The Hypertension Initiative and OQUIN

Programs and Progress to Date: CVD Mortality in SC improved from 50th in 1995 to 34th nationally in 2009

Use of database to facilitate and advance quality improvement

Summary

Strategies (effective, low cost/complexity, scalable): 1. Healthy lifestyles – physical activity & good nutrition Healthy lifestyles – physical activity & good nutrition 2.Effective health care – access to care & medications

Mission Statement: To facilitate the transition of SC and the Southeast from a leader in CVD to a model of heart & vascular health

Goal:1. Improve overall health2. Cut heart attack &

stroke in ½

Intervention Requirement•High cost•Time intensive•High level staff expert•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 implementat’n

Research Design

•Not relevant

•Not representative of patients, 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.

• Double the number of OQUIN sites from 108 to 216 in SC• Increase the number of adult patients in OQUIN from 800,000 to 1.7 million and

the number of pediatric patients from 100,000 to 250,000 in SC

• Increase number of ASH-Designated Hypertension Specialists in SC from 47 to 70

• Contracts in place to add 75 clinical sites (blue=adult, green=pediatric)• Contracts in place to add ~300K adults and ~150K pediatric patients

OQUIN Overview July 31, 2012 5

Coverage/Growth in the Practice Network

Practices as of 2010(108 sites)

Current sites plus new adult and pediatric practice sites (183 sites)

ASH Clinical HTN Specialists in the Carolinas & Georgia

Clinical HTN Specialists in GA, NC, SC. ASH goal: At least 1 HTN Specialist in every country / parish with 1 Specialist for every 20 primary care physicians

There are too many uncontrolled hypertensive patients to be managed by Specialists, so their expertise must be leveraged through–Education of patients and colleaguesPatient Care; manage challenging HTN / CVD risk management referrals Research; practical clinical trials, comparative effectiveness research.

Am J Hypertens 2002;15:372-379.

Quality Reports and Certifications

Learn yourABC’S

Quality Reports and Certifications

ABC’S Report• Providers can see at a

glance how they are performing compared to ABC’S Standards

• Confidential Report for each physician and provider

• Results by patient to identify potential actions and see results of actions taken

• Averages by category to identify areas for improvement and role model behavior

• Linked to Recognition programs and bonus payments

OQUIN Heart and Stroke Recognition Program Patient ReportNCQA, Bridges to Excellence, DHEC, and OQUINConfidential Report for "Example Provider" Summer 2011

in control Heart/Strokeminimum ABC'S Pointsout of control min=40

cont=50# Patient Name sort by ↑↓1 Doe, John 125/75 10 129 5 yes 10 yes 10 yes 10 452 Doe, John no data 0 145 0 yes 10 yes 10 no 0 203 Doe, John 135/88 10 99 10 yes 10 yes 10 yes 10 504 Doe, John 145/95 5 99 10 yes 10 yes 10 yes 10 455 Doe, John 125/75 10 90 10 yes 10 yes 10 yes 10 506 Doe, John 125/75 10 no data 0 no 0 no 0 yes 10 207 Doe, John 145/95 5 129 5 yes 10 yes 10 yes 10 408 Doe, John 135/88 10 85 10 yes 10 yes 10 yes 10 509 Doe, John 155/100 0 no data 0 no 0 no 0 no 0 010 Doe, John 135/88 10 99 10 yes 10 yes 10 yes 10 5011 Doe, John 125/75 10 120 5 yes 10 yes 10 yes 10 4512 Doe, John 125/75 10 85 10 yes 10 yes 10 yes 10 5013 Doe, John 125/75 10 129 5 yes 10 no 0 yes 10 3514 Doe, John 145/95 5 145 0 yes 10 yes 10 yes 10 3515 Doe, John 125/75 10 120 5 yes 10 yes 10 yes 10 4516 Doe, John 140/95 5 99 10 yes 0 yes 10 no 0 2517 Doe, John 125/75 10 90 10 yes 10 yes 10 yes 10 5018 Doe, John 125/75 10 85 10 yes 10 yes 10 yes 10 5019 Doe, John 125/75 10 85 10 yes 10 yes 10 yes 10 5020 Doe, John 125/75 10 85 10 yes 10 yes 10 yes 10 5021 Doe, John 125/75 10 85 10 yes 10 yes 10 yes 10 5022 Doe, John 140/95 5 120 5 yes 0 no 0 yes 10 2023 Doe, John 125/75 10 99 10 yes 10 no 0 yes 10 4024 Doe, John 125/75 10 90 10 yes 10 yes 10 yes 10 5025 Doe, John 125/75 10 120 5 yes 10 no 0 yes 10 35

