Focus on Cardiovascular Disease

Improving Hypertension Control

Approximately 50 million Americans suffer from hypertension, a major risk factor for myocardial infarction, stroke, and renal disease.[14] In 1997, the health plan found that hypertension was the most common ambulatory diagnosis for men 40 to 64 years of age and the second most common for men >65 years of age. In women, it was the second most common ambulatory diagnosis for those 40 to 64 years of age and the most common for those >65 years of age.

Finding hypertension to be a common diagnosis, the health plan began its efforts to improve hypertension management with a review of the literature and a physician survey in 1997. This research revealed that there was disagreement among physicians as to the definition of hypertension and confusion over which medications to prescribe. In response, the health plan developed and disseminated guidelines, solicited the support and endorsement of clinicians for a hypertension project, and provided feedback to practitioners regarding their control rates. Unfortunately, despite there interventions, the health plan recognized that progress from 1997 to 1999 was minimal and began to investigate other options to improve the quality of care for hypertensive patients.

The Need for Early Consensus In the area of blood pressure control, differences of opinion abound in both the literature and among physicians as to when to initiate treatment. The health plan found that reaching a consensus about this issue was extremely challenging, but critical to the success of its disease management program. It urged other health plans to get early practitioner buy-in on the diagnosis and treatment of hypertension - and its importance - in order to get its initiatives off to a good start.

Using HEDIS^® methodology, the health plan targeted the members who met the following criteria:

• Continuously enrolled
• Aged 46 to 85 years
• At least one outpatient encounter with an ICD-9 diagnosis code of 401 during the first six months of the measurement year; diagnosis confirmed via medical record review
• No end-stage renal disease (CPT codes 90921 or 90925)

The health plan used the HEDIS measure for blood pressure (BP) control as its performance measure. The representative BP was the reading obtained at the most recent visit to the doctor’s office of clinic, during which a BP reading was noted during the measurement year, but after the diagnosis of hypertension was made. Outpatient visits solely for the purpose of having a diagnostic test or surgical procedure performed, or to an urgent care center, were excluded.

The definition of BP control differed between the baseline and remeasurement periods due to a change in HEDIS specifications. During the baseline period, BP was considered to be in control if it was <140/90 mm Hg. However, during the first remeasurement period, the definition of BP control changed to a reading of <140/90 mm Hg. Therefore, BP data obtained during the first remeasurement period (2000) was measured twice (once for each specification) to allow for year-to-year comparability.

Baseline performance, measured between January 1999 and December 1999 on 411 patients, showed a rate of 37.23% of patients achieving BP control (Table 6). The initial goal had been set at 42% based on earlier measurements taken in 1997 and 1998. Because the goal had not been reached, it remained at 42% for the first remeasurement period.

The plan identified several barriers to the successful diagnosis, treatment, and control of hypertension, and also investigated barriers to the successful implementation of disease management programs:

• BP was not measured on all patients seen by practitioners for any reason
• Nonpreferred medications were sometimes used instead of preferred medications
• The BP of patients who had have elevated readings was not consistently monitored over time, especially once systolic or diastolic goal had been reached
• Because PCPs were participating in many disease management programs, a lack of focus was a barrier to improved hypertension control through this intervention

Research revealed that financial incentives were an effective way to target improvement for identified goals. The health plan also hired an outside health outcomes vendor (for a single project) to conduct an intense chart audit, collect and analyze data, and help develop appropriate interventions.

Because the health plan had found that pilot studies were an effective way to develop interventions and fine-tune its programs, the renewed effort to improve hypertension control began with the initiation of a two-clinic pilot program in late 1999. Office staff had primary responsibility for the majority of the program components, and physicians were consulted only as needed for changes to treatment plans. Program components included:

• BP reading on every patient seen by the practitioner
• Notification of nurse and recheck of BP if the first BP reading is >140/90 mm Hg
• Chart review for an active treatment plan if the BP is still elevated
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• Patient return visits for BP readings if there is no active treatment plan
• Physician notification if there is a treatment plan
• BP flow sheet for an at-a-glance picture of patient BP and medications

In January 2000, the health plan implemented a reimbursement plan that attached physician management bonus fees ($0.10 per member per month for all members in the practice or clinic) to the quality measure for hypertension control (BP controlled to a level of <140/90 mm Hg in 40% or more of hypertensive patients sampled). Physicians received annual, unblinded data on the performance of the health plan overall, regions, care groups (see Quality Lesson: Peer Pressure), clinics, and individual physicians, as well as “helpful hint” sheets (quick reference tools on how to achieve the quality indicator). Physicians received a quarterly list of their hypertensive patients to improve familiarity with these patients and to facilitate internal chart audits and patient-outreach activities.

