Undiagnosed Hypertension How to Fix your HIPS Problem
Undiagnosed Hypertension: How to Fix your “HIPS” Problem MEG MEADOR, MPH, C-PHI DIRECTOR, CLINICAL INTEGRATION & EDUCATION, NACHC APRIL 1, 2016
Overview • The problem of undiagnosed hypertension – “HIPS” – and why you should care! • What you can do to address the issue • Results from the NACHC Million Hearts project • Tools and Resources
Who is NACHC? National Association of Community Health Centers (NACHC) • Founded in 1971 • Our Mission: “To promote the provision of high quality, comprehensive and affordable health care that is coordinated, culturally and linguistically competent, and community directed for all medically underserved populations. ” • National Association and voice for health centers o o Research-based advocacy Education about the mission and value of health centers Training/TA to health center staff and boards Clinical Workforce, Innovation, Performance
The Problem of Undiagnosed Hypertension (and why you should care)
Hypertension Prevalence and Consequences Why Should I Care? • • • 75 million U. S. adults have hypertension (HTN) 1 Every 44 seconds, someone in the U. S. has a heart attack 2 Every 4 minutes, someone dies of a stroke 2 1 out of every 3 adults dies from cardiovascular disease U. S. prevalence of HTN is 31% - how does your health center compare? 1 o 40. 3% among non-Hispanic blacks o 41. 2% among adults 40 -64 o 69. 6% among adults 60+ It’s a huge problem 1. 2. National Health and Nutrition Examination Survey, 2013 -2014 CDC Million Hearts
Uncontrolled HTN 34. 6 M US Adults have uncontrolled HTN 11. 5 M 16. 1 M Aware and treated Aware and untreated "Unaware" 7 M Source: 2013 -2014 National Health and Nutrition Examination Survey and Hilary Wall, MPH, Senior Health Scientist for Million Hearts, Division for Heart Disease and Stroke Prevention, CDC
“Unaware” – A Closer Look Unaware of their High Blood Pressure 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 81. 8% 82. 5% 61. 7% Have Health Insurance Have a Usual Source of Care Have Received Care 2+ Times in Past Year Wall HK, Hannan JA, Wright JS. Patients with Undiagnosed Hypertension: Hiding in Plain Sight. JAMA. 2014; 312(19): 1973 -74.
Why is finding patients with undiagnosed hypertension important? Diagnosed hypertension patients: • • 100 adults with essential HTN (ICD-9: 401 or ICD-10: I 10) 70 of those adults with BP <140/90 70% BP control What if a practice has 50 patients with multiple BP readings ≥ 140/90 but do not have the official diagnosis? • • 100 + 50 adults with possible HTN 70 with BP <140/90 47% BP control Source: Hilary Wall, MPH, Senior Health Scientist for Million Hearts, Division for Heart Disease and Stroke Prevention, CDC
Hypertension Costs Why Should I Care? • Estimated average costs for HTNIt’s a huge health care cost -related hospitalization: - $31, 106 for patients with ischemic heart disease (IHD) - $17, 298 for those with cardiovascular disease (CVD) - $18, 693 for those without IHD or CVD 1 • Annual person expenses of treating HTN with outpatient visits and medication: $7842 • Consider costs from a value-based model perspective – health system and shared savings, performance incentives 1. 2. Wang G, Zhang Z, Ayala C. Hospitalization costs associated with hypertension as a secondary diagnosis among insured patients aged 18 -64 years. Am J Hypertens 2010; 23: 275 -281. Medical Expenditure Panel Survey, Agency for Healthcare Research and Quality, 2012
Hypertension and Health Outcomes Why Should I Care? • Life expectancy 5 years longer in those with normal blood pressure than those with high blood pressure 1 • Lowering blood pressure by 5 mm. Hg diastolic reduces the risk of stroke by 34% and ischemic heart disease by 21%2 • Antihypertensive therapy associated with: - 35% to 40% reduction in stroke - 20% to 25% reduction in heart attack - Over 50% decrease in heart failure 3 1. 2. 3. Controlling HTN works Franco OH, Peeters A, Bonneux L, de Laet C. Blood pressure in adulthood and life expectancy with cardiovascular disease in men and women: Life course analysis. Hypertension. 2005; 46: 280. Law M, Wald N, Morris J. Lowering blood pressure to prevent myocardial infarction and stroke: a new preventive strategy. Health Technol Assess. 2003; 7(31): 1 -94 Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment
They’re in Your Health Center Consider. . . How many patients in your organization are clinically hypertensive but undiagnosed? How many preventable heart attacks and strokes will happen as a result? Where do you start? !
