Improvement Measures for Hypertension Management September 26, 2012 Colette Rush, RN, BSN, CCM Practice Improvement Section Washington State Department.

Improvement Measures for Hypertension ManagementImprovement Measures for Hypertension ManagementSeptember 26, 2012September 26, 2012

Colette Rush, RN, BSN, CCMColette Rush, RN, BSN, CCMPractice Improvement SectionPractice Improvement Section

Washington State Department of HealthWashington State Department of Health

WACMHC - QI/PCMH ROUNDTABLEWACMHC - QI/PCMH ROUNDTABLE

Session Objectives

• Make the case for selecting blood pressure control along with PCMH as quality improvement objectives.

• Describe how PCMH and hypertension QI initiatives could inform one another.

• Review key interventions for the management of hypertension.

• Discuss selecting quality improvement measures for a hypertension QI initiative.

Hypertension is….A National Health ConcernThe most common DX seen in primary care affecting approximately 1 in 3 adults in the U.S. (65 million people)

The number one risk factor for stroke and second most common risk factor for chronic kidney disease

< 50% have achieved BP control, leaving more that 32 million Americans at risk for complications from HBP. Controlling BP could avoid 46,000 deaths making it the single most effective clinical service for reducing mortality. (Margolius/Bodenheimer)

Over 60% of people with hypertension do not have it under control.

Only 34% are on a medication and have their BP controlled. (nhanes)

25% are on a medication but their BP is not controlled. (nhanes)

41 % are not on a medication and their BP is not controlled. (nhanes)

Prevalence of Hypertension (Ave of 33% in adult US Population (1 in 3)

4

52.6%

64.3%

HTN >140/90, National Heart Lung & Blood Institute Statistics, 1988

33%

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#End Stage Renal Disease – 500,000

Hypertension is the 2nd Leading Risk Factor for Development of Kidney Disease

# with Chronic Kidney Disease – 20

Million (1 in 7 people)

# at Risk for Chronic Kidney Disease (DM, HTN, Race,

Age, Family HX) – 20 Million

7 % of entire Medicare budget

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HHS and the Million Hearts Campaign – Focusing on CVD Prevention

• Federal agencies and private sector partners will focus and align measurement strategies

• Beginning in 2012, HRSA will require all community health centers to report annually on the ABCS measures to track and improve performance.

Public-Sector Support for Million Hearts Campaign

• Administration on Aging• Agency for Healthcare Research and Quality• Centers for Disease Control and Prevention• Centers for Medicare and Medicaid Services• Food and Drug Administration

• Health Resources and Services Administration• Indian Health Service• National Heart, Lung, and Blood Institute• National Prevention Strategy• National Quality Strategy• Office of the Assistant Secretary for Health• Substance Abuse and Mental Health Services• Administration• U.S. Department of Veterans Affairs

Million Hearts (HRSA UDS?)

Getting BP to GoalUDS Baseline Target Clinical

Target

Million Hearts 46% 65% (population wide)

70% (for clinical systems)

Are you focusing on BP Control as one of your QI Initiatives?

What interventions are you focusing on to improve the percent of patients with BP controlled?

Using the PCMH Model as Your Guide

PCMH and the Management of Hypertension

Review Hypertension Change Package and Relationships to PCMH– Show Document

Key Interventions for BP Control Corresponds to Which PCMH Elements? – Group Exercise (Handout)

• Accurate measurement- BP control starts with accurate measurement• Evidenced-based treatment protocols embedded in system and used

• *Technology used to identify patients needing visits, care prompts, and needing additional support

• Treat to Target - home monitoring, health coaching and medication titration

• *Team-based care- improved communication, new roles, efficient workflow with laser focus on medications and adherence

• Screen for and treat depression to manage hypertension• Address the challenges of multi-condition care

• *Support patient engagement and SMS

*CDC reports large meta analysis showing that these three are top interventions for control of BP. 77 studies were reviewed showing team-based care (specifically the use of nurses and pharmacists in

medication management) as a top intervention.

BP Management Starts with Accurate Measurement

The determination of blood pressure is one of the most important measurements in all of clinical medicine, yet …

The American Heart Association reports:

“Blood Pressure readings are one of the most inaccurately performed measurements in clinical medicine.”

