Target: BP Overview with Lake Superior QIN Wednesday, February 22, :00 PM 1:00 PM CST

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1 Target: BP Overview with Lake Superior QIN Wednesday, February 22, :00 PM 1:00 PM CST Presenters American Heart Association Stefanie Worth, Senior Community Health Director, Michigan Sueling Schardin, Senior Community Health Director, Minnesota 2 1

2 85.7 Million Adults have HBP New Stat! Prevalence of HBP varies by race and ethnicity: Whites roughly 1 in 3 Blacks roughly 2 in 5 Latinos roughly 1 in 4 Asians roughly 1 in 5 AHA 2015 Statistical Update 3 Michigan In 2013, 34.6% of adults reported ever being told they have HBP 75.7% of adults with diagnosed HBP reported taking BP medication in 2013 An increased percentage of adults are being diagnosed with HBP each year, due to an increase in aging of the overall state population. By 2030, heart disease cases are projected to rise from 600,000 to 2.9 million In 2010, $10.2 billion was spent on heart disease related medical costs. Heart Disease was the leading cause of death in men and women in 2012 In the past 5 years, 58,298 women have died of heart disease More than 25% of deaths in 2013 were due to CVD and stroke Statistics from the Michigan Department of Community Health 4 2

3 Minnesota In 2013, almost 27% of adults reported having HBP In 2012, hypertensive heart disease was listed as the underlying or contributing cause of death for 6,764 Minnesotans 29% of African Americans report HBP, compared to 28% of whites Individuals with no formal education after a high school diploma report much higher rates of HBP than those with at least a college degree In 2013, approximately 77% adults with HBP reported taking medications prescribed to reduce their BP In 2012, 75% of adults aged in managed care plans who received a diagnosis of HTN had their BP adequately controlled to 140/90 mm Hg or lower within 1 year after the diagnosis Quick Facts from the Minnesota Department of Health 5 Wisconsin In 2001, there were approximately 204,000 individuals with heart disease. Most individuals with CVD are over the age of 60. More men than women have CVD and heart attacks, though heart attacks are more likely to be fatal for women. HBP is more prevalent among minority populations. HBP is more prevalent among low-income populations % of the Medicare population has HBP CVD is the number 1 cause of death: about 18,000 deaths in 2001 If all CVD were eliminated through medication, dietary changes, exercise and not smoking individual life expectancy would increase nearly 10 years Facts from the Wisconsin Department of Health Services 6 3

4 Why controlling BP is important Morbidity and mortality due to CVD are directly related to BP. When BP is lowered in people with hypertension, there is less vascular damage to organs. We have known since the 60 s through the landmark VA-1 and VA-2 trials that treating HBP with medication reduces risk for heart attacks, strokes and death % Our Goal for Better Control From 2009 to 2012 among US adults with HBP % AHA 2015 Statistical Update 8 4

5 HBP and Heart Disease and Stroke 9 AHA/ACC/CDC HBP Treatment Algorithm In November 2013, AHA partnered with the ACC and the CDC to publish a scientific statement recognizing best practices in clinical care that have significantly increase HBP control rates and put forth a customizable algorithm based on these practices. In July 2015, AHA began a focused drive to promote and implement the algorithm among healthcare systems and clinics. 10 5

6 What is Target: BP? A call to action motivating medical practices, practitioners and health services organizations to prioritize blood pressure control Recognition for healthcare providers who attain high levels of blood pressure control in their patient populations, particularly those who achieve 70, 80 percent or higher control A source for tools and assets for healthcare providers to use in practice, including the AHA/ACC/CDC Hypertension Treatment Algorithm and the AMA s M.A.P. Checklist 11 Three Major Components Target: BP Recognition Program: Recognizing physician practices and health systems working to improve blood pressure control rates and reduce the number of Americans who have heart attacks or strokes. Physician support: Supporting physician practices and health systems to attain and sustain blood pressure control rates of 70% or higher among the patients they serve. Patient support: Providing tools and resources to help patients reduce their risk of heart attack or stroke by selfmanaging their blood pressure at home and in partnership with their health care providers. 12 6

7 Who is our Target Audience? Primary Care System - Federally Qualified Health Clinic (FQHC) - Federally Designated Rural Health Clinic (RHC) - Indian Health Service practice/clinic - Practice/Clinic with mission to serve publicly insured, underinsured, or uninsured - Private Clinical System (non-fqhc) Government Agency or Organization providing care to patients 13 Why should a clinic participate? We know what medicines work but systems aren t in place to drive control rates Algorithm and the systems approach described in AHA s treatment algorithm have been shown to increase control rates within a clinical setting Sites will received recognition from the AHA Help meet required performance metrics Improved health and care of their patients!

