Joel Handler, MDKaiser Permanente
•Hypertension Control Success in Kaiser Permanente:
•Implementology Science
Disclosure of Relationships
I HAVE NO DISCLOSURES
Educational Objectives
• Review key elements of a successful approach to hypertension control performance
• Construct a simple hypertension treatment algorithm
• Define the advantages of population care in an integrated health care system
• Use equitable care to close the racial performance gap
Kaiser Permanente – National
Kaiser Permanente Nationwide
• 10.2 million members• 18,000 physicians• 177,000 employees• 600-700 residents &
fellows• 619 medical office
buildings • 38 hospitals• Nation’s largest
nonprofit health plan7 regions serving 8 states and D.C.
Southern California Permanente Medical Group (SCPMG)
• 4.5 million members• 74,290 employees • 7,421 physicians• 21,167 nurses• 15 hospitals• 230 medical offices
SCPMG: Who we are in 2018
• 319,000 hospital discharges• 42,500 babies delivered• 23.2 million outpatient visits• 29 million prescriptions filled• 473,934 home care
Controlling High Blood Pressure
HEDIS 2016 Top Ten PerformanceMedicare Population
Controlling High Blood Pressure
HEDIS 2016 Top Ten PerformanceCommercial Population
WHY KEEP TALKING ABOUT HTN?
• HTN is quantitatively the most important risk factor for premature CVD, being more common than smoking, dyslipidemia and diabetes.
• HTN accounts for an estimated 54% of all strokes and 47% of all ischemic heart disease events globally. (Lancet 2008; 371; 1513 – Global Burden of blood pressure related disease 2001).
• Increases the risk for CKD, HF, afib and PVD.
Treatment WorksNow We Need Implematology!
Large scale RCTs show that antihypertensive treatment results in following:• 50% reduction in heart failure• 30-40% reduction in stroke• 20-25% reduction in MI
BMJ 2008: BP Lowering Treatment Trialists’ Collaboration
SCAL HTN Control 2004 - 2010
No.
of I
ndiv
idua
ls
with
HTN
(100
0’s)
CSG Performance & CSG Population
108150
204261 295 321 34393
84
86
9775
6661
0
50
100
150
200
250
300
350
400
450
2004 2005 2006 2007 2008 2009 2010
Controlled Uncontrolled
64%
71%
73%80% 83% 84%
54%
% = Controlled
Key Elements of SuccessfulImplementation
• Hypertension registry• Expansion of the Medical Home with
walk-in no copay BP checks and a triage algorithm
• Regular performance feedback at the team level
• Simple treatment algorithm
Create a Hypertension Registry
Health System-Wide Hypertension Registry
Expand the Medical Home
Medical Assistant BP Check
• Expands access to the medical home (1800 PMDs for 800,000 pts)
• No copayment • Triage with no escape; addresses
clinical inertia• Fulfils scope of practice
requirements
Provider Feedback
HEDIS Controlling High BP Measure September 2018
Hypertension – Standard Deviation and Control Rate May 2005 through August 2008
Handler J, Lackland DT. JASH 2011; 5: 197-207
Create a Simple Treatment Algorithm Based on a
Single Combination Pill
Management of Adult Hypertension1
1.
If ACEI intolerant or pregnancy potential
Calcium Channel Blocker
Add amlodipine 5 mg X ½ daily à 5 mg X 1 daily à 10 mg daily
Spironolactone
IF on thiazide AND eGFR ≥ 60 ml/min AND K < 4.5 Add spironolactone 12.5 mg daily à 25 mg daily
If not in control
If not in control
If not in control
Thiazide Diuretic
Chlorthalidone 12.5 mg à 25 mg
OR HCTZ 25 mg à 50 mg
If not in control
ACE-Inhibitor2 / Thiazide Diuretic
Lisinopril / HCTZ (Advance as needed) 20 / 25 mg X ½ daily 20 / 25 mg X 1 daily 20 / 25 mg X 2 daily
Pregnancy Potential: Avoid ACE-Inhibitors2
Kaiser Permanente Hypertension Treatment Algorithm
Management of Adult Hypertension1
1.