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The costs of making small measurement errors.

An error of -5 mmHg = Missing 21 million borderline hypertensive patients (42 percent of all patients with hypertension) [2002 data].

An error of + 5 mmHg = Moving 27 million people into the high blood pressure range. [2002 data]

Cost of care: 27 billion for ‘non-disease’

Where are the errors?

American Family Physician; Practice Guidelines - New AHA Recommendations for Blood Pressure Measurement; Vol 72, Number 7, Oct . 2005

Cause Systolic EffectCuff too small +10-40 mm Hg

Cuff too large -5-25 mm Hg

Cuff placed over clothing +/-10-40 mm Hg

Arm above heart level +2 mm Hg per inch

Arm below the heart level -2 mm Hg per inch

Feet not flat on floor +5-15 mm Hg

Back not supported +5-15 mm Hg

Legs crossed +5-8 mm Hg

Patient doesn’t rest 3-5 min +10-20 mm Hg

Tobacco or Caffeine use + 6-11 mm Hg

Patient in pain +10-30 mm Hg

Patient talking + 10-15 mm Hg

Full bladder + 10-15 mm Hg

Difficulty breathing + 5-8 mm Hg

Artery line not centered +4-6 mm Hg

White Coat Syndrome +/- 10-40 mm Hg

For BP Measurement Training Kit

Http://here.doh.wa.gov/materials/bp-measurement-training-kit

Address BP Early and Treat Quickly – Overcome Clinical Inertia

SBP/DBP (mmHg)SBP/DBP (mmHg)

Lewington S et al. Lancet. 2002;360:1903−1913.

Relative Risk Doubles With Each 20/10 mmHg Increase

Rela

tive R

isk

Rela

tive R

isk

(RR

(RR

) )

of

CV

Death

of

CV

Death

N=958,074 N=958,074

RR = 1RR = 1

115/75

RR = 2RR = 2

135/85

RR = 4RR = 4

155/95

RR = 8RR = 8

175/105

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Early Benefit of BP Lowering

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Staessen JA et al. J Hypertens. 2004;22:847–857.

(Systolic Hypertension in Europe)

Stroke 28% (Stroke 28% (P P = 0.01) = 0.01)

CV Events 15% (CV Events 15% (P P = 0.03)= 0.03)

All-cause Mortality 13% (All-cause Mortality 13% (P P = 0.09)= 0.09)

Prompt vs. delayed BP control prevented

17 strokes or 25 major CV events per 1000 patients followed for 6 years

Potential Benefits of Rapid BP Control

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- Patient spends less time in high-risk state

- Less opportunity for patient and physician to accept inadequate control (clinical inertia)

- Patient compliance increases when BP control is achieved within weeks rather than in months

(convinced of the efficacy and the importance of taking medication)

Neutel JM et al. Am J Hypertens. 2001;14:286–292.

Key Factors that Contribute to Poor Blood Pressure Control

1. Poor understanding of clinician instructions (50% of patients leaving a visit)

2. Lack of patient participation in decision making (patients actively participate in decisions in only 9% of visits)

3. Low medication adherence (2/3 of patients)

4. Clinical inertia (in one study, 83% of patients with HBP had either poor adherence or there was a failure for the clinician to appropriately intensify medications)

Margolius D., BodemheimerT., Controlling Hypertension Requires a new Primary Care Model, The American Journal of Managed Care, 2010

Treat to Target Addresses the 4 Key Reasons for Poor BP Control

• Melding three complementary components• Use of home blood pressure monitors• Health coaching (nurses, pharmacists, medical assistants

or other non-clinicians) trained in behavior change counseling providing coaching on diet, exercise and medication adherence

• Use physician-approved stepped treatment protocols or standing orders in order to intensify medications to get the BP to goal.

Drugs Don’t Work in People that Don’t Take Them. C. E. Koop, MD

Increase Patient Engagement

• Introduce collaboration (that patient is part of the team)• Identify literacy issues• Develop interventions/tools to address low literacy• Provide support that is individualized and relevant• Support patient in problem solving/scenario based learning• Promote the ‘Ask Me Three’ campaign• Use teach-back, show-back technique• Coach patient in setting his/her own goals• Provide training for the team to give them the skills they need

to coach effectively increase patient engagement

Self-Management Support• Review of 4 Chronic Care Model (CCM)

components in 39 studies: 19 out of 20 studies with improved outcomes included self-management support. Bodenheimer, et al. JAMA Oct 2002.

