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.
Hypertension affects nearly all Veterans, and the Veterans Health Administration is leading the nation in improving blood pressure control. However, we have found that older Veterans with diabetes are more likely to be over-treated with blood pressure medications than younger Veterans. This research stems from concern over older patients' intolerance to low blood pressure and multiple medications, potentially leading to injurious falls. We will develop a new measure of Aggressive Hypertension Control (AHC) in older Veterans, and study whether AHC leads to harm from fall injury that outweighs benefit from cardiovascular events. We will consider if the risk-benefit balance differs depending on individual Veterans' prior risk of cardiovascular disease or falling. Last, we will investigate system-level mechanisms leading to AHC, leading to new ways to improve health outcomes in a Veteran-centered way.
