Improving Outcomes for Hypertension

Transcription

1 Spectrum of Health September 2017 Improving Outcomes for Hypertension Highlights: Recommendations of the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 8) HEDIS Requirements for Hypertension Tools and Tips for Your Patients September 2017 Spectrum of Health 1

2 Smoking Cessation IMPROVING OUTCOMES FOR HYPERTENSION Dear Colleague: Healthfirst joins you and public health, community health, and delivery system partners in a heightened focus on promoting control of high blood pressure. Hypertension affects 43 million adults in the United States, 95% of whom have essential hypertension with no identifiable and treatable cause. Cardiovascular disease continues to lead all other conditions in its negative impact on the longevity and quality of life of our members and communities. I m sure you ll agree that the recommendations of the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 8) i remain the cornerstone of identifying and managing patients with, or at risk of developing, hypertension. This Spectrum of Health bulletin is designed to highlight key aspects of these guidelines, along with pragmatic tools that can further the delivery of evidence-based care to our members your patients. 2 Spectrum of Health September 2017

3 What does this mean for you? 1. Adjust your practice workflows to promote adherence to the JNC 8 guidelines. Strict management of blood pressure control for your patients living with hypertension, especially titration to control, or medication adjustment within one month for most patients. 2. Control is the goal! 3. Healthy lifestyle changes and empowerment with knowledge about the management and consequences of high blood pressure are critical success factors. 4. Hypertension impacts up to 10% of pregnancies. ii Be a part of the pregnancy planning and postpartum management of women in your practice. Take a careful obstetrical history, especially understanding a history of preeclampsia, eclampsia, or other form of hypertension during past pregnancies. 5. Up to 5% of hypertension is secondary. Be alert for new-onset hypertension below the age of 30 and after the age of 50 years. 6. Demonstrate caring and support for your patients as they try to implement the difficult lifestyle modifications that can contribute to hypertension control. Lead your practice in becoming more culturally sensitive, avoiding labels like non-compliant that harm patient confidence. Understand reasonable choices that your patients can make in the context of their daily lives. I appreciate your hard work in caring for our members. Warm regards, Susan J. Beane, M.D. Vice President and Medical Director Clinical Partnerships sbeane@healthfirst.org September 2017 Spectrum of Health 3

4 Smoking Cessation IMPROVING OUTCOMES FOR HYPERTENSION JNC 8 Hypertension Guideline Algorithm Adult aged 18 years with HTN Implement lifestyle modifications Set BP goal, initiate BP-lowering medication based on algorithm General Population (no diabetes or CKD) Diabetes or CKD present Age 60 years Age < 60 years All Ages Diabetes present No CKD BP Goal < 150/90 BP Goal < 140/90 BP Goal < 140/90 All Ages and Races CKD present with or without diabetes BP Goal < 140/90 Nonblack Initiate thiazide, ACEI, ARB, or CCB, alone or in combo Black Initiate thiazide or CCB, alone or in combo Initiate ACEI or ARB, alone or in combo w/another class At blood pressure goal? Yes Reinforce lifestyle and adherence Titrate medications to maximum doses or consider adding another medication (ACEI, ARB, CCB, Thiazide) Yes At blood pressure goal? No Reinforce lifestyle and adherence Add a medication class not already selected (i.e., beta blocker, aldosterone antagonist, others) and titrate above medications to max (see back of card) No Yes At blood pressure goal? No Reinforce lifestyle and adherence Titrate meds to maximum doses, add another med and/or refer to hypertension specialist Reference: James PA, Ortiz E, et al evidence-based guideline for the management of high blood pressure in adults: (JNC8). JAMA Feb 5;311(5): Card developed by Cole Glenn, Pharm.D. & James L Taylor, Pharm.D. Continue tx and monitoring Initial Drugs of Choice for Hypertension ACE inhibitor (ACEI) Angiotensin receptor blocker (ARB) Thiazide diuretic Calcium channel blocker (CCB) Strategy A B C Description Start one drug, titrate to maximum dose, and then add a second drug. Start one drug, then add a second drug before achieving max dose of first. Begin two drugs at same time, as separate pills or combination pill. Initial combination therapy is recommended if BP is greater than 20/10mm Hg above goal. Lifestyle changes: Smoking cessation Control blood glucose and lipids Diet üeat healthy (i.e., DASH diet) ümoderate alcohol consumption üreduce sodium intake to no more than 2,400 mg/day Physical activity ümoderate-to-vigorous activity 3 4 days a week averaging 40 min per session. 4 Spectrum of Health September 2017

