System-level intervention leads to better BP control

A five-component hypertension control program implemented across the Kaiser Permanente Northern California (KPNC) system led to better blood pressure control compared with the rest of the state and nation, according to a study published in the Aug. 21 issue of JAMA. The program involved the creation of a registry of all patients with hypertension, the tracking of all control rates of these patients, the development of evidence-based treatment guidelines, regular patient follow-ups by medical assistants after medication initiation and the use of a one-pill combination treatment consisting of a thiazide diuretic and an ACE inhibitor.

“Many quality improvement strategies for control of hypertension exist, but to date, no successful, large-scale program sustained over a long period has been described,” wrote the authors, led by Marc G. Jaffe, MD, of Kaiser Permanente South San Francisco Medical Center in California.

KPNC is a nonprofit, fully integrated healthcare system that cares for and insures more than 2.3 million adults. The system developed its hypertension control program in 2001.

Researchers implemented the multifaceted program on patients in a health system registry identified as hypertensive between 2001 and 2009. They compared them to insured patients in the Healthcare Effectiveness Data and Information Set (HEDIS) commercial measurement for hypertension control between 2006 and 2009. HEDIS is a set of performance measures developed by the National Committee for Quality Assurance (NCQA). According to HEDIS, blood pressure control is defined as the proportion of hypertensive adults between 18 and 85 years of age whose blood pressure is less than 140/90 mm Hg.

The researchers found that patients in the system's hypertension registry totaled 349,937 people in 2001 and 652,763 in 2009. The HEDIS control rate within for the KPNC system rose from 43.6 percent in 2001 to 80.4 percent in 2009. The national control rate increased from 55.4 percent to 64.1 percent and rates in California were 63.4 percent in 2006 when data became available and 69.4 percent in 2009.

The KPNC rate continued to increase after the study period. Between 2010 and 2011, the rate rose from 83.7 percent to 87.1 percent.

In addition to the hypertension registry, Jaffe and his colleagues tracked hypertension control rates.

“However, unlike the NCQA HEDIS measurement, which included only a random sample of eligible individuals, the internal metric included all KPNC patients eligible for inclusion in the NCQA HEDIS hypertension control metric,” they wrote. These patients were all continuously enrolled and between the ages of 18 and 85 with documented hypertension on or before June 30 of the prior year. Control rates were regularly reported to each of KPNC medical centers and a team of hypertension management experts identified and communicated successful control strategies.

Evidence-based guidelines were also part of KPNC's experiment. The guidelines included a four-step medication regimen consisting of thiazide diuretics and other drugs and were updated every two years.

Additionally, starting in 2007, patients reported to medical assistants for follow-up visits two to four weeks after adjustments in medications. The medical assistants informed physicians of the patients' blood pressure and physicians then made treatment-appropriate recommendations.

“This system accelerated treatment intensification without significantly increasing the need for repeat clinician visits, while simultaneously improving patient convenience and affordability,” they explained.

The final facet of the program involved the use of a one-pill combination of lisinopril and hydrochlorothiazide. These pills, the authors said, offer the advantage of lower cost, better compliance and improved blood pressure control.

While only observational, the authors wrote that their study suggests this type of program could lead to better blood pressure control.

In an accompanying editorial, Abhinav Goyal, MD, MHS, and William A. Bornstein, MD, PhD, of Emory School of Medicine in Atlanta, wrote that the changing face of healthcare may enhance the value of programs such as KPNC's.

“The transition to value-based models in all sectors of U.S. healthcare and the looming growth of accountable care organizations and shared savings models provides a framework wherein healthcare organizations have the flexibility to implement care models optimized to deliver the best outcomes at the lowest cost, without being constrained to face-to-face physicians to drive reimbursement,” they wrote.

The study, they hope, will “prompt hypertension guidelines and perhaps other guidelines to include recommendations about system-level approaches to managing risk factors.”