Peter Emery, MD Specialist in Clinical Hypertension InterMed Portland, ME

 Epidemiology of Hypertension  Hypertension Practice Guidelines  Experience of Kaiser Permanente  Experience of InterMed

 Million American Adults  29-31% of American Adults  $69.9 Billion in 2008 ◦ Direct and indirect (CAD, stroke, renal failure) costs  15% of the 2.4 Million Deaths in 2009

Control of hypertension is inadequate 81.5% are aware they have it 74.9% are being treated 52.5% are under control

Date of download: 11/12/2014 Copyright © 2014 American Medical Association. All rights reserved. From: US Trends in Prevalence, Awareness, Treatment, and Control of Hypertension, JAMA. 2010;303(20): doi: /jama Data are presented as means with 95% confidence intervals (error bars). For all curves, the statistical significance of change over time between and was P ≤.04, except for hypertension awareness for individuals aged 18 to 39 years (P =.36) and hypertension prevalence, treated, treated and controlled, and controlled for individuals aged 18 to 39 years (insufficient data to reliably calculate significance using weighted linear regression). Figure Legend:

 Coronary Artery Disease  Stroke  Renal failure  Congestive Heart Failure

Lancet 2002;360:1903

 JNC  Over the past year ◦ JNC 8 ◦ ASH ◦ AHA/ACC

 Goal BP of <150 systolic for 60 or older- JNC 8  Staging of hypertension- AHA/ACC, ASH ◦ Stage 1: /90-99 ◦ Stage 2: >160/100  Initiate therapy with 2 agents  Initial Therapy for Black Patients- JNC 8, ASH ◦ Thiazide diuretic or CCB  “Compelling Indications”- JNC 8, AHS ◦ JNC 8- CKD ◦ ASH- CKD, DM, CAD, Stroke, CHF  Beta blockers not first line therapy- all 3

 Mixed Messages  What are we supposed to do?

 Poor outcomes- only 50% controlled  Multiple guidelines

 Best evidence: ◦ organized, comprehensive system of regular population review and intervention Cochrane Database Syst Rev. 2010;(3)CD005182

 LOWER THE BP AT THE POPULATION LEVEL

 “High-quality blood pressure management is multifactorial and requires engagement of patients, families, providers, healthcare delivery systems, and communities.” ◦ Science Advisory from AHA/ACC, CDC  J Am Coll Cardiol. April 1, 2014, 63(12)

 Large Managed Care Consortium based in CA ◦ 9.3 Million health plan members

 HTN control as defined by NCQA HEDIS  KP Northern California HTN registry ◦ 652,763 patients in 2009 out of 2.3 million adult patients  ◦ HTN control at KPNC increased from 43.6% to 80.4% ◦ Nationally 55.4% to 64.1% JAMA. 2013;310(7):

 System-wide hypertension program  5 components ◦ Registry of hypertensive patients ◦ Development and sharing of performance metrics  Internal control reports every 1-3 months  Successful practices were identified and adopted across the system ◦ Evidence-based guidelines ◦ MA visits for BP measurement every 2-4 weeks  NO CHARGE for visit  Medications adjusted by primary care provider ◦ Single-pill combination pharmacotherapy  Lisinopril-HCTZ; could be used as initial therapy JAMA. 2013;310(7):

 Continued success  2011 control rate of 87.1%

 Multispecialty group practice focusing on primary care  75 thousand patients

 Clinical Microsystems ◦ Front-line units comprised of a small group of people that provide health care  Places where patients, families, and care teams meet  Including support staff  Where recurring patterns of information, behavior, and results take place ◦ Linked processes ◦ Produces performance outcomes ◦ Embedded in larger organizations

 Team Approach ◦ “Pod” system at InterMed  “Working from the ground up” ◦ Structured approach to organizational improvement ◦ “laboratory” for finding and refining successful practices that can be adopted across the organization

 Practice-wide training in correct BP technique ◦ Aneroid sphygmomanometers  Performance Metric ◦ Terminal digit bias  Prescription refill protocol ◦ Reducing delays in BP medication refills ◦ Improving staff efficiency  24 hour blood pressure monitor  Home BP monitoring

 Practice-Wide Registry  Adopting and modifying an algorithm/practice guidelines  NP/PA hypertension experts to see patients in follow up for medication titration  Hypertension Specialty Practice ◦ For resistant hypertension and challenging cases

 Hypertension is prevalent, expensive and a major contributor to cardiovascular mortality  There are several practice guidelines and algorithms  Population management is the key ◦ Evidence supports organized, comprehensive system of regular population review and intervention to improve the goal of lowering BP  We are making strides in this direction at InterMed