Clinical decision-making in blood pressure management of patients with diabetes mellitus: An Oklahoma Physicians Resource/Research Network (OKPRN) study

Background: Outcomes can be improved when the blood pressure (BP) is kept below 130/80 in patients with diabetes mellitus. However, physicians and patients achieve this target less than 50% of the time. The purpose of this study was to determine the reasons for this apparent quality deficit from the perspective of a small random sample of family physicians. Methods: Nine family physicians completed interviews about encounters with diabetic patients with BP >= 130/80 for whom no change in management was recorded. Four investigators analyzed the transcribed interviews to identify and categorize reasons for failure to intervene. Results: Ninety-eight (62%) of 159 patients had BP >= 130/80 at the index visit. No change in management was recorded in 73 (74%). Physicians gave 175 reasons for nonintervention in 3 broad categories, physician-related, patient-related, and information/measurement- related reasons, and 10 subcategories. In most cases they gave more than one reason ( mean 2.4) per case. The most frequent subcategories were limited treatment options (47/73; 64%), inadequate information on which to intervene (43/73; 59%), and patient nonadherence (27/73; 37%). Competing demands were mentioned in 10 cases (13.7%). Physicians differed with regard to the kinds of reasons given. Conclusions: Physicians have a variety of clinical reasons for not responding to elevated BP in diabetic patients. Some might be addressed with better technology (eg, more reliable BP measurements) or health care system reforms ( eg, less expensive medications). Others ( eg, patient nonadherence) are more challenging. Methods for measuring quality must be robust enough to account for legitimate clinical reasons for not achieving BP targets. Physician-based interventions will need to take into account different physician personalities and practice styles.