If ACEI intolerant or pregnancy potential
Calcium Channel Blocker
Add amlodipine 5 mg X ½ daily à 5 mg X 1 daily à 10 mg daily
Beta-Blocker OR Spironolactone
Add atenolol 25 mg daily à 50 mg daily (Keep heart rate > 55) OR
IF on thiazide AND eGFR ≥ 60 ml/min AND K < 4.5 Add spironolactone 12.5 mg daily à 25 mg daily
If not in control
If not in control
If not in control
Thiazide Diuretic
Chlorthalidone 12.5 mg à 25 mg
OR HCTZ 25 mg à 50 mg
If not in control
ACE-Inhibitor2 / Thiazide Diuretic
Lisinopril / HCTZ
(Advance as needed) 20 / 25 mg X ½ daily 20 / 25 mg X 1 daily 20 / 25 mg X 2 daily
Pregnancy Potential: Avoid ACE-Inhibitors2
Begin with Lisinopril/HCTZ
Simplified Treatment Intervention to Control Hypertension Study
(STITCH)
• Cluster randomization trial in Canada• 93 practices randomized• Compared sequential add-on
monotherapy vs 1rst step combination therapy, then add on
• Control rate at 6 months: 64.7% vs 52.7% favoring combination therapy
Feldman RD. Hypertens 2009; 53: 646-653
Simple Algorithm: Fixed Dose Combination Based
SIMPLICITY = PERFORMANCE§ Fewer steps§ Fewer pills, for adherence§ Faster control§ Fewer visits/ improved access
Lisinopril/HCTZ Rate vs HTN Performance
Management of Adult Hypertension1
1.
If ACEI intolerant or pregnancy potential
Calcium Channel Blocker
Add amlodipine 5 mg X ½ daily à 5 mg X 1 daily à 10 mg daily
Beta-Blocker OR Spironolactone
Add atenolol 25 mg daily à 50 mg daily (Keep heart rate > 55) OR
IF on thiazide AND eGFR ≥ 60 ml/min AND K < 4.5 Add spironolactone 12.5 mg daily à 25 mg daily
If not in control
If not in control
If not in control
Thiazide Diuretic
Chlorthalidone 12.5 mg à 25 mg
OR HCTZ 25 mg à 50 mg
If not in control
ACE-Inhibitor2 / Thiazide Diuretic
Lisinopril / HCTZ
(Advance as needed) 20 / 25 mg X ½ daily 20 / 25 mg X 1 daily 20 / 25 mg X 2 daily
Pregnancy Potential: Avoid ACE-Inhibitors2 Amlodipine is Third Drug
Managementof AdultHypertension1
1.
If ACEI intolerant or pregnancy potential
Calcium Channel Blocker
Add amlodipine 5 mg X ½ daily à 5 mg X 1 daily à 10 mg daily
Spironolactone
IF on thiazide AND eGFR ≥ 60 ml/min AND K < 4.5 Add spironolactone 12.5 mg daily à 25 mg daily
OR consider bisoprolol 5 mg daily (Keep heart rate > 55)
If not in control
If not in control
If not in control
Thiazide Diuretic
Chlorthalidone 12.5 mg à 25 mg
OR HCTZ 25 mg à 50 mg
If not in control
ACE-Inhibitor2 / Thiazide Diuretic
Lisinopril / HCTZ (Advance as needed) 20 / 25 mg X ½ daily 20 / 25 mg X 1 daily 20 / 25 mg X 2 daily
Pregnancy Potential: Avoid ACE-Inhibitors2
Spironolactone PreferredFourth Drug
Protocol-Based Treatment of Hypertension
• Reduction of clinical variability• Encourages teamwork• Use of treatment algorithm
reminders in EHR• Cost efficiency• Facilitates quality of care
prioritizationFrieden TR JAMA 2014; 311: 21-22
Medication Adherence
• Adherence ≥80% with prescribed medication is an often used standard for pharmacologic benefit
• Provider understanding of medication and messaging makes a difference
Thiazide and Quality of Life
• TOMHS: 8 QOL domains; chlorthalidone = placebo
• ALPINE: no difference in sexual satisfaction thiazide vs candesartan
• SHEP: sexual problems, thirst, nocturia chlorthalidone 25mg = placebo
Frequency (%) of Adverse Effects
31Stress Reaction11Rash5.9-10.37-17.6Headache36Fatigue1-5.91.2-11.8Dizziness2.34.9Asthenia33Abnormal UrinationN=173N=168HCTZ PlaceboAdverse Effect
Weir et al. Am J Med 1996; 101: 835-925
Dear Dr. Handler,Again I request another pill to replace “amlodipine” to eliminate the swelling of my ankles. Please!! Summer is coming soon and my capri pants will not cover my swollen ankles.
