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2016-Symposium-Fix-Your-HIPS-Problem-Meador.pptx
- 2. Undiagnosed Hypertension: How to Fix your “HIPS” Problem M E G M E AD O R , M P H , C - P H I D I R E C TO R , C L I N I C AL I N T E G R AT I O N & E D U C AT I O N , N AC H C AP R I L 1 , 2 0 1 6
- 3. 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
- 4. 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 Research-based advocacy o Education about the mission and value of health centers o Training/TA to health center staff and boards o Clinical Workforce, Innovation, Performance
- 5. The Problem of Undiagnosed Hypertension (and why you should care)
- 6. • 75 million U.S. adults have hypertension (HTN) 1 • Every 44 seconds, someone in the U.S. has a heart attack2 • Every 4 minutes, someone dies of a stroke2 • 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+ 1. National Health and Nutrition Examination Survey, 2013-2014 CDC 2. Million Hearts Why Should I Care? It’s a huge problem
- 7. Uncontrolled HTN 16.1 M 7 M 11.5 M Aware and treated Aware and untreated "Unaware" 34.6 M US Adults have uncontrolled HTN 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
- 8. “Unaware” – A Closer Look Wall HK, Hannan JA, Wright JS. Patients with Undiagnosed Hypertension: Hiding in Plain Sight. JAMA. 2014;312(19):1973-74. 81.8% 82.5% 61.7% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Have Health Insurance Have a Usual Source of Care Have Received Care 2+ Times in Past Year Unaware of their High Blood Pressure
- 9. Why is finding patients with undiagnosed hypertension important? Diagnosed hypertension patients: • 100 adults with essential HTN (ICD-9: 401 or ICD-10: I10) • 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
- 10. - $31,106 for patients with ischemic heart disease (IHD) - $17,298 for those with cardiovascular disease (CVD) - $18,693 for those without IHD or CVD1 • Annual per 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. 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. 2. Medical Expenditure Panel Survey, Agency for Healthcare Research and Quality, 2012 Why Should I Care? It’s a huge health care cost • Estimated average costs for HTN-related hospitalization:
- 11. • Life expectancy 5 years longer in those with normal blood pressure than those with high blood pressure1 • Lowering blood pressure by 5 mmHg diastolic reduces the risk of stroke by 34% and ischemic heart disease by 21%2 • Antihypertensive therapy associated with: 1. 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. 2. 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 3. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment Why Should I Care? Controlling HTN works - 35% to 40% reduction in stroke - 20% to 25% reduction in heart attack - Over 50% decrease in heart failure3
- 12. Where do you start?! Consider . . . How many patients in your organization are clinically hypertensive but undiagnosed? How many preventable heart attacks and strokes will happen as a result?
- 13. QI Foundations and Key Strategies
- 14. Source: Adapted from TMIT Consulting, LLC Successful QI Projects are Win-Win-Wins Health Center Leaders/Broader Safety Net Better clinical and business results Accountability Scalable QI approaches Expanded Care Team Efficient workflow/ information flow Better clinical outcomes Patients Excellent experience Better health Lower Cost Win!
- 15. People • Partner Solicitation/Selection • Stakeholder Engagement • Team Preparation & Training • Transformation Culture • QI Coaching • Peer Learning Opportunities • Financial Incentives Processes • Analyze Workflows/Identify Improvement Opportunities • Design/Configure Interventions • Measure and Benchmark • Standardize Workflows • Spread Successful practices Technology • Population Management Data Reporting & Analytics • Web-based Collaborative Workspace • Other HIT Systems & Tools (EHRs, Registries, CDS, HIE) QI Core Success Principle Source: Adapted from IHI
- 16. Evidence-based/Emerging Successful Practices Learning Community Workflow Assessment/Redesign http://www.hea lthit.gov/provid ers- professionals/cl inical-decision- support-cds
- 17. The CDS 5 Rights Framework To improve targeted care processes/ outcomes, interventions must provide: ◦ the right information e.g., evidence-based guidance, actionable, response to clinical need… [what] ◦ to the right people consider entire care team, including the patient… [who] ◦ through the right channels EHR, population management system, smartphones, patient portal… [where] ◦ in the right formats documentation tools, data dashboards, registries, order sets, alerts… [how] ◦ at the the right times for decision-making or action… [when] 17 Source: TMIT Consulting, LLC
- 18. Leverage Expanded Care Team Tools (registries, flow sheets, alerts, etc.) and Interventions (nurse visits, staff training, motivational interviewing) Model for Improvement/ PDSA Cycles Near real-time data Change Package
- 19. How to Fix your HIPS Problem
- 20. The BP Control Big Picture The steps to find and address undiagnosed HTN fit here and should be part of your overall hypertension protocol that optimizes efficiency and effectiveness of diagnosing HTN How do you manage a HTN patient you don’t know about?
