients had a blood pressure treatment change at the visit. The following factors made treatment change less likely: repeated blood pressure by provider recorded as less than 140/90 mm Hg versus 140/90 mm Hg or greater or no recorded repeated blood pressure (13% vs. 61%; P < 0.001); home blood pressure reported by patients as less than 140/90 mm Hg versus 140/90 mm Hg or greater or no recorded home blood pressure (18% vs. 52%; P < 0.001); provider systolic blood pressure goal greater than 130 mm Hg versus 130 mm Hg or less (33% vs. 52%; P = 0.002); discussion of conditions unrelated to hypertension and diabetes versus no discussion (44% vs. 55%; P = 0.008); and discussion of medication issues versus no discussion (23% vs. 52%; P < 0.001).

LIMITATION:

Providers knew that the study pertained to diabetes and hypertension, and treatment change was assessed for 1 visit per patient.

CONCLUSION:

Approximately 50% of diabetic patients presenting with a substantially elevated triage blood pressure received treatment change at the visit. Clinical uncertainty about the true blood pressure value was a prominent reason that providers did not intensify therapy.

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PMID:
18490685
[Indexed for MEDLINE]
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