Heart&StrokeHigh Blood Pressure Strategy:

Hypertension Management Initiative

Margaret Moy Lum-Kwongmoylumkwong@hsf.on.ca

February 2007

An urgent and important issue for An urgent and important issue for the health of Canadiansthe health of Canadians

Cardiovascular disease is the underlying cause of death for one in three Canadians, making it the No.1 cause of death for Canadian men and women.

High blood pressure is the number one modifiable risk factor for stroke and affects nearly 22% (about five million) of adult Canadians.

According to the World Health Organization, hypertension contributes to about half of all cardiovascular disease.

An urgent and important issue for An urgent and important issue for the health of Canadiansthe health of Canadians

Among those afflicted with hypertension, the statistics are alarming:• 16% are treated and controlled• 23% are treated and not controlled• 19% are not treated and therefore

not controlled• A staggering 42% of those with

hypertension are unaware of their condition

Source: Canadian Heart Health Surveys 1986- 1992

Top 10 Diagnoses in Canada, 2005

  Patient visits % Male % Female

Patient visits with drug recos Top 2 specialties most-often seen

All diagnoses 323,537,000 41% 59% 60% General Practice/Family practice

Hypertension 21,829,000 47% 53% 80%General Practice/Internal

medicine

Depression 8,900,000 32% 68% 79% General Practice/Psychiatry

Health check-up 8,814,000 44% 56% 3% General Practice/Paediatrics

Diabetes mellitus w/o complications 8,780,000 55% 45% 69% General Practice/Internal medicine

Anxiety 5,746,000 34% 66% 55% General Practice/Psychiatry

Acute upper respiratory infection 5,696,000 43% 57% 43% General Practice/Paediatrics

Hyperlipidemia 5,284,000 60% 40% 80% General Practice/Internal medicine

Normal pregnancy supervision 5,088,000 0% 100% 19% General Practice/Obstetrics/Gynaecology

Ear infection (otitis media) 3,802,000 52% 48% 76% General Practice/Paediatrics

Contact dermatitis and other eczema 3,545,000 42% 58% 88% General Practice/Dermatology

High Blood Pressure Strategy

“An area of focus that, with leadership, significant investment and a cross-Foundation approach, has the potential to reduce the risk of premature death and disability from heart disease and stroke in Ontario.”

To pave the way towards optimal blood pressure management that will result in a dramatic improvement in the future health of Canadians.

Our VisionOur Vision

HBP AIMCross Foundational

Hypertension Management Initiative:

Primary Healthcare Providers + Patients

Prevalence Study

Social Determinants Systolic Blood

Pressure

Advocacy & Communications

Business Development

High Blood Pressure StrategyKnowledge Exchange

Key Milestones and TimelinesKey Milestones and Timelines

Sept 04 Sept 06 Jan 10Sept 08

Alpha Phase Beta Phase

Hypertension Management Initiative (=Provider Management +Patient Self Management)

ResearchSD Issues Identified SD Interventions Researched

HBP Prevalence Study

Elevated Systolic Adults 45+ Research

What Success Looks Like

Impact on mission! Improved HBP management practices among

participating primary health care providers Improved patient adherence with pharmacologic and

non-pharmacologic therapies in affected patients at participating sites

Improved BP readings in affected patients at participating sites

New understandings in 2 emerging HPB issues Updated data on the prevalence of hypertension in

Ontario, with the first ever data on key ethnic groups in Ontario

Heart&StrokeHypertension Management

Initiative

Key Elements of the Hypertension Management Initiative interactive, inter-professional education

workshops, reflective exercises practice outreach and support to healthcare

providers to support and assist in the integration of the tools and interventions in their practices

inter-professional, evidence-informed healthcare provider toolkit that incorporates clinical reminders and prompts and practice audit feedback and aids inter-professional communication

evidence-informed, leading edge patient toolkit that provides information and education and supports patient self-management.

Alpha Phase

Objective: develop, test and refine a toolkit aimed at improving hypertension management and control using the Quality Improvement methodology (PDSA)

June 2005 to June 2006 3 Pilot Sites: 20 MDs, 3 Nurses, 31 Community

Pharmacists

• Kingston - Family Health Network (3 office locations)

• Toronto - Health Services Organization (1 office location)

• Huntsville - Family Health Network (1 office location)

Alpha Evaluation Components – Chart Reviews

Chart Reviews for Participating Physicians• Chart Review methodology was designed by consultant

and conducted by 3 RNs. Inter-rater reliability based on 10% sample of charts was 0.90. Chart reviews were conducted in March/April 2006.