- 21. 1. Benchmark your HTN prevalence 2. Establish clinical criteria for potential undiagnosed HTN 3. Leverage EHR to find patients who meet clinical criteria 4. Implement a plan for addressing the identified population Adapted from: Hilary Wall, Senior Health Scientist for Million Hearts, Division for Heart Disease and Stroke Prevention, CDC Steps for Finding and Addressing Undiagnosed Hypertension Adapted from: Hilary Wall, MPH, Senior Health Scientist for Million Hearts, Division for Heart Disease and Stroke Prevention, CDC
- 22. 1. Benchmark your HTN prevalence Compare practice HTN prevalence to regional, state, or national average OR Use Million Hearts Hypertension Prevalence Estimator Tool 2. Establish clinical criteria for potential undiagnosed HTN Use evidence-based guidelines Consider stages of HTN, # of elevated values, time period Putting it into Action Adapted from: Hilary Wall, MPH, Senior Health Scientist for Million Hearts, Division for Heart Disease and Stroke Prevention, CDC
- 23. 3. Leverage EHR to find patients who meet clinical criteria EHR registry Population management software Embed automated algorithms into EHR 4. Implement a plan for addressing the identified population Workflow to confirm assessment and diagnose Patient Engagement BP Accuracy Training or AOBP machines Timely and time-bound follow-up Adapted from: Hilary Wall, MPH, Senior Health Scientist for Million Hearts, Division for Heart Disease and Stroke Prevention, CDC Putting it into Action
- 24. • 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?
- 25. 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 /RecommendationStatementDraft/hypertension-in-adults- screening-and-home-monitoring
- 26. • Consider importance/impact • Consider feasibility: Effort Time Cost Tips for Choosing Change Strategies Choosing Change Strategies (Prioritizing Enhancements)
- 28. Improve awareness and control of HTN, and ultimately, health outcomes Get the true hypertension population denominator right Improve detection and diagnosis of hypertensive patients “hiding in plain sight” at health centers Goals Year 1 Year 2
- 29. Year 1 Aims 3. Develop and spread tested change package to additional health center sites 2. Successfully embed algorithm into clinical and information workflows, leveraging HIT, QI, and expanded care team 1. Develop/test undiagnosed HTN algorithm in health centers
- 30. NACHC Million Hearts Partners • 4 HCCNs • 5 States • 10 Health Centers • At least 20,000 adult patients, ages 18-85 per network; actual: 150,000+ HCCN PCA/HCCN Central Valley Health Network (CA) Health Center Partners of Southern California Kentucky Health Center Network (KY/AR/TN) Missouri Quality Improvement Network (MO) Our Partners
- 31. Stage 1 Algorithm: Patients ages 18 to 85 years without a diagnosis of essential or secondary HTN who have BP readings ≥140mmHg SBP or ≥90mmHg 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 ≥160mmHg SBP or ≥100mmHg DSP at any one medical visit during the past 12 months. Exclusions: pregnancy and ESRD.
