hypertension control success in kaiser permanente

Joel Handler, MDKaiser Permanente

•Hypertension Control Success in Kaiser Permanente:

•Implementology Science

Disclosure of Relationships

I HAVE NO DISCLOSURES

Educational Objectives

• Review key elements of a successful approach to hypertension control performance

• Construct a simple hypertension treatment algorithm

• Define the advantages of population care in an integrated health care system

• Use equitable care to close the racial performance gap

Kaiser Permanente – National

Kaiser Permanente Nationwide

• 10.2 million members• 18,000 physicians• 177,000 employees• 600-700 residents &

fellows• 619 medical office

buildings • 38 hospitals• Nation’s largest

nonprofit health plan7 regions serving 8 states and D.C.

Southern California Permanente Medical Group (SCPMG)

• 4.5 million members• 74,290 employees • 7,421 physicians• 21,167 nurses• 15 hospitals• 230 medical offices

SCPMG: Who we are in 2018

• 319,000 hospital discharges• 42,500 babies delivered• 23.2 million outpatient visits• 29 million prescriptions filled• 473,934 home care

Controlling High Blood Pressure

HEDIS 2016 Top Ten PerformanceMedicare Population

Controlling High Blood Pressure

HEDIS 2016 Top Ten PerformanceCommercial Population

WHY KEEP TALKING ABOUT HTN?

• HTN is quantitatively the most important risk factor for premature CVD, being more common than smoking, dyslipidemia and diabetes.

• HTN accounts for an estimated 54% of all strokes and 47% of all ischemic heart disease events globally. (Lancet 2008; 371; 1513 – Global Burden of blood pressure related disease 2001).

• Increases the risk for CKD, HF, afib and PVD.

Treatment WorksNow We Need Implematology!

Large scale RCTs show that antihypertensive treatment results in following:• 50% reduction in heart failure• 30-40% reduction in stroke• 20-25% reduction in MI

BMJ 2008: BP Lowering Treatment Trialists’ Collaboration

SCAL HTN Control 2004 - 2010

No.

of I

ndiv

idua

ls

with

HTN

(100

0’s)

CSG Performance & CSG Population

108150

204261 295 321 34393

84

86

9775

6661

0

50

100

150

200

250

300

350

400

450

2004 2005 2006 2007 2008 2009 2010

Controlled Uncontrolled

64%

71%

73%80% 83% 84%

54%

% = Controlled

Key Elements of SuccessfulImplementation

• Hypertension registry• Expansion of the Medical Home with

walk-in no copay BP checks and a triage algorithm

• Regular performance feedback at the team level

• Simple treatment algorithm

Create a Hypertension Registry

Health System-Wide Hypertension Registry

Expand the Medical Home

Medical Assistant BP Check

• Expands access to the medical home (1800 PMDs for 800,000 pts)

• No copayment • Triage with no escape; addresses

clinical inertia• Fulfils scope of practice

requirements

Provider Feedback

HEDIS Controlling High BP Measure September 2018

Hypertension – Standard Deviation and Control Rate May 2005 through August 2008

Handler J, Lackland DT. JASH 2011; 5: 197-207

Create a Simple Treatment Algorithm Based on a

Single Combination Pill

Management of Adult Hypertension1

1.

If ACEI intolerant or pregnancy potential

Calcium Channel Blocker

Add amlodipine 5 mg X ½ daily à 5 mg X 1 daily à 10 mg daily

Spironolactone

IF on thiazide AND eGFR ≥ 60 ml/min AND K < 4.5 Add spironolactone 12.5 mg daily à 25 mg daily

If not in control

If not in control

If not in control

Thiazide Diuretic

Chlorthalidone 12.5 mg à 25 mg

OR HCTZ 25 mg à 50 mg

If not in control

ACE-Inhibitor2 / Thiazide Diuretic

Lisinopril / HCTZ (Advance as needed) 20 / 25 mg X ½ daily 20 / 25 mg X 1 daily 20 / 25 mg X 2 daily

Pregnancy Potential: Avoid ACE-Inhibitors2

Kaiser Permanente Hypertension Treatment Algorithm

Management of Adult Hypertension1

1.

