The ASH Model for Hypertension Control and role of ASH Regional Chapters

ASH Regional ChaptersASH Clinical HTN SpecialistsThe O’QUIN HTN InitiativeBCBS / O’QUIN HTN Initiative QI-P4P

Collaborative

Year Aware Treated Rx/CControl

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.

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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 (lackland@musc.edu) for information on the Carolinas-Georgia Chapter.

Initiative, TEMR, and VRS project: Contact: Kim Edwards (edwardk@musc.edu); phone 843-792-1715

There are too many uncontrolled Htn Pts There are too many uncontrolled Htn Pts to be managed by Specialists, so their to be managed by Specialists, so their expertise must be leveraged throughexpertise must be leveraged through––

EducationEducation of patients and colleaguesof patients and colleagues Patient CarePatient Care; referrals of challenging ; referrals of challenging

Htn PtsHtn Pts Health Services Research Health Services Research & clinical & clinical

trialstrials––CMS 7CMS 7thth scope of work; IOM report 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 ChaptersASH Clinical HTN Specialists

The O’QUIN HTN InitiativeThe O’QUIN HTN InitiativeBCBS / O’QUIN HTN Initiative QI-P4P

Collaborative

Strategies: 1. Healthy lifestyles – physical activity & Healthy lifestyles – physical activity & good nutrition good nutrition 2. Effective health care – access to care & medications

Mission Statement:

To facilitate the tran-sition of the Southeast from a leader in CVD to a model of heart & vascular health

Goal:1. Improve health2. Cut heart attack

& stroke in ½

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)

Strategies: 1. Healthy lifestyles – physical activity & good nutrition 2. Effective health care – access to care & . Effective health care – access to care & medicationsmedications

Mission Statement:

To facilitate the tran-sition of the Southeast from a leader in CVD to a model of heart & vascular health

Goal:1. Improve health2. Cut heart attack

& stroke in ½

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

Medications Patient ID (Masked) Drug ID (FDA ID/NDID) Start, End Date Dose Unit Frequency

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

Outcomes (SC only) ER visits, Dx, Cost Hosp, Dx, Cost Prescriptions filled (Medicaid)

BP Control 2000-2005

010

2030

4050

6070

8090

100

Date

Pe

rce

nt

Co

ntr

oll

ed

BP<150/95

BP<140/90

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. Egan, et al. Egan, et al. J Clin HypertensJ Clin Hypertens, 2006., 2006.

0

10

20

30

40

50

60

70

80

90

100

BP<130/80

LDL<100

HbA1c<7.0

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.

Egan, et al. Egan, et al. J Clin HypertensJ Clin Hypertens, 2006., 2006.

Time Trends

0

10

20

30

40

50

60

Jan-00 Jan-01 Jan-02 Jan-03 Jan-04 Jan-05

Date

Pe

rce

nta

ge

Diabetics on ACEIDiabetics on ARBHeart Failure Patients on Beta BlockersHeart Failure Patients on Alpha-Beta Blockers

Time Trends in Application of Evidence-Based Therapies:The ASH Carolinas-Georgia Chapter Database

HF Pts on -B

HF Pts on ,-B

Diabetics on ACEI

Hypertension Indicators for Dr. John Doe

P<0.01 P<0.001

30.0%

35.0%

40.0%

45.0%

50.0%

55.0%

60.0%

65.0%

70.0%

VA Non-VA

%B

P <

140

/90

Caucasians

African American

Rehman S, et al: Arch Int Med 2005;165:1041–1047.

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.

0

10

20

30

40

50

60

70

80

Q1 Q2 Q3 Q4 Q5

Quintiles of therapeutic inertia score

% w

ith B

P <

140/

90 m

mHg

mm

Hg

First visit

Last visit

Okonofua E, et al: Hypertension 2006;47:1–7.

