1. Presented by: National Forum for Heart Disease and Stroke Prevention Improving Hypertension Control The Kaiser Permanente Hypertension Control Project: How a large health care organization improved blood pressure control from 44% to 80% in 8 years Marc Jaffe, MD Clinical Leader, Kaiser Permanente Northern California Cardiovascular Risk Reduction Program Associate Clinical Professor of Medicine, UCSF October 17, 2012

2. 2 Marc Jaffe, MD The Permanente Medical Group, Inc. Oakland, CA 10/11/2014 Kaiser Permanente Northern California (KPNC) 3.3 million members 2.7 million adults >5,000 MDs 17 medical centers 35 outpatient facilities

3. 3 Marc Jaffe, MD The Permanente Medical Group, Inc. Oakland, CA 10/11/2014 KPNC Hypertension Implementation Timeline 1995 1997 1999 2001 2003 2005 2007 2009 1995 Guideline Created, updated every 2 yrs 2002 Performance Measures Distributed Successful practices disseminated 2005 Single Pill Combination Promoted 2007 Non-MD BP Visits 2000 HTN Registry developed

4. 4 Marc Jaffe, MD The Permanente Medical Group, Inc. Oakland, CA 10/11/2014 Evolution of the Hypertension Guideline Year2001*2003200520072009 Step 1 TD or BBTDTD or TD + ACEI TD or TD + ACEI TD or TD + ACEI Step 2 TD + BBTD + ACEI or TD + BB TD + ACEI Step 3 TD + BB + ACEI TD + BB + ACEI TD + ACEI + BB TD + ACEI + BB TD + ACEI + DCCB Step 4 TD + BB + ACEI + DCCB TD + BB + ACEI + DCCB TD + BB + ACEI + DCCB TD + BB + ACEI + DCCB TD + ACEI + DCCB + BB or Spir TD=Thiazide Diuretic, BB=Beta Blocker, ACEI=Angiotensin Converting Enzyme Inhibitor, DCCB=Dihydropyridine Calcium Channel Blocker, Spir=Spironolactone*1995-2001 No Significant changes after step 2

5. 5 Marc Jaffe, MD The Permanente Medical Group, Inc. Oakland, CA 10/11/2014 Evolution of the Hypertension Guideline Year2001*2003200520072009 Step 1 TD or BBTDTD or TD + ACEI TD or TD + ACEI TD or TD + ACEI Step 2 TD + BBTD + ACEI or TD + BB TD + ACEI Step 3 TD + BB + ACEI TD + BB + ACEI TD + ACEI + BB TD + ACEI + BB TD + ACEI + DCCB Step 4 TD + BB + ACEI + DCCB TD + BB + ACEI + DCCB TD + BB + ACEI + DCCB TD + BB + ACEI + DCCB TD + ACEI + DCCB + BB or Spir TD=Thiazide Diuretic, BB=Beta Blocker, ACEI=Angiotensin Converting Enzyme Inhibitor, DCCB=Dihydropyridine Calcium Channel Blocker, Spir=Spironolactone.*1995-2001 No Significant changes after step 2 BB not 1 st ACEI or BB 2 nd SPC OK 1 st ACEI 2 nd BB 3 rd DCCB 3 nd BB OK 4 th BB OK 1 st BB OK 2 nd BB 3 rd BB still 3 rd BB OK 4 th

6. 6 Marc Jaffe, MD The Permanente Medical Group, Inc. Oakland, CA 10/11/2014 Hypertension Registry Development Outpatient Coding HTN Registry: Lab Results Medications Demographics Comorbid Conditions BP Measurements Visit Information Hospital Pharmacy Membership Data Clinical Laboratory Outpatient EMR

7. 7 Marc Jaffe, MD The Permanente Medical Group, Inc. Oakland, CA 10/11/2014 Hypertension Registry Definition  Hypertension (HTN) Registry Population:  2 visits for HTN in the past 2 yrs  No age limits  Designed to be very inclusive

8. 8 Marc Jaffe, MD The Permanente Medical Group, Inc. Oakland, CA 10/11/2014 Hypertension Control Definition  Hypertension Control Rate  Age 18-85 yrs with an encounter diagnosis of Hypertension (46-85 before 2006) in the 1 st 6 months of the reporting year  Blood Pressure at last clinic visit <140/90 (≤140/90 before 2006)  Exclusions: End Stage Renal Disease, Renal Transplant, pregnancy, or blood pressure measurements during hospitalization, Emergency Department visit, diagnostic test, or surgical procedure.

9. 9 Marc Jaffe, MD The Permanente Medical Group, Inc. Oakland, CA 10/11/2014 Medical Center Hypertension Control 2001 Performance Reports Distributed to Medical Directors Quarterly Report 2001-2007, Monthly after 2007 High Performing sites identified and practices shared

10. 10 Marc Jaffe, MD The Permanente Medical Group, Inc. Oakland, CA 10/11/2014 Evolution of Single Pill Combination Therapy in KPNC 1995 1997 1999 2001 2003 2005 2007 2009 Not generally advised Advised Optional

11. 11 Marc Jaffe, MD The Permanente Medical Group, Inc. Oakland, CA 10/11/2014 1/4 of ACEI Rx ’ s dispensed as Single Pill Combination Therapy

12. 12 Marc Jaffe, MD The Permanente Medical Group, Inc. Oakland, CA 10/11/2014 Non-MD Blood Pressure Check BP at goal Doctor clinic visit BP over goal Follow up non-MD visit Treatment intensification BP check Advantages Shorter visit for patient No charge for visit Scheduling flexibility Improves access to MD

13. 13 Marc Jaffe, MD The Permanente Medical Group, Inc. Oakland, CA 10/11/2014 Hypertension Control Rates 2001-2009 Commercial Rate as reported to HEDIS 44% 80%

14. 14 Marc Jaffe, MD The Permanente Medical Group, Inc. Oakland, CA 10/11/2014 Hypertension Control Rates 2001-2010 in Kaiser Permanent Northern California Commercial Rate as reported to HEDIS

15. 15 Marc Jaffe, MD The Permanente Medical Group, Inc. Oakland, CA 10/11/2014 Hypertension Results 2001-2009  From 2001 to 2009 in KPNC  HTN control rate nearly doubled from 44% to 80%  HTN registry increased by 167%  Controlled HTN tripled from 171,000 to 531,000  359,00 more people had controlled HTN  6 care processes implemented  Evidence Based Guideline development  HTN Registry creation  Performance measure distribution  Successful practice dissemination  Single Pill Combination therapy promotion  Non-physician BP visit creation

16. 16 Marc Jaffe, MD The Permanente Medical Group, Inc. Oakland, CA 10/11/2014 Heart Attack Rates are declining in KPNC 16