Provider Results ≥75% 82% ≥50% 70% ≥80% 92% ≥80% 76% ≥80% 88% 40Uses last labs, must have labs within last 2 years or values will show 0

sort by ↑↓ sort by ↑↓ sort by ↑↓ sort by ↑↓ sort by ↑↓

SmokingStatus/AdviceTreatmentyes=10

CompleteLipidProfileyes=10

Aspirin /Anti-thromboticyes=10

Blood Pressuremin, <145/95control, <140/90min=5, cont=10

LDL Cholesterolmin, <130control, <100min=5, cont=10

OQUIN: Control of BP and LDL in Hyperlipidemic Hypertensives

(2000-2011)

OQUIN Overview October, 201210

In one decade, SC OQUIN practices had a relative improvement of:• 56% in BP Control to <140/<90 mm Hg • 78% in LDL Control to <100 mg/dL • 167% in both BP and LDL Control, which reduces CHD 50%

National Rankings and Improvement

SC Improvement in CV Mortality Rank vs. Other ‘Stroke Belt’ States: 1995 – 2009.

STROKE BELT

1995 Rank 2008 Rank Change

31—Virginia 27—Virginia +434—North Carolina 32—North Carolina +235—Indiana 34—South Carolina +1641—Arkansas 39—Indiana −443—Alabama 40—Georgia +444—Georgia 44—Kentucky +246—Kentucky 45—Tennessee +447—Louisiana 46—Arkansas −549—Tennessee 48—Louisiana −150—South Carolina 50—Alabama −751--Mississippi 51--Mississippi 0

Source: CDC WONDER Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File 1979-1998. CDC WONDER On-line Database, compiled from Compressed Mortality File CMF 1968-1988, Series 20, No. 2A, 2000 and CMF 1989-1998, Series 20, No. 2E, 2003. Accessed at http://wonder.cdc.gov/cmf-icd9.html on Jun 11, 2012 2:54:38 PM and CDC WONDER Online Database, compiled from Compressed Mortality File 1999-2008 Series 20 No. 2N, 2011.

OQUIN Overview July 31, 2012 11

WORST (50th in US,1995)

FIRST (34th & Most Improved in Stroke Belt)

Million Hearts: ABCS Status

Source: CDC Million Hearts: Strategies to Reduced the Prevalence of Leading Cardiovascular Disease Risk Factors --- United States, 2011, Early Release, Vol. 60. Source: OQUIN CY 2011 network total. These are patients in treatment, not total population.

Indicator

Target Population

US Populati

on

Targets

US Populati

on Curren

tAverag

es

US Clinic

al Targe

ts

OQUIOQUIN N

PractiPracticece

2011 2011 ResulResul

tsts

AAspirinspirin People at increased People at increased risk of cardiovascular risk of cardiovascular disease who are disease who are taking Aspirintaking Aspirin

6565%%

4747%%

7070%%

3636%%

BBlood lood PressurePressure

People with People with hypertension who hypertension who have adequately have adequately controlled blood controlled blood pressurepressure

6565%%

4646%%

7070%%

7373%%

CCholesteholesterolrol

People with high People with high cholesterol who have cholesterol who have adequately managed adequately managed hyperlipidemiahyperlipidemia

6565%%

3333%%

7070%%

7272%%

SSmokingmoking People trying to quit People trying to quit smoking and who smoking and who get helpget help

6565%%

2323%%

7070%%

7272%%

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, et al: Okonofua, et al: Hypertension, Hypertension, 2006.2006.

Therapeutic inertia accounted for 19% of the variance in BP control

Hypertension. 2012; 59:1124–1131.

Data on 50 HTN Pts. The 1st BP reading was taken by the physician using the BpTRU. The 2nd through 6th BP readings were taken using the BpTRU with only the Pt in the exam room.

Myers. Blood Press Monit 2006; 11:59–62.

The white coat response associated with office BP can be virtually eliminated with the BpTRU device.

Myers, et al. J Hypertens 2009; 27:280–286.

Selassie, et al. Hypertension 2011;58:579 – 587.

White

Database: Guide & evaluate

CME Inform practice-

based QI, CER interventions

Preliminary data for grant apps esp T3, T4, i.e, CER, PCT; D & I

Publications: CVD and non-CVD

The Hypertension Initiative and OQUIN

Programs and Progress to Date: CVD Mortality in SC improved from 50th in 1995 to 34th nationally in 2009

Use of database to facilitate and advance quality improvement

Summary