Many patients at Rush University Medical Center on Chicago’s West Side face barriers to optimal health such as food insecurity, poverty and low health literacy. Meanwhile, the average life expectancy of patients who live on the West Side is only 66, largely driven by poor cardiometabolic disease. The city, which has four or five large academic centers, suffers from a fragmented health care landscape, with patients traveling from center to center and experiencing long wait times for primary care.
All these factors make it very difficult to keep up with blood-pressure control.
BP control “requires a lot of patient engagement, patient understanding, patient actions,” said Michael Cui, MD, MS, MBA, assistant professor in the division of general internal medicine and associate chief medical informatics officer at Rush University Medical Center.
Rush University Medical Center is part of the Rush University System for Health, which is a member of the AMA Health System Program that provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Given the social drivers of health affecting their patient population and the challenges inherent to effective BP control, leaders at Rush adopted the AMA MAP™ Hypertension program in 2022, embedding metrics and reports in its EHR.
AMA MAP Hypertension is an evidence-based quality improvement program that provides a clear path to significant, sustained improvements in BP control. MAP stands for the program’s three key components:
- Measure accurately.
- Act rapidly.
- Partner with patients.
Since 2022, BP control at Rush has improved by 3–4%, helping hundreds of patients. This is significant, given that it’s actually very difficult to get even a 1% increase in blood-pressure control, said Dr. Cui.
Among all the AMA MAP Hypertension metrics, Rush has improved the most on BP rechecks, rising from 30–40% compliance to 70–80%, a threefold improvement. This is an important metric because initial high BP readings can sometimes be due to improper technique, faulty equipment or transient factors. Rechecking ensures the measurement is accurate.
There was also a twofold improvement in getting patients to come back for a four-week follow-up visit and have their BP rechecked, which is important because high blood pressure during a single visit may not indicate chronic hypertension. A follow-up visit ensures that any initial high reading is consistent over time before diagnosing hypertension. It also gives an additional data point and time to intervene (start and adjust medications) so that physicians and their teams can get patients to proper blood pressure control faster.
Another measure that is part of the MAP Hypertension program is therapeutic intensification, which is part of the “Act Rapidly” arm and is the term used to describe the process of adjusting treatment to better control blood pressure. It involves increasing the intensity or modifying the approach to therapy to ensure BP is brought to and maintained within recommended levels. Measuring performance in this area is vital to better outcomes because therapeutic intensification can help improve control rates to 75% and higher.
Rush’s therapeutic intensification performance went from 10–12% to nearly 20%. Dr. Cui noted that measure is “more difficult to move” because it requires persuading physicians that changing their prescribing habits is needed to get their patients’ BP under control.
Having such data makes quality improvement efforts more tactical, he continued. It breaks down care for a chronic condition such as hypertension into actionable steps, which leads to more targeted care and better outcomes.
In an interview, Dr. Cui talked about the paths to AMA MAP Hypertension program adoption and how collaborative efforts with physicians and practice champions moved the needle forward on BP control.
A customized approach
Cardiovascular disease is a top contributor of morbidity and mortality. “It’s a large problem that we have,” said Dr. Cui. The medical center wasn’t performing as well as it should in controlling heart disease and was on the lookout for better solutions.
The AMA MAP Hypertension program was a good fit for Rush, he said, noting that the program provides multiple services to ensure the program’s success.
“The destination, the construct, everything was already there,” making the program easy to implement, said Dr. Cui.
That enabled Rush to customize the MAP Hypertension program for its specific needs, instead of just providing a cookie cutter model for implementation.
The AMA put a great deal of thought into considering the time and resource constraints in the health care environment, which “probably was the single biggest thing that made this easier to adopt,” said Dr. Cui.
Meanwhile, the program also had the AMA’s credibility behind it and published data on the efficacy of the program.
“It was easy for leaders and other physicians to trust that this is a program that actually works,” he said.
Making the right adjustments
That having been said, some steps that help effectively control BP can require an adjustment in practice flow. One of those steps is double-checking BP in the office. While rechecking blood pressure is a standard step that most clinical personnel are asked to do, staff at Rush were often busy and forgot to recheck a blood pressure.
“Now we have a systematized way of doing that. We know it’s important to recheck blood pressure during an office visit, so physicians can take action on a patient’s blood pressure reading,” said Dr. Cui. “We also believe it is equally important to bring patients back to recheck their blood pressure in four weeks so we can intervene further and bring patients’ blood pressure under control faster.”
The concern was time, given understandable fears that BP rechecks could put physicians and care teams behind schedule. This was addressed by adopting automated BP cuffs so when teams were rechecking blood pressure, the medical assistants could do other charting. The time component about bringing patients back in four weeks was addressed by using nurse visits to check BP and preserve clinic time.
Another important step in BP control is therapeutic intensification, which is a key component of the “act rapidly” metric. Yet some patients may feel it gives short shrift to their ability to avoid medications and pursue effective lifestyle changes.
“The way we've adjusted it is that these medications are a short-term solution—a stopgap. That way, we get the blood pressure under control and then we can always take them off,” said Dr. Cui.
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Physician and site champions guided journey
To ensure the program’s success, Rush invested in “site champions” at each individual clinic to help disseminate the MAP Hypertension Program. Each site had a physician champion and a practice champion. The practice champion was either a registered nurse (RN) or medical assistant (MA).
“You need local people that other physicians, other medical assistants, RNs trust,” said Dr. Cui.
Empowering these champions to do change management was a key component to implementing the MAP Hypertension program. It took some “elbow grease” at some of these clinics to explain why these changes were important, address concerns, then move the program forward, he said.
Democratizing the data
To help make this quality improvement effort more effective, “we wanted to do something different where we had the data dashboard embedded within our EHR” instead of storing it someplace else, explained Dr. Cui.
Rush leveraged its technology resources to build that dashboard, making it easy for physicians to access MAP Hypertension metrics. “We've democratized this data so anybody can take a look at it and see how well they're doing” in comparison with other clinics and across the entire Rush health system, he said.
This data is useful to share at practice meetings—to show that it’s possible for a practice with a 50% BP-recheck rate to reach another clinic’s 80% mark on that measure at Rush.
Overall, the AMA MAP Hypertension program has strengthened the partnership between physicians and their teams, said Dr. Cui.
Hypertension control is an issue that everyone in health care knows, understands and cares about, he added. “It’s easy to rally behind this initiative to improve blood pressure control.”
