Will hypertension performance measures used for pay-for-performance programs penalize those who care for medically complex patients?

Abstract

Background: There is concern that performance measures, patient ratings of their care, and pay-for-performance programs may penalize healthcare providers of patients with multiple chronic coexisting conditions. We examined the impact of coexisting conditions on the quality of care for hypertension and patient perception of overall quality of their health care.

Methods and results: We classified 141 609 veterans with hypertension into 4 condition groups: those with hypertension-concordant (diabetes mellitus, ischemic heart disease, dyslipidemia) and/or -discordant (arthritis, depression, chronic obstructive pulmonary disease) conditions or neither. We measured blood pressure control at the index visit, overall good quality of care for hypertension, including a follow-up interval, and patient ratings of satisfaction with their care. Associations between condition type and number of coexisting conditions on receipt of overall good quality of care were assessed with logistic regression. The relationship between patient assessment and objective measures of quality was assessed. Of the cohort, 49.5% had concordant-only comorbidities, 8.7% had discordant-only comorbidities, 25.9% had both, and 16.0% had none. Odds of receiving overall good quality after adjustment for age were higher for those with concordant comorbidities (odds ratio, 1.78; 95% confidence interval, 1.70 to 1.87), discordant comorbidities (odds ratio, 1.32; 95% confidence interval, 1.23 to 1.41), or both (odds ratio, 2.25; 95% confidence interval, 2.13 to 2.38) compared with neither. Findings did not change after adjustment for illness severity and/or number of primary care and specialty care visits. Patient assessment of quality did not vary by the presence of coexisting conditions and was not related to objective ratings of quality of care.

Conclusions: Contrary to expectations, patients with greater complexity had higher odds of receiving high-quality care for hypertension. Subjective ratings of care did not vary with the presence or absence of comorbid conditions. Our findings should be reassuring to those who care for the most medically complex patients and are concerned that they will be penalized by performance measures or patient ratings of their care.

Figure 1

Algorithm to Assess Appropriate Hypertension Quality of Care. BP indicates blood pressure; HTN, hypertension; and FY, fiscal year.

Figure 2

Process to Identify Patients with Hypertension Meeting Study Cohort Rules. VA indicates Veterans Affairs: FY, fiscal year: HTN. hypertension: ICD-9-CM. International Classification of Disease. 9^th revision, Clinical Modification; and BP, blood pressure. ^*2 outpatient or 1 inpatient diagnosis code ^†Elevated blood pressure reading defined as ≥ 140/90 mm Hg

Figure 2

Process to Identify Patients with Hypertension Meeting Study Cohort Rules. VA indicates Veterans Affairs: FY, fiscal year: HTN. hypertension: ICD-9-CM. International Classification of Disease. 9^th revision, Clinical Modification; and BP, blood pressure. ^*2 outpatient or 1 inpatient diagnosis code ^†Elevated blood pressure reading defined as ≥ 140/90 mm Hg