At 16 primary care practices implementing key elements of a blood-pressure improvement program, hypertension control rose from 65.6 percent to 74.8 percent over just six months, while the mean systolic blood pressure and diastolic blood pressure fell from 149/85 to 139/80 in uncontrolled patients.
Accurate measurement, rapid action to address high BP readings, and effective partnerships with patients, families and communities were used as part of a quality improvement program that achieved these results. These elements are central to the BP Improvement Program, an evidence-based approach that is part of the AMA-American Heart Association’s Target: BP™ initiative. And more research shows how well—and how quickly—it can work.
That new research, presented at the AHA Hypertension 2017 Scientific Sessions in September in San Francisco, the abstract for which was published in the journal Hypertension, was the impetus for a recent expert panel discussion in the AMA Integrated Health Model Initiative (IHMI) digital community. Key stakeholders, physicians and the authors of this study gathered to discuss hypertension control’s barriers and opportunities. Here are some highlights from that digital exchange of viewpoints.
What are the hurdles to improving BP control?
Rob Davis, executive director, Care Coordination Institute Labs: Taking and recording an accurate blood-pressure reading presented a challenge. Many misconceptions existed concerning taking a BP. There was some resistance to an office automated BP device. These were overcome with data and with encouragement to try a new option. Practice site patient flow varies and this too presented an opportunity to work the automated office BP into the practice flow without adding significantly to time. By understanding the current flow, we were able to work the office team to find good solutions.
Mark Jaffe, MD, senior vice president of the Cardiovascular Health Initiative for the RESOLVE program, a division of Vital Strategies: Certainly there are no shortage of hurdles to the control of blood pressure on the population level. Several comments have been made about increasing the accuracy and the convenience of BP measurements—and I agree with the discussion. Another large hurdle is (or was in my practice setting) the absence of sustained and reliable systems to ensure all patients have a system to ensure follow up.
After patients have had drug escalation, or if a long period of time has passed since the last verification of controlled BP, then a mechanism to document the current BP control is essential. A reliable system like this ensures that patient BP control is continually monitored and tracked, with special attention to those who are overdue for assessment and perhaps intervention. Systems like these, engineered to identity and repatriate overdue patients, are essential components for systems seeking to have maximal population blood pressure control.
What was some early clinic-level feedback?
Dr. Jaffe: The performance of various clinics was shared in an unblended fashion so that clinic directors could make changes such as redesign workflow, hire or deploy more staff, enhance training, develop outreach programs or create incentives within the clinic and other processes. Feedback at this level allows systemic changes to care and what’s fascinating is that the clinics develop plans based on their unique care environment and needs.
Susan Sutherland, PhD, an author of the study and a senior biostatistician for the Care Coordination Institute Labs: Primary care practices are busy and needed to be able to adopt with QI project without adding additional time to their daily schedules. At the beginning of the project, a facilitator worked with each of the 16 clinics to optimize the workflow to include the “measure accurately” phase. … Allowing flexibility in the protocol to design the best workflow process in each clinic for accurate BP assessment was a key component of the project’s success.
Were clinics hesitant to adopt new protocols?
Dr. Jaffe: Absolutely there will be some clinics/providers who embrace change, including a new protocol, while there are others who are less eager for change. Those clinics/providers more reluctant to change do so for many reasons—so understanding which reasons is often helpful to address any concerns. If the issue is about unfamiliarity of the new components then information sharing can help. Often, the issue is that the clinics/providers feel left out of the adoption process—so involving them earlier may help implementation later if they feel a better sense of ownership.
Davis: Uniformity often meets with resistance as it most often requires some to change. We found that keeping the protocols as simple as possible and spending time upfront explaining the decisions helped. We also found that linking the feedback and patient reports to fit with the protocol was useful in adoption.
The AMA invites all physicians, health care and technology stakeholders to join IHMI and contribute their unique expertise in this effort to transform health care. The IHMI platform brings health and technology sectors together around a common data model, aiming to create a framework for organizing data across health care. It seeks to provide a shared framework for organizing health data, emphasizing patient-centric information and data elements most predictive of achieving better outcomes, goals and wellness for patients.
Recent IHMI discussions have focused on the new hypertension guidelines, behavioral interventions for diabetes prevention, and expanded Medicare coverage for telehealth and remote patient monitoring services. Beginning Jan. 9, an IHMI, expert-led discussion will discuss the keys to success in pediatric asthma QI programs.