- 32. 62.3% 29.8% 0% 10% 20% 30% 40% 50% 60% 70% Percent of Cohort Month of Reporting Undiagnosed Cohort Patients with Follow-Up Visit Patients w/FU Visit and Diagnosed
- 33. Who are the undiagnosed in Arkansas? Women - white, ages 18 - 39 with little obesity or depression
- 34. 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
- 35. 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
- 36. Undiagnosed HTN in the Field • 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 1. NorthShore University Health System 2. Geisinger Health 3. Palo Alto Medical Foundation 4. University of Wisconsin 5. Health Center Network of New York (article in progress) 6. NACHC Million Hearts health centers (article in progress) Who’s Done it?
Editor's Notes
- Welcome and Introductions – Thank you, Nicole; it’s an honor and a pleasure to be here in my home state, sharing the stage with staff from two amazing health centers, La Maestra and Neighborhood Healthcare. We’re very excited to speak with you today about the issue of undiagnosed hypertension and more specifically, how you can fix your HIPS problem.
- So, what is HIPS? HIPS is a term we coined with the CDC that stands for hiding in plain sight – more specifically, patients with undiagnosed hypertension who are hiding in plain site. And, I can almost guarantee that you have them in your health center… Today, we’re going to explore the problem of undiagnosed hypertension, why you should care, what the NACHC Million Hearts project teams have done to address HIPS, and what your health center can do about it. Topics will include a step-by-step approach and practical, specific strategies, tools, resources, and lessons learned health centers can apply to improve the efficiency and effectiveness of identifying and diagnosing undiagnosed hypertension patients in order to move them into management.
- First – who is NACHC? NACHC stands for the National Association of Community Health Centers and is the national organization that serves as the voice of health centers. A non-profit organization representing a national network of more than 1,200 health centers and 9,300 sites in every US state and territory. NACHC works with state primary care associations and health center controlled networks to provide NACHC works to serve health centers in a variety of ways …education, advocacy, training, capacity-building and development of partnerships that support primary care delivery and improved population health. Achieving this mission depends to a large degree on partnering with PCAs, HCCNs, health centers, as well as other strategic partners I’m here today because recently, we partnered with several networks, including the Health Center Partners of Southern California, and two of their affiliated health centers, in a CDC-sponsored project to address undiagnosed hypertension.
- I understand that all of you have taken some time to document your current workflows around SOGI and sexual health risk assessment data collection – that’s fantastic. While there are many possible formats to use, I’m going to focus on this one, since this is what you have in your folders to start thinking about and planning potential enhancements. I encourage you to pull it out if you haven’t already to follow along, as some of the text on the slides might be easier to read if its on the table in front of you.
- 75 million adults in the US have hypertension – that’s about 1 in every 3. We all know that hypertension is a significant contributor to heart attack and stroke when it is not controlled, but the when you break it down to a rate, it’s really pretty staggering. Consider that the US prevalence of HTN is 31% - statistics suggest that if your health center prevalence is lower, you may have undiagnosed HTN patients in your care who are at greater risk for heart attack and stroke. That said, since health centers care for more vulnerable populations, even if your prevalence is at or above 31%, undiagnosed HTN may still be an issue. That’s because prevalence is higher among certain sub-populations 40.3% among non-Hispanic blacks 41.2% among adults 40-64 69.6% among adults 60+
- Let’s focus in for a moment on those at greatest risk – so of those 75 million adults with HTN, 34.6 million U.S. adults have uncontrolled HTN1 Of those 34.6 million, about two-thirds are aware of their HTN The remaining one-third, or 11.5 million (33%) – the purple piece on this pie - are not aware of their HTN1 And that’s what’ we’re going to focus on today. These are people who were asked, “Have you ever been told by a health care provider that you have HTN or high blood pressure?” and said no, and who were not on an anti-hypertensive medication. These data are the National Health and Nutrition Examination Survey (NHANES); this is a nationally representative cross-sectional survey of the non-institutionalized US population. It combines both interviews and physical examinations as part of the survey process. So they have clinical staff ride around in special trailers that use very specific protocols to take BP measures (repeated), draw blood, assess BMI, etc.
