Keeping up with Changing Guidelines and Improving

Outcomes in a Primary Care-Based Hypertension Specialty

Peter Emery, MDSpecialist in Clinical Hypertension

InterMedPortland, ME

Epidemiology of Hypertension Hypertension Practice Guidelines Experience of Kaiser Permanente Experience of InterMed

Objectives

58-78 Million American Adults 29-31% of American Adults $69.9 Billion in 2008

◦ Direct and indirect (CAD, stroke, renal failure) costs

15% of the 2.4 Million Deaths in 2009

Hypertension: By the Numbers

Control of hypertension is inadequate

81.5% are aware they have it74.9% are being treated52.5% are under control

NHANESNational Health and Nutrition Examination Survey

2007-2010

.

Date of download: 11/12/2014Copyright © 2014 American Medical Association.

All rights reserved.

From: US Trends in Prevalence, Awareness, Treatment, and Control of Hypertension, 1988-2008JAMA. 2010;303(20):2043-2050. doi:10.1001/jama.2010.650

Data are presented as means with 95% confidence intervals (error bars). For all curves, the statistical significance of change over time between 1988-1994 and 2007-2008 was P ≤ .04, except for hypertension awareness for individuals aged 18 to 39 years (P = .36) and hypertension prevalence, treated, treated and controlled, and controlled for individuals aged 18 to 39 years (insufficient data to reliably calculate significance using weighted linear regression).

Figure Legend:

Coronary Artery Disease Stroke Renal failure Congestive Heart Failure

Hypertension is really bad for us

Ischemic Heart Disease mortality rate by age and BP

Lancet 2002;360:1903

Relation between HTN and development of ESRD

JNC 7- 2003 Over the past year

◦ JNC 8◦ ASH◦ AHA/ACC

Hypertension Practice Guidelines

Confused?

JNC 7

Goal BP of <150 systolic for 60 or older- JNC 8 Staging of hypertension- AHA/ACC, ASH

◦ Stage 1: 140-159/90-99◦ Stage 2: >160/100

Initiate therapy with 2 agents Initial Therapy for Black Patients- JNC 8, ASH

◦ Thiazide diuretic or CCB “Compelling Indications”- JNC 8, AHS

◦ JNC 8- CKD◦ ASH- CKD, DM, CAD, Stroke, CHF

Beta blockers not first line therapy- all 3

What are the differences?

Mixed Messages What are we supposed to do?

Guideline Fatigue

Which Guideline Is Best?

Poor outcomes- only 50% controlled Multiple guidelines

How Do We Improve Outcomes?

Best evidence: ◦ organized, comprehensive system of regular

population review and intervention

Blood Pressure Control in Primary Care

Cochrane Database Syst Rev. 2010;(3)CD005182

LOWER THE BP AT THE POPULATION LEVEL

Keep our Eye on the Goal

Which Guideline is Best?

“High-quality blood pressure management is multifactorial and requires engagement of patients, families, providers, healthcare delivery systems, and communities.”

◦ Science Advisory from AHA/ACC, CDC

J Am Coll Cardiol. April 1, 2014, 63(12)

AHA/JCCHypertension: The Public Health Perspective

Large Managed Care Consortium based in CA◦ 9.3 Million health plan members

Kaiser Permanente

HTN control as defined by NCQA HEDIS KP Northern California HTN registry

◦ 652,763 patients in 2009 out of 2.3 million adult patients

2006-2009◦ HTN control at KPNC increased from 43.6% to

80.4%◦ Nationally 55.4% to 64.1%

Kaiser Permanente

JAMA. 2013;310(7):699-705

System-wide hypertension program 5 components

◦ Registry of hypertensive patients◦ Development and sharing of performance metrics

Internal control reports every 1-3 months Successful practices were identified and adopted across

the system◦ Evidence-based guidelines◦ MA visits for BP measurement every 2-4 weeks

NO CHARGE for visit Medications adjusted by primary care provider

◦ Single-pill combination pharmacotherapy Lisinopril-HCTZ; could be used as initial therapy

Kaiser Permanente

JAMA. 2013;310(7):699-705

Continued success 2011 control rate of 87.1%

Kaiser Permanente

Multispecialty group practice focusing on primary care

75 thousand patients

InterMed

Clinical Microsystems◦ Front-line units comprised of a small group of

people that provide health care Places where patients, families, and care teams meet Including support staff Where recurring patterns of information, behavior,

and results take place◦ Linked processes◦ Produces performance outcomes◦ Embedded in larger organizations

InterMed

Team Approach◦ “Pod” system at InterMed

“Working from the ground up”◦ Structured approach to organizational

improvement◦ “laboratory” for finding and refining successful

practices that can be adopted across the organization

InterMedClinical Microsystems

Practice-wide training in correct BP technique◦ Aneroid sphygmomanometers

Performance Metric◦ Terminal digit bias

Prescription refill protocol◦ Reducing delays in BP medication refills◦ Improving staff efficiency

24 hour blood pressure monitor Home BP monitoring

InterMed Hypertension ProgramClinical Microsystems

Practice-Wide Registry Adopting and modifying an

algorithm/practice guidelines NP/PA hypertension experts to see patients

in follow up for medication titration Hypertension Specialty Practice

◦ For resistant hypertension and challenging cases

InterMed Hypertension Program

Hypertension is prevalent, expensive and a major contributor to cardiovascular mortality

There are several practice guidelines and algorithms

Population management is the key◦ Evidence supports organized, comprehensive system of

regular population review and intervention to improve the goal of lowering BP

We are making strides in this direction at InterMed

Conclusion