Risk-adjusted comparison of blood pressure and low-density lipoprotein (LDL) noncontrol in primary care offices

Abstract

Objectives: Population-level control of modifiable cardiovascular disease (CVD) risk factors is suboptimal. The objectives of this study were (1) to demonstrate the use of electronically downloaded electronic health record (EHR) data to assess guideline concordance in a large cohort of primary care patients, (2) to provide a contemporary assessment of blood pressure (BP) and low-density lipoprotein (LDL) noncontrol in primary care, and (3) to demonstrate the effect of risk adjustment of rates of noncontrol of BP and LDL for differences in patient mix on these clinic-level performance measures.

Methods: This was an observational comparative effectiveness study that included 232,172 adult patients ≥18 years old with ≥1 visit within 2 years in 33 primary care clinics with EHRs. The main measures were rates of BP and LDL noncontrol based on current guidelines and were calculated from electronically downloaded EHR data. Rates of noncontrol were risk-adjusted using multivariable models of patient-level variables.

Results: Overall, 16.0% of the 227,122 patients with known BP and 14.9% of the 136,771 patients with known LDL were uncontrolled. Clinic-level, risk-adjusted BP noncontrol ranged from 7.7% to 26.5%, whereas that for LDL ranged from 5.8% to 23.6%. Rates of noncontrol exceeded an achievable benchmark for 85% (n = 28) and 79% (n = 26) of the 33 clinics for BP and LDL, respectively. Risk adjustment significantly influences clinic rank order for rate of noncontrol.

Conclusions: We demonstrated that the use of electronic collection of data from a large cohort of patients from fee-for-service primary care clinics is feasible for the audit of and feedback on BP and LDL noncontrol. Rates of noncontrol for most clinics are substantially higher than those achievable. Risk adjustment of noncontrol rates results in a rank-order of clinics very different from that achieved with nonadjusted data.

Keywords: Blood Pressure; Cholesterol; Clinical Practice Guideline; Electronic Health Records; Feedback; Health Information Management.

Figure 1

Flow Diagram Illustrating Both JNC7 Criteria for BP Control and Number and Percent of Patients at Each Step.

Figure 2

Flow Diagram Illustrating NCEP Criteria for LDL Control and Number and Percent of Patients at Each Step.

Figure 3

Risk-Adjusted Percent of Patients with Blood Pressure Not Controlled by Clinic.

Figure 4

Comparison of Rank-Order of Clinics by Unadjusted and Risk-Adjusted Blood Pressure Control.

Figure 5

Risk-Adjusted Percent of Patients with LDL-Cholesterol Not Controlled by Clinic.

Figure 6

Comparison of Rank-Order of Clinics by Unadjusted and Risk-Adjusted LDL-Cholesterol Control.

Appendix Figure 1

Risk-Adjusted Percent of Patients with Blood Pressure Not Controlled by Clinic.

Appendix Figure 2

Risk-Adjusted Percent of Patients with LDL-Cholesterol Not Controlled by Clinic.