- Let’s take a closer look at those who are unaware of their high blood pressure. You might assume that these people are primarily uninsured and/or have poor access to the health care system, but in actuality, about 82% of these 11.5M are insured, 83% have a usual source of care, and over 60% have received care at least twice in the past year – that group alone represents over 7 million adults who are regularly accessing care, meet the criteria for hypertension, but are not diagnosed and are not being treated for it – in other words, they are hiding in plain sight and the opportunity for diagnosis, management, and control is being missed. 81.8% have health insurance 82.5% report having a usual source of care 61.7% have received care two or more times in the past year
- What if a health center – a very small one – had 100 adults diagnosed with HTN and 70 had their BP under 140/90. That would mean a 70% control rate, which should be celebrated – there’s always room for improvement, but it meets the Million Hearts target of 70%, etc. However, what if a practice has an additional 50 patients with multiple elevated BP readings but they do not have a diagnosis and aren’t being managed? Their true BP control rate is actually 47%. From a health outcomes and downstream cost perspective, this has the potential for significant impacts.
- Here are the actual costs – slightly more, as these figures are based on a 2010 study, but the comparison still stands. Compare the average annual cost of managing a hypertensive patient – in this research, about $800 – to the tens of thousands it costs for HTN-related hospitalization. Consider financial costs from a value-based care model perspective – there may be health system cost savings and possibly shared savings or performance incentives for health centers that actually make a difference in preventing strokes and heart attacks
- Finding patients hiding in plain sight who are clinically hypertensive but undiagnosed – SAVES LIVES, and controlling HTN is one of the most cost-effective treatments there is. Antihypertensive therapy associated with: 35% to 40% mean reduction in stroke incidence 20% to 25% reduction in myocardial infarction incidence decrease of more than 50% in heart failure incidence5 In summary – you should care because hypertension is a huge health problem in our country, it’s a significant health care cost, and controlling HTN works!
- One of the worst things someone can do is provide a bunch of information about a problem, explain all the ways it strikes close to home, and then offer no solutions… So now that you are thinking about how many patients in your organization are clinically hypertensive but undiagnosed and how many preventable heart attacks and strokes will happen as a result, let’s talk about what can be done.
- I’m going to start out with a few big picture/conceptual slides just to provide a framework for the approach we used; it’s really important to keep this framework in mind as the backdrop for why we do this work and the fact that it should be undertaken in a way that will yield wins on all levels. What that really translates to is that successful QI projects are a microcosm of what we’re trying to achieve nationally with the Triple Aim and operational excellence in health centers. They’re a win for patients when they yield a better experience, better health, and lower costs, they’re a win for clinicians and staff when they produce more efficient workflows and better health outcomes, and they’re a win for leaders and the broader safety net when improved quality yields better clinical and business results, improved accountability to all stakeholders (payers, staff, patients, community) and successful practices that can be scaled.
- Another core QI success principle that underpinned our work on this project was the notion that improving care delivery and outcomes requires meticulous attention to: People (engagement, capacity) Processes (for care and QI) Technology (e.g., HIT) In that order! Because the nature of our goal in this project, which was centered on embedding an undiagnosed hypertension algorithm into workflows and information flows, there’s a real inclination to dive right into trying to fix processes, without addressing what underlies those things – people. Similarly, you may have recently acquired a new technology and so be tempted to begin there or worse, not really consider the other two gears. The point is, inadequately addressing one of these jeopardizes each item above it. Thus, we began this project with deliberate efforts around stakeholder engagement, team preparation, helping establish a transformation culture within our teams and providing training on the Model for Improvement and QI Coaching.
- These are key strategies NACHC uses in most of its QI projects. There isn’t a large body of work on undiagnosed HTN, as you know, but work has been done by a few health systems across the country, and certainly we looked to those practices to inform our efforts. We also structured projects as a learning community so that we have those opportunities to come together and learn from each other. However, probably our most fundamental strategy was our systematic workflow assessment and redesign process. This visual provides a high-level look at the CDS/QI Worksheet developed by TMIT Consulting as a guide for organizations and teams to think about information flows and clinical workflows around health issues like undiagnosed hypertension and then drill down to the specific activities that influence performance at each care step, at the population management level, and in terms of foundations in place. Our teams use this structured approach because it illuminates gaps and opportunities for improvement and leads them to where they need to target interventions.