QI Foundations and Key Strategies
The QI Trifecta Successful QI Projects are Win-Wins Health Center Leaders/Broader Safety Net Expanded Care Team Patients Better clinical and business results Efficient Accountability workflow/ information flow Scalable QI approaches Better clinical outcomes Source: Adapted from TMIT Consulting, LLC Excellent experience Better health Lower Cost Win!
QI Core Success Principle Technology • Population Management Data Reporting & Analytics • Web-based Collaborative Workspace • Other HIT Systems & Tools (EHRs, Registries, CDS, HIE) Processes • Analyze Workflows/Identify Improvement Opportunities • Design/Configure Interventions • Measure and Benchmark • Standardize Workflows • Spread Successful practices Source: Adapted from IHI People • Partner Solicitation/Selection • Stakeholder Engagement • Team Preparation & Training • Transformation Culture • QI Coaching • Peer Learning Opportunities • Financial Incentives
Key Strategies ü Evidence-based/Emerging Successful Practices ü Learning Community ü Workflow Assessment/Redesign http: //www. hea lthit. gov/provid ersprofessionals/cl inical-decisionsupport-cds
Key Strategies ü The CDS 5 Rights Framework To improve targeted care processes/ outcomes, interventions must provide: ◦ the right information ü e. g. , evidence-based guidance, actionable, response to clinical need… [what] ◦ to the right people ü consider entire care team, including the patient… [who] ◦ through the right channels ü EHR, population management system, smartphones, patient portal… [where] ◦ in the right formats ü documentation tools, data dashboards, registries, order sets, alerts… [how] ◦ at the right times ü for decision-making or action… [when] Source: TMIT Consulting, LLC 17
Key Strategies ü Leverage Expanded Care Team ü Tools (registries, flow sheets, alerts, etc. ) and Interventions (nurse visits, staff training, motivational interviewing) ü Model for Improvement/ PDSA Cycles ü Near real-time data ü Change Package
How to Fix your HIPS Problem
The BP Control Big Picture How do you manage a HTN patient you don’t know about? The steps to find address undiagnosed HTN fit here and should be part of your overall hypertension protocol that optimizes efficiency and effectiveness of diagnosing HTN
Steps for Finding and Addressing Undiagnosed Hypertension 1. Benchmark your HTN prevalence 2. Establish clinical criteria for potential undiagnosed HTN Adapted from: Hilary Wall, Senior Health Scientist for Million Hearts, Division for Adapted from: Hilary Wall, MPH, Senior Health Scientist for Million Heart Disease and Stroke Hearts, Division for Heart Disease and Stroke Prevention, CDC 3. Leverage EHR to find patients who meet clinical criteria 4. Implement a plan for addressing the identified population
Putting it into Action 1. Benchmark your HTN prevalence 2. Establish clinical criteria for potential undiagnosed HTN Compare practice HTN prevalence to regional, state, or national average OR Use Million Hearts Hypertension Prevalence Estimator Tool Use evidence-based guidelines Adapted from: Hilary Wall, MPH, Senior Health Scientist for Million Hearts, Division for Heart Disease and Stroke Prevention, CDC Consider stages of HTN, # of elevated values, time period
Putting it into Action 3. Leverage EHR to find patients who meet clinical criteria 4. Implement a plan for addressing the identified population EHR registry Workflow to confirm assessment and diagnose Population management software Patient Engagement Embed automated algorithms into EHR Adapted from: Hilary Wall, MPH, Senior Health Scientist for Million Hearts, Division for Heart Disease and Stroke Prevention, CDC BP Accuracy Training or AOBP machines Timely and time-bound follow-up
Does your HTN Protocol Cover Diagnosis? • HTN Diagnosis Protocols - Obtaining accurate BP readings ? ? - Standardizing # readings/ # visits/ timeframe “Assess the patient for hypertension using the BP measure at initial visit and repeated measurements taken at home or at office visits. ” based on JNC-7 What does this mean? How many readings? How many visits? In what timeframe?
