It’s no secret that high blood pressure is one of the most prevalent health conditions in the U.S., facing about 50% of American adults, while many don’t even know they have the condition. That’s why improving blood-pressure control may require getting creative. And that is exactly what one accountable care organization did.
In the fall of 2019, AMA member Jen Brull, MD, a family physician in Plainville, Kansas and vice president of clinical engagement at Aledade, headquartered in Bethesda, Maryland, helped pilot the AMA MAP BP™ program in three Aledade, Kansas primary care practices. Aledade operates accountable care organizations across 37 states in partnership with more than 1000 primary care practices. By March 2020, the pilot was paused as COVID-19 was declared a pandemic. Fortunately, the six-month curriculum was already intended to be virtual, allowing each practice to resume the pilot program a month later with only slight modifications.
AMA MAP BP is an evidence-based quality improvement program that provides a clear path to significant, sustained improvements in BP control. It’s named for three key elements, which help physicians and care teams focus to measure BP accurately, act rapidly to treat high blood pressure and partner with patients.
“It was really important to talk about partnering with patients and the self-monitored blood pressure [SMBP] in the environment of increasing telehealth during the early pandemic,” said Dr. Brull. “So, the AMA SMBP resources worked very well with what they were trying to do in terms of newly managing their patients in this largely virtual space. That's why we changed the order of MAP and did and did MPA instead.”
After a year of the pilot, two practices had statistically significant increases in BP control. But amid the continuing pandemic, those practices saw their control rate flatten and then rise again slightly. One practice’s BP control rate rose from 73% to 82%, while another practice went from 54% to 58%.
Another practice faced significant barriers—with large staff turnover being the primary barrier—and did not see a statistically significant improvement in their BP-control rate. They did, however, improve their terminal digit preference rates, which meant they were documenting blood pressure measurements more accurately. Terminal digit preference is the tendency of an observer to round off a measurement to a digit of their own choosing, most commonly zero. This can cause significant discrepancies in BP measurements.
In an interview, Dr. Brull highlighted some of the successes of the AMA MAP BP pilot program at these three Aledade practices.
Getting creative with workflows
Part of this success could be the result of a few tangible reminders for the practice team, Dr. Brull said. To establish a proper workflow for blood pressure measurement and management, Aledade practices used a heart magnet, which was red on one side and green on the other.
The magnet “went on the door of the exam room and if it was red, the patient needed a repeat blood pressure check. If it was green, their blood pressure was controlled,” she said. There is also a “door hanger called the red card door hanger, and we have a whole workflow around if you have a red card, then you recheck and you reschedule for two weeks.”
“A lot of what we’ve learned is something as simple as a door hanger or magnet that just reminds everybody on the team the person in this room doesn’t have a normal blood pressure,” Dr. Brull said. “It’s a physical reminder of what to do about that blood pressure.”
Setting priorities
In addition to tracking the practices’ BP measurement accuracy, Dr. Brull said one shift was to focus on a particular class of BP cases.
“We looked at what we called the stale blood pressure—so what were the abnormal blood pressures that were old?” she added. This meant looking at severely elevated blood pressures that were more than four weeks old, or moderately elevated BPs more than three months old.
“We picked those because it felt like an achievable goal to go after those two levels and that people would have a sense of urgency about severe blood pressure,” Dr. Brull said. The Aledade practices looked at “what is your rate of stale blood pressures, which we hoped would go down, and it did.”
The first practice saw their rate of stale blood pressures drop from 44% to 23% while the second practice dropped from 22% to 13%. For the third practice, their stale BP rate dropped from 28% to 9%.
The AMA has developed online tools and resources created using the latest evidence-based information to support physicians to help manage their patients’ high BP. These resources are available to all physicians and health systems through AMA MAP BP, an evidence-based quality improvement program, providing a clear path to significant, sustained improvements in BP control.
