Large-scale hypertension program improved BP control rates

Implementation of a large-scale hypertension program that included evidence-based guidelines and development and sharing of performance metrics was associated with a near doubling of hypertension control between 2001 and 2009, according to a new report.

Marc G. Jaffe, MD,and colleagues conducted a study to examine the results of the Kaiser Permanent Northern California hypertension program and to compare rates of hypertension control in that program with statewide and national estimates.

The Kaiser Permanente Northern California hypertension program increased from 349,937 (52.1% women) patients with hypertension in 2001 to 652,763 (52.7% women) in 2009. During the study period, BP control rates increased from 43.6% (95% CI, 39.4-48.6) in 2001 to 80.4% (95% CI, 75.6-84.4) in 2009. In contrast, the national rate of BP control increased from 55.4% in 2001 to 64.1% in 2009, and the rate of BP control in California increased from 63.4% in 2006, the first year for which statewide figures were available, to 69.4% in 2009.

BP control was defined as systolic BP <140 mm Hg and diastolic BP <90 mm Hg (systolic BP ≤140 mm Hg and diastolic BP ≤90 mm Hg before 2006).

Monitoring and intervention systems

“This successful program is evidence that large-scale and comprehensive monitoring and intervention systems can improve BP control,” Jaffe, clinical leader of the Kaiser Permanente Northern California Cardiovascular Risk Reduction Program, said in a press release. “More importantly, this model has tremendous potential to improve the health of millions of people.”

According to the report, the Kaiser Permanente Northern California program consisted of five major components:

A registry was developed and updated quarterly to identify patients with hypertension. Identifications were based on outpatient diagnostic codes, pharmacy data and hospitalization records, not on recorded BP measurements alone. The registry helped identify people who could benefit from treatment intensification.
Hypertension control reports were generated every 1 to 3 months for each Kaiser Permanente Northern California medical center. A central hypertension management team identified the best practices of the centers with the best performance in BP control, and encouraged the other centers to implement the practices. A focus on clinic-level feedback helped generate operational and system-level change.
A four-step hypertension control algorithm based on current evidence was developed in 2001 and provided to clinicians within the system who were encouraged to follow it. It was updated every 2 years based on new clinical evidence and guidelines.
Starting in 2007, medical assistants followed up with patients within 2 to 4 weeks after a medication adjustment. Patients were not charged for these visits. The assistant measured BP and reported findings to a physician, who then determined the next steps for treatment. According to the researchers, “This system accelerated treatment intensification without significantly increasing the need for repeat clinician visits, while simultaneously improving patient convenience and affordability.”
Starting in 2005, single-pill combination therapy with lisinopril-hydrochlorothiazide was encouraged. The strategy has been associated with improved adherence, lower patient cost and improved BP control.

Improved detection

Patients in the hypertension registry comprised 15.4% of the Kaiser Permanente Northern California adult population in 2001 and 27.5% of the population in 2009. Between 2001 and 2009, the number of prescriptions per month written by Kaiser Permanente Northern California clinicians for the most commonly prescribed antihypertensive medication classes rose by 82%. “Collectively, these data suggest that the apparent increase in hypertension reflects primarily improved detection and documentation of hypertension,” Jaffe and colleagues wrote.

In a related editorial, Abhinav Goyal, MD, MHS, and William A. Bornstein, MD, PhD, both of the office of quality and risk at Emory Healthcare, Atlanta, wrote that, “Health care systems interested in replicating the success achieved by [Kaiser Permanente Northern California] must recognize that quality improvement cannot be achieved through makeshift solutions and suboptimal staffing methods.”

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For more information:

Goyal A. JAMA. 2013;310:695-696.

Jaffe MG. JAMA. 2013;310:699-705.

Disclosure: The researchers and Goyal report no relevant financial disclosures. Bornstein reports serving on an advisory panel for CIGNA.