Adjusting for Patient Economic/Access Issues in a Hypertension Quality Measure

Introduction: The American Heart Association and American College of Cardiology have proposed adjusting hypertension-related care quality measures by excluding patients with economic/access issues from the denominator of rate calculations. No research to date has explored the methods to operationalize this recommendation or how to measure economic/access issues. This study applied and compared different approaches to populating these denominator exceptions. Methods: Electronic health record data from 2019 were used in 2021 to calculate hypertension control rates in 84 community health centers. A total of 10 different indicators of patient economic/access barriers to care were used as denominator exclusions to calculate and then compare adjusted quality measure performance. Data came from a nonprofit health center‒controlled network that hosts a shared electronic health record for community health centers located in 22 states. Results: A total of 5 of 10 measures yielded an increase in adjusted hypertension control rates in ≥50% of clinics (average rate increases of 0.7–3.71 percentage points). A total of 3 of 10 measures yielded a decrease in adjusted hypertension control rates in >50% of clinics (average rate decreases of 1.33–13.82 percentage points). A total of 5 measures resulted in excluding >50% of the clinic's patient population from quality measure assessments. Conclusions: Changes in clinic-level hypertension control rates after adjustment differed depending on the measure of economic/access issue. Regardless of the exclusion method, changes between baseline and adjusted rates were small. Removing community health center patients experiencing economic/access barriers from a hypertension control quality measure resulted in excluding a large proportion of patients, raising concerns about whether this calculation can be a meaningful measure of clinical performance.