Ambulatory BP Monitoring – USPSTF • • Draft recommendations; public comment period closed 1/26/16 If made final, ABPM should be covered by most plans under ACA http: //www. uspreventiveservicestaskforce. org/Page/Document /Recommendation. Statement. Draft/hypertension-in-adultsscreening-and-home-monitoring
Tips for Choosing Change Strategies (Prioritizing Enhancements) • Consider importance/impact • Consider feasibility: Ø Effort Ø Time Ø Cost
NACHC’s HIPS Project
NACHC Million Hearts “HIPS” Project Goals Year 2 Year 1 Improve detection and diagnosis of hypertensive patients “hiding in plain sight” at health centers Get the true hypertension population denominator right Improve awareness and control of HTN, and ultimately, health outcomes
HIPS Project Aims Year 1 Aims 1. Develop/test undiagnosed HTN algorithm in health centers 2. Successfully embed algorithm into clinical and information workflows, leveraging HIT, QI, and expanded care team 3. Develop and spread tested change package to additional health center sites
NACHC Million Hearts Partners • • HCCN PCA/HCCN Our Partners 4 HCCNs 5 States 10 Health Centers At least 20, 000 adult patients, ages 18 -85 per network; actual: 150, 000+ Central Valley Health Network (CA) Health Center Partners of Southern California Kentucky Health Center Network (KY/AR/TN) Missouri Quality Improvement Network (MO)
The Undiagnosed HTN Algorithms Stage 1 Algorithm: Patients ages 18 to 85 years without a diagnosis of essential or secondary HTN who have BP readings ≥ 140 mm. Hg SBP or ≥ 90 mm. Hg DSP at two separate medical visits, including the most recent visit, during the past 12 months. OR Stage 2 Algorithm: Patients ages 18 to 85 years without a diagnosis of essential or secondary HTN who have a BP reading ≥ 160 mm. Hg SBP or ≥ 100 mm. Hg DSP at any one medical visit during the past 12 months. Exclusions: pregnancy and ESRD.
How are the algorithms working? Undiagnosed Cohort Patients with Follow-Up Visit Patients w/FU Visit and Diagnosed 70% 62. 3% 60% 40% 29. 8% 30% 20% 10% Month of Reporting Feb-16 Jan-16 Dec-15 Nov-15 Oct-15 Sep-15 Aug-15 Jul-15 Jun-15 May-15 Apr-15 Mar-15 Feb-15 0% Jan-15 Percent of Cohort 50%
Using HIT and Data to Inform QI Who are the undiagnosed in Arkansas? Women - white, ages 18 - 39 with little obesity or depression
Ah-Has • Patient engagement is a key step to addressing undiagnosed hypertension • There are no concrete diagnosis guidelines in the U. S. ! • Undiagnosed HTN clinical criteria needs to achieve a balance between patient needs and provider capacity • The accuracy of blood pressure measurement is foundational • Plan your patient recall strategy • “HIPS Exist! It’s one thing to hear about it and another to see real patient names on your own health center’s registry” – Grace Community Health Center
Resources • Hypertension Prevalence Estimator Tool - an online tool that may be used to calculate an expected hypertension prevalence among an ambulatory patient population http: //millionhearts. hhs. gov/tools-protocols/tools. html • National Association of Community Health Centers’ Undiagnosed Hypertension “HIPS” Change Package – a compilation of materials to help clinicians map and identify enhancements to clinical workflows that improve detection and diagnosis of HTN http: //mylearning. nachc. com/diweb/fs/file/id/229350/d/1 • Hiding in Plain Sight Whiteboard - an animated video that outlines concrete steps that can be taken to find potentially undiagnosed patients
Undiagnosed HTN in the Field Who’s Done it? 1. 2. 3. 4. 5. 6. North. Shore University Health System Geisinger Health Palo Alto Medical Foundation University of Wisconsin Health Center Network of New York (article in progress) NACHC Million Hearts health centers (article in progress) • Rakotz MK, Ewigman BG, Sarav M, et al. A technology-based quality innovation to identify undiagnosed hypertension among active primary care patients. Ann Fam Med. 2014; 12(4): 352 -358. • Shah NR. Identifying hypertension in electronic health records: a comparison of various approaches. Paper presented at: AHRQ Comparative Effectiveness Research Methods Symposium; June 2009; Rockville, MD. Of Various Approaches. AHRQ Comparative Effectiveness Research Methods Symposium, Rockville, MD, June 2009 • Banerjee D, Chung S, Wong EC, Wang EJ, Stafford RS, Palaniappan LP. Underdiagnosis of hypertension using electronic health records. Am J Hypertens. 2012; 25(1): 97 -102. • Johnson HM, Thorpe CT, . Bartels CM, Schumacher JR, Palta M, Pandhi N, Sheehy AM, Smith MA. Undiagnosed hypertension among young adults with regular primary care use. J Hypertens. 2014, 32: 65– 74
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