Best Practices in Managing Hypertension Sponsored by AMGA and Daiichi Sankyo.

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Molly Sparks
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2008-2009 Best Practices in Managing Hypertension Sponsored by AMGA and Daiichi Sankyo.

1 Best Practices in Managing Hypertension Sponsored by AMGA and Daiichi Sankyo. Wrap-Up Meeting November 18-20, 2009 San Diego, CA HATTIESBURG CLINIC, PA Hattiesburg, Mississippi Clinical Inertia in Hypertension: Identifying Barriers to Improve Quality 1

3 Cardiovascular mortality rate attributable to higherthan-optimal blood pressure in women, 2001 Ezzati, M. et al. Circulation 2008;117:

4 Quality Issue: Clinical Inertia What factors are associated with failure to address uncontrolled hypertension (HTN), and can we do better?

5 Project Goal and Objectives Goals: Identify level of HTN control Identify Clinical Inertia in visits with inadequate HTN control Clinical Inertia : the failure of health care providers to initiate or intensify therapy when indicated Evaluate potential factors associated with HTN control and clinical inertia 5

6 Project Goals and Objectives Provider Report Cards Educational programs informed by findings Education for clinical staff on hypertension treatment and control 6

Sample Characteristics N=1295 55.8% female Mean age 63.2 Mean BMI 31.

7 Sample Characteristics N= % female Mean age 63.2 Mean BMI 31.4 Class III obesity (BMI 40): 16% Ethnicity NHW: 78.0% African-American: 21.3% Other: 0.7% Diabetes: 34.8% Number of medications Median: 8 Insurance Status

8 Project Goal and Objectives Goals: Identify level of HTN control 8

9 Hypertension Targets Hypertensive Patients with BP < 140/90 *Based on sample of 1295 **NCQA. The State of Health Care Quality 2009

10 Hypertension Targets Hypertensive Patients with DM and BP < 130/80 *Based on sample of 451 **NCQA. The State of Health Care Quality 2009

11 Project Goal and Objectives Goals: Identify level of HTN control Identify Clinical Inertia in visits with inadequate HTN control Clinical Inertia : the failure of health care providers to initiate or intensify therapy when indicated 11

12 Of those not at goal BP (n=746), no action was taken in 63% of cases (n=469) 12

13 Project Goal and Objectives Goals: Identify level of HTN control Identify Clinical Inertia in visits with inadequate HTN control Clinical Inertia : the failure of health care providers to initiate or intensify therapy when indicated Evaluate potential factors associated with HTN control and clinical inertia 13

15 Factors Related to Inertia: Blood Pressure Clinical Inertia by Systolic Blood Pressure SBP Category (mmhg) 15

16 Factors Related to Inertia: Blood Pressure Clinical Inertia by Magnitude of SBP Shortcoming mmhg above target SBP 16

17 Factors Related to Inertia: Diabetes Clinical Inertia by Diabetes Status 17

18 Factors Related to Inertia: Ethnicity Clinical Inertia by Ethnicity 18

19 Factors Related to Inertia: Ethnicity (cont.) Hypertension Control by Ethnicity 19

20 Factors Related to Inertia: Ethnicity (cont.) 80% Clinical Inertia by SBP mmhg Above Goal 74.8% 70% 60% 56.3% 50% 40% 36.7% 43.7% 30% 20% AA NHW AA NHW 10% 0% 10 mmhg > 10 mmhg 20

21 Factors Related to Inertia: Provider Volume Clinical Inertia by Quartile of Provider Patient Volume Number of other patients seen on date of visit 21

22 Why was no action taken? A reason was documented in 47% (220/469) of visits when patient was not at goal BP and no action was taken Documented Reasons for No Action Taken 22

23 Team Composition Bryan Batson, MD (PI) Philip Mellen, MD, MS (Co-Investigator) Lisa Freeman, RN, BSN Director of Clinical Risk Management and Nursing Dean Hopstein Information Services William Smith, DBA Data Management and Analysis Data Extractor Nurse Educator 23

24 Modifications/Enhancements De-emphasized the provider report card component, given small sample for each provider 24

25 Hypertension Care Report Card

26 Modifications/Enhancements De-emphasized the provider report card component, given small sample for each provider Plan to fold in ancillary staff education into provider education efforts Incorporation of bi-monthly HTN control tracking 26

27 Measuring Success DATA! (more to come) 27

28 Challenges Limited support staff resources in initial phases significantly slowed project startup Has allowed for longer collection of baseline data during project run-up period Parallel QI projects with conflicting emphases threatened to dilute message/intervention Identified ways to synergize, stagger efforts 28

29 Future Steps On-site/remote educational efforts with added emphasis on targeting goal attainment in high-risk patients (DM) (1/10-4/10) Re-assess clinical inertia (12/10) Evaluate practical implications of findings on provider volume 29

30 Hattiesburg Clinic HTN Control: 12/08-9/09 30

32 Lessons Learned Non-automated data extraction takes a long time Need for strategic overview of quality improvement with buy-in from key stakeholders 32

33 Questions... What are current approaches to prioritize QI initiatives, recognizing limiting factor of QI fatigue? 33

34 Thanks! 34

Blood Pressure Management: A Journey in Quality Improvement Phil E. Yphantides, M.D.

Blood Pressure Management: A Journey in Quality Improvement Phil E. Yphantides, M.D. Medical Director, Urgent Care Hypertension and Diabetes Physician Champion Sharp Rees-Stealy Medical Group San Diego,