0. 00

0. 25

0. 50

0. 75

1. 00

t i me

0 500 1000 1500 2000 2500

STRATA: s t at usd=1 Censor ed s t at usd=1 st at usd=2 Censor ed s t at usd=2st at usd=3 Censor ed s t at usd=3 st at usd=4 Censor ed s t at usd=4

130-139

120-129

110-119

<110

Time (Days)

500 1000 1500 2000 2500

Database:Database:

Guide CMEGuide CME

Publications: CVD Publications: CVD and non-CVDand non-CVD

Preliminary data for Preliminary data for grant applications; grant applications; T2 and T3 researchT2 and T3 research

Network:Network:

Quality Quality improvement improvement

——CV, diabetesCV, diabetes

——most chronic most chronic diseasedisease

— — CMECME

Clinical TrialClinical Trials: T2 s: T2 and T3 rand T3 research esearch incl genetic epi, incl genetic epi, pharmacogenomicspharmacogenomics

Walsh, et al: Med Care 2006.Walsh, et al: Med Care 2006.

Provider education Provider reminders Audit & feedback Facilitated relay Patient education Pt self-management Patient reminders Team Change*

Fahey, et al. Fahey, et al. Cochrane Rev Cochrane Rev 20092009

Self-monitoring* Patient education Physician education Nurse or Pharmacist

care* Organizational

interventions (too much heterogeneity)

* Interventions with largest effect size

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. Glasgow RE, Emmons KM. Ann Rev Publ HealthAnn Rev Publ Health. 2007;28:413–433.. 2007;28:413–433.

The ASH Model for Hypertension Control and role of ASH Regional Chapters

ASH Regional ChaptersASH Clinical HTN Specialists The O’QUIN HTN InitiativeThe O’QUIN HTN Initiative

BCBS / O’QUIN HTN Initiative QI-BCBS / O’QUIN HTN Initiative QI-P4P CollaborativeP4P 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

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

Vision: The right care for every person every time

TRIP:1. Scientific discovery

2. Disseminate discoveries

3. Evidence-based guidelines

4. Performance measures

5. Develop clinical decision support and QI tools

6. Directed-cause campaigns

QI P4P:1. Promote safe, effective,

patient-centered, timely, efficient care

2. Use rigorous methods; risk-adjust, standardize, EBM

3. Promote quality-of care systems & infrastructure

4. Evaluate if goals reached, unintended effects occur

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 only25% both61% groups only

Group less effect single MD; Small sample prob for MD; ind incentive less system

Paying right amount

$$ for improvementShared savingSponsor market share

Maximum perform-ance bonuses to docs avg 9% in 2005

Incentive must compen-sate for incremental cost of desired action

Select high-impact measures

Coordination across payors; foci: quality, appropriate use; pt sat

91% clinical quality50% cost efficiency42% IT; 37% satisfac

Regardless of items chosen; coordination w/i market ↑ effectiveness

Payment reward for all quality care

1 or more thresholds; reward improvement; $ ea pt mtg standard

70% use thresholds; 25% reward improvements

MDs respond to ↑$ / task; threshold doesn’t reward + or ↑ threshold

QI for under-served groups

Recog extra $$ of improving care; may need pt incentives

Example: $$ for cultural competency training; no data

If higher $$ for improving care in some groups, then reward needs adjustment

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

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.

NEJM 2009;361:368–378.

“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 moPrescribed >2 BP Meds

Process OutcomeHbA1c q 3mo until controlled then q 6 mo

HbA1c <7%HbA1c >9%

Lipid profile annually for most LDL <100Serum creat and urine albumin BP <130/<80

BP >140/>90Statin if CAD (eq) or >40 and >1 other CVD riskASA 75–162 mg if CAD or >40 yrs or other CVD risk

Process Outcome

Visit freq: q 6wk until controlled, then q 4 – 6 mo

LDL <100 (optional <70) CHD and risk 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 ChaptersASH Clinical HTN SpecialistsThe O’QUIN HTN InitiativeBCBS / O’QUIN HTN Initiative QI-P4P

Collaborative