By Stephen Spotswood
BEDFORD, MA — In his role as the Bedford, MA, VAMC’s chief of staff, Dan Berlowitz, MD, MPH, has a vantage point that allows him to see the bigger picture when it comes to veteran care. It’s a way of thinking he’s employed for much of his career and part of the reason he was awarded the 2015 Under Secretary’s Award for Outstanding Achievement in Health Services Research in August.
The other reason is that his work has not only helped add to the understanding of the treatment of hypertension and other chronic conditions, but it’s helped transform the culture of care, not only at VA but also in hospitals and doctors’ offices everywhere.
Berlowitz’s work has focused largely on identifying what a medical system can do to improve patient outcomes. During the early 1990s, that work was centered on common outpatient medical conditions, including hypertension.
“Our premise was to identify process measures that are linked to outcomes,” Berlowitz explained in an interview with U.S. Medicine. “Then we can tell clinicians what they must focus on to improve care. We wanted to give clinicians the ability to focus on measures that have the biggest impact.”
At first, Berlowitz and his associates went over well-worn ground. They looked at differences in checking blood pressure when lying, sitting and standing. They looked at the use of an EKG and tried different blood tests.
“When we tried to link any of it to blood pressure control, we found no association. Because, frankly, no matter how many times you do a blood test, it’s not going to lower your BP,” he said. “What matters is how clinicians are managing medications for hypertension.”
Berlowitz and his team created a method for measuring hypertension care and found that patients with high blood pressure were leaving their physician’s office untreated over and over again. At the time, the fault was placed on the patients. They were not following recommendations or adhering to their medication regimen. Sometimes they would give excuses, and the physician would put off treatment until the next visit.
“They would wait another month and then another month, and patients would go for long periods of time without intensifying therapy,” Berlowitz explained.
Similar work being done in diabetes care had led to the coining of the phrase “clinical inertia,” which Berlowitz recognized was happening with hypertension.
“Rather than patients not taking their medications, it was the physicians who were not aggressive enough in their management of hypertension,” he said.
VA’s nature as a self-contained healthcare system allowed it not only to track hypertension treatment but also to employ sweeping changes in care and ensure clinicians stuck to them. Thanks to this effort — one that now has spread far beyond VA — blood pressure control is much better in the United States, strokes are down, and mortality from hypertension is down.
“Today, people are much more aggressive in managing hypertension and getting it under control. Providers are being held accountable,” Berlowitz said.
Hypertension control is the most visible result of Berlowitz’s work, but it’s the effect on physician practice and culture that might be most important. Helping clinicians recognize clinical inertia and break free of it translates to areas of care far beyond blood pressure control.
In the very near future, Berlowitz’s work will again become important for hypertension care. The National Institutes of Health’s Systolic Blood Pressure Intervention Trial (SPRINT) released preliminary data last month that will likely lead to recommendations calling for more-aggressive treatment — lowering the target systolic blood pressure from 140 mm Hg to 120 mm Hg. Data from the study, which has followed 9,000 patients for several years, shows that such a change could reduce the risk of death from cardiovascular incidents by almost 25%.
The 140 systolic blood pressure target has been the goal for many years, and adapting to a change like that could be difficult for medical systems. It likely would mean that hypertensive patients would add at least one new drug to their regimen. The full report from SPINT is due to come out in December and will contain more-nuanced data about what patient populations would be best served by more aggressive treatment.
“Advocating 120 is a tremendous change,” Berlowitz said. “My original work becomes important again: figuring out how to get clinicians to intensify therapy. All that effort that went into getting 140 now had to be intensified even further. From my perspective, that’s the challenge now.”