Large-scale hypertension program doubles BP control rates

HealthDay News -- A large-scale hypertension program instituted at Kaiser Permanente nearly doubled the proportion of patients that achieved blood pressure control during an eight-year period compared with only modest improvements in state and national rates, researchers found.

Hypertension control at the health system's Northern California locations increased from 43.6% to 80.4% from 2001 to 2009 (P<0.001 for trend), as defined by National Committee for Quality Assurance (NCQA) and Healthcare Effectiveness Data and Information Set (HEDIS) commercial measurements (systolic blood pressure ≤ 140 mm Hg and diastolic blood pressure l≤ 90 mm Hg).

In contrast, national mean NCQA HEDIS control rates increased from 55.4% to 64.1% between 2001 and 2009, and California-wide control rates, which have only been available since 2006, improved from 63.4% vs. 69.4%.

"Key elements of the program include establishment of a comprehensive hypertension registry, development and sharing of performance metrics, evidence-based guidelines, medical assistant visits for BP measurement and single-pill combination pharmacotherapy," Marc G. Jaffe, MD, of the Kaiser Permanente South San Francisco Medical Center reported in the Journal of the American Medical Association.

Although effective hypertension therapies have been available for more than 50 years, fewer than half of Americans with hypertension had their BP under control in 2001-2002.

"Many quality improvement strategies for control of hypertension exist, but to date, no successful, large-scale program sustained over a long period has been described," the researchers wrote.

So they reviewed data from 72 clinical trials to identify the best strategies for improving BP in primary care settings, and developed the Kaiser Permanente Northern California (KPNC) hypertension program, a system-level, multifaceted quality improvement program that consisted of five major components:

  • Creating heath system-wide hypertension registry using outpatient diagnostic codes for hypertension diagnosis, pharmacy data indicating one or more filled prescriptions for hypertension medication in the previous 6 months, one or more stroke related hospitalization or a history of CHD, HF or diabetes
  • Generating regular performance records on hypertension control every one to three months for each medical center
  • Developing and disseminating a four-step, evidence-based hypertension control algorithm updated every two years based on emerging evidence from clinical trials and national guidelines
  • Scheduling follow-up visits with a medical assistants trained to use standardized BP competency assessments ftwo to four weeks after a medication adjustment
  • Promoting single pill combination (SPC) therapy with lisinopril-hydrochlorothiazide

Between 2001 and 2009, the number of patients in the KPNC hypertension registry increased from 349,937 to 652,763. Average patient age was 63 years, and more than half of registry members were women.

The rate of lisinopril-hydrochlorothiazide SCP prescriptions in KPNC increased from 13 to 23,144 prescriptions per month from 2001 to 2009, the researchers found. During this period, the percentage of angiotensin-converting enzyme (ACE) inhibitor prescriptions dispensed as an SPC in combination with a thiazide diuretic also increased from less than 1% to 27.2%.

Furthermore, BP control continued to improve beyond the study period, from 83.7%in 2010 to 87.1% in 2011.

In an accompanying editorial Abhinav Goyal, MD, MHS, and William A. Bornstein, MD, PhD, both of the Emory School of Medicine in Atlanta, praised the study in the context of accountable care organizations and shared saving models for "providing a framework wherein health care organizations have the flexibility to implement care models optimized to deliver the best outcomes at the lowest cost, without being constrained to face-to-face physician encounters to drive reimbursement."

They called the study "particularly powerful," adding that they hoped it "will prompt hypertension guidelines and perhaps other guidelines to include recommendations about system-level approaches to managing risk factors."


References

  1. Jaffe MG et al. JAMA. 2013;310(7):699-705.
  2. Goyal A, Bornstein WA. JAMA. 2013;310(7):695-696.
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