Care of hypertensive women short on quality
Care of hypertensive women short on quality
According to a recent study in the Archives of Internal Medicine, the quality of care for women with high blood pressure falls considerably short of the standards set by a panel of medical experts. The report also indicates a clear relationship between better care processes and better blood pressure control.1
The study evaluated care based on medical records of 613 women enrolled in a West Coast managed care plan. The findings include the following:
• Blood pressure screening occurred at rates of more than 80%.
• Of the 234 women who had been diagnosed as hypertensive, or who had an average blood pressure greater than 140/90 mm Hg, most did not received an adequate initial history, physical examination, or laboratory tests.
• Only 37% of those with persistently high blood pressure (>160/90) were advised to make changes in their therapy or in their lifestyles.
"This article is condition-specific," notes Steven M. Asch, MD, MPH, the article’s lead author, who is affiliated both with RAND and with the Veterans Affairs Greater Los Angeles Health System in Los Angeles. "It uses 13 indicators of quality of care to look at the care for hypertension in one health plan. It is a bit more in-depth than the leading indicators approach . . . proposed by HEDIS. As such, we hope it allows quality managers to more accurately see where processes are lacking, and to fix them. Leading indicators don’t tell you where to fix the process.
The study also shows that if you follow these quality indicators your patient is more likely to have a better control-process-outcome link." (See "Indicators of quality of care for hypertension in women," in this issue.) The quality indicators are part of a new quality measurement system being developed by RAND called QATools. "We first developed indicators for pediatric care, and then for cancer care," notes Asch.2,3 "But the system as a whole is designed to be a general measure of quality of care."
The QATools methodology, he notes, differs from previous quality measurement methodologies. "It intends to be global," Asch explains. "It takes a random patient rather than having to sample patients for specific conditions to determine the quality of care. Instead, we have a sufficient number of evaluable quality indicators so that random patients can be evaluated."
As for why quality of care is falling short, Asch notes there are many potential causes. "What I can tell you is that from my experience as a clinician, it is often the case that the sort of care processes in this system are well-known to both the clinician and the patient. There may be an adherence problem, or maybe the doctors are just forgetting to do things. We did try to count even offers of indicated care, and we tried to evaluate physicians’ actions, but we were not wholly successful."
There is one thing of which Asch is sure: Blaming individual doctors will not solve the problem. "What the literature shows is that systems for improving hypertensive care are what work, rather than trying to blame the doctor. We need to develop systems to track whether patients receive the appropriate care, and to remind the patients and the physicians what needs to be done. We hope to develop such systems."
References
1. Asch SM, Kerr EA, Lapuerta P, et al. A new approach for measuring quality of care for women with hypertension. Arch Intern Med 2001; 161:1,329-1,335.
2. Schuster MA, Asch SM, McGlynn EA, et al. Development of a quality of care measurement system for children and adolescents. Archives Pediatr Adolesc Med 1997; 151:1,085-1,092.
3. Malin JL, Asch SM, Kerr EA, McGlynn EA. Evaluating the quality of cancer care: Development of cancer quality indicators for a global quality assessment tool. Cancer 2000; 68:701-707.
Need more information?
For more information, contact:
• Steven M. Asch, MD, MPH, Veterans Affairs Greater Los Angeles Health System, 11301 Wilshire Blvd., Los Angeles, CA 90073.
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