The Impact of Multiple Chronic Conditions

• Can have a profound effect on patients’ ability to manage their self-care and each condition has competing demands.– Competing time demands for self-management– Medication adherence an issue with juggling regimens– Can sap finances with out of pocket expenses

• Challenging for providers to manage multiple treatment demands in a 15 minute visit

Meta-Analysis of the Effect of Meta-Analysis of the Effect of Depression on Patient AdherenceDepression on Patient Adherence

Compared to non-depressed patients, the odds are 3 times greater that depressed patients would

be non-adherent with medical treatment recommendations

DiMatteo MR et al. Arch Intern Med 2000

What Criteria/Information Will You Use to Select Measures to Track and Evaluate Improvement for the BP Control Objective? Group Exercise

UDS Numerator/Denominator for BP Control (required)

• Denominator• Patients 18-85 yrs of age by

December 31 of the *measurement year and…

• With DX of hypertension before June 30 of the *measurement year and…

• Seen at least twice during **reporting year

• Numerator • Those with most recent

SBP < 140 and DBP< 90.

* Measurement Year (for denominator)

Example: If reporting today , the measurement year would be Jan –Dec 2012

18-85 yrs of age by December 31, 2012

DX of HTN by June 30, 2012

** Reporting Year (for denominator)

Example: If reporting today the reporting year would be from September 1, 2011 – August 31, 2012

Patient would need to have been seen at least twice during that period.

Select and Define Measures

• Not feasible or effective to track data on everything you do for your population of patients with HTN but do consider:• Core measures• Baseline data• Monthly data• Track the changes that are made

Measurement (Long term)

•Blood pressure controlled (UDS): % of patients with BP less that 140/90

•Consider Blood pressure controlled (adjusted): % of patients at target – No DM/CKD BP <140/90; With DM/CKD <130/80

Measurement – Intermediate

• Average systolic/diastolic for population• % patients with (depending on the interventions you are targeting)

• Document self-management goal• Sodium reduction counseling• Use of home-monitoring• Anti-hypertensive medication adherence (challenging)• Also tobacco-cessation counseling• Screening for overweight and obesity• Weight reduction counseling• Level of PA • Screening for renal disease (eGFR)• Approp use of antihypertensive medication for patients with DM or CKD

Measurement – Intermediate

PCMH – A – tracking progress over time and zeroing in on hypertension through the following survey questions.

Measure – Via Survey Question For Who

Accurate BP measurement (per approved protocol) is successfully integrated into practice

Practice Team

Practice demonstrates regular planned visits for hypertensive patients with increased frequency until at goal

Clinician (pulled from EHR)

Practice demonstrates a team approach to care Practice Team

Practice demonstrates a patient - centered approach to care Practice Team/Patient

Practice demonstrates organized arrangements with specialists and/or community organizations

Practice Team

Practice demonstrates coordination of care activities for patients Practice Team

Patient satisfaction in hypertension care Patient

Staff/Clinician satisfaction in caring for hypertensive patients Practice Team

Identify a Pilot Population - Ideally Freeze the Population to Track Improvement

• Define the pilot population before you start• What provider(s)will participate?• Define the population of patients that are considered ‘active’ for that provider• Define criteria for patients with hypertension (ICD-9 codes, use of medications, BP

readings)• Freeze a panel of patients for reasonable period • For clinics with very transient populations

• Freeze just one pilot practice for a short time and intensify efforts here • Use cohorts (follow for awhile then start fresh cohorts)• Track the entire population as dynamic as it is tracking trends over time. Track

evidence based practice changes that have been shown to improve BP control

Resources Available October 15 , 2012

• Comprehensive QI manual titled, “Improving the Screening, Prevention and Management of Hypertension: An Implementation Tool for Clinic Practice Teams”

• Blood Pressure Measurement Training Kit• Patient educational Posters/Handouts/Booklets• Video Training Modules – later date

Will be located on the H.E.R.E. Website http://here.doh.wa.gov/

Contact Information

Colette Rush

360-236-3839

[email protected]

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