One Size Doesn’t Fit All When Treating Blood Pressure in People with Diabetes

Aggressive efforts to lower blood pressure in people with diabetes are paying off – perhaps too well, according to a new study

The research shows that there have been dramatic improvements in blood pressure control among patients with diabetes in the U.S. Department of Veterans Affairs, with as many as 82 percent of patients having blood pressure controlled and 94 percent getting appropriate BP treatment.

However, given the dramatic rise in control, as many people now may be getting over-treated with blood pressure medications as are being under-treated.

That suggests it might be time to reconsider the current one-size-fits-all approach to blood pressure control, and turn to a new model that adjusts the blood pressure goal according to the individual, say a team of researchers from the VA Ann Arbor Healthcare System and the University of Michigan Health System.

Modern healthcare electronic record systems should help make this possible, they say, because blood pressure, prescription and other health data on individual risks such as heart disease or balance problems can all be combined.

In a paper being published online in the Archives of Internal Medicine, the team finds that over 8 percent of the 977,000 VA patients nationwide with diabetes are possibly being over-treated. Meanwhile, 6 percent were not being treated as aggressively as they could be.

“Appropriately treating blood pressure in people with diabetes is extremely important, and good blood pressure control should still be the goal to reduce risk of heart attack, stroke and other conditions,” says first author Eve Kerr, M.D., director of the Center for Clinical Management Research at the VAAAHS and professor of internal medicine at the U-M Medical School.

“But just treating to a BP target in all patients may result in over-treating and harming some patients because their blood pressures actually fall too low,” she adds. “We need to find better ways to measure and incentivize appropriate BP management to make sure that patients who need aggressive treatment are getting it, and to decrease the rate of inappropriate overtreatment.”

The team looked back at electronic records from people with diabetes and high blood pressure who were treated at any of 879 VA hospitals and clinics in 2009 and 2010. Almost 714,000 of them were between the ages of 18 and 75. Drawing on the expertise of dozens of VA clinical and measurement experts, they developed a “clinical action measure”, or way of assessing the appropriateness of a patient’s care by looking at treatment factors and contraindications, not just the target blood pressure. They also defined a monitor of potential overtreatment, to signal that some patients could be receiving overly aggressive treatment.

Appropriate BP management was defined by the clinical action measure having a BP either less than 140/90 or less than 150/65; or having appropriate management of elevated blood pressure (medication intensification or being on 3 or more BP medications). Potential overtreatment was defined as having blood pressure that was less than 130/65 while also receiving three or more BP medicines or having recent medication increases. They focused on the patients under the age of 75 when assessing under-treatment, and all patients when looking for overtreatment.