Overcoming clinical inertia: A visit-specific scale for measuring quality in hypertension care

• Objective: To develop a valid, reproducible scale that quantifies a provider's reaction to uncontrolled blood pressure. • Design: Retrospective chart review. • Setting and participants: 70 patients with hypertension who were treated with antihypertensive medication at the Durham Veterans Affairs Medical Center primary care clinic. • Methods: Three raters blinded to each other's assessments rated each patient visit using the hypertension quality of care scale. This scale includes 4 categories reflecting the extent of provider recognition of elevated blood pressure and action to lower it (0: blood pressure not recorded at visit; 1: blood pressure not controlled, not mentioned in the medical record, and nothing further done; 2: blood pressure not controlled, mentioned in the medical record, but nothing further done; 3: blood pressure not controlled and the provider acted in some manner to lower it). • Results: Providers failed to recognize or act on inadequately controlled blood pressure at 48% of visits. The average frequency of scores for all raters was 2.9% (no blood pressure recorded), 30.5% (blood pressure recorded but not mentioned), 14.3% (blood pressure recorded, provider recognized elevation, but no action), and 25.3% (provider acted to lower blood pressure); blood pressure was adequately controlled in 27.1% of patients. Inter-rater agreement was excellent (Kendall's W = 0.92). Scale scores were moderately related to the extent of systolic blood pressure elevation (r = 0.29, averaged across raters). • Conclusion: The scale demonstrated excellent interrater agreement and moderate correlation with elevation in systolic blood pressure. The scale could be used to measure the effectiveness of interventions designed to prompt providers to respond to inadequately controlled hypertension.

Duke Scholars

Author Wendy Owen Henderson Medicine, General Internal Medicine

Author Hayden Barry Bosworth Population Health Sciences

Author Eugene Zaverio Oddone Medicine, General Internal Medicine