Peer Pressure Because financial incentives are often used by health plans to get clinicians to focus on a particular QI initiative, the health plan felt it needed an edge to keep its QIA top of mind. Thus, it devised a method for encouraging peer-to-peer conversations and strategy sharing. First, it divided physicians into “care groups”: groups of single doctors, a clinic, or a group of clinics. Then, it tied payment of the bonus fee to the performance of the entire care group, encouraging all clinicians within the same care group to work together to meet goals. And, finally, the health plan reported unblinded performance rates by physician and care group. As the results demonstrated, peer pressure can sometimes be a good thing.

Hypertension control rates were measured two ways because of the change in HEDIS® specifications during the remeasurement period (January 2000 to December 2000). The first rate (49.14%) used a BP reading of <140/90 mm Hg as the criteria for hypertension control, while the second rate (57.18%) used a reading of <140/90 mm Hg (Table 7). The difference between the two rates was significant, which prompted a frequency analysis to investigate the cause. This analysis revealed that significant rounding occurs when BP levels are recorded, thus identifying another area (the importance of accurate BP assessment and documentation) that needed to be incorporated into clinician education.

Although pleased with the results - both rates exceeded the goal of 42% - the health plan analyzed failures proactively in an attempt to identify opportunities for interventions (Figure 1 on page 57.) Uncovering a high rate of uncontrolled systolic BP levels, this analysis underscored the need to focus clinician education on the importance of improving systolic control.

The health plan then went on to perform a root cause barrier analysis on the data collected by the outside vendor who had been hired to audit charts and collect data, as well as an evaluation of information from the pilot program.

These barriers were also informally reviewed by actively practicing clinicians who concurred with the following barriers to improved hypertension control, which had been identified during this analysis:

• Physician knowledge deficit regarding:


• Current control rates and prescribing patterns


• Importance of systolic control


• Current recommendations of national organizations for BP levels for groups with special needs/attention


• Effective office processes that improve hypertension diagnosis, treatment, and control (eg, taking a BP reading at every office visit regardless of the reason for visit and alerting the physician about any out-of-control results)


• Strategies to improve patient lifestyle and medication compliance


• Recommended treatment protocols and formulary guidelines


• Tools not available to:


• Quickly and effectively educate patients about hypertension control


• Enable patients to track their BP over time


• Provide practitioners with a quick reference to clinical information


• Patient knowledge deficit and noncompliance

To address these barriers, the following new interventions were rolled out in 2001:

• Presentations on barriers were given to high-volume clinicians and their nursing staff, and clinical guidelines, reference articles, and patient education tools were provided


• The ETC program (see Quality Lesson: Getting Everyone Involved in Teaching Compliance) was launched for hypertension


• Letters to low-volume clinicians on Hypertension CQI Team findings; letters to PCPs on overall year-end 2000 rates, BP control in diabetics, and strategies to control rates; quarterly member newsletter articles; and pocket/wallet cards for patients to track BP readings were also utilized

These new interventions, in combination with the ongoing reimbursement plan and the quarterly patient lists, were expected to further improve hypertension control rates in 2001.

Figure 1. Hypertension Control: Analysis of Failures from Baseline to Remeasurement 1

Getting Everyone Involved in Teaching Compliance In late 1999, the health plan’s pharmacy manager - who also worked at a local retail pharmacy - began asking patients refilling prescriptions if they knew what they were taking and why. In fact, very few did. After confirming this observation with other pharmacists, PCPs, and specialists, the health plan identified the need for fast, effective, and simple patient communications from all health care providers (doctors, nurses, and pharmacists) on proper treatment, its goal, and the importance of compliance. That is how “Everyone Teaching Compliance” (ETC) was launched. Utilizing easily understood tear-off sheets, all members of the health care team became involved in patient education. Pads were left at clinics and pharmacies, and use was encouraged. Additional pads were available free of charge. The program was well received by both members and providers and now covers several topics other than hypertension.

They hypertension control rate from January 2001 to December 2001 - which used a reading of <140/90 mm Hg as the criterion for hypertension control - remained stable at 59.85% (Table 8). Despite its efforts, the health plan did not achieve its goal of 66%, which the plan had believed was reasonable and would produce a result that could achieve statistical significance.