5 Hypertension Treatment Indication Heart Failure Post-MI/Clinical CAD CAD Diabetes CKD Recurrent stroke prevention Pregnancy Compelling Indications Treatment Choice ACEI/ARB + BB + diuretic + spironolactone ACEI/ARB AND BB ACEI, BB, diuretic, CCB ACEI/ARB, CCB, diuretic ACEI/ARB ACEI, diuretic labetolol (first line), nifedipine, methyldopa Drug Class Agents of Choice Comments Diuretics HCTZ mg, chlorthalidone mg, indapamide mg triamterene 100mg K+ sparing spironolactone 25-50mg, amiloride 5-10mg, triamterene 100mg furosemide 20-80mg twice daily, torsemide 10-40mg ACEI/ARB ACEI: lisinopril, benazapril, fosinopril and quinapril 10-40mg, ramipril 5-10mg, trandolapril 2-8mg ARB: candesartan 8-32mg, valsartan mg, losartan mg, olmesartan 20-40mg, telmisartan 20-80mg Beta-Blockers metoprolol succinate mg and tartrate mg twice daily, nebivolol 5-10mg, propranolol mg twice daily, carvedilol mg twice daily, bisoprolol 5-10mg, labetalol mg twice daily, Calcium Channel Blockers Vasodilators Dihydropyridines: amlodipine 5-10mg, nifedipine ER 30-90mg, Non-dihydropyridines: diltiazem ER mg, verapamil mg 3 times daily or ER mg hydralazine mg twice daily, minoxidil 5-10mg Monitor for hypokalemia Most SE are metabolic in nature Most effective when combined w/ ACEI Stronger clinical evidence w/chlorthalidone Spironolactone - gynecomastia and hyperkalemia Loop diuretics may be needed when GFR <40mL/min SE: Cough (ACEI only), angioedema (more with ACEI), hyperkalemia Losartan lowers uric acid levels; candesartan may prevent migraine headaches Not first line agents reserve for post-mi/chf Cause fatigue and decreased heart rate Adversely affect glucose; mask hypoglycemic awareness Cause edema; dihydropyridines may be safely combined w/ B-blocker Non-dihydropyridines reduce heart rate and proteinuria Hydralazine and minoxidil may cause reflex tachycardia and fluid retention usually require diuretic + B-blocker Centrally-acting Agents terazosin 1-5mg, doxazosin 1-4mg given at bedtime clonidine mg twice daily, methyldopa mg twice daily guanfacine 1-3mg Alpha-blockers may cause orthostatic hypotension Clonidine available in weekly patch formulation for resistant hypertension Beta-1 Selective Beta-blockers possibly safer in patients with COPD, asthma, diabetes, and peripheral vascular disease: metoprolol bisoprolol betaxolol acebutolol Visit to identify the drugs that are covered for Healthfirst members. Formularies are posted for all Healthfirst plans. September 2017 Spectrum of Health 5

