GSHTP Webinar Hypertension Update 2014: The Kaiser Permanente Northern California Experience Presented by: Marc Jaffe, MD Associate Clinical Professor of Medicine, UCSF Kaiser Permanente Northern California South San Francisco Medical Center
Kaiser Permanente Northern California Northern California (KPNC) n More than 2.3 million adult members n Comprehensive inpatient and outpatient services n 21 hospitals and 45 medical centers n More than 7,000 physicians Map of Kaiser Permanente Northern California (KPNC) Medical Centers 2
Hypertension Program Improvement Process Create Your Team Who does the work? Staff regionally and locally Identify the Population Who is at risk? Create registry Agree on the Treatment Examine the evidence Create/adopt guidelines Assess Performance Evaluate status Create performance metrics 3
The Hypertension Teams Central Hypertension Team Physician Leaders Analytic Support Program Managers Local Hypertension Team Physician Champion Facility Manager/ Administrator Local Care Providers Clinicians (MD, NP, RN, Pharmacist, etc.) Medical Assistants 4
Central Hypertension Management Team Central Hypertension Team Physician Leaders Analytic Support Program Managers n Activities Generates/distributes HTN control reports Reviews quality performance and sets goals Organizes Champion training and networking Develops support tools (handouts, etc.) Identifies/disseminates successful strategies 5
Local Hypertension Management Team Local Hypertension Team Physician Champion Facility Manager/ Administrator n Activities Distributes local HTN control reports Reviews local quality performance Allocates resources to improve performance Attends regional training and networking Organizes local training and networking Distributes support tools (handouts, etc.) Imports successful strategies 6
Local Hypertension Care Providers Local Care Providers Clinicians (MD, NP, RN, Pharmacist, etc.) Medical Assistants n Activities Review local HTN control reports Reviews local quality performance Utilize resources to improve performance Attend local training and networking Use support tools (handouts, etc.) Import successful strategies 7
Medical Assistant BP Measurement Checks Because Doctor Office Visits are neither costeffective nor convenient for BP measurement n Enables asynchronous communication n Medical Assistant BP measurement reduces white-coat effect n Enhanced compliance because No co-pay Member convenience - delays are rare n Enables repatriation to Primary Care when BP measurement is high outside of Primary Care (for example in specialty clinic). 8
Health System-Wide Hypertension Registry n Patients with hypertension are identified using outpatient diagnostic codes, pharmacy data, and hospitalization records from health plan databases, and diagnoses are verified through chart review audits of random samples of identified members. n Per National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) specifications, patients are not included based on recorded blood pressure measurements alone. 9
Health System-Wide Hypertension Registry Comprehensive Hypertension Registry Customizable queries Clinically important data-enabled prioritization of patient subgroups Evaluated for appropriateness of treatment intensification The most effective intervention to improve blood pressure control in primary care settings is an organized system of regular population review rather than primarily patient- or clinicianfocused interventions. 10
Health System-Wide Hypertension Registry Patients were included if they met any of the following: n 2 or more HTN diagnoses coded in primary care visits in the prior 2 years n 1 or more primary care HTN diagnoses and 1 or more hospitalizations with a primary or secondary HTN diagnosis in the prior 2 year n 1 or more primary care HTN diagnoses and 1 or more filled prescriptions for HTN medication within the prior 6 months n 1 or more primary care HTN diagnoses and 1 or more stroke-related hospitalizations or a history of coronary disease, heart failure, or diabetes mellitus. 11
Evidence Based Practice Guidelines n An evidence based guideline is updated every 2 years based on emerging randomized trial evidence and national guidelines. n Clinicians are encouraged to follow the algorithm unless clinical discretion required otherwise. 12