If ACEI intolerant or pregnancy potential

Calcium Channel Blocker

Add amlodipine 5 mg X ½ daily à 5 mg X 1 daily à 10 mg daily

Beta-Blocker OR Spironolactone

Add atenolol 25 mg daily à 50 mg daily (Keep heart rate > 55) OR

IF on thiazide AND eGFR ≥ 60 ml/min AND K < 4.5 Add spironolactone 12.5 mg daily à 25 mg daily

If not in control

If not in control

If not in control

Thiazide Diuretic

Chlorthalidone 12.5 mg à 25 mg

OR HCTZ 25 mg à 50 mg

If not in control

ACE-Inhibitor2 / Thiazide Diuretic

Lisinopril / HCTZ

(Advance as needed) 20 / 25 mg X ½ daily 20 / 25 mg X 1 daily 20 / 25 mg X 2 daily

Pregnancy Potential: Avoid ACE-Inhibitors2

Begin with Lisinopril/HCTZ

Simplified Treatment Intervention to Control Hypertension Study

(STITCH)

• Cluster randomization trial in Canada• 93 practices randomized• Compared sequential add-on

monotherapy vs 1rst step combination therapy, then add on

• Control rate at 6 months: 64.7% vs 52.7% favoring combination therapy

Feldman RD. Hypertens 2009; 53: 646-653

Simple Algorithm: Fixed Dose Combination Based

SIMPLICITY = PERFORMANCE§ Fewer steps§ Fewer pills, for adherence§ Faster control§ Fewer visits/ improved access

Lisinopril/HCTZ Rate vs HTN Performance

Management of Adult Hypertension1

1.

If ACEI intolerant or pregnancy potential

Calcium Channel Blocker

Add amlodipine 5 mg X ½ daily à 5 mg X 1 daily à 10 mg daily

Beta-Blocker OR Spironolactone

Add atenolol 25 mg daily à 50 mg daily (Keep heart rate > 55) OR

IF on thiazide AND eGFR ≥ 60 ml/min AND K < 4.5 Add spironolactone 12.5 mg daily à 25 mg daily

If not in control

If not in control

If not in control

Thiazide Diuretic

Chlorthalidone 12.5 mg à 25 mg

OR HCTZ 25 mg à 50 mg

If not in control

ACE-Inhibitor2 / Thiazide Diuretic

Lisinopril / HCTZ

(Advance as needed) 20 / 25 mg X ½ daily 20 / 25 mg X 1 daily 20 / 25 mg X 2 daily

Pregnancy Potential: Avoid ACE-Inhibitors2 Amlodipine is Third Drug

Managementof AdultHypertension1

1.

If ACEI intolerant or pregnancy potential

Calcium Channel Blocker

Add amlodipine 5 mg X ½ daily à 5 mg X 1 daily à 10 mg daily

Spironolactone

IF on thiazide AND eGFR ≥ 60 ml/min AND K < 4.5 Add spironolactone 12.5 mg daily à 25 mg daily

OR consider bisoprolol 5 mg daily (Keep heart rate > 55)

If not in control

If not in control

If not in control

Thiazide Diuretic

Chlorthalidone 12.5 mg à 25 mg

OR HCTZ 25 mg à 50 mg

If not in control

ACE-Inhibitor2 / Thiazide Diuretic

Lisinopril / HCTZ (Advance as needed) 20 / 25 mg X ½ daily 20 / 25 mg X 1 daily 20 / 25 mg X 2 daily

Pregnancy Potential: Avoid ACE-Inhibitors2

Spironolactone PreferredFourth Drug

Protocol-Based Treatment of Hypertension

• Reduction of clinical variability• Encourages teamwork• Use of treatment algorithm

reminders in EHR• Cost efficiency• Facilitates quality of care

prioritizationFrieden TR JAMA 2014; 311: 21-22

Medication Adherence

• Adherence ≥80% with prescribed medication is an often used standard for pharmacologic benefit

• Provider understanding of medication and messaging makes a difference

Thiazide and Quality of Life

• TOMHS: 8 QOL domains; chlorthalidone = placebo

• ALPINE: no difference in sexual satisfaction thiazide vs candesartan

• SHEP: sexual problems, thirst, nocturia chlorthalidone 25mg = placebo

Frequency (%) of Adverse Effects

31Stress Reaction11Rash5.9-10.37-17.6Headache36Fatigue1-5.91.2-11.8Dizziness2.34.9Asthenia33Abnormal UrinationN=173N=168HCTZ PlaceboAdverse Effect

Weir et al. Am J Med 1996; 101: 835-925

Dear Dr. Handler,Again I request another pill to replace “amlodipine” to eliminate the swelling of my ankles. Please!! Summer is coming soon and my capri pants will not cover my swollen ankles.

