Assessing Hypertension Care for Aged Veterans: Balancing Risks and Benefits

评估老年退伍军人的高血压护理：平衡风险和收益

基本信息

批准号：
8978569
负责人：
Lillian Chiang Min
金额：
--
依托单位：
VETERANS HEALTH ADMINISTRATION
依托单位国家：
美国
项目类别：
财政年份：
2015
资助国家：
美国
起止时间：
2015-10-01 至 2019-12-31
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/8978569
关键词：
Adherence Adherence Affect Affect Age Age Aging Aging Algorithms Algorithms Award Award Benefits and Risks Benefits and Risks Blood Pressure Blood Pressure Cardiac Cardiac Cardiovascular Diseases Cardiovascular Diseases Cardiovascular system Cardiovascular system Caring Caring Characteristics Characteristics Chronic Chronic Clinic Clinic Data Data Data Element Data Element Data Reporting Data Reporting Data Set Data Set Databases Databases Development Development Diabetes Mellitus Diabetes Mellitus Diagnostic Diagnostic Disputes Disputes Early identification Early identification Elderly Elderly Electronic Health Record Electronic Health Record Equilibrium Equilibrium Event Event Fright Fright Health Health Health and Retirement Study Healthcare Healthcare Hip Fractures Hip Fractures Hypertension Hypertension Hypotension Hypotension Individual Individual Injury Injury Interview Interview Lead Lead Link Link Measures Measures Medical Records Medical Records Medical center Medical center Medicare Medicare Methods Methods Myocardial Infarction Myocardial Infarction Outcome Outcome Patients Patients Performance Performance Pharmaceutical Preparations Pharmaceutical Preparations Polypharmacy Polypharmacy Predisposing Factor Predisposing Factor Provider Provider Quality of Care Quality of Care Reporting Reporting Research Research Retirement Risk Risk STEM research Sampling Sampling Severities Severities Site Site Stroke Stroke Structure Structure Subgroup System System Taxonomy Taxonomy Testing Testing Translational Research Translational Research Variant Variant Veterans Veterans Work Work acute stroke acute stroke age group age group aged aged aggressive therapy base base blood pressure medication blood pressure reduction blood pressure regulation blood pressure regulation cardiovascular disorder risk cardiovascular disorder risk cardiovascular risk factor cardiovascular risk factor comorbidity comorbidity control trial design design diabetic diabetic electronic data electronic data fall injury fall risk fall risk falls falls health administration health administration human old age (65+)hypertension control hypertension control improved improved meetings novel novel older patient older patient overtreatment patient oriented patient oriented patient subsets primary outcome primary outcome research to practice research to practice response response stem success success

Adherence Adherence Affect Affect Age Age Aging Aging Algorithms Algorithms Award Award Benefits and Risks Benefits and Risks Blood Pressure Blood Pressure Cardiac Cardiac Cardiovascular Diseases Cardiovascular Diseases Cardiovascular system Cardiovascular system Caring Caring Characteristics Characteristics Chronic Chronic Clinic Clinic Data Data Data Element Data Element Data Reporting Data Reporting Data Set Data Set Databases Databases Development Development Diabetes Mellitus Diabetes Mellitus Diagnostic Diagnostic Disputes Disputes Early identification Early identification Elderly Elderly Electronic Health Record Electronic Health Record Equilibrium Equilibrium Event Event Fright Fright Health Health Health and Retirement Study Healthcare Healthcare Hip Fractures Hip Fractures Hypertension Hypertension Hypotension Hypotension Individual Individual Injury Injury Interview Interview Lead Lead Link Link Measures Measures Medical Records Medical Records Medical center Medical center Medicare Medicare Methods Methods Myocardial Infarction Myocardial Infarction Outcome Outcome Patients Patients Performance Performance Pharmaceutical Preparations Pharmaceutical Preparations Polypharmacy Polypharmacy Predisposing Factor Predisposing Factor Provider Provider Quality of Care Quality of Care Reporting Reporting Research Research Retirement Risk Risk STEM research Sampling Sampling Severities Severities Site Site Stroke Stroke Structure Structure Subgroup System System Taxonomy Taxonomy Testing Testing Translational Research Translational Research Variant Variant Veterans Veterans Work Work acute stroke acute stroke age group age group aged aged aggressive therapy base base blood pressure medication blood pressure reduction blood pressure regulation blood pressure regulation cardiovascular disorder risk cardiovascular disorder risk cardiovascular risk factor cardiovascular risk factor comorbidity comorbidity control trial design design diabetic diabetic electronic data electronic data fall injury fall risk fall risk falls falls health administration health administration human old age (65+)hypertension control hypertension control improved improved meetings novel novel older patient older patient overtreatment patient oriented patient oriented patient subsets primary outcome primary outcome research to practice research to practice response response stem success success

