Siegel little impact (Davis et al 1995). The most commonly effective single-method interventions were outreach visits, including academic detailing, patient reminders and educational materials, and physician reminders. Academic detailing, originally developed in the early 1980s, was termed counter-detailing to indicate the promotion of drug use and to counter the pharmaceutical industry’s overpromotion of other drugs (Soumerai 1988; Soumerai et al 1989). It uses the pharmaceutical industry method of drug detailing to promote an institution’s desired use of drugs or other elements of patient care, and involves face-to-face meetings of providers with typically a pharmacist or another healthcare provider. At the meeting, often of just a few minutes duration, the detailer explains the specific area of promotion and leaves written materials as reference. While not extensively studied, research suggests that academic detailing is a useful way to improve prescribing practices and to successfully implement practice guidelines (Davis et al 1995; Barreuther 1997). In a recent VA study, academic detailers met with providers to discuss their past prescribing of anti- hypertensive medications and to suggest changes that would bring their practice more into compliance with JNC VI guidelines (Siegel et al 2003). Over the initial six-month period following the first meeting, thiazide diuretic use increased by 20% and calcium channel blocker use decreased by 11%. Different approaches to the prescribing of medication might improve patient adherence. Changes in dosing schedules have been tried. In one study, enalapril once daily compared with twice daily resulted in no differences in treatment outcomes (Girvin et al 1999). Combination therapy might simplify dosing schedules but usually at the expense of increased costs. Other approaches may result in improvement of care. Change in practice-wide systems may improve medication prescribing as well as other healthcare practices (Pearson et al 1996). These include disease state or case management, the use of information systems to prompt treatment of appropriate patients, and other quality improvement strategies. Appropriate public education campaigns may also be useful as well as other interventions aimed at the patient. This appears particularly important given the large number of hypertensives that remain untreated (Burt et al 1995). All of these approaches require further study to determine which are the most effective. Other efforts to improve hypertensive treatment in the US Department of Veterans Affairs Approximately 40% of VA patients have hypertension due, in part, to its older population (Meier et al 1999). Consequently, medications used to control hypertension are used extensively in VA. To address the large hypertensive disease burden on the healthcare system, VA has developed and promoted hypertension management guidelines that closely resemble JNC VI (Department of Veterans Affairs Medical Advisory Panel 1996). This has been part of a program to improve clinical outcomes via quality improvement initiatives. National performance measures starting in the late 1990s tracked the proportion of patients achieving target blood pressure and set increasing targets for the proportion of patients that should be at their goal. Perhaps partly due to these performance measures, data from a study of quality indicators demonstrated that VA out performs private-sector US healthcare systems (Jha et al 2003). VA antihypertensive medication utilization trends for 1997–1999 suggested a downward trend in calcium antagonist use and an increase in β-blocker and thiazide diuretic use (Siegel et al 1998, 2001). This continued shift from calcium antagonists to β-blockers and diuretics plus the large use of ACE inhibitors indicate greater adherence to treatment guidelines. Emphasis on evidence-based medicine together with the publication of clinical trials suggesting a lack of benefit for calcium antagonist use and safety concerns such as gastrointestinal bleeding or cancer may have had an impact on medical practice regarding this antihypertensive drug class (Psaty et al 1995; Pahor, Guralnik, Furberg, et al 1996; Pahor, Guralnik, Salive, et al 1996). However, in accord with recent data on VA’s quality, we feel the strongest agent for change in hypertension management and for the shift in medication use patterns are VA’s performance measures (Jha et al 2003). These measures grade a VA, develop accountability, and may have institutional financial incentives associated with meeting targets. This managerial approach to improving care has the net effect of engaging clinical managers, who sign performance contracts, and practitioners toward achieving specific measurable goals. This approach has resulted in improved hypertension control while producing savings in drug expenditures. The use of performance measurement as a way to improve quality in VA has, at least in part, increased the number of VA hypertensive patients with blood 12 Vascular Health and Risk Management 2005:1(1)