Edith Wins, 100 years old

Pathophysiology of Calcium Channel Blocker Related Edema

• Not caused by fluid overload• Not responsive to furosemide• CCBs target precapillary arterioles to

increase intracapillary pressure • Intracapillary hypertension leads to fluid

transudation into soft tissue and edema• Edema is dependent, worse later in day

and better in morning

Managing Calcium Channel Blocker Related Edema

1. Always consider other etiologies of edema, ie right heart failure due to sleep apnea, steroids, anegrilide, NSAIDs; heart, kidney, and liver failure

2. Lisinopril and losartan act on venular side of capillary circuit to reduce intracapillary pressure

3. Additional antihypertensive agents permit reduction of dose of CCB

4. Daytime compression stockings, leg elevation5. Switch to another calcium blocker: nifedipine XL 30 mg 6. Reassurance

‘Blast’ Automated Reminder Calls RESULTS

Foundation: KP’s widely used communication models - crosswalk

Thank You

Modification Approximate SBP Reduction (range)

• Weight Reduction 5-10 mmHg/10kg

• Adopt DASH eating plan 8-14 mmHg

• Dietary sodium reduction 2-8 mmHg

• Physical activity 4-9 mmHg

• Moderation of alcohol consumption 2–4 mmHg

Lifestyle modifications

SCHEDULED 2 to 4 WEEK FOLLOW-UP

Accurate Measurement is Key

241/157

“Sir, is this the same technique you use for your home blood pressure readings??”

Common blood pressure errors that raise SBP 5-10 mmHg

mmHg too high• Cuff too small 5-10• Unsupported arm 5-10• Patient talking 10• Patient actively listening 5• Back unsupported 5-10• Feet not on floor 5-10• Legs crossed 5-10• Full bladder 10• Forearm blood pressure 5-10

Instructions

Instructions for Blood Pressure Spot Check

Team leaders to complete one spot check per day (5 per week), every week, capturing all staff multiple times throughout the year.

Important criteria to be assessed:a. Is the patient’s arm bare?b. Is the patient’s arm totally supported at heart level? c. Neither the patient nor the MA/Nurse should be talking during

the procedure.d. Proper size cuff

If any of the important criteria is missed, please privately coach the MA/Nurse on the criteria missed.

Please return the completed form to the DA/ADA.

Blood Pressure Spot Check March 2016

Aggregated Data Received From:Antelope Valley, Baldwin Park, Downey, Fontana, Kern County, Los Angeles, Orange County,

Panorama City, Riverside, San Diego, South Bay, West Los Angeles and Woodland Hills

Antelope Valley: •Remove clothes from arm•Reminders to pull sleeves of shirt up•Shirt sleeve too tight, advised could take shirt off

Fontana:•Patient had to be told to keep feet flat on the floor

AOBPM Technique

• Oscillometric device• Average of three readings:

§ Following 5 minutes of rest§ Three readings at 1 minute intervals

Ayanian J. NEJM 2014; 371:2288-2297

EQUALCARE EQUITABLECARE

Southern California Region

Targeted Antihypertensive Therapy

56

2,525/14, 139 (18%) black patients with uncontrolled hypertension are receiving potassium replacement, and would be good candidates for spironolactone

HTN Demographics and Utilization

57

3-4RxClasses+36.35%

>4=10.29%

3.27%

Closing AA Disparity Gap

AA HTN Uncontrolled

Lisinopril/HCTZ underdosed

2601 patients

Thiazide Naïve2331 patients

No Spironolactone1180 patients

Thiazide-naive and Suboptimal Lisinopril/HCTZ Initiatives

2500

2600

2700

2800

2900

3000

3100

3200

3300

3400

Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

# of

pat

ient

s

Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14# SUBOPTIMAL PRINZIDE 3297 3226 3197 3139 3051 3030 3090# THIAZIDE NAÏVE 3046 2955 2970 2989 2937 2812 2829

AA POINT HTN Patients with uncontrolled or no BP

6% decrease since starting initiative

4% decrease since starting initiative

Optimize thiazide dose to HCTZ 50 mg or chlorthalidone 25

mg

Use combo drug with ACEI, then add CCB

Spironolactone 4rth drug, especially if

hypokalemic

Lifestyle improvement, salt

reduction

Targeted Interventions

ACC/AHA Hypertension Guideline 2017

• “Use of BP-lowering medication is recommended for primary prevention for an estimated 10 yr ASCVD score < 10%..for BP >/= 140/90” grade 1 page 71

• “Use of BP-lowering medication is recommended for secondary prevention of recurrent CVD events…and primary prevention for an estimated 10 yr ASCVD score >/= 10%...for BP >/= 130/80” grade 1 [SPRINT criterion was score >/= 15%]

ACC/AHA Guideline Critique

• JNC 8 DBP goal < 90 mmHg is based on 5 high quality DBP trials (HDFP, HTN-Stroke Cooperative, MRC, ANBP, VA Cooperative)

• HOT is only RCT to address DBP 90 vs 80, finding no difference

• SPRINT eligibility for ~ 20% of adults treated for hypertension and ~ 10% total adults in U.S.

Letters to the Editor

Questions?