Although the BP control rates rose 22.6 percentage points from baseline to remeasurement 2, claims about improvements across the entire study interval cannot be made because of the change in HEDIS® measures during the study (Table 9).

Subsequent to the final measurement, the health plan continued to assess barriers to improved hypertension control. It found that an important barrier to improvement was the decision to keep the reimbursement goals for hypertension control steady at 40% in both 2000 and 2001. Since nearly every care group achieved the 40% reimbursement goal in 2000 - and knew that the goal would remain at 40% - physicians and their staff had little incentive to improve their control rates. The health plan therefore raised the reimbursement goal to 65% in 2002. This rate was more in line with then-current rates and HEDIS® goals, and it was hoped this would positively impact rates by year-end 2002.

The health plan reported that the QI initiative was “hugely successful” in 2002, producing a 70.9% hypertension control rate. This rate was nearly five percentage points above the goal of 66% and significantly higher than the 2001 rate (P=.0006).

The health plan will continue its efforts as before with the following exceptions, scheduled for late 2003 or early 2004:

• Recognizing that patients with diabetes are at high risk for CVD, the health plan will encourage tighter hypertension control in patients with diabetes by changing the reimbursement measure such that - to be counted as under control - diabetics must meet diabetes BP control criteria.


• Clinicians will be re-educated on the findings of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)


• The use of combination medications will be encouraged, as the health plan feels that combination medications are associated with fewer side effects and better compliance.

These two profiles illustrate how the management of cardiovascular risk factors can be improved through integrated QI initiatives. The fact that the same plan conducted these activities over the same time period suggests that it recognized the multifactorial nature of CVD as early as 1997. It was also advanced in the implementation of a data warehouse in 2001, which is an excellent example of how electronic medical records can be used to improve the quality of cardiovascular care (see A Look to the Future, The Future of Cardiovascular Care, Electronic Medical Records). Just as this plan assumed a leadership role in improving the management of both dyslipidemia and hypertension, all health plans and clinicians should strive to identify and manage multiple risk factors.

[1] - Data on file, Pfizer Inc, New York, NY.

[2] - National Diabetes Education Program. The link between diabetes and cardiovascular disease. Available at: www.ndep.nih.gov/control/CVD.htm Accessed June 6, 2003.

[3] - Keevil JG, Stein JH, McBride PE. Cardiovascular disease prevention. Prim Care Clin Office Pract. 2002;29:667-696.

[4] - Pearson TA, McBride PE, Miller NH, Smith Stephen Covey Jr. 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 8. Organization of preventive cardiology service. J Am Coll Cardiol. 1996;27:1039-1047.

[5] - American Heart Association. Heart Disease and Stroke Statistics - 2003 Update. Dallas, Tex: American Heart Association; 2002.

[6] - World Health Organization. Cardiovascular death and disability can be reduced more than 50 percent [press release]. October 17, 2002. Available at: www.who.int/mediacentre/releases/pr83/en/print.html. Accessed June 19, 2003. . Accessed July 24, 2003.

[7] - Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003;348:383-393.

[8] - Goldman L, Garber AM, Grover SA, Hlatky MA. 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task force 6. Cost effectiveness of assessment and management of risk factors. J Am Coll Cardiol. 1996;27:964-1047.

[9] - Elliott WJ, Weir DR. Comparative cost-effectiveness of HMG-CoA reductase inhibitors in secondary prevention of acute myocardial infarction. Am J Health Syst Pharm. 1999;56:1726-1732.

[10] - Grover SA, Coupal L, Zowell H, Dorais M. Cost-effectiveness of treating hyperlipidemia in the presence of diabetes: who should be treated? Circulation. 2000;102:722-727.

[11] - Physician Consortium for Performance Improvement. Clinical performance measures: chronic stable coronary artery disease. American Medical Association. Available at: www.americanheart.org/downloadable/heart/1055798504173CADMiniSetR030158_final.pdf. Accessed August 23, 2003.

[12] - Tipton ML, Fleming M. Stroke prevention in managed care: a five-dimensional health improvement model. In: Gorelick PB, After M, eds. The Prevention of Stroke. New York, NY: The Parthenon Publishing Group; 2002:123-130.

[13] - National Cholesterol Education Program. Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Bethesda, MD: National Heart, Lung, and Blood Institute; 2002. NIH publication 02-5215.

[14] - Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA. 2003;289:2560-2572.