Physicians and QIOs Improving Health Outcomes Together AHQA 2014 Annual Meeting
Aims for Today Introduce AMA focus on improving health outcomes Describe our work on: Preventing cardiovascular disease and type 2 diabetes Promoting clinical-community linkages Reducing racial/ethnic disparities Discuss alignment between our work and 11th Scope of Work 2
Founded on May 7 th, 1847 at The Academy of Natural Sciences in Philadelphia Mission: To promote the art and science of medicine and the betterment of public health Guiding principle: There is a national imperative to chart a successful course for health care delivery that will improve the health of the nation Largest medical association in America 3
AMA Focus on Improving Health Outcomes One of 3 focus areas under new strategic plan (2012): Improving health outcomes Shaping new delivery and payment models Accelerating change in medical education Improving health outcomes: Long-term goals Prevent heart disease, stroke and type 2 diabetes Improve health outcomes for these conditions 4
Emphasis on Primary & Secondary Prevention Hypertension, prediabetes and hyperlipidemia are key risk factors for cardiovascular disease and type 2 diabetes Therefore, our initial focus is on improving blood pressure control and preventing diabetes Will begin work on improving hyperlipidemia in the near future 5
Why These Clinical Topics Heavy toll on patients, families, and society with total costs of cardiovascular disease and type 2 diabetes >$500 billion/year Every physician in every specialty in every type of practice sees patients with hypertension and prediabetes Strong evidence base for addressing these conditions but evidence is not applied consistently Major focus of national, government-led initiatives 6
Our General Approach Learn from those who have succeeded Implement & test Reassess & adjust Scale for impact Collaborate with those who share our goals Devise interventions Research & evaluate 7
67 million American adults have high blood pressure That s 1 in every 3 Source: CDC 8
Small Reductions in Systolic BP * Can Save Many Lives Primary prevention of hypertension: Weight loss Reduced dietary Na Reduced alcohol Increased physical activity * Across the general population (JAMA 2002;288:1882-1888.) 9
Significant Opportunity for Improvement 90% of the 35.8 million U.S. adults with uncontrolled HTN had a usual source of care, health insurance coverage and received health care in the previous year (CDC. MMWR 2012;61(35):703-709.) 11
Large-Scale Improvement is Possible HTN control improved from 43% to 80% over 8 years due to: Measuring and reporting BP control rates using a HTN registry Sharing best practices among clinics Using updated practice guidelines Following-up abnormal BP readings Single-pill combination therapy (JAMA 2013;310:699-705.) 12
Objective: AMA: Collaborating to Improve BP Control Improve BP control in patients with hypertension receiving care in ambulatory medical practices Approach: Engage medical practices and health centers in improving BP control Adapt proven models (e.g., TRIP-CUSP) to improve care delivery Develop, test and disseminate relevant tools and resources Support efforts to measure and report BP control rates Identify and pursue relevant advocacy opportunities 13
Current Work on Improving BP Control Collaborators: Johns Hopkins Medicine HHS Million Hearts initiative Finalizing relevant tools, resources and change model Pilot testing in a diverse group of 10 medical practices Late 2014, begin spreading tools and resources Collaborate with networks of medical practices and health centers Launch PI-CME and submit application for Part IV MOC Advocacy opportunities: Sodium reduction in processed foods Exploring options for discounts on home BP monitoring devices 14
Checklists, Tools and Resources A collection of checklists to improve care delivery: Measure accurately Act rapidly Partner with patients/community Checklists summarize best practices validated through pilot testing in diverse settings & vetted by a panel of hypertension control experts Accompanying tools and resources to facilitate implementation: Posters to illustrate proper technique and share information One-pagers to assess current practices and evaluate improvement Step-by-step guide to assess clinical inertia and pinpoint areas for improvement Recorded webinars and a team of content, QI and measurement experts 15
Change Model and Measurement Adapt key lessons from CLABSI work to ambulatory setting Underscore importance of culture and teamwork Use practical tools to assess and improve culture and teamwork Emphasis on learning from mistakes in a non-punitive setting Measurement to support improvement work Population management data platform (3 rd party vendor) Monthly reporting on all patients with hypertension, with minimal time lag Train care teams to drill-down on data, identify improvement opportunities 16
29 million Americans have diabetes 86 million American adults have prediabetes 90% are unaware of their elevated risk status Source: CDC 17
In the absence of any intervention: 1.34% of people with fasting blood glucose 100-109 progress to diabetes each year 5.56% of people with fasting blood glucose 110-125 progress to diabetes each year Nichols et al. Progression from newly acquired impaired fasting glucose to type 2 diabetes. Diabetes Care 2007;30:228-233. 18
Reducing Risk: The Diabetes Prevention Program (DPP) Randomized trial (N=3234) comparing metformin vs intensive diet and physical activity coaching vs usual care Lifestyle coaching most effective with modest weight loss (5-7%) reducing type 2 diabetes by 58% (71% if age 60) (N Engl J Med 2002;346:393-403.) 19
Lifestyle Intervention 16 weekly core sessions followed by 8 monthly sessions (1 year) Each session is facilitated by a trained lifestyle coach CDC-approved curriculum and coach training Goal is to lose >5% of body weight Cut down dietary calories and fat intake 150 min/week moderate physical activity Training in behavior modification and peer support 20
