Health System–Wide Quality Programs to Improve Blood Pressure Control

More observational studies and clinical trials have been conducted, more drugs have been approved for treatment, and more clinical practice guidelines have beenwritten for hypertension than fornearly anyother cardiovascular risk factor, yet hypertensionstill remainsunderrecognizedandundertreated.1 Whydoeshypertensioncontrol remainsoelusive in theUnited States? Current guidelines are intended to help clinicians diagnose hypertension and prescribe effective therapies for individual patients2 but offer little guidance to health systems on how to improve hypertension control in the populations they serve. This deficiency in the guidelines is largely attributable to the lack of science behind health system approaches to blood pressure control. Although substantial knowledge is available regarding the epidemiology, pharmacotherapy, andgeneticsofhypertension,manypeoplewithhypertension will remain underdiagnosed and undertreated if healthsystemscannot identify themmoreefficientlyandeliminate barriers to delivering health care. In this issue of JAMA, Jaffe and colleagues3 make an important contribution to the science of improving systems of care to detect and treat community-based hypertension. One of 8 divisions under the national Kaiser Permanente umbrella, Kaiser Permanente NorthernCalifornia (KPNC) is a large, integrated managed care organization that insures and provides comprehensive health care for approximately 2.4 million members. In 2000, KPNCdeveloped a system-wide,multifacetedprogram to improve blood pressure control. From 2001 to 2009, KPNC reported annual rates of hypertension control to the National Committee forQualityAssurance (NCQA), anorganization that accredits health care plans that demonstrate a commitment to improving the health of their members. The NCQA has developed approximately 75 performance metrics called the Healthcare Effectiveness Data and Information Set (HEDIS) measures,whichhealthplansarestrongly incentivizedtoadopt and report. Blood pressure control is a HEDISmeasure defined as the proportion ofmembers aged 18 to 85 yearswith a diagnosis of hypertensionwhosebloodpressure is controlled to lower than 140/90mmHg during themeasurement year.4 Based on data for the KPNC hypertension registry, which included 349 937 adults in 2001 and652 763adults in 2009, Jaffe et al report that HEDIShypertension control rateswithinKPNC increased substantially after implementation of the hypertension program, from 44% in 2001 to 80% in 2009. In comparison, nationalHEDIShypertensioncontrol ratesduring thesameperiod showedmoremodest increases (from55%to64%), asdidCalifornia state control rates from 2006-2009 (63% to 69%). The authorswereunable toprovidehypertensioncontrol rates from KPNC that were adjusted for individual patient and systemlevel covariates, because these datawere not available for national and state-wide comparisons. Theauthors also acknowledge that thenear-doublingofhypertensionprevalencewithin KPNC from 15.4% in 2001 to 27.5% in 2009wasmost likely attributable to improved detection and documentation of hypertension,3 and therefore hypertension control rates during the early part of the study may have been less accurate than those reported later.Despite these limitations, the gains inhypertension control reported within KPNC are impressive. WhatmadetheKPNChypertensioncontrolprogramsosuccessful?Theprogramconsistedof5componentsappliedacross theKPNCnetwork.First, in2000KPNCcreatedan internal registry to identify patients with hypertension based on diagnosis codes,KPNCpharmacyrecords,hospitalizationrecords,and confirmatory chart audits. From 2001-2005, paper case report formswereusedfordatacollectionfor theregistry. In2005, KPNC implemented a comprehensive electronicmedical record system that provided medical staff immediate access to all blood pressure readings and greatly facilitated data collection. Second, rather than rely on annualNCQAHEDIS data reportsbasedonachart sampleofonly300to400patients,KPNC used its hypertension registry to track internal hypertension control rates in theentireKPNCpopulation.Reportsweregenerated for each center every 1 to 3months, and a central KPNC team identified best practices from high-performing centers anddisseminatedthosereports toallothercenters.Third, starting in 2001, Kaiser Permanente developed its own evidencebased hypertension guideline that was adopted nationally across all of its divisions (includingKPNC). This guideline has been updated every 2 years; the current version (2011) is rigorously researched andmore than 140 pages long but distills its actionable content into 2 pages for clinicians to digest and implement easily.5 Importantly, the guideline provides clear advice on how to initiate and escalate both doses and numbers of drugs to achieve blood pressure control but does so in amanner that is not prescriptive and enables clinicians to retain decision-making autonomy. Fourth, after initial patientphysician encounters in which drug therapy was started for hypertension, medical assistants conducted follow-up visits for bloodpressure checks andmedicationadjustments (which required physicians’ approval but not their physical presence). Advantages to patients for thesemedical assistant visits (compared with repeat physician visits) included ease of Related article page 699 Opinion