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Presented as a poster at the Kaiser Permanente Care Management Institute Conference, October 18, 2004, San Francisco, California; as a poster at the Kaiser Permanente National Quality Conference, June 27-July 1, 2005, Monterey, California; and at the Kaiser Permanente National Hypertension Implementation Committee teleconference, September 13, 2005. Hypertension (HTN) or high blood pressure, is defined as consistently elevated systolic BP above 140 mmHg or diastolic above 90 mmHg. For certain groups of people, ideal blood pressure is even lower than this. Uncontrolled hypertension can lead to end organ damage, including heart failure, heart attacks, nephropathy, peripheral vascular disease, aortic dissection, blindness, or stroke. Because there are no symptoms of hypertension until organ damage occurs, hypertension is known as the "silent killer." Problem
Kaiser
Permanente of the Mid-Atlantic States (KPMAS) serves approximately 500,000
people in Maryland, Virginia and Washington, DC. KPMAS is composed of
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc, and the
Mid-Atlantic Permanente Medical Group, PC, an independent medical group
with more than 900 physicians providing care for members and the community
throughout the area.
In
2001, KPMAS scored 49% in the "Controlling High Blood Pressure"
measure for the Health Plan Employer Data and Information Set (HEDIS)
and below the 25th percentile of performance for health plans nationwide.
More importantly, these 2001 results meant fewer than half of KPMAS' members
with documented hypertension had their blood pressure controlled (defined
as <140/90). Approximately 50,000 members were at increased risk for
complications of hypertension, damage that is entirely preventable with
appropriate care.
Assessment KPMAS leadership recognized the need for a quality improvement program to improve control of high blood pressure. A well-attended, multidisciplinary barrier analysis meeting was held in October 2001 to identify and discuss the barriers to providing the highest quality of care for patients with hypertension. Participants at the meeting included physicians from internal medicine, family practice, cardiology, neurology, nephrology, and urgent care. In addition, nursing, pharmacy, nutrition, behavioral health, case management, nurse advice, quality, measurement, health education, risk management, health information management services (HIMS), and information technology (IT) representatives fully participated. The group identified the obstacles preventing KPMAS from providing the best possible care for members with hypertension, including:
Systematically addressing these barriers formed the basis of whole system change to improve care. Goal From its inception, the HTN program was designed to serve not only patients with known hypertension, but also patients at risk (people with diabetes, chronic kidney disease [CKD], heart failure, and coronary artery disease). Using the HEDIS 2001 national 90th percentile for blood pressure control as a benchmark (62.3%), leadership decided that the program goal was 63% of adult members with a diagnosis of hypertension would have BP <140/90. Because the program also included patients with a chronic disease, our internal metric was consistent with the clinical practice guidelines, and more stringent than HEDIS control specifies. We defined BP control in members with diabetes and CKD as a BP <130/80. While a 14% improvement was a stretch as a goal, it was believed that once KPMAS could accurately identify and track blood pressures administratively, the Region would be able to lower blood pressure for the 14,000 additional patients' blood pressure that it would take to reach target.
Interventions While many interventions were implemented over the following years (Figure 1), the most significant interventions included:
Results With these multifaceted interventions, along with the high-level sponsorship of the importance of HTN control, KPMAS saw its HEDIS score for controlling high blood pressure jump to 78.8% in 2004 (Figure 3). Although the HEDIS score dipped to 73% in 2005, the variation is not statistically significant and KPMAS remains the leader in HTN control among all the KP Regions.
Discussion The significant results of the project validate the published literature3 on process redesign employing quality improvement concepts: an involvement of the entire organization and information sharing are critical to controlling hypertension. It is important to note that this project was completed without added personnel or administrative or financial incentives. It used the existing electronic legacy medical record systems. Involvement
of KPMAS leadership, primary care and specialty physicians, nurses,
nutritionists, pharmacists, clinical assistants, data entry personnel,
medical coders, data analysts, health education specialists, quality
experts, information technology specialists, health information personnel
and members, all made this project successful. Each discipline brought
an action-oriented passion for controlling hypertension that allowed
for organizational agility in implementation perseverance and sustained
clinical improvements. References
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