Transcript Hypertension Initiative: Data Management & Security


The ASH Model for Hypertension Control
and role of ASH Regional Chapters

ASH Regional Chapters

ASH Clinical HTN Specialists

The O’QUIN HTN Initiative

BCBS / O’QUIN HTN Initiative QI-P4P
Collaborative
Year
Aware Treated Rx/C
Control
2000
63%
47%
50%
25%
2002
63%
50%
64%
30%
2004
67%
54%
64%
33%
2010
80%
72%
70%
50%
All data are age-adjusted.
1Egan, Basile: J Invest Med, 2003.
2Ong, et al: Hypertension, 2007.

Continuing national leadership role in professional
education & research and by developing an
educational / interactive website for the lay public

Expanding educational influence thru regional ASH
Chapters committed to optimizing awareness, Rx,
and control of Htn and concomitant CV risk factors.

Impacting HTN control locally thru a network of ASH
Specialists and others focused on patient /
community activation and practice optimization

Implementing CQI using a data-driven process.
Rocky
Mountains
Chapter in
Planning
PA, DE
FLORIDA

Patient, provider, community, and systems
characteristics vary by region

Local and regional solutions require coordinated &
active input from local and regional stakeholders

Chapters serve as a focal point for stakeholders to
identify best public health and practice models &
methods for prevention and awareness, Rx &
control of hypertension & other CV risk factors
Egan, Lackland, Basile: Am J Hypertens 2002;15:372-379.

Greater CV risk: More elderly, more minorities,
more obesity

Feds unlikely to solve problem

We can make a difference by:
–educating the public, payors and policy makers
–promoting implementation of best practices
–developing a database to guide CME and CQI
Egan, Lackland, Basile: Am J Hypertens 2002;15:372-379.

Commit to excellence in CV risk control

Become an active member of ASH, a Regional
Chapter (Carolinas-Georgia), and the Initiative

ASH:  www.ash-us.org for information on ASH,
ASH Chapters, and ASH Hypertension Specialists

Chapter: Contact Dr. Lackland’s office
([email protected]) for information on the
Carolinas-Georgia Chapter.

Initiative, TEMR, and VRS project: Contact: Kim
Edwards ([email protected]); phone 843-792-1715
There are too many uncontrolled Htn Pts to
be managed by Specialists, so their expertise
must be leveraged through–

Education of patients and colleagues

Patient Care; referrals of challenging Htn Pts

Health Services Research & clinical trials–
CMS 7th scope of work; IOM report.
ASH Clinical HTN Specialists
in the Carolinas & Georgia
Clinical
Hypertension
Specialists in
GA, NC, SC.
ASH goal: At
least 1 HTN
Specialists in
every country /
parish with 1
Specialist for
every 20
primary care
physicians
South Carolina
 Top 10% for HTN Specialists / capita
 Better geographic dispersion of Specialists
 Majority of Specialists Primary Care
Reasons
 Promote Specialists at all CME program
 BCBS $5,000 incentive
 BCBS pays Specialists for consultant service

The ASH Model for Hypertension Control
and role of ASH Regional Chapters

ASH Regional Chapters

ASH Clinical HTN Specialists

The O’QUIN HTN Initiative

BCBS / O’QUIN HTN Initiative QI-P4P
Collaborative
Mission Statement:
To facilitate the transition of the Southeast
from a leader in CVD to a
model of heart & vascular
health
Goal:
1. Improve health
2. Cut heart attack &
stroke in ½
Strategies:
1. Healthy lifestyles – physical activity & good nutrition
2. Effective health care – access to care & medications
Proverbs 23:1-3. Avoid rich (royal) food and
gluttony. When you sit to dine with a ruler (royal
food), note well what is before you, and put a knife
to your throat if you are given to gluttony. Do not
crave his delicacies, for that (royal) food is deceptive.
Daniel 1:12,15. Please test your servants for 10 days.
Give us nothing but vegetables to eat and water to
drink. At the end of 10 days they looked healthier
and better nourished than the young men who ate
the royal food.