- The CDS/QI worksheet also provides a structured framework for applying the Clinical Decision Support 5 Rights in optimizing health center workflows and developing clinical decision support tools – this is ensuring that the right information goes to the right person in the right format through the right channel at the right time in the workflow. All have to be in place to work – for example, one Million Hearts health center had this great blood pressure flow sheet that their system produced, which would give them valuable historical blood pressure data on their patients – great except that it took three clicks for the provider to get there and then two minutes to load. They never used it. It’s not enough to get four out of five right…
- We also ensure that every person on the care team is contributing in the most efficient and effective way to yield improved performance and outcomes. We then develop or adapt tools and intervention strategies aimed at improving specific targets; this includes supports to ensure uptake and sustainment. We’ll hear from two of the project’s health center’s in a moment who will be sharing more about their specific tools and intervention strategies. These are implemented using Model for Improvement’s PDSA cycles to test workflow changes or specific interventions and determine what’s working, what’s not, and if modifications are needed. These strategies are all bolstered by having regular data to measure progress and hone targets for improvement. Key to our projects has been establishing a guiding principle of open data sharing, both between health center teams and internally, at the care team level. Finally, I wanted to mention that we compiled the best resources from the HIPS project into a change package so that the learning can be spread. I’ll be sharing the link with you at the end of my talk so that you can access it.
- I think it’s worth taking a step back and thinking about the blood pressure control big picture – if you think about most hypertension guidelines or protocols practices have in place, they usually focus on patients who are already diagnosed and have a decision tree about types of treatment options. In other words, they start with management, and rely on provider discretion and luck for the first three steps. What we aimed to do in the our HIPS project was to put a little more structure around the first three steps.
- These are the high level steps you can take to find undiagnosed hypertension in your health center. Benchmarking your HTN prevalence, establishing criteria to identify potentially undiagnosed HTN, leveraging your EHR and population health management systems to find patients who meet the criteria, and then developing and implementing a plan to address the identified population.
- Let’s talk a little more about each one of these steps – specifically, what these steps mean practically and how to operationalize them in your health center. First, to benchmark your prevalence…. Second, establish clinical criteria – while there aren’t any nationally endorsed criteria or measures that you can use, you also don’t need to reinvent the wheel here. You can base your criteria off of evidence-based guidelines like JNC-7 or JNC-8 or whatever your health center supports. Ultimately, you’ll want to consider the stages or levels of HTN, the number and recency of elevated values you want to use as your trigger point, and the overall lookback timeframe. And then you’ll want to come up with who to exclude – patients with ESRD, pregnancy, who have died, etc. A little later in the presentation, we’ll get into the specifics of the NACHC Million Hearts project, including the specific clinical criteria or algorithm we used that you could certainly use or adapt.
- When we talk about Step 3, leveraging your EHR to find patients who meet the criteria you established, what we mean is using the criteria to create registries for outreach, using population management software to segment the population and understand where to target efforts, and embedding the algorithms in your EHR for pre-visit planning and other point of care clinical decision support. Finally, it’s important, as it is in any QI project where you are identifying a population, to make a plan for how you’re going to address it. First – if you don’t have a workflow to confirm elevated blood pressure and a clear process for diagnosing HTN, these are foundational pieces. Second, if you recall the slide I showed earlier with the colored bubbles, one of the precursers to HTN management and control is getting the patient into your health center and engaging them in care. You can’t confirm an elevated reading or diagnose, let alone manage a patient who doesn’t come in for visits. Third, under implementing a plan, how will you ensure accuracy of blood pressure readings so that providers and staff trust the data and you are focusing on patients who aren’t white coat syndrome but who are truly at risk for hypertension? Will you incorporate ambulatory or self-measured blood pressure monitoring into your diagnosis process? How will you follow up with patients you identify as potentially undiagnosed? What happens if you identify 200 potentially undiagnosed HTN patients – who do you prioritize? How do you roll this out so that you don’t overwhelm your staff? I’m glad to share some thoughts if we have time at the end.