8 Target:BP Recognition Program Overview Recognize clinical practices and health care systems for: Participation in the Target: BP program; Improvement in blood pressure control; and Achievement of a designated blood pressure control rate threshold and sustainability of results Accommodate either self-reported aggregate data or patient population data submission and validation, providing flexible options for practices with varying resources Provide performance and benchmark data in dashboard Offer opportunities for improvement and achievement through adoption and implementation of program tools/resources 15 Target:BP Recognition Program Snapshot Recognition Categories Participation in Target: BP Improvement in BP control XYZ: 10% improvement in BP control rate over baseline or 10% on BP improvement measure Achievement in BP control XYZ: 70% BP control rate XYZ PLUS: 70% BP control rate and one of three quality improvement measures XYZ: 80% BP control rate XYZ PLUS: 80% BP control rate and one of three quality improvement measures 16 8

9 The M.A.P. framework Measure blood pressure accurately Act rapidly to manage uncontrolled hypertension Partner with patients, families and communities to promote self-management Actionable data Evidence based tools Adaptive change

10 Why measuring blood pressure accurately is important Uncertainty of patients true blood pressure is the leading cause for failure of a clinician to act on a high blood pressure in the office Significant BP variability exists in all patients Poor measurement technique decreases reliability of a patient s BP, which can lead to poor clinical decisions, adversely affecting the health of a patient How does this impact clinicians in practice? 19 Common errors made during office BP measurement 20 10

11 Why use office BP measurement? Opportunity to obtain BPs Technology has improved measurement reliability (validated, automated machines less human error) Protocols improve reliability, reduce variability and errors and can improve workflow efficiency Obtaining confirmatory measurements increases diagnostic accuracy and reduces misclassification of hypertension By reducing errors and increasing reliability of BP measurement, clinicians are less likely to hesitate when initiating or escalating treatment (clinical inertia) 21 Correct patient position for BP measurement For screening BP measurement Automated, validated device Sitting in a chair with back and arm supported (1) Legs uncrossed, feet on the ground or a stool (2) Cuff over a bare arm (3) Correct cuff size No talking or texting If the screening BP is > 140/90 mm Hg, obtain confirmatory BP measurements For confirmatory BP measurements, same as above, plus Ensure patient has an empty bladder Rest for at least 5 minutes Obtain the average of at least 3 measurements 22 11

12 Most common factors contributing to uncontrolled hypertension 1. Clinicians miss opportunities to treat a patient with a BP > 140/90 Fail to initiate or escalate therapy during an office visit Fail to stress frequent follow up until BP is controlled CLINICAL INERTIA 2. Patient non adherence to treatment plan Usually due to not taking medications as instructed

13 Factors leading to clinical inertia CLINICIAN Failure to initiate treatment Failure to titrate to goal Failure to recommend follow up Failure to set clear goals Underestimating patient needs Failure to identify and manage comorbid conditions Not enough time Insufficient focus or emphasis on goal attainment Reactive rather than proactive 25 Factors leading to clinical inertia PATIENT Medication side effects Failure to take meds Too many medications Cost of medications Denial of disease Forgetfulness Perception of low susceptibility Absence of symptoms Poor communication Mistrust of clinician Mental illness Low health literacy 26 13

14 Factors leading to clinical inertia HEALTH SYSTEM Lack of clinical guidelines Lack of care coordination No visit planning Lack of decision support Poor communication among office staff No disease registry No active outreach 27 Why standardized treatment protocols are important In patients with HTN with systolic BPs >150 mm Hg, increased risk of acute cardiovascular events or death can occur with Delays in medication intensification >6 weeks Delays in follow-up appointments >10 weeks after medication intensification 28 14

15 29 Evidence-based communication strategies Patient engagement is important if we expect patients to adhere to therapy When clinicians use this style of communicating we often learn important details that help us determine a preferred treatment approach When patients use this kind of communication they are more engaged/committed and as a result, more likely to adhere Using these communication techniques does not lengthen visits 30 15