Key challenges: Scaling the DPP Nationally Awareness: >90% with prediabetes are unaware of condition Affordability: limited coverage by health insurers (public/private) YMCA offers discount based on financial status Availability: not enough programs available across the U.S. Physician buy-in: limited success in increasing prediabetes screening and referrals to community-based programs 21
Objective: AMA: Collaborating to Prevent Diabetes Increase screening for prediabetes and referral to evidence-based diabetes prevention programs Approach: Engage primary care practices in diabetes prevention Link practices to credible diabetes prevention programs Develop, test and disseminate relevant tools and resources Leverage practices HIT infrastructure to increase screening/referral Advocate for inclusion of lifestyle change programs in health benefits 22
Current Work on Diabetes Prevention Collaborators: YMCA of the USA (Y-USA) CDC National Diabetes Prevention Program Focus on Medicare patients (Y-USA Health Care Innovation Award) Finalizing relevant tools, resources and best practices Pilot work in communities in DE, FL, IN and MN Late 2014: begin spreading tools and best practices Additional Innovation Award states: AZ, NY, OH and TX Launch PI-CME and submit application for MOC part IV Advocacy for passage of Medicare Diabetes Prevention Act 23
Tools and Resources Screening and referral guide for primary care practices Point-of-care and retrospective methods for identifying at-risk patients Templates for referral forms, informational materials, etc. Guidance on using EHRs to identify patients, create alerts Working with Regional Extension Centers to generate patient lists Promoting clinical-community linkages AMA in communities, with state medical societies, connecting primary care practices to local YMCA-based diabetes prevention programs Collaborating with CDC to create version of tools for use with all adults 24
Promoting Health Equity Tapping into expertise of Johns Hopkins Center to Eliminate Cardiovascular Health Disparities Incorporated key lessons from Project ReDCHiP: Reducing Disparities in Controlling Hypertension in Primary Care BP control performance reporting stratified by race/ethnicity Commission to End Health Care Disparities Working collaboratively with NMA and NHMA Strategic focus: race/ethnicity data collection and use 25
Alignment with 11 th SOW Task B.1 Task B.1.5.3 Task B.2 Task B.4 Improving Cardiac Health and Reducing Cardiac Healthcare Disparities Provider Technical Assistance for Blood Pressure (BP) Control Reducing Disparities in Diabetes Care: Everyone with Diabetes Counts Improving Prevention Coordination through Meaningful Use of HIT and Collaborating with RECs 26
Opportunities for Collaboration Provide program guide and toolkit for adaptation and use Assist in adapting program guide and toolkit to local needs Conduct train-the-trainer workshops on checklists and accompanying tools and resources Provide faculty to Learning and Action Networks (LANs) Serve on advisory group or multi-stakeholder network Other options? 27
Omar Hasan, MBBS, MPH, MS, FACP omar.hasan@ama-assn.org Donna Daniel, PhD donna.daniel@ama-assn.org www.ama-assn.org/go/improveoutcomes 28
Appendix 29
M.A.P. for Achieving Optimal HTN Control Measure accurately Without credible BP measurements, clinicians cannot make wise therapeutic decisions Act rapidly Therapeutic inertia is often the primary reason for uncontrolled hypertension when BP control rates are low Partner with patients to promote self-management Evidence-based ways for supporting patients ability to adhere to and self-manage their care are underutilized 30
Measure accurately (Draft) When screening patients for high blood pressure: Use a validated automated device Use the correct cuff size Ensure the patient is in the correct position Seated with back supported Feet flat on floor or other support with legs uncrossed Bare arm supported and at heart level Resting quietly without speaking or texting At initial visit, obtain measurements from both arms 31
Measure accurately (continued) If screening BP 140/90 in either arm, obtain confirmatory measurements in the arm with higher BP reading: Ensure the patient has emptied his or her bladder Ensure the patient sits quietly 5 minutes before rechecking Use a validated automated device Use the correct cuff size Ensure the patient is in the correct position Obtain at least 3 measurements and calculate the average systolic and diastolic values 32
Act rapidly (Draft) When uncontrolled hypertension is present: Make an explicit change in the care plan before the interaction ends Ensure there will be a follow-up interaction* every 2-4 weeks until BP is less than 140/90 mmhg Use an evidence-based protocol, such as the Million Hearts template, to guide selection of antihypertensive medications * Interactions include home BP measurements reported to the office 33
Partner with patients to promote self-management (Draft) To empower a patient with uncontrolled hypertension Assess adherence to the care plan as well as potential barriers Elicit patient goals and opinions regarding proposed care plans and customize plans to his/her priorities Review medications to facilitate adherence: Minimize the number of daily pills Favor low-priced medications or those with low or no copays Offer pill boxes and reminder systems Use teach-back to ensure understanding 34
Measuring Accurately Common problems that account for inaccurate blood pressure measurement When the patient has Cuff over clothing A full bladder A conversation or is talking Unsupported arm An unsupported back Unsupported feet Crossed legs BP can appear higher by ¹ ² 10-40 mmhg 10-15 mmhg 10-15 mmhg 10 mmhg 5-10 mmhg 5-10 mmhg 2-8 mmhg 1. Pickering, et al. Circulation 2005 2. O Brien, et al. Blood Press Mon. 2002 35