Implementation of JNC- 8 Hypertension Recommendations: Combining evidence and value-based practice strategies for accountable care

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1 Implementation of JNC- 8 Hypertension Recommendations: Combining evidence and value-based practice strategies for accountable care Shari Bolen MD, MPH MetroHealth/Case Western Reserve University 1

2 Disclosure Presenters reported no financial interest relevant to this presentation 2

3 Objectives 1. Describe the evidence behind the JNC-8 targets for older adults with hypertension 2. Define a value-based HTN best practice 3. Identify barriers and facilitators to implementing a HTN best practice within primary care 4. Develop HTN treatment approaches for several common primary care cases 5. Increase awareness of cultural issues as they arise in HTN treatment within primary care 3

4 Hypertension Background 1 in 3 Americans have high blood pressure Leads to heart disease and stroke (leading cause of death in U.S.) & 1000 deaths/day 54% of all Americans do NOT have good blood pressure control Minorities and those with low socioeconomic status (SES) have greater complications and greater deaths 4

Hypertension prevalence and control nationally 60 50 40 30 20 African Americans Hispanic Whites 10 0 Hypertension prevalence Hypertension control

5 Hypertension prevalence and control nationally African Americans Hispanic Whites 10 0 Hypertension prevalence Hypertension control Reference: CDC website at and 5

6 Hypertension Case 65 year old male here for blood pressure followup. Taking blood pressure medications without side effects and no missed doses Lisinopril/HCTZ 20/25 mg and amlodipine 5 mg daily No other comorbid conditions besides high cholesterol, osteoarthritis, and heartburn Other Meds: acetaminophen, zantac, and statin Feels good. BP-146/86. P-76. What is his BP goal or target? 6

7 JNC- 8 Targets 1. For adults with diabetes or chronic kidney disease of any age, BP target <140/90 mmhg 2. For adults with hypertension who are <60 years old, BP target < 140/90 mmhg 3. For adults with hypertension who are >=60 years old without diabetes or chronic kidney disease, BP target < 150/90 mmhg 7

8 Major Trials Testing SBP Goals in General Populations SHEP Syst-Eur HYVET JATOS VALISH Number 4,736 4,695 3,845 4,418 3,260 Entry SBP Goal SBP <148 <150 <150 <140 <140 Achieved SBP Stroke 36% 42% ns ns ns CVD 32% 31% 34% ns ns Mortality ns ns 21% ns ns SBP = systolic blood pressure CVD = cardiovascular disease 8

9 Blood Pressure Levels (mmhg) and Event Reduction in Selected Clinical Trials Trial Baseline BP Treated BP Event Active Control HDFP 159/ /86 142/91 17% - mortality SHEP 170/77 143/68 155/73 36% - stroke Syst-EUR 174/86 151/79 161/84 42% - stroke HYVET 173/91 144/78 159/84 21% - mortality Hypertension Detection and Follow-up Program (HDFP). JAMA. 1979;242(23): Systolic Hypertension in the Elderly Program (SHEP) Cooperative Research Group. JAMA. 1991;265(24): Systolic Hypertension in Europe Trial (Syst-EUR) Investigators. Lancet. 1997;350: Hypertension in the Very Elderly Trial (HYVET) N ENGL J MED 2008; 358:

JATOS RCT used to determine a higher cut-point for adults >60 years old Japanese adults 65-85 yrs old with essential hypertension followed for 2 years Randomized about 2000 patients to strict

10 JATOS RCT used to determine a higher cut-point for adults >60 years old Japanese adults yrs old with essential hypertension followed for 2 years Randomized about 2000 patients to strict (SBP<140) and 2000 to mild treatment (SBP<150) Initial drug: long-acting calcium channel blocker Primary endpoint: combined cardiovascular incidence and renal failure Secondary endpoints: total deaths and safety Hypertens Res Dec;31(12):

11 JATOS continued Trial Baseline BP Treated BP Events/Deaths (%) Strict Mild Outcome Strict (N=2212) JATOS 172/89 136/75 146/78 Morbidity Mortality 86 (3.89) 9 (0.41) Mild (N=2206) 86 (3.90) 8 (0.36) 11

