Transcript Improvement Measures for HTN - Washington Association of

WACMHC - QI/PCMH ROUNDTABLE
Improvement Measures for Hypertension Management
September 26, 2012
Colette Rush, RN, BSN, CCM
Practice Improvement Section
Washington State Department of Health
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 Concern
The 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)
64.3%
52.6%
33%
HTN >140/90, National Heart Lung & Blood Institute Statistics, 1988
4
Hypertension is the 2nd Leading Risk
Factor for Development of Kidney Disease
Progressive disease if risk
factors are not controlled
#End Stage Renal
Disease – 500,000
5
# 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
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 Goal
UDS
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.”
13
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?
Cause
Systolic Effect
Cuff 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
American Family Physician; Practice Guidelines - New AHA Recommendations for Blood Pressure Measurement; Vol 72, Number 7, Oct . 2005
For BP Measurement
Training Kit
Http://here.doh.wa.gov/materials/bp-measurementtraining-kit
Address BP Early and Treat Quickly
– Overcome Clinical Inertia
RR = 8
N=958,074
of CV Death
Relative Risk (RR)
Relative Risk Doubles With Each
20/10 mmHg Increase
RR = 4
RR = 2
RR = 1
175/105
155/95
135/85
115/75
SBP/DBP (mmHg)
1
Lewington S et al. Lancet. 2002;360:1903−1913.
Early Benefit of BP Lowering
(Systolic Hypertension in Europe)
 Stroke 28% (P = 0.01)
 CV Events 15% (P = 0.03)
 All-cause Mortality 13% (P = 0.09)
Prompt vs. delayed BP control prevented
17 strokes or 25 major CV events per 1000 patients
followed for 6 years
Staessen JA et al. J Hypertens. 2004;22:847–857.
1
Potential Benefits of
Rapid BP Control
- 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 selfmanagement 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
Depression 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]
3