Transforming Population‐Based Hypertension Management—An Efficient and Effective Approach
Authors: Dugdale D. , Khor S. , Lee E.S. , Marcotte L. , Flum D. 
Published: August 2020

Hypertension is a leading cause of cardiovascular and kidney disease and a major public health challenge. As part of the Center for Medicare and Medicaid Innovation Practice Transformation Network, UW Medicine launched a population health care transformation initiative that included a focus on blood pressure (BP) control. The initiative included a pathway for primary care clinicians and staff to use that included standardizing BP measurement, increasing the frequency of follow‐up visits, and prompts for advancing pharmacotherapy in a standard fashion. The initiative incorporated staff retraining and electronic health record (EHR)‐based prompts, but did not require the hiring of additional clinical staff. Since it was not launched at all clinics simultaneously, we leveraged this “natural experiment” to assess its impact on process of care and clinical outcomes, controlling for temporal trends.Quasi‐experimental study design using EHR data from UW Medicine primary care clinics, before and after program initiation (2017‐2019), with clinics that did not adopt the initiative during the study period serving as a control. Process measures included same‐day BP recheck after an elevated measurement (BP ≥ 140/90 mm Hg), 90‐day follow‐up BP measured for those with an elevated BP, and per‐protocol medication advancement (ie, a change/addition of drug subclass or an increase in daily dose within 90 days of an elevated BP) for the subset with medication information. Clinical outcomes included BP control (BP < 140/90 mm Hg) and nonsevere BP (systolic BP < 155 mm Hg). We used a difference‐in‐difference comparison of the intervention group (15 clinics) to a contemporaneous control group (39 clinics) to assess the impact of the initiative on each outcome, applying logistic regressions with robust, cluster‐corrected standard errors to account for within‐clinic similarities. We adjusted for patient demographics, insurance status, comorbidities, and time trends.Adults with a diagnosis of hypertension and at least one primary care visit at one of 54 clinics.Among 74 051 patients (mean age: 62 years (SD 15); 48% female), 54 897 (74.1%) were in the intervention group and 19 154 served as controls. Before the initiative was implemented in the intervention group, BP recheck rate was 30.9%, 68.2% had 90‐day BP measurement, 59.9% achieved BP control, and 84.3% had nonsevere BP. Difference‐in‐difference analyses adjusting for the temporal trends in the control group found that implementation was associated with ~4‐fold increase in BP recheck (OR: 4.70; 95% CI: 4.36‐5.06), 14% increase in BP control (OR: 1.14; 95% CI: 1.08‐1.19), and 14% increase in nonsevere BP (OR: 1.14; 95% CI: 1.06‐1.23). The implementation was also associated with 23% increase in medication advancement (OR: 1.23; P = 0.014), but not with changes in 90‐day follow‐up (OR: 1.06; 95% CI: 0.98‐1.15).The UW Medicine hypertension care transformation initiative improved the use of some, but not all process measures (BP recheck and medication advancement, but not follow‐up visits) and improved clinical outcomes (BP and severe BP) across a diverse population, without significant cost to the system.Care transformation for hypertension management using structured EHR‐based prompts, medication advancement algorithms, and staff retraining is an efficient and effective approach to improving BP control at the population level.The study was funded by Centers for Medicare and Medicaid Services.