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Million Hearts® 2022 and Best Practices for Hypertension Control Adriane Burke Health Systems Coordinator New Hampshire Division of Public Health Services Georgette Verhelle, RN, BS, CPHQ Program Coordinator, New England QIN-QIO

The Million Hearts® Initiative in New Hampshire Adriane Burke Health Systems Coordinator New Hampshire Division of Public Health Services October 26, 2017

Accurate Blood Pressure Measurement Saves Lives: Best Practices Presented By: Georgette Verhelle, RN, BS, CPHQ New England QIN-QIO

Objectives To list the classifications of blood pressure. To use correct patient positioning for an accurate BP measurement. To be able to select the correct size BP cuff for accurate measurement. To identify at least 3 lifestyle modifications that you can discuss with patients who have prehypertension or hypertension.

What is Blood Pressure (BP)? The force of blood against the walls of the arteries BP is recorded as 2 numbers: Systolic: the force exerted when the heart contracts Diastolic: the force exerted when the heart relaxes Hypertension is persistently high BP

BP Classification Blood Pressure Category Systolic mm Hg (upper #)   Diastolic mm Hg (lower #) Normal less than 120 and less than 80 Prehypertension middle 120 – 139 or 80 – 89 High Blood Pressure (Hypertension) Stage 1 middle 140 – 159 90 – 99 High Blood Pressure (Hypertension) Stage 2 160 or higher 100 or higher Hypertensive Crisis (Emergency care needed) Higher than 180 Higher than 110 https://www.heart.org/HEARTORG/Conditions/HighBloodPressure/MakeChangesThatMatter/Changes-You-Can-Make-to-Manage-High-Blood-Pressure_UCM_002054_Article.jsp#.Wei87f6ouig

Why is this Important? “In 2013, high blood pressure was a primary or contributing cause of death for more than 360,000 Americans – nearly 1,000 deaths per day.” (Million Hearts®) Hypertension increases one’s risk of heart disease, stroke, kidney disease, and early death. 1 in 3 US adults have high blood pressure and only half have their condition under control. Inaccurate blood pressure measurement can lead to misdiagnosis of hypertension.

Patient Positioning Feet flat, legs uncrossed Back supported Arm exposed & level with heart No talking during measurement Avoid smoking 30 minutes prior to measurement Avoid full bladder

Arm Selection Avoid taking BP on the side that has/had: Pain or injury Breast or axilla surgery including Mastectomy Lymphedema Dialysis Shunt/Fistula Subclavian Stenosis (narrowing/constriction) IV/arterial line

Check Equipment Calibrate according to manufacturer's directions Visually inspect before use The needle on the sphygmomanometer must be within the zero box prior to inflation or take the unit out of service until fixed

Selecting the Correct Cuff Size

Cuff too Big Cuff too Small index line left of range reading will be inaccurately low Cuff too Small index line right of range reading will be inaccurately high

Correct Cuff Size Correct Placement Index line within range Apply the cuff snugly around arm,1 inch above antecubital fossa.

AVOID: Artifactual Sounds Tourniquet Effect Muffled Sounds

The Cost of Making Small Measurement Errors Small errors may result in either… undiagnosed cases of hypertension (undertreated) misdiagnosed cases of hypertension in patients who are really pre-hypertensive (over-treatment)

Factors Affecting Accuracy of Blood Pressure Measurements

Obtaining and Recording an Accurate Blood Pressure Obtain BP Reading: apply cuff snugly around arm, 1 inch above the antecubital fossa. Inflate cuff, then deflate at 2 – 3 mmHg/sec. Note systolic pressure: 1st two or more consecutive faint tapping beats (Korotkoff sound, phase 1) Note diastolic pressure: last sound heard or disappearance of sound (2mmHg below the last sound) Both methods are recognized standards: refer to your agency’s policy & procedure Listen for another 10 – 20 mmHg beyond last sound heard, then quickly deflate cuff to zero.