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项目摘要

DESCRIPTION (provided by applicant): Hypertension, the most commonly-treated condition in the VHA, affects more than 80% of older Veterans. With continuing improvements in quality of VHA care, more older Veterans meet blood pressure (BP) targets than older patients in Medicare. Despite known benefits of BP control, one concern as Veterans age and accumulate multiple conditions is that overly-aggressive control may result in unintended outcomes such as falls. We propose to better understand both cardiovascular benefits and fall injury risks associated with overly-aggressive hypertension care. This work will lead to a development of a novel measure of harmful or wasteful BP treatment for > 1.6 million Veterans. The VHA has been highly successful at improving BP control, exceeding performance on existing BP measures by 79% versus only 62% in Medicare. Older individuals stand to benefit from good BP control, especially in stroke reduction. However, older individuals are at risk of falls due to polypharmacy. One concern is that our existing dichotomous BP targets result in inadvertently-low BPs, especially as aging Veterans develop geriatric conditions such as falls. We have previously found that nearly one-third of older Veterans with diabetes are potentially-over-treated. Whether or not VHA providers should consider de-intensifying BP care in older Veterans has not been well-studied. We aim to define Aggressive Hypertension Care (AHC) in Veterans age 65 and older using national VHA databases. First, we will validate data elements of AHC using medical record review. Next, we will test whether AHC (in comparison to adequate care) is associated with falls injury, and whether the risks outweigh reduction in strokes and cardiac events. Last, we will measure inter-facility variation in AHC. We will involve VHA providers throughout these Aims to review results, guide analytic decisions and provide early identification of potential barriers to implementation. By the end of the award, we aim to develop a novel measure of appropriate hypertension care of relevance to older Veterans specific to age group, co-morbidity burden, and baseline risk for cardiovascular and fall events. Aim 1 (Validating data elements of AHC): Working with our provider panels and steering committee, we will review data elements of AHC (BP < 130/65 mmHg in combination with continuing 3+ or escalating 1+ BP medications) for appropriateness in older Veterans age 65 and older. Then, in a small subsample, we will validate the data elements by full review of the electronic health record. Aim 2 (Harms and Benefits of AHC): In Sub-Aim 2A, We will use the Health and Retirement Study which captures both interview-based fall injury and diagnostic injury data from Medicare, thus facilitating development of a fall injur severity algorithm that we can apply to the VHA-Medicare data. Then, in Sub-Aim 2B, we will use two years of VHA data merged with Medicare to test whether AHC (compared to adequate care) is linked with increased risk of severe falls injury, and if so, whether the risks exceed the cardiovascular benefits (acute strokes and myocardial infarction). We will consider refinement of the AHC as guided by our provider panels and steering committee. We will consider subgroups of patients depending on baseline cardiovascular or falls risk. Aim 3: We will identify site/facilty characteristics that predict AHC using 2 years of national VHA data and measure the factors associated with the most variation between sites. We will consider results with provider panels and steering committee to implement potential ways to reduce AHC. Aim 4: Throughout Aims 1-3, we will convene a panel of VA providers across medical centers and clinics to provide input on how to define AHC, structure the measure of modest/appropriate AHC, identify barriers to implementation, and best prepare the new indicator for dissemination.

描述（由申请人提供）：高血压是VHA中最常见的疾病，影响了80％以上的老年退伍军人。随着VHA护理质量的持续提高，与Medicare的老年患者相比，年长的退伍军人达到血压（BP）目标。尽管BP控制已知好处，但作为退伍军人年龄和丙烯酸多种条件的一个问题是，过度攻击性的控制可能会导致意想不到的结果，例如跌倒。我们建议更好地了解与过度攻击性高血压护理相关的心血管益处和跌落伤害风险。这项工作将导致对> 160万退伍军人的有害或浪费BP治疗的新颖测量。 VHA在改善BP的控制方面非常成功，超过现有的BP测量值79％，而在Medicare中仅超过62％。老年人将从良好的BP控制中受益，尤其是减少中风。但是，年龄较大的人由于多药而有跌倒的风险。一个问题是，我们现有的二分BP靶标导致无意中的BP，尤其是当老化的退伍军人发展老年病情（如跌倒）时。我们以前已经发现，糖尿病的老年退伍军人中有几乎三分之一是有可能经过治疗的。 VHA提供者是否应考虑在年长的退伍军人中脱颖而出，我们旨在使用国家VHA数据库在65岁及以上的退伍军人中定义积极的高血压护理（AHC）。首先，我们将使用病历审查验证AHC的数据元素。接下来，我们将测试AHC（与足够的护理相比）是否与跌倒受伤有关，以及风险是否大于中风和心脏事件的降低。最后，我们将测量AHC中的邻际变化。在这些目标中，我们将涉及VHA提供商，以审查结果，指导分析决策并尽早确定实施的潜在障碍。在奖项结束时，我们旨在开发针对特定年龄段，同胞伯恩（Burnen）和心血管疾病的基线风险的老年退伍军人相关性的适当高血压护理的新颖测量。 AIM 1（验证AHC的数据要素）：与我们的提供商小组和指导委员会合作，我们将审查AHC的数据要素（BP <130/65 mmHg与持续3+或升级1+ BP药物相结合），以在65岁及以上的老年退伍军人中提供适当性。然后，在一个小的子样本中，我们将通过对电子健康记录进行全面审查来验证数据元素。 AIM 2（AHC的危害和益处）：在Sub-Aim 2a中，我们将使用健康和退休研究，该研究既捕获基于面试的跌倒受伤和Medicare的诊断损伤数据，从而支持我们可以应用于VHA Medicare数据的跌落伤害严重性算法的发展。然后，在Sub-aim 2b中，我们将使用与Medicare合并的两年VHA数据来测试AHC是否与严重跌倒受伤的风险增加有关心血管益处（急性中风和心肌梗塞）。我们将考虑在我们的提供商小组和指导委员会的指导下对AHC的改进。我们将根据基线心血管或跌倒风险考虑患者的亚组。目标3：我们将确定使用2年的国家VHA数据来预测AHC的站点/便利性特征，并衡量与站点之间最大变化相关的因素。我们将考虑提供者小组和指导委员会的结果，以实施减少AHC的潜在方法。目标4：通过目标1-3，我们将在医疗中心和诊所召集一个VA提供商小组，以提供有关如何定义AHC的意见，构建衡量适中/适当的AHC，确定实施障碍，并最好地准备新的散布指标。