6 Smoking Cessation IMPROVING OUTCOMES FOR HYPERTENSION Tools and Tips for Your Patients When it comes to improving the health of your patients who have prehypertension or high blood pressure, your practice can be of real assistance. We recommend that you and your team partner with your patients to: Understand high blood pressure and what it does to the body Work up to an average of 40 minutes of moderate- to vigorous-intensity aerobic activity three or four times per week iii Achieve and maintain a healthy weight (BMI < 25) by following a heart-healthy diet iv ü Gather baseline diet information: It might be easiest to obtain this information through a self-administered diet instrument such as the Rate Your Plate diet tool, a more informal form, or even a two-minute diet history in which patients recall what they typically eat for breakfast, lunch, dinner, and snacks. ü Start with small diet-pattern changes. For patients who indicate they drink large quantities of soda, one to two minutes could be devoted to the importance of eliminating or replacing sugar-sweetened beverages with reduced-calorie beverages or water. ü Use food-based approaches to target specific risk factors. ü Be sensitive to patient-specific cultural, religious, and economic factors: Patients should be encouraged and educated on how to adapt the recommended dietary pattern to their personal and cultural preferences. ü Use motivational and behavioral approaches: Behavioral counseling comprises two distinct elements: Why and How. ü Make use of outside nutrition resources. Fill prescriptions: Patients should be encouraged to fill prescriptions on time and to report back to the practice or physician when there may be a gap Limit alcohol: Two drinks a day for most men and one drink a day for women and lighter-weight individuals v Get help to quit smoking: You and your staff should readily share information about support, counseling, and medication to help your patients quit: ü Patients can contact the NY Quitline at NY-QUITS for additional support and coaching. ü Call the Asian Smokers Quitline. Another way to find support is by calling the Asian Smokers Quitline, a free, nationwide telephone assistance for Chinese-, Korean-, and Vietnamese-speaking individuals who want to quit smoking. ü Chinese (Cantonese and Mandarin): ; Korean: ; Vietnamese: Above all, remind patients to talk freely with you and your staff about any and all concerns or questions about hypertension, lifestyle, and their medicines. 6 Spectrum of Health September 2017

7 CONSEQUENCES of High Blood Pressure High blood pressure is often the first domino in a chain or domino effect leading to devastating consequences, like: STROKE HBP can cause blood vessels in the brain to burst or clog more easily. VISION LOSS HBP can strain the vessels in the eyes. HEART FAILURE HBP can cause the heart to enlarge and fail to supply blood to the body. HEART ATTACK HBP damages arteries that can become blocked. SEXUAL DYSFUNCTION This can be erectile dysfunction in men or lower libido in women. KIDNEY DISEASE/ FAILURE HBP can damage the arteries around the kidneys and interfere with their ability to effectively filter blood. A simple blood pressure check is the first step to preventing the domino effect. Learn more at heart.org/hbp American Heart Association, Inc. All rights reserved. September 2017 Spectrum of Health 7

8 Smoking Cessation IMPROVING OUTCOMES FOR HYPERTENSION Supporting Your Patients with High Blood Pressure Visit Checklist E improves health and saves time. Use this checklist as a guide during visits with patients working to control high blood pressure. Explain the roles of each member of the healthcare team. Ask, What is most important for you to accomplish during your visit today? The answer helps set the agenda. Review blood pressure goal against current reading(s). Have an open conversation about goals, achievements, confidence, and barriers. See sidebar for some examples. Questions to Ask Consider asking these questions to get a discussion going: What have you been doing to control your blood pressure since our last visit? What concerns you the most about your high blood pressure? What specifically would you like to work on to manage your high blood pressure? How confident are you that you could do [behavior] to help control your blood pressure? What might get in the way or keep you from being successful? What do you think would make it easier to control your high blood pressure? Million Hearts is a national initiative to prevent 1 million heart attacks and strokes by It is led by the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services, two agencies of the Department of Health and Human Services. The Million Hearts word and logo marks and associated trade dress are owned by the U.S. Department of Health and Human Services (HHS). Use of these marks does not imply endorsement by HHS. Help set small, achievable goals based on patients answers. For example, if the patient is working to improve diet, establish a goal to swap out favorite food items for lower-sodium versions. Small changes can gradually lead to more heart-healthy meals, cooked at home. Use the Ask-Tell-Ask technique to address actions for each behavioral goal: Ask permission to provide information on a specific topic. For example, for medication adherence, you might say, There are several things I want to tell you about your new medication. Is that okay? Tell the patient what they need to know (e.g., when they should take the medication, diagrams or pictures. Ask the patient to repeat back the information in their own words. Provide the patient with the following tools: Blood pressure tracker with target numbers written prominently Home blood pressure monitoring instructions Healthy diet information Community options for exercising Support groups to join Tools and Resources American Medical Group Foundation s Provider Toolkit to Improve Hypertension Control includes printable assessments for patients around goal-setting and assessing self-management knowledge (see pages 49 and 51). Hypertension Control Change Package for Clinicians includes change concepts, care for patients with hypertension. Visit the Million Hearts website for more information and resources for helping patients control hypertension. Make control your goal. millionhearts.hhs.gov May Spectrum of Health September 2017