Obtaining and Recording an Accurate Blood Pressure Record and Recheck as Needed: Record BP, rounding up to the nearest 2mmHg Wait at least 5 minute between BP readings Notify provider of all readings of concern (some agencies have a policy that an RN will recheck prior to this step) Always follow your agency’s BP Policy & Procedure

What Can Your Practice Do to Ensure Accurate BP Measurements? Develop a BP policy & procedure Provide staff training Do competency testing Calibrate BP equipment Rearrange furniture in exam rooms to accurately take a BP Position patient properly

Lifestyle Modifications to Discuss with Patients Always take BP medication as prescribed – don’t stop or skip a dose without consulting with your provider Maintain normal body weight Eat a healthy diet: high in fruits/vegetables, low in fat, reduce salt intake Physical Activity: at least 30 minutes, most days Avoid tobacco Limit alcohol use Manage stress/diabetes Have BP checked regularly & consider self-monitoring

Name at least 4 of Judy’s risk factors Case Study Judy is a 50 yo African American woman who is 5’2” (62”) and weighs 180lbs (BMI = 33). She is an administrative assistant at a large insurance agency and does not exercise on a regular basis. She is a diabetic and smokes 1 pack of cigarettes/day. Her BP was 180/92 today. Name at least 4 of Judy’s risk factors

List 3 lifestyle modifications that Judy can try to lower her BP Case Study Judy is a 50 yo African American woman who is 5’2” (62”) and weighs 180lbs (BMI = 33). She is an administrative assistant at a large insurance agency and does not exercise on a regular basis. She is a diabetic and smokes 1 pack of cigarettes/day. Her BP was 180/92 today. List 3 lifestyle modifications that Judy can try to lower her BP

Lifestyle Modifications to Discuss with Patients Always take BP medication as prescribed – don’t stop or skip a dose without consulting with your provider Maintain normal body weight Eat a healthy diet: high in fruits/vegetables, low in fat, reduce salt intake Physical Activity: at least 30 minutes, most days Avoid tobacco Limit alcohol use Manage stress/diabetes Have BP checked regularly & consider self-monitoring

Acknowledgements The material presented was originally developed by Dr. Rudolph Fedrizzi, Director of Community Health Clinical Integration and the Education, Training and Development Department at Cheshire Medical Center/Dartmouth-Hitchcock in Keene. Thank you for sharing the slides and allowing us to use some of the pictures/content for this program. Also thank you to the New Hampshire DPHS for their contribution to this presentation. Updates have been made to some slides using information from the Million Hearts® website and the American Heart Association website.

References Department of Health and Human Services, Maine. (July 2010). Maine health care systems intervention to improve the detection and control of high blood pressure. A story from the field, 1-30. Education, Training and Development Department. Obtaining Accurate Blood Pressure Measurements In The Ambulatory Setting. Keene, NH: Cheshire Medical Center and Dartmouth Hitchcock. New Hampshire Medical Society. (2011). To Control Your High Blood Pressure You Need To…Know Your Numbers. Keene, NH: Cheshire Medical Center and Dartmouth Hitchcock. New Hampshire Medical Society. (2011).When it Comes to Blood Pressure You Need To…Know Your Numbers. Keene, NH: Cheshire Medical Center and Dartmouth Hitchcock.

References Quality Improvement Organizations. (2012). QIO tool kit: Reducing Cardiac Risk Factors, 1-41. Utah Department of Health. (July 2006). Blood Pressure Measurement: Standardization Protocol, 1-41. Washington State Department of Health. (August 2013). Improving the screening, prevention, and management of hypertension. An Implementation Tool For Clinic Practice Teams, 80-90. Wisconsin Department of Health Services. Blood Pressure Measurement Toolkit: Improving Accuracy, Enhancing Care,1-28.

