Project aims to get 80% of hypertension patients under control

A trade group that represents more than 400 integrated health systems and medical groups that employ 130,000 physicians is launching an initiative to dramatically improve the quality of hypertension care.

More than 120 health care organizations, including Mayo Clinic, Kaiser Permanente and Cleveland Clinic, have signed on for the Measure Up, Pressure Down campaign. The project was started by the American Medical Group Foundation, the nonprofit research and education arm of the American Medical Group Assn. The foundation hopes that at least three-quarters of AMGA members will take part in the campaign, whose goal is for each organization to achieve an 80% rate of blood-pressure control among its patients with uncomplicated hypertension by 2016.

That 80% rate would represent a huge improvement over the 46% nationwide prevalence of blood pressure control among patients with hypertension, according to the Centers for Disease Control and Prevention. About a third of Americans have hypertension, and the condition leads to heart attacks and strokes that kill an estimated 348,000 U.S. patients annually. Hypertension is responsible for $131 billion in annual medical expenses and about $25 billion in lost productivity, the CDC says.

According to an online survey of 1,212 U.S. adults conducted in November on behalf of the foundation, 88% of patients said their blood pressure was checked during their last physician visit, while 48% said the doctor mentioned something about their score. Only 56% of patients with hypertension reported talking with their physicians about ways to control blood pressure, the survey said.

Guidelines in the seventh report of the Joint National Committee on Prevention, Evaluation and Treatment of High Blood Pressure, referred to as JNC 7, say patients' blood pressure should be below 140/90 mmHg, while those with diabetes or chronic kidney disease should have a blood pressure of less than 130/80.

Discuss BP at every visit

The foundation's initiative, which officially begins Jan. 1, 2013, asks participating medical groups and health systems to undertake at least one of eight campaign “planks” — quality improvement steps that can help physician practices improve their performance on hypertension outcomes. These include elements such as ensuring that staff members are trained in how to measure blood pressure accurately, following JNC 7 guidelines, addressing blood pressure numbers at every visit for hypertensive patients, educating patients about how to manage the condition and using registries to track patients with hypertension.

“It's not rocket science to get patients under control,” said Donald Fisher, PhD, president and CEO of the AMGA and secretary of the board of the foundation. “We know it can be done, and that we're not doing what could be done. This takes a team approach and a coordinated care approach.”

Campaign members will report their performance to the foundation on a quarterly basis to measure progress, and that data will be made publicly available, Fisher said. The data also will be analyzed to determine which quality improvement changes made the most impact in improving hypertension outcomes. The campaign's planks emerged from an earlier quality collaborative the foundation convened that involved more than a dozen medical groups sharing knowledge on how to redesign care to improve patients' BP control.

From that quality collaborative, it emerged that some clinics were failing on the basics. For example, nurses or medical assistants would record BP numbers to the nearest multiple of 10, marking down a 134 systolic blood pressure as 130. Those points might not make much difference at any given time, but without them it is harder to track trends in a patient's BP. Also, many physicians would retake patients' blood pressure even though other staffers had done it before they entered the exam room.

Don't assume patients are compliant

Another area for improvement targeted by the campaign is monitoring patients with hypertension. The campaign is asking clinics to see patients newly diagnosed with hypertension within 30 days of being prescribed medication to address potential side effects, ensure that patients are adherent and measure if their blood pressure is coming down.

“There are some offices where patients come in for an episodic visit and BP isn't taken,” Fisher added. “They just assume patients are taking the meds and are in control. If we are going to have patients pay attention themselves, we need to take the blood pressure at every encounter.”

Doing these basics may help prevent some patients from falling through the cracks, but sophisticated process improvement is needed to improve hypertension outcomes significantly, said Robert E. Matthews, president and CEO of MediSync, a Cincinnati-based management consultancy that helps physician groups improve their quality performance. One of the firm's clients, PriMed Physicians, achieved BP control for 92% of its 30,000 uncomplicated hypertension patients across 17 multispecialty offices in the Dayton, Ohio, area. The group took part in the foundation's earlier quality collaborative on hypertension. A key to improvement was supporting physicians in being more aggressive in their use of drug therapies to lower blood pressure, Matthews said.

“We discovered that some doctors were concerned about using additional drug classes,” he said. “What happens is that most patients can get to their goal using generic drugs, but a certain number of patients need additional agents. Doctors aren't really keen on doing that unless they have a formal process and support method to help them do that.”

JNC 7 guidelines say that if a patient's blood pressure is more than 20/10 mmHg above goal, physicians should consider using two agents, one of which should be a thiazide-type diuretic.