The need for improved medical management of patients with concomitant hypertension and type 2 diabetes mellitus.

OBJECTIVES: To determine level of blood pressure (BP) control and to evaluate hypertension management strategies in patients with hypertension and type 2 diabetes mellitus. STUDY DESIGN: Retrospective review of 2 consecutive years of pharmacy and medical insurance claims data and medical charts from patients participating in 10 health plans in 9 states. PATIENTS AND METHODS: Patients 18 years and older with a medical or pharmacy claim related to hypertension were identified and assessed for inclusion in the database. A random sample of medical charts was reviewed to confirm the diagnoses of hypertension and diabetes mellitus and degree of BP control and to assess the prevalence of other cardiovascular disease risk factors and current antihypertensive treatment. RESULTS: Type 2 diabetes mellitus was documented in 977 patients. The mean age was 64.3 years, and 55.1% were women. A BP goal of less than 130/85 mm Hg was achieved in 192 patients (19.7%), and a BP goal of less than 130/80 mm Hg was achieved in 135 patients (13.8%). Fifty-two percent of patients had dyslipidemia, and 87.6% were overweight, obese, or morbidly obese; tobacco use was documented in 19.5%. CONCLUSIONS: Hypertensive diabetic patients are frequently not treated to their goal BP, which requires the use of 2 or more agents in most patients. Quality improvement programs should emphasize the importance of treating hypertensive diabetic patients to their goal BP, as well as controlling other major cardiovascular disease risk factors, such as smoking, dyslipidemia, and overweight or obesity, that are prevalent among these high-risk patients.

Predicting physician guideline compliance: an assessment of motivators and perceived barriers.

BACKGROUND: Although clinical practice guidelines are widely accepted as "best practices," provider compliance remains low. OBJECTIVES: To examine the relationship between providers' behavioral intentions and their compliance with practice guidelines; to assess the impact of perceived barriers that were most inhibiting to compliance; and to examine the ability of factors in the Physician Guideline Compliance Model to predict intention to comply and compliance with guidelines implemented at specific practice sites. METHODS: Survey research methods were used to assess effects of antecedents (attitudes, subjective norms, past behavior, and perceived behavioral control) on providers' intentions to comply and compliance with clinical practice guidelines. Provider survey I was conducted at the time of guideline introduction and survey II 4 months after implementation. RESULTS: Scores for the antecedents to behavior and behavioral intention reflected favorable responses toward the use of guidelines. The mean self-reported compliance behavior was 65%, whereas compliance as assessed by chart review was 54%. Approximately 68% of the variance in the physicians' behavioral intentions was accounted for by variables included in the Physician Guideline Compliance Model. A significant negative correlation was found between perceived barriers and self-reported behavior but not between perceived barriers and chart-review-assessed behavior. CONCLUSIONS: Some variables, particularly perceived barriers to guideline implementation, predicted a provider's practice intentions and self-reported behavior. Future guideline intervention efforts should identify and reduce these barriers to guideline compliance prior to implementation.

The hypertension management program: identifying opportunities for improvement.

To date, relatively few programs have been evaluated that were designed to affect the clinical practice patterns of primary care physicians who treat patients with hypertension. In particular, studies that have evaluated blood pressure control as a clinical outcome before and after an intervention are lacking. The Hypertension Management Program, developed by Applied Health Outcomes, is a quality improvement program designed to improve the medical management of hypertension in population-based health care settings. This program is in the process of continuing to collect baseline data from health maintenance organizations, conducting physician-focused interventions designed for improving clinical care, and collecting postintervention data between 6 and 12 months after the intervention is completed to determine its effect. The authors present the rationale for conducting large-scale hypertension management programs that measure outcomes, as well as preliminary baseline and postintervention data from the Hypertension Management Program, based on a current database of more than 1.9 million individuals enrolled in eight health care plans.

A randomized trial of an acid-peptic disease management program in a managed care environment.

OBJECTIVE: To study the effectiveness of a disease management program for patients with acid-related disorders. STUDY DESIGN: A cluster-randomized clinical trial of 406 patients comparing a disease management program with "usual practice." PATIENTS AND METHODS: Enrolled patients included those presenting with new dyspepsia and chronic users of antisecretory drugs in 8 geographically separate physician offices associated with the Orlando Health Care Group. There were 35 providers in the intervention group and 48 in the control group. The disease management program included evidence-based practice guidelines implemented by using physician champions, academic detailing, and multidisciplinary teams. Processes of care, patient symptoms, quality of life, costs, and work days lost were measured 6 months after patient enrollment. RESULTS: Compared with usual practice, disease management was associated with improvements in Helicobacter pylori testing (61% vs 9%; P = .001), use of recommended H pylori treatment regimens (96% vs 10%; P = .001), and discontinuation rates of proton pump therapy after treatment (70% vs 36%; P = .04). There were few differences in patient quality of life or symptoms between the 2 study groups. Disease management resulted in fewer days of antisecretory therapy (71.7 vs 88.1 days; P = .02) but no difference in total costs. CONCLUSION: This disease management program for patients with acid-related disorders led to improved processes of care. The effectiveness of such a program in other settings requires further study.

Effect of a primary care physician-focused, population-based approach to blood pressure control.

BACKGROUND AND OBJECTIVES: A large majority of hypertensive patients are cared for in primary care settings, and most of them do not have adequately controlled blood pressure. AvMed Health Plan, a large Florida-based, nonprofit, physician network health maintenance organization, initiated a program to assist primary care physicians to achieve a greater degree of blood pressure control in their hypertensive patients. Concomitantly, a study was designed to determine whether this physician-focused intervention improved blood pressure control in these patients. METHODS: Data were collected from pharmacy claims and medical charts for random samples of treated hypertensive patients prior to and following a 6-month educational intervention aimed at providers. Analysis of the data sets was conducted to determine what percentage of subjects achieved target blood pressure goals before and after the intervention. RESULTS: At baseline, 41% of the total population had achieved a target blood pressure of <140/90 mm Hg; 52% achieved this goal following the intervention. When target blood pressure goals were defined as <140/90 mm Hg for nondiabetic subjects and < 130/85 mm Hg for diabetic subjects, 36% of the total population achieved target blood pressure goals at baseline; 47% achieved these goals following the intervention. CONCLUSIONS: A physician-focused intervention significantly improved blood pressure control in diabetic and nondiabetic hypertensive patients enrolled in AvMed Health Plan.