HUNGER: Insatiable appetite (Eccl 6:7, Phil 3:18,19)

UP WITH: Obesity, Fatigue, Sleep Apnea

3 FREE HIGHS: Blood Pressure, Sugar, Cholesterol

ATTACKS & FAILURE of brain, heart, Kidney

CANCERS of the Breast, Colon, Esophagus, Kidney,
Prostate, Uterus

WORN OUT PARTS: Loss of ‘Nature,’ Old Timer’s
disease, Arthur(itis)
Mission Statement:
To facilitate the transition of the Southeast
from a leader in CVD to a
model of heart & vascular
health
Goal:
1. Improve health
2. Cut heart attack &
stroke in ½
Strategies:
1. Healthy lifestyles – physical activity & good nutrition
2. Effective health care – access to care & medications
The HTN Initiative
includes >280
practices in the
Southeast including
~150 with EMRS &
>1,600,000 patients
that provide
recurring data. The
Initiative returns
confidential reports
to physicians
designed to
facilitate quality
improvement in Rx
and control of HTN,
hyperlipidemia and
diabetes.
.
Patients
Patient ID (Masked)
Birth Date (mo/yr)
Race / Ethnicity
Sex
Insurance Status
Zip Code / RUCA
Visits
Patient ID (Masked)
Date of Visit
Site of visit (Masked)
Provider Seen (Masked)
Weight (kg); Height (m)
Systolic , Diastolic BP
ICD9s / CPT codes
Patient ID (Masked)
ICD9 / Problem List
CPT codes
Dates
Labwork
Patient ID (Masked)
Date of Lab
Lab Name
Lab Result, Unit
 Available in limited data set with IRB approval
Medications
Patient ID (Masked)
Drug ID (FDA ID/NDID)
Start, End Date
Dose
Unit
Frequency
Outcomes (SC only)
ER visits, Dx, Cost
Hosp, Dx, Cost
Prescriptions filled
(Medicaid)
100
90
80
70
60
50
40
30
20
10
0
BP<150/95
BP<140/90
Ja
n00
Ju
l-0
Ja 0
n01
Ju
l-0
Ja 1
n02
Ju
l-0
Ja 2
n03
Ju
l-0
Ja 3
n04
Ju
l-0
Ja 4
n05
Percent Controlled
BP Control 2000-2005
Date
Egan, et al. J Clin Hypertens, 2006.
BP control in
patients among
practices in the
Initiative. In
>200,000
patients with at
least 5 visits in
different 6 month
intervals, BP
control to
<140/<90
improved from
49% to 66% in
the 5-year period
from 2000 - 2005.
100
90
80
70
60
50
BP<130/80
LDL<100
40
HbA1c<7.0
30
20
10
Ja
n
M -00
ay
Se -00
pJa 00
n
M -01
ay
Se -01
pJa 01
n
M -02
ay
Se -02
pJa 02
n
M -03
ay
Se -03
pJa 03
n
M -04
ay
Se -04
pJa 04
n05
0
Egan, et al. J Clin Hypertens, 2006.
Multiple risk
factor control
for >80,000
diabetic
patients with
hypertension
and
hyperlipidemia
who had at
least 5 visits
over the 5-year
period 2000 200s.
Time Trends in Application
Evidence-Based Therapies:
Time of
Trends
The ASH Carolinas-Georgia Chapter Database
60
Diabetics on ACEI
50
Percentage
40
HF Pts on -B
30
20
HF Pts on ,-B
10
0
Jan-00
Jan-01
Jan-02
Jan-03
Jan-04
Date
Diabetics on ACEI
Diabetics on ARB
Heart Failure Patients on Beta Blockers
Heart Failure Patients on Alpha-Beta Blockers
Jan-05
Hypertension
Indicators for
Dr. John Doe
70.0%
%BP < 140/90
65.0%
60.0%
P<0.01
P<0.001
55.0%
Caucasians
50.0%
African American
45.0%
40.0%
35.0%
30.0%
VA
Non-VA
Initiative data
use f evaluation
of racial and
healthcare
system
differences in
CV risk factor
treatment and
control. At the
VA, BP control
was better for
black men and
the racial
disparity was
less.
Rehman S, et al: Arch Int Med 2005;165:1041–1047.
% with BP < 140/90 mmHg mmHg
80
70
60
50
First visit
40
Last visit
30
20
10
0
Q1
Q2
Q3
Q4
Q5
Quintiles of therapeutic inertia score
Okonofua E, et al: Hypertension 2006;47:1–7.
1. 00
<110
110-119
0. 75
120-129
0. 50
130-139
0. 25
0. 00
500
0
500
1000
1500
1000
1500
2000
2000
2500
2500
t i me
S T RA T A :
Time (Days)
s t at us d=1
Ce n s o r e d
s t at us d=1
s t at us d=2
Ce n s o r e d
s t at us d=2
s t at us d=3
Ce n s o r e d
s t at us d=3
s t at us d=4
Ce n s o r e d
s t at us d=4
Database:

