Hypertension

Keep tabs on performance to boost your practice’s BP control

In one year, a health system in Greenville, South Carolina, saw a 10 percent improvement in hypertension control—boosting it to nearly 75 percent—during a pilot study. About three-quarters of the adult patients with hypertension saw improved blood-pressure control. Learn how monthly scorecards to keep teams on task in the difficult challenge of controlling hypertension in their patients helped achieve these impressive results.

Greenville Health System participated in a six-month trial—published in the journal Hypertension—that included 16 diverse, community-based family medicine clinics. BP-control improved from 64.4 percent to 74.3 percent. And after one year, the control rate was 73.6 percent. 

About 152 Greenville Health System clinical sites exceeded a 70 percent BP control rate, which earned them recognition from Target: BP™, a joint initiative between the AMA and American Heart Association (AHA) to improve blood-pressure control and build a healthier nation.

In 2017, the AMA and AHA acknowledged early adopters of the recognition program by identifying over 300 organizations. In 2018, nearly 800 organizations were recognized for their efforts focusing on blood pressure control within the populations they serve.

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“For most people [hypertension] is a lifelong disease, so getting six months or a year of good control is useful, but it is much more useful when it is sustained over a long period of years and it looks like M.A.P. is giving us durable results, which is very important,” said AMA member Brent Egan, MD, the study’s lead author.

Dr. Egan is professor of medicine at the University of South Carolina School of Medicine, Greenville, and serves as the vice president of research at the Care Coordination Institute.

“It is really important because a lot of times when a practice does a quality-improvement program they move on to the next thing and forget about what they have just done,” he said. “It is not like a vaccination that you just gave a patient; it is something that needs to be done on a regular basis.”

Each clinic is tracked through monthly scorecards. This process helps to ensure each practice is maintaining BP-control. And if a practice is dropping off, they will be alerted to a decrease in their control rates and why.

“With a monthly scorecard they can see their blood-pressure control, and we can give them reminders about one or more of the three M.A.P. process measures that may be responsible for the fall in blood-pressure control,” said Dr. Egan.

Here is how Greenville Health System achieved—and maintained—BP-control with monthly scorecards, according to the study, co-written by AMA Vice President of Health Outcomes Michael Rakotz, MD, and Gregory Wozniak, PhD, director of outcomes analytics in Improving Health Outcomes at the AMA.

Overcoming time concerns

Measuring accurately initially saw some resistance from staff and physicians because performing automated office BP readings three times per patient often takes up to five minutes to complete.

“Part of the initial facilitation is getting those practices through the redesign period without compromising their other care duties,” she Dr. Egan. “Physicians and staff only have so much time and we are asking them to do something that they weren’t previously doing, so it takes time to dive in.”

In more than 2,000 patients with hypertension with an elevated initial attended BP, their automated office blood pressure was not hypertensive in about 600, or 30 percent, eliminating the office effect. Measuring accurately helped reduce what Dr. Egan and his co-authors dubbed “pseudouncontrolled hypertension” in patients. 

Taking more aggressive prescribing approach

When the automated office BP was high, the practice facilitator encouraged physicians to intensity therapy. However, physicians were often reluctant to prescribe more medication, said Dr. Egan. In fact, most patients with uncontrolled BP were not prescribed three medications at half-maximal doses.

This resistance to therapeutic intensification is an educational opportunity for physicians to help ensure their patients with uncontrolled hypertension receive an effective antihypertensive drug regimen. The BP-lowering effect of adding a BP medication from a different drug class at half-maximal dose is about four times greater than titrating the dose of a current medication from half-maximal to maximal dose.

Sharing the decision-making process

Practices were encouraged to maintain follow-up visits for patients with uncontrolled BP, perform shared decision-making, prescribe affordable and single-pill medications, and teach patients about self-measured blood pressure monitoring.

“We encourage shared decision-making with patients because patients who are involved in the decision process are more likely to take their medications,” said Dr. Egan.

“We’re also trying to work with clinicians to prescribe single pill combinations, which improve patients’ adherence,” he said. “The number of pills and their cost are both barriers to adherence and single-pill combinations can address both barriers.”

For example, after intensifying antihypertensive therapy, the decline in systolic BP more than doubled in the first six months of M.A.P. compared to the baseline period before M.A.P. This suggests that adherence to blood pressure management improved.