9 Control high blood pressure and reduce your health risk HEALTHY VILLAGE September 2017 Spectrum of Health 9

10 Smoking Cessation IMPROVING OUTCOMES FOR HYPERTENSION Understanding High Blood Pressure Normal Blood Pressure In most cases, your blood pressure is normal if it s below 120/80 mm Hg. The numbers show how much pressure is in your arteries: When your heart beats (120)/While your heart rests between beats (80). Prehypertension (120 to 139/80 to 89 mm Hg) Brain Stroke Slightly higher than normal blood pressure is known as prehypertension. It tends to worsen over time unless you make lifestyle changes such as getting more exercise and eating healthier foods. Both prehypertension and high blood pressure increase your risk of heart attack, stroke, and heart failure. Stage 1 Hypertension (140 to 159/90 to 99 mm Hg) This is the beginning stage of high blood pressure. You may experience symptoms such as dull headaches, dizzy spells, or a few more nosebleeds than normal. Vision Loss Heart Attack Kidney Failure Bone Loss Stage 2 Hypertension (160/100 or higher mm Hg) This stage is also known as severe high blood pressure. Your doctor may start you on anti-hypertension medicines immediately. Stage 2 is a very serious form of high blood pressure and requires more frequent blood pressure checks and a high level of careful monitoring. Symptoms of very high blood pressure include severe headache, blurry vision, nausea, or vomiting. Blood Vessel Damage Anyone with severe hypertension should seek immediate treatment. 10 Spectrum of Health September 2017

11 Here s what you can do to reduce your high blood pressure High blood pressure (hypertension) is a dangerous condition that can quietly damage your body for years before any symptoms develop. That s why it s known as a silent killer. Left uncontrolled, it may cause heart disease, stroke, kidney disease, vision loss, or even a fatal heart attack. Fortunately, your risk of life-threatening complications can be reduced through treatment and lifestyle changes that can help control your high blood pressure. Eight ways to manage high blood pressure: Visit your healthcare provider regularly Regular visits help your doctor closely monitor your blood pressure and modify treatment if necessary. Take medications properly Medications, along with lifestyle changes, are an important part of your treatment. Take them exactly as directed and always refill on time. If you experience side effects, talk to your doctor about ways to manage them. Quit smoking If you need help, talk to your doctor, call New York State Smokers Quitline at NYQUITS ( ), or visit nysmokefree.com. Eat a well-balanced, low-salt diet Eat foods unsalted or low in salt (sodium), and plenty of whole grains, fish, poultry, nuts (unsalted or raw), beans, low-fat dairy, fresh fruits, and vegetables. Get regular physical activity Try taking a brisk 30-minute walk every day. Maintain a healthy weight Make smarter food choices, eat less, and gradually increase your level of physical activity. Limit alcohol Even if you re healthy, alcohol can raise your blood pressure. Reduce stress Relaxing is important. Take a few minutes a day to sit quietly and take deep breaths. September 2017 Spectrum of Health 11

12 Smoking Cessation IMPROVING OUTCOMES FOR HYPERTENSION Bring this sheet to your doctor visits to easily track your blood pressure: Date Blood pressure Sources: Managing Blood Pressure with a Heart-Healthy Diet, American Heart Association. High Blood Pressure, Emedicine Health. What is Stage 2 Hypertension?, Verywell. High Blood Pressure (Hypertension), Mayo Clinic. Symptoms Associated with Stage 1 Hypertension, Livestrong.com. Prehypertension, Mayo Clinic. Changes You Can Make to Manage High Blood Pressure, American Heart Association, December 19, Controlling Blood Pressure, CDC, June 24, Managing Weight to Control High Blood Pressure, American Heart Association, October Managing Stress to Control High Blood Pressure, American Heart Association, December 14, Warning Signs of a Heart Attack, American Heart Association, September 29, Understanding Blood Pressure Readings, American Heart Association, January Spectrum of Health September 2017