16 Use evidence-based communication strategies STRATEGY Begin with open-ended questions about adherence, including recent medication use Explore reasons for possible non-adherence Elicit patient views on options and priorities to customize a care plan for each patient Remain non-judgmental at all times Use teach-back to ensure understanding of the care plan 31 Key takeaways Goals for collaboration: To understand patients, not interrogate them To encourage patients, not persuade them To support patients, not fix them 32 16

17 Why SMBP is clinically useful SMBP better predicts CV morbidity and mortality than office BPs Reduces variability and provides more reliable BP measurement Provides better assessment of hypertension control Empowers patients to self manage their HTN May improves medication adherence 33 Empower patients to self-manage SMBP empowers patients to: Check their BP Communicate results Make adjustments between visits Self manage HTN regular self-measurements of blood pressure and a simple predetermined titration plan for anti-hypertensive drugs, is more effective in lowering systolic blood pressure than is usual care Richard J McManus, Jonathan Mant, Emma P Bray, Roger Holder et al. Telemonitoring and self management in the control of hypertension (TASMINH2): a randomised controlled trial. Lancet 2010; 376:

18 How to use SMBP in clinical practice Educating staff to train patients on proper use of SMBP is critical and includes: Proper measurement technique Proper frequency to measure SMBPs How to record SMBPs A plan for patients to act if BPs are out of the desired range How to communicate SMBP readings to the clinical team 35 Lifestyle changes for hypertensive patients Healthy diet, such as DASH diet Reduced sodium intake Weight loss Aerobic exercise Taking a pill to lower BP Moderate alcohol consumption No smoking 36 18

19 Impact of lifestyle changes for improving blood pressure in patients with HTN Lifestyle change DASH diet, compared with typical American diet Can lower SBP/DBP up to: 11.6/5.3 mm Hg Reduce sodium intake by average of 1150 mg/d 4/2 mm Hg Average weight loss of 11 lbs 4.4/3.6 mm Hg 40 minutes of moderate intensity aerobic physical activity, 3 4 times a week 5/4 mm Hg 37 Key messages when advising patients about healthy lifestyle choices to lower BP Reduce the amount of salt in food and processed foods Eat at least 5 servings of fruits and vegetables per day Choose whole-grain products and high-fiber foods over refined grains Gradually build up to 40 minutes of physical activity most days of the week Limit calories to meet and not exceed daily needs. Use personalized and cultural food preferences 38 19

20 Partner with patients, families and communities checklist To empower patients to control their blood pressure: Help patients accurately self-measure BP Direct patients and families to resources that support medication adherence and healthy lifestyles Engage patients using evidence-based communication strategies 39 Check. Change. Control. Program AHA s community-level BP monitoring program Proven to improve the BP of people with HTN The average drop in systolic BP of participants is 11 mm Hg. Key evidence-based components include: Self-monitoring of BP outside of the healthcare setting An online tool to track BP readings, with reports for organization coordinator Awareness and educational tools for participants A 4-month educational program plan for the coordinator Check. Change. Control. 20

21 41 Self Monitoring Solution 21

22 Website Demonstration TargetBP.Org Website Demonstration TargetBP.Org 22

23 Website Demonstration TargetBP.Org Recognition Timeline Recognition Program November 2016: Announce 2017 roll out FAQs and update Affiliates Calendar Q1 (January) 2017: Forward Health Group portal for application, data submission Construct participant dashboard, affiliate staff dashboard Calendar Q2 (April May) 2017: Data submission deadline for 2017 awards Calendar Q3 (September) 2017: Announce Participant, Improvement and Achievement Awardees 46 23

24 Resources Patient and participant resources on Website Podcasts Videos Fact Sheets Supporting Materials Patient Education Materials Patient Tracking Tools Clinical Implementation Tools 47 How can you help? Visit and register for Target: BP Review the resources on our website to learn more about improving BP management Share information on Target: BP with your clinic or healthcare system Commit to improving blood pressure control in your clinic and community Get recognition for your practice s achievement in patient BP control 48 24

25 Questions? Local AHA Contacts Michigan: Stefanie Worth Minnesota: Sueling Schardin Wisconsin: Tim Nikolai