- One important action item that I want to hone in on specifically is to establish a clearly defined hypertension diagnosis protocol to be able to effectively and efficiently move patients from identification of HTN to management of HTN. One of the problems is that in America, most guidelines on hypertension focus on management only, and only very vaguely explain the procedures to follow for diagnosis. This leads to wide variation in how providers diagnose and certainly contributes to the issue of undiagnosed hypertension patients hiding in plain sight. If you don’t feel comfortable with a set number of readings, at least establish a range of readings within a set timeframe that will prevent patients from getting caught in a loop of follow up readings…
- When you develop your diagnosis protocol, consider using out of office readings, whether that be through a home BP monitor or using ambulatory monitoring. Just a note on ambulatory monitoring – this is a device a patients wear for 24-hours that takes BP readings intermittently and provides a much more accurate average of actual BP than office-based readings do. This past October, the USPSTF officially recommended ambulatory blood pressure monitoring to confirm high blood pressure before the diagnosis of hypertension. An “A” rated recommendation means that there is high certainty that the net benefit is substantial. Thus historically, payers cover services that receive USPSTF “A” ratings. Thus, it may not be financially feasible now, but using these devices could soon be reimbursed, given the “A” rating by USPSTF.
- I outlines some practical steps to address undiagnosed HTN, but each of these involves making changes. Here are some tips to think about when you are considering what to prioritize. When you think about impact, think about how it benefits patients, care teams, and health center leaders/the broader safety net. Ideal is to hit all three. Then, you want to consider feasibility – what’s the lift? How much time does it take to design, purchase, or implement, etc.? How much does it cost? An example of getting creative is to get supplies donated or shift around responsibilities.
- I’d like to transition from the broader undiagnosed HTN steps you can take to talking about some of the specific goals, strategies and lessons learned from the NACHC Million Hearts project, and then leave you with some practical take-aways and resources you can bring back to your health centers. The purpose of Year 1 was to focus on the first two links in the chain – that is, do the foundational work in improving detection and diagnosis of hypertensive patients “hiding in plain site”. You can see the logical progression of why it’s important to put systems in place that will yield an accurate hypertensive population before interventions to improve control can have the most impact.
- Our Year 1 HIPS project had three key Aims -
- Here are our partners. Our partners included 4 HCCNs that spanned 5 states, 10 of their affiliated health centers, and over 150,000 adult patients. With year 2, we added one additional health centers and many more sites within existing health centers, so that the net number of patients affected is now closer to 200,000.
- We’re also continuing to work with the population health data analytics vendors the networks are using to understand more about who our populations are and how we can better target and focus interventions to improve outcomes. This slide shows ARCare’s data on their study group of patients identified at baseline as potentially undiagnosed for HTN and who had a follow-up visit. The dark blue are those with a HTN dx after the study began and the light blue are those who have not been dx with HTN. The discovery in ARCare’s data is that the undiagnosed are mostly white, young females – ages 18 to 39 with little obesity or depression (other patterns identified in the data). Keep in mind this is only the study group who came back in – it would be important to understand who didn’t come back in as well. The point here is that who we might have expected the undiagnosed to be and who they really are is only discernable if we use the data to drive our understanding. Ultimately, these factors can help us target and refine how we address the issue of undiagnosed hypertension in different populations.
- Undiagnosed HTN clinical criteria needs to achieve a balance between patient needs and provider capacity; the sensitivity needs to cast a wide enough net to ensure truly hypertensive patients are not overlooked, but does not inundate providers with patients who are not truly hypertensive. Undiagnosed HTN identification is a science and an art – use HIT to create your initial patient list; use care team discretion to refine The accuracy of blood pressure measurement is foundational to providers trusting blood pressure readings as a basis for diagnosis. There are no concrete diagnosis guidelines in the United States (2+ BP readings at 2+ visits can cause an endless loop of visits) Plan your patient recall strategy – use registries to prioritize who to call in first; establish a specific appointment type in the EHR to track, dedicate one provider or certain time slots to seeing these patients, consider using nurse visits “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