Edith Wins, 100 years old
Pathophysiology of Calcium Channel Blocker Related Edema
• Not caused by fluid overload• Not responsive to furosemide• CCBs target precapillary arterioles to
increase intracapillary pressure • Intracapillary hypertension leads to fluid
transudation into soft tissue and edema• Edema is dependent, worse later in day
and better in morning
Managing Calcium Channel Blocker Related Edema
1. Always consider other etiologies of edema, ie right heart failure due to sleep apnea, steroids, anegrilide, NSAIDs; heart, kidney, and liver failure
2. Lisinopril and losartan act on venular side of capillary circuit to reduce intracapillary pressure
3. Additional antihypertensive agents permit reduction of dose of CCB
4. Daytime compression stockings, leg elevation5. Switch to another calcium blocker: nifedipine XL 30 mg 6. Reassurance
‘Blast’ Automated Reminder Calls RESULTS
Foundation: KP’s widely used communication models - crosswalk
Thank You
Modification Approximate SBP Reduction (range)
• Weight Reduction 5-10 mmHg/10kg
• Adopt DASH eating plan 8-14 mmHg
• Dietary sodium reduction 2-8 mmHg
• Physical activity 4-9 mmHg
• Moderation of alcohol consumption 2–4 mmHg
Lifestyle modifications
SCHEDULED 2 to 4 WEEK FOLLOW-UP
Accurate Measurement is Key
241/157
“Sir, is this the same technique you use for your home blood pressure readings??”
Common blood pressure errors that raise SBP 5-10 mmHg
mmHg too high• Cuff too small 5-10• Unsupported arm 5-10• Patient talking 10• Patient actively listening 5• Back unsupported 5-10• Feet not on floor 5-10• Legs crossed 5-10• Full bladder 10• Forearm blood pressure 5-10
Instructions
Instructions for Blood Pressure Spot Check
Team leaders to complete one spot check per day (5 per week), every week, capturing all staff multiple times throughout the year.
Important criteria to be assessed:a. Is the patient’s arm bare?b. Is the patient’s arm totally supported at heart level? c. Neither the patient nor the MA/Nurse should be talking during
the procedure.d. Proper size cuff
If any of the important criteria is missed, please privately coach the MA/Nurse on the criteria missed.
Please return the completed form to the DA/ADA.
Blood Pressure Spot Check March 2016
Aggregated Data Received From:Antelope Valley, Baldwin Park, Downey, Fontana, Kern County, Los Angeles, Orange County,
Panorama City, Riverside, San Diego, South Bay, West Los Angeles and Woodland Hills
Antelope Valley: •Remove clothes from arm•Reminders to pull sleeves of shirt up•Shirt sleeve too tight, advised could take shirt off
Fontana:•Patient had to be told to keep feet flat on the floor
AOBPM Technique
• Oscillometric device• Average of three readings:
§ Following 5 minutes of rest§ Three readings at 1 minute intervals
Ayanian J. NEJM 2014; 371:2288-2297
EQUALCARE EQUITABLECARE
Southern California Region
Targeted Antihypertensive Therapy
56
2,525/14, 139 (18%) black patients with uncontrolled hypertension are receiving potassium replacement, and would be good candidates for spironolactone
HTN Demographics and Utilization
57
3-4RxClasses+36.35%
>4=10.29%
3.27%
Closing AA Disparity Gap
AA HTN Uncontrolled
Lisinopril/HCTZ underdosed
2601 patients
Thiazide Naïve2331 patients
No Spironolactone1180 patients
Thiazide-naive and Suboptimal Lisinopril/HCTZ Initiatives
2500
2600
2700
2800
2900
3000
3100
3200
3300
3400
Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14
# of
pat
ient
s
Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14# SUBOPTIMAL PRINZIDE 3297 3226 3197 3139 3051 3030 3090# THIAZIDE NAÏVE 3046 2955 2970 2989 2937 2812 2829
AA POINT HTN Patients with uncontrolled or no BP
6% decrease since starting initiative
4% decrease since starting initiative
Optimize thiazide dose to HCTZ 50 mg or chlorthalidone 25
mg
Use combo drug with ACEI, then add CCB
Spironolactone 4rth drug, especially if
hypokalemic
Lifestyle improvement, salt
reduction
Targeted Interventions
ACC/AHA Hypertension Guideline 2017
• “Use of BP-lowering medication is recommended for primary prevention for an estimated 10 yr ASCVD score < 10%..for BP >/= 140/90” grade 1 page 71
• “Use of BP-lowering medication is recommended for secondary prevention of recurrent CVD events…and primary prevention for an estimated 10 yr ASCVD score >/= 10%...for BP >/= 130/80” grade 1 [SPRINT criterion was score >/= 15%]
ACC/AHA Guideline Critique
• JNC 8 DBP goal < 90 mmHg is based on 5 high quality DBP trials (HDFP, HTN-Stroke Cooperative, MRC, ANBP, VA Cooperative)
• HOT is only RCT to address DBP 90 vs 80, finding no difference
• SPRINT eligibility for ~ 20% of adults treated for hypertension and ~ 10% total adults in U.S.
Letters to the Editor
Questions?