Evidence Based Practice Guidelines use of electronic medical record to optimize selection of medication printed documents e-mail partnering with pharmacy managers Dissemination of guidelines clinical tools (eg, pocket cards) lectures Videoconferences 13
Evidence Based Practice Guidelines n Health system wide adoption, evaluation, and distribution of an evidence-based practice guideline that has timely incorporation of new evidence facilitates the ability to introduce new treatment options and to re-emphasize existing evidence-based recommendations. n β-blockers example 14
Kaiser Permanente Hypertension Care Pathway Kaiser Permanente National Hypertension Treatment Care Pathway (http:// kpcmi.org/how-we-work/hypertension-control/) 15
What treatment protocol is best? n Standardized, protocol-driven care, facilitated through the use of a single hypertension treatment guideline remains essential n Within a country, a single treatment protocol developed and/or endorsed by key stakeholders, nationally relevant, evidence-based, clear, simple and implementable should be used. n Core medications should be integrated into guidelines and the treatment protocol Angell S, Ordonez P. Identification of a Core Set of Medications & Care Delivery Models for the Medical Treatment of Hypertension, CDC/PAHO Global Treatment Standardization Project (GTSP), March 2013 16
Does this work?? 17
Percentage of ACE-I Prescriptions dispensed as Single-Pill Combination (SPCs) tablets 35% Percentage Dispensed 30% 25% 20% 15% 10% 5% 0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year Percentage of Angiotensin-Converting Enzyme Inhibitor Prescriptions Dispensed as Single-Pill Combination Angiotensin-Converting Enzyme Inhibitor-Hydrochlorothiazide Combination Tablets for Kaiser Permanente Northern California Members, 2001-2012 18
KP Northern California Hypertension Control Rates vs. California and U.S. Rates 2001-2013 Kaiser Permanente Northern California (KPNC) National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) Hypertension Control Rate vs. National and California Rates, 2001-2013 19
Declines in Heart Disease and Stroke Mortality 2000-2008 KPNC Since Year 2000: 30.4% reduction in mortality from CVD 42.2% reduction in mortality from stroke 10.9% reduction in mortality from cancer Mortality from cancer, heart disease (HD) and stroke in Kaiser Permanente Northern California (KPNC), 2000-2008. (Sidney S et al. Closing the Gap Between Cardiovascular and Cancer Mortality in an Integrated Health Care Delivery System, 2000-2008: The Kaiser Permanente Experience. Circulation 2011; 124: A13610) 20
Heart Attack Rates are Falling in Kaiser Permanente Northern California Age and Sex Adjusted Incidence Rates of Acute Myocardial Infarction (MI), Non- STEMI (Non-ST Elevation Myocardial Infarction), and STEMI (ST Elevation Myocardial Infarction) in Kaiser Permanente Northern California (KPNC), 1999-2008.(Yeh RW, et al. Population trends in the incidence and outcomes of acute myocardial infarction. N Engl J Med 2010;362:2155-165) 21
Selected References James PA, Oparil S, Carter BL, et al. 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). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427. Jaffe MG, Lee GA, Young JD, Sidney S, Go AS. Improved blood pressure control associated with a large-scale hypertension program. JAMA. doi:10.1001/jama.2013.108769. Yeh RW, Sidney S, Chandra M, Sorel M, Selby JV, Go AS. Population trends in the incidence and outcomes of acute myocardial infarction. N Engl J Med 2010;362:2155-165. Sidney S, Jaffe M, Nguyen-Hyunha M, Kushi L, Young J, Sorel M, Selby J, Go A. Closing the Gap Between Cardiovascular and Cancer Mortality in an Integrated Health Care Delivery System, 2000-2008: The Kaiser Permanente Experience. Circulation 2011; 124: A13610 Angell S, Ordonez P. Identification of a Core Set of Medications & Care Delivery Models for the Medical Treatment of Hypertension, CDC/PAHO Global Treatment Standardization Project (GTSP), March 2013 Glynn LG, Murphy AW, Smith SM, Schroeder K, Fahey T. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev. 2010; (3):CD005182. 22