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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