13 Summary of HEDIS Requirements for Hypertension MEASURE: CONTROLLING HIGH BLOOD PRESSURE (CBP) How members are identified: The percentage of members years of age who had a diagnosis of hypertension (HTN) Requirements Most recent BP is adequately controlled during the measurement year. Adequate control is defined as meeting any of the following criteria: Members years of age whose BP was < 140/90 mm Hg Members years of age with a diagnosis of diabetes whose BP was < 140/90 mm Hg Members years of age without a diagnosis of diabetes whose BP was < 150/90 mm Hg Frequently Asked Questions Regarding Improving Outcomes for Hypertension 1. How can I access the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure? Feel free to find the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) at the following link: aspx?articleid= Does Healthfirst have tools that can assist me in explaining hypertension or that can assist my patients with smoking cessation in their preferred language? Yes. Our website provides helpful tools for you and your patients. or 3. What immediate safety concerns are there upon initiating hypertension therapy? How quickly should I expect my patients blood pressure to be at goal? JNC 8 recommends blood pressure to be at goal within one month or therapy modification is required. It is important for medication doses to be titrated in order to safely achieve the anticipated response. See the algorithm in this bulletin. September 2017 Spectrum of Health 13

14 Smoking Cessation IMPROVING OUTCOMES FOR HYPERTENSION Frequently Asked Questions Regarding Improving Outcomes for Hypertension (continued) 4. How can I encourage my patients to initiate lifestyle modifications to improve their cardiovascular health? These are difficult conversations to have with any patient. Talking With Your Older Patient: A Clinician s Handbook Supporting Patients With Chronic Conditions shares best practices that can be applied to any patient, regardless of age. The following excerpts from this handbook can help you inform patients and their caregivers about medical conditions and their treatment: Doctors advice generally receives greatest credence, so the doctor should introduce treatment plans. Try to take a universal, non-threatening approach. Start by saying, Many people your age experience... or Some people taking this medication have trouble with... Try: I have to ask you a lot of questions, some that might seem silly. Please don t be offended... Let your patient know you welcome questions. Indicate whom on your staff he or she can call later to have questions answered. Encourage the patient or caregiver to take notes. It s helpful to offer a pad and pencil. Active involvement in recording information may promote your patient s retention and adherence. Check that the patient and his or her caregivers understand what you say. One good approach is to ask that they repeat the main message in their own words. Repeat key points about the health problem and treatment at every office visit. Provide encouragement. Call attention to strengths and ideas for improvement. Some patients avoid issues that they think are inappropriate for their own clinicians. One way to overcome this is to keep informative brochures and materials readily available in the waiting room. In addition to talking with the patient, you can use fact sheets, drawings, models, videotapes, or audiotapes. In many cases, referrals to websites and support groups can be helpful. i James P, Oparil S, Carter B, et al Evidence-Based Guideline for the Management of High Blood Pressure in Adults. The Journal of the American Medical Association. 2014; 311: Accessed July 25, ii American College of Obstetricians and Gynecologists. Hypertension in pregnancy. Work-Group-Reports/Hypertension-in-Pregnancy. Accessed July 13, iii Adults_UCM_307976_Article.jsp#.WWdlqD_rvq4. Accessed July 13, iv Translating the ACC/AHA Lifestyle Management Guideline Into Practice: Advice For Cardiologists From Experts in Nutrition Behavioral Medicine and Cardiology - American College of Cardiology. Accessed July 13, v UCM_303244_Article.jsp#.WWeOSj_rvq4. Accessed July 13, vi Ibid. vii Accessed April 20, Spectrum of Health September 2017