Maxing Out BP Meds in Diabetics Questioned

Overly aggressive treatment of hypertension in diabetic patients occurred almost as often as undertreatment at facilities included in a review of Veterans Affairs (VA) hospitals and outpatient clinics.

Overall, 94% of hypertensive diabetic patients seen at 879 VA facilities received care consistent with a clinical action measure of appropriate treatment of hypertension. However, 20% of patients had lower-than-recommended blood pressure values, and examination of records revealed potential overtreatment in 40% of the cases (8% of all diabetic patients).

Rates of overtreatment ranged as high as 20% at individual facilities, particularly facilities that achieved high rates of compliance with threshold blood pressure values, according to an article published online in Archives of Internal Medicine.

"While 94% of diabetic veterans met the action measure, rates of potential overtreatment are currently approaching the rate of undertreatment, and high rates of achieving current threshold measures are directly associated with overtreatment," Eve A. Kerr, MD, of the VA Ann Arbor Healthcare System and University of Michigan in Ann Arbor, and co-authors wrote.

"Implementing a clinical measure for hypertension management, as the Veterans Health Administration is planning to do, may result in more appropriate care and less overtreatment."

Treat-to-target has become the clinical mantra for controlling cardiovascular risk factors, particularly lipids and blood pressure. However, dichotomous threshold measures (such as blood pressure <140/90 mm Hg) fail to take into account individual variation in risk, patient preferences, treatment intensity, disease severity, or adherence, the authors explained.

Moreover, available evidence has not consistently supported a treat-to-target strategy. Randomized trials have shown causal associations between treatment and benefit, but not achievement of a specific threshold for a risk factor.

"Dichotomous threshold measures, however, are silent on the manner of achieving risk factor control," the authors continued. "Consequently, such measures can promote overtreatment and diastolic hypotension, which has been shown in multiple studies to be associated with worse cardiovascular outcomes."

In contrast, "tightly linked" clinical action measures based on evidence better reflect the complexities and nuances of clinical decision making in the treatment of hypertension. Clinical action measures do not focus solely on attainment of a risk factor level but also the implementation of evidence-based treatment when a risk factor threshold is not attained.

In collaboration with the Department of Veterans Affairs, the authors developed a clinical action measure for blood pressure management. They also identified a marker of potential overtreatment that could result in a patient receiving overly aggressive, risky treatment.