• 290 charts of patients enrolled in Strategy (by 20 participating physicians across all sites) were abstracted from each visit occurring between June 2004 and March 2006. Pre-program period (June 2004-May 2005) was compared to program period (June 2005-March 2006).

• 77 charts of patients diagnosed with HTN but not enrolled in Strategy (by participating physicians at Kingston sites) were abstracted from each visit occurring between October 2004 and May 2005.

Results Significant increase in screening:

• BP measured documented in twice as many visits during program period (45.7%) vs. pre-program period (27.8%).

Significant increase in patients diagnosed with HTN:• Newly diagnosed patients twice as high in program

period (11%) vs. pre-program period (4.8%)

Directional increase in patients with HTN controlled to target:• In non-diabetic HTN patients, 31% controlled in

program period vs. 25% in pre-program period• In diabetic HTN patients, 58% controlled in program

period vs. 46% in pre-program period

Results cont’d

Significant decrease in elapsed time from diagnosis to target BP:• Time to target BP was 4 months for patients in pre-

program period (who “crossed over” into program period) vs. 6.3 months for patients in historic control group not enrolled in program

Significant decrease in elapsed time from 1st elevated BP reading to follow up visit:• Time between visits was 64.8 days for patients in pre-

program period (who “crossed over” into program period) and 68.4 days for patients in program period vs. 113.8 days for patients in historic control group not enrolled in program

Results cont’d

92% of physicians & pharmacists rated Strategy as somewhat/very effective in helping them manage patients with HTN overall• Perceived to be most effective in promoting

communication with patients, counseling patients re. lifestyle issues, diagnosing HTN (physicians)

83% of physicians & 92% of pharmacists agreed strongly/somewhat that participation in Strategy had positive impact on knowledge re. management of patients with HTN

Results cont’d

100% of physicians & 84% of pharmacists agreed strongly/somewhat that participation in Strategy had positive impact on management of patients with HTN

Significant increase in physicians’ familiarity with CHEP Recommendations (62% pre vs. 92% post)

84% of physicians & 60% of pharmacists indicated they were spending more time speaking with patients about lifestyle issues

Beta Sites

1. Register patients

3. Diagnosis

- BpTRU

- Waist Circumference Tape Measure

- CHEP Recommendations

- CHEP Recommendations

2. Subjective/Objective Assessment+ labs

1. Register patients

3. Diagnosis

4. Counsel and Meds

- BP/CV Guide

- Flow sheet to document lifestyle and readiness to change

- Rx Dx pads

2. Subjective/Objective Assessment+ labs

1. Consent Date

2. Baseline info and date of visit

3. Medical Hx, Family Hx, and Physical Measures/Lab

4. Lifestyle Counseling

5. Meds

6. Plan

Scope The diagram below illustrates the scope of the

systems development initiative.

Patient Physician

Consent

Examination

Encounter

EMR

3. Web Data Entry

2. Fax

1. EMR Extraction

Database

Reports and

Analysis

Confidential Practice Audit Reports

Export to web based dataset

Examples:

- Patient Profile

- % of hypertension patients with BP controlled to target

RNAO-HSFO Nursing Best Practice Guideline, Nursing Management of Hypertension

- BpTRU

- Tape Measure

- CHEP Recommendations

- CHEP Recommendations

1. Register patients

3. Diagnosis

4. Counsel and Meds- BP/CV Guide- Flow sheet to document lifestyle and readiness to change

5. Plan- Take The Pressure Off Book

- Patient Provider Agreement- Patient Log Book

- BPAP

- Rx Dx pads

2. Subjective/Objective Assessment+ labs

Tools for Pharmacists:

1. Patient Interaction Guide

2. Reach Your Goal Fact Sheet

3. Dash Diet Fact Sheet

E-health Tool for Patients

Blood Pressure Action Plan/Heart and Stroke Risk Assessment

Finding answers. For life.See what happens when you put your heart into it.