Guide CME

Publications: CVD and
non-CVD

Preliminary data for
grant applications; T2
and T3 research
Network:
Quality improvement
—CV, diabetes
—most chronic disease
— CME
Clinical Trials: T2 and T3
research incl genetic epi,
pharmacogenomics
Provider education
 Provider reminders
 Audit & feedback
 Facilitated relay
 Patient education
 Pt self-management
 Patient reminders
 Team Change*

Walsh, et al: Med Care 2006.
Self-monitoring*
 Patient education
 Physician education
 Nurse or Pharmacist care*
 Organizational interventions
(too much heterogeneity)

* Interventions with largest effect size
Fahey, et al. Cochrane Rev 2009
Intervent’n Characteristics
• High cost
• Time intensive
• High level staff expertise
• Not well packaged
• Ignore user needs
• Not self-sustaining
• Setting specific
• Not ‘customizable’
Target Setting Limitations
• Competing demands
• Client needs
• Outside program
• Limited resources/support
• Established work patterns
• Inadequate incentives
• Low-quality
implementation
Research Design
• Not relevant
• Not
representative of
patients and
practices
• Fail to evaluate
cost, RE-AIM,
sustainability
Interactions among intervention, setting, and design barriers
• Given participation barriers, program reach and/or participation are low
• Interventions are inflexible, inappropriate for target population
• Staffing not matched to intervention needs/requirements
• Practice setting organization and intervention team philosophies misaligned
• Practice setting unable to implement intervention as designed
Glasgow RE, Emmons KM. Ann Rev Publ Health. 2007;28:413–433.

The ASH Model for Hypertension Control
and role of ASH Regional Chapters

ASH Regional Chapters

ASH Clinical HTN Specialists

The O’QUIN HTN Initiative

BCBS / O’QUIN HTN Initiative QI-P4P
Collaborative

What’s wrong with the current reimbursement system

P4P: Definition, objectives, measures

Brief review CMS QI Roadmap

AHA translation and QI principles

QI-P4P key design elements

Previous experience; early adopters

Provider’s standpoint
 Providers are paid the same amount regardless of
outcome.
 From an economic standpoint, there is no
incentive to improve “quality” (clinical outcomes).
 The current system also does not incentivize
providers and practices to:
▪ Expand preventive services
▪ Enhance patient safety and satisfaction

Insurers’ standpoint
 Health insurers want to
account for the quality
and the economy of
medical services.
 They recognized the
financial benefits of
improving the health of
their subscribers
 Employers’ standpoint

There is a strong need
to control health care
costs / premiums

Productivity suffers
when employees have
medical problems /
issues
Defining P4P:

“Pay-for-performance (P4P) programs offer
financial incentives to physicians for achieving
specific, measurable patient safety, quality,
satisfaction or efficiency objectives.

P4P programs generally base a portion of physician
payment on quantitative measures. These may
include patient care process and/or outcome
measures and/or patient satisfaction scores.”

Any P4P program should have as its central purpose
to improve the quality of patient care, satisfaction
and clinical outcomes.

Most P4P programs focus primarily on clinical
outcomes and patient satisfaction
 Utilize the Health Plan Employer Data and
Information Set (HEDIS) measures from the NCQA.

Half also include efficiency measures (e.g., the
number of inpatient admissions or rate of prescribing
generic medications)