12 Caution on using achieved BP Mean achieved BPs are not Goal BPs Post Hoc Analyses of patients achieving lower BPs tend to identify those at lower risk: less LVH, lower baseline BPs, fewer meds, improved med adherence 12

13 Incorporating JNC-8 BP targets Better Health will be reporting BP<150/90 and 140/90 for adults years old For age yrs, use target BP <140/90 Consider BP goal <150/90 for those at risk for harms Examples: med adherence, side effects, orthostatic hypotension, wide pulse pressure/low diastolic If patient has diabetes or CKD, goal <140/90 no matter the age 13

14 Effective value-based HTN best practice 14

15 Team-based care 15

16 Cleveland Area: Blood Pressure Control % of Patients with BP < 140/ Medicare Commercial Medicaid Uninsured High Income Middle Income Low Income High Education Middle Education Low Education White African-Amer. Hispanic Other Race/Eth

17 Improvements in BP control by practice BP < 140/90 Improvement

18 HTN Best Practice Best Practice Elements Evidence-based treatment algorithm Timely followup (within 1 month) and outreach Accurate BP measurement Communication and crosscultural communication skillbuilding Relevant Internal Processes 1) Algorithm education 2) EHR prioritizes meds from algorithm 1) Nurse/MA-led visits every 2-4 weeks until BP controlled 2) Outreach using HTN registry BP measurement education and annual competency review Structured curriculum for communication skill building 18

19 Treatment Algorithm ACE or ARB/diuretic combination Yes BP controlled? No Pregnancy potential Start with diuretic (avoid ACE or ARB) Continue current therapy Yes Uptitrate to highest dose No Continue current therapy Add calcium channel blocker and uptitrate See also J Clin Htn 2013 Dec 15 (12) *Adapted from the AHA; and Feldman et al Hypertension 2009; 53: No Yes Add alpha blocker, beta blocker, or spironolactone Continue current 19 therapy

20 Providing value to patients Treatment algorithm prioritizes use of once daily low cost medications No copay for Nurse or MA-led visits Reduces blood pressure and complications Better communication with patients builds trust and improves patient satisfaction 20

21 Providing value to the health system Reducing blood pressure is financially rewarded in ACOs, CMS PQRI and some value-based contracts Reducing blood pressure should ultimately reduce ED use and hospitalizations for complications benefits systems in ACOs and value-based contracting Outreach to patients with elevated blood pressure can be used to meet meaningful use requirements Nurse or MA-led visits improve access for patients Better communication improves patient satisfaction 21

22 Benefits to practice/providers Improve blood pressure outcomes and help reduce disparities in the region Practice coach facilitation at no additional cost Maintenance of Certification (MOC) credit for implementing the best practice 22

23 Expectations of the practice Monthly 1-hr meetings with practice coaches for 6 months Commitment/interest in implementing the best practice Complete a 10 minute baseline and 6 month follow-up surveys 23

24 Experiences from those undergoing implementation of the HTN best practice Erick Kaufman MD Neighborhood Family Practice/FQHC Kim Brown Nurse Care Coordinator at Lee Harvard Clinic/MetroHealth 24

25 Questions? 25

26 Small Group Cases Break into groups Choose a scribe Review case assigned to your group using handout (20 min). If extra time, can discuss other cases Present key findings back to the group Open discussion 26

27 Summary after return from small groups Improving BP and choosing appropriate BP targets are critical to improving the health of our community Using a BP target <140/90 or <150/90 when appropriate will reduce complications Implementing a value-based HTN best practice has the potential to strongly improve BP Especially in a health care environment transitioning to value-based care 27

28 Thank You 28

Clinical Updates in the Treatment of Hypertension JNC 7 vs. JNC 8. Lauren Thomas, PharmD PGY1 Pharmacy Practice Resident South Pointe Hospital

Clinical Updates in the Treatment of Hypertension JNC 7 vs. JNC 8 Lauren Thomas, PharmD PGY1 Pharmacy Practice Resident South Pointe Hospital Objectives Review the Eighth Joint National Committee (JNC