Contact Information Georgette Verhelle, RN, BS, CPHQ Georgette.verhelle@area-N.hcqis.org (603) 573-0336

Self-Measured Blood Pressure Program

What is Self-Measured Blood Pressure ? SMBP is the regular measurement of blood pressure by the patient outside the clinical setting, either at home or elsewhere. SMBP requires the use of a home blood pressure measurement device by the patient to measure blood pressure at different points in time. There is strong evidence to support the use of SMBP especially when tied with clinical support.

Benefits of SMBP Monitoring SMBP yields many results over time with fewer office visits: Can help determine if a change in therapy is needed It can prevent over-treatment Improves BP control, especially when used with clinical support When SMBP monitoring interventions were combined with additional support, systolic blood pressure decreased by an average of 4.6 mmHg and diastolic blood pressure decreased by an average of 2.3 mmHg (Community Guide). Improves adherence to antihypertensive therapy

*Graphic from Million Hearts webpage

Hypertension at NH FQHC’s Data Source: 2015 UDS Data of New Hampshire FQHCs: https://bphc.hrsa.gov/uds/datacenter.aspx?year=2015&state=NH

Recommendations The Community Guide (2015) SMBP when used alone – Recommended SMBP when combined with additional support – Recommended Agency for Healthcare Regulation & Quality Comparative Effectiveness Study (2012) Evidence is high showing the effectiveness of SMBP with additional clinical support in lowering blood pressure and improving control among patients with hypertension, compared with usual care. United States Preventive Health Services Task Force (2015) “A Level Recommendation” for screening for high blood pressure in adults aged 18 years or older. Obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment is recommended using ABPM or SMBP.

Joint Scientific Statement A Joint Scientific Statement from AHA, ASH, and PCNA encourages increased regular use of SMBP by clinicians for the majority of patients with known or suspected hypertension as a way to increase patients’ engagement and ability to self-manage their condition. AHA- American Heart Association ASH – American Society of Hypertension PCNA - Preventive Cardiovascular Nurses Association Pickering TG, Miller NH, Ogedegbe G, Kra-koff LR, Artinian NT, Goff D. Call to action on use and reimbursement for home blood pressure monitoring: executive summary: a joint scientific statement from the Ameri-can Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. J Am Soc Hypertens. 2008;2:192–202

Additional Support for SMBP Monitoring Other organizations who do not have a formal recommendation but support the use of SMBP through various initiatives include: Million Hearts® American Medical Association American Heart Association CDC’s 6/18 Initiative

SMBP Program in New Hampshire There is evidence to support the use of SMBP Insurance coverage of monitors is “spotty” and unclear. There was an identified need in the state NH DPHS was able to obtain funding for monitors and partnered with the NE QIN/QIO to help implement a program.

Getting Started Clinics who were already doing HTN QI projects through grants/contracts with the state were targeted as pilot sites Each clinic had to apply and be accepted into the program Monitors sent to clinics September 2016 Clinics started the program once they had their procedure manual developed. 13 clinics are participating

Program Requirements Develop a written procedure which outlines the program and meets specific requirements Identify patient education materials Report back data at 6 months and 12 months: Number of patients receiving monitors and reason Number of patients who reported their blood pressures back to the clinic at least once? Number of patients who had a reduction in blood pressure Number of patients now in control (below 140/90) Any challenges and success

Resources We encouraged using these resources as good examples of how a program should look

# of patients with a reduction in BP Six month results Data is starting to roll in and the results are exciting! Clinic # of patients enrolled # of patients with a reduction in BP # of patients below 140/90 Clinic A 31 24 15 Clinic B 26 20 14

Next Steps: Phase 2 Phase 2 applications are now available. If you are interested in Phase 2 send an email to adriane.burke@dhhs.nh.gov or Georgette.Verhelle@area-N.hcqis.org and we’ll send you an application.

Adriane.Burke@dhhs.nh.gov (603) 271-1075 Thank you! Adriane.Burke@dhhs.nh.gov (603) 271-1075

Questions? This material was prepared by the New England QIN-QIO, the Medicare Quality Innovation Network-Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSQINB12017101212