More programs are measuring the use of Information
Technology

Typically, the incentive is weighted among the
different measures
Vision: The right care for every person every time
 Make care:
 Safe
 Effective
 Efficient
 Patient-centered
 Timely
 Equitable
 Strategies
 Work through partnerships
 Measure quality and report
comparative results
 Value-Based Purchasing: improve
quality and avoid unnecessary costs
 Encourage adoption of effective
health information technology
 Promote innovation and the evidence
base for effective use of technology
QI P4P:
TRIP:
1.
Promote safe, effective,
patient-centered, timely,
efficient care
2.
Use rigorous methods; riskadjust, standardize, EBM
Develop clinical decision
support and QI tools
3.
Promote quality-of care
systems & infrastructure
Directed-cause campaigns
4.
Evaluate if goals reached,
unintended effects occur
1.
Scientific discovery
2.
Disseminate discoveries
3.
Evidence-based guidelines
4.
Performance measures
5.
6.
AHA Special Report. Circulation 2008;118:687–696.
AHA Policy Recommendation. Circulation 2006;113:1151–1154.
Dimension
Major Issues
Program Features
Evidence / Theory
Individual vs.
group Incentive
Clear accountability;
address system issues
14% physician only
25% both
61% groups only
Group less effect single MD;
Small sample prob for MD;
ind incentive less system 
Paying right
amount
$$ for improvement
Shared saving
Sponsor market share
Maximum performIncentive must compenance bonuses to docs sate for incremental cost of
avg 9% in 2005
desired action
Select highimpact
measures
Coordination across
payors; foci: quality,
appropriate use; pt sat
91% clinical quality
50% cost efficiency
42% IT; 37% satisfac
Regardless of items
chosen; coordination w/i
market ↑ effectiveness
Payment reward 1 or more thresholds;
for all quality
reward improvement;
care
$ ea pt mtg standard
70% use thresholds;
25% reward
improvements
MDs respond to ↑$ / task;
threshold doesn’t reward
+  or ↑ threshold
QI for underserved groups
Example: $$ for
cultural competency
training; no data
If higher $$ for improving
care in some groups, then
reward needs adjustment
Recog extra $$ of
improving care; may
need pt incentives
JAMA 2007;297:740 – 744.

In 2004, P4P on 136 clinical indicators began.

Quality of care for asthma, diabetes and heart disease was
increasing before P4P incentives. “Between 2003 and 2005, the
rate of improvement in quality indicators increased for asthma
and diabetes but not heart disease.

By 2007, the rate of improvement slowed for all three; quality of
care for services not associated with an incentive declined.

Continuity (seeing same doc) declined promptly after P4P began
NEJM 2009;361:368–378.

English doctors happier than California doctors with QI / P4P;
less resentment/frustration, more motivated, greater change

English doctors more chart data (vs claims); can remove difficult
patients from denominator
Ann Fam Med 2009;7:121–127.
“Our findings suggest that leading-edge
sponsors of P4P have expanded the reach of
their efforts, particularly with regard to
specialists, and increasingly are focused on
outcome and cost-efficiency measures, rather
than clinical outcome measures alone.”
Rosenthal, et al: Health Affairs 2007: Nov-Dec 1674 – 1682.
Inaugural meeting of the ‘Healthcare Quality and
Reimbursement (HQR) Advisory Board’, comprised of key
opinion leaders from 12 practices. Three ‘domains’ were
identified as essential to a successful collaboration.
 Quality indicators. Thoughtful selection of high impact
process and outcome indicators that can be clearly
defined and rigorously measured across practice settings.
 Quality improvement. Develop, share, refine best
practices to ensure productive encounters and attain goals
of the process and outcome indicator selected.
 Reimbursement/incentives. Define & implement
incentives that compensate for time and resources
invested to meet goals of process and outcome indicators.
Process
Outcome
Serum K+ yearly
BP <140/<90 if no DM or CKD
Serum creatinine yearly
BP <130/<90 if DM and/or CKD
Care freq: monthly until BP controlled
then q 3–6 mo
Prescribed >2 BP Meds
Process
HbA1c q 3mo until controlled then q 6
mo
Lipid profile annually for most
Serum creat and urine albumin
Statin if CAD (eq) or >40 and >1 other
CVD risk
ASA 75–162 mg if CAD or >40 yrs or
other CVD risk
Outcome
HbA1c <7%
HbA1c >9%
LDL <100
BP <130/<80
BP >140/>90
Process
Outcome
Visit freq: q 6wk until controlled, then LDL <100 (optional <70) CHD and risk
q 4 – 6 mo
equiv
Therapeutic Lifestyle Change
education
LDL <130 (2+ risk factors, 10-yr CHD
risk 10–19%)
Prescribed >1 lipid lowering
medication
LDL <160 (0 – 1 risk factors, 10-yr CHD
risk <10%)

The ASH Model for Hypertension Control
and role of ASH Regional Chapters

ASH Regional Chapters

ASH Clinical HTN Specialists

The O’QUIN HTN Initiative

BCBS / O’QUIN HTN Initiative QI-P4P
Collaborative