marc jaffe, md
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National Forum for Heart Disease and Stroke Prevention Improving Hypertension Control The Kaiser Permanente Hypertension Control Project: How a large health care organization improved blood pressure control from 44% to 80% in 8 years. Marc Jaffe, MD. Clinical Leader, - PowerPoint PPT PresentationTRANSCRIPT
Presented by:Presented by:
National Forum for Heart Disease and Stroke Prevention
Improving Hypertension ControlThe Kaiser Permanente Hypertension Control Project: How a large health care organization improved blood pressure control from 44% to 80% in 8 years
Marc Jaffe, MDClinical Leader,
Kaiser Permanente Northern California Cardiovascular Risk Reduction Program
Associate Clinical Professor of Medicine, UCSFOctober 17, 2012
2Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/22/2023
Kaiser Permanente Northern California (KPNC)
3.3 million members2.7 million adults>5,000 MDs17 medical centers35 outpatient
facilities
3Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/22/2023
KPNC Hypertension Implementation Timeline
1995 1997 1999 2001 2003 2005 2007 2009
1995GuidelineCreated, updatedevery 2 yrs
2002Performance Measures Distributed
Successful practices disseminated
2005 Single Pill Combination Promoted
2007 Non-MDBP Visits
2000HTNRegistry developed
4Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/22/2023
Evolution of the Hypertension Guideline
Year 2001* 2003 2005 2007 2009
Step 1
TD or BB TD TD or TD + ACEI
TD or TD + ACEI
TD or TD + ACEI
Step 2
TD + BB TD + ACEIor TD + BB
TD + ACEI TD + ACEI TD + ACEI
Step 3
TD + BB +ACEI
TD + BB +ACEI
TD + ACEI +BB
TD + ACEI +BB
TD + ACEI+ DCCB
Step 4
TD + BB +ACEI +DCCB
TD + BB +ACEI +DCCB
TD + BB +ACEI +DCCB
TD + BB +ACEI +DCCB
TD + ACEI +DCCB +BB or Spir
TD=Thiazide Diuretic, BB=Beta Blocker, ACEI=Angiotensin Converting Enzyme Inhibitor, DCCB=Dihydropyridine Calcium Channel Blocker, Spir=Spironolactone *1995-2001 No Significant changes after step 2
5Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/22/2023
Evolution of the Hypertension Guideline
Year 2001* 2003 2005 2007 2009
Step 1
TD or BB TD TD or TD + ACEI
TD or TD + ACEI
TD or TD + ACEI
Step 2
TD + BB TD + ACEIor TD + BB
TD + ACEI TD + ACEI TD + ACEI
Step 3
TD + BB +ACEI
TD + BB +ACEI
TD + ACEI +BB
TD + ACEI +BB
TD + ACEI+ DCCB
Step 4
TD + BB +ACEI +DCCB
TD + BB +ACEI +DCCB
TD + BB +ACEI +DCCB
TD + BB +ACEI +DCCB
TD + ACEI +DCCB +BB or Spir
TD=Thiazide Diuretic, BB=Beta Blocker, ACEI=Angiotensin Converting Enzyme Inhibitor, DCCB=Dihydropyridine Calcium Channel Blocker, Spir=Spironolactone. *1995-2001 No Significant changes after step 2
BB not 1st
ACEI or BB 2nd
SPC OK 1st
ACEI 2nd
BB 3rd DCCB 3nd
BB OK 4th BB OK 1st BB OK 2nd BB 3rd BB still 3rd
BB OK 4th
6Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/22/2023
Hypertension Registry Development
Outpatient Coding
HTN Registry:Lab ResultsMedicationsDemographicsComorbid ConditionsBP MeasurementsVisit Information
Hospital
Pharmacy
Membership Data
Clinical Laboratory
Outpatient EMR
7Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/22/2023
Hypertension Registry Definition
Hypertension (HTN) Registry Population: 2 visits for HTN in the past 2 yrs No age limits Designed to be very inclusive
8Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/22/2023
Hypertension Control Definition Hypertension Control Rate
Age 18-85 yrs with an encounter diagnosis of Hypertension (46-85 before 2006) in the 1st 6 months of the reporting year
Blood Pressure at last clinic visit <140/90 (≤140/90 before 2006)
Exclusions: End Stage Renal Disease, Renal Transplant, pregnancy, or blood pressure measurements during hospitalization, Emergency Department visit, diagnostic test, or surgical procedure.
9Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/22/2023
Medical Center Hypertension Control 2001
Performance Reports Distributed to Medical Directors
Quarterly Report 2001-2007, Monthly after 2007
High Performing sites identified and practices shared
HTN Control Rate 2001
0%
10%
20%
30%
40%
50%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Medical Center
HTN
Con
trol
10Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/22/2023
Evolution of Single Pill Combination Therapy in KPNC
1995 1997 1999 2001 2003 2005 2007 2009
Not generally advised Advised
Optional
11Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/22/2023
1/4 of ACEI Rx’s dispensedas Single Pill Combination Therapy
0%
20%
40%
60%
80%
100%
2001 2002 2003 2004 2005 2006 2007 2008 2009
% O
f All
AC
EI R
xs
ACEI OnlyTabletACEI +HCTZ Tablet
12Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/22/2023
Non-MD Blood Pressure Check
BP at goal
Doctor clinic visit
BP over goal
Follow upnon-MD visit
Treatmentintensification
BP check
Advantages Shorter visit for patient No charge for visit Scheduling flexibility Improves access to MD
13Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/22/2023
Hypertension Control Rates 2001-2009
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
% C
ontro
lled
Commercial Rate asreported to HEDIS
44%
80%
14Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/22/2023
Hypertension Control Rates 2001-2010in Kaiser Permanent Northern California
172
222
252
302
428
435
477
512
531
222
202
233
228
135
158
148
125
130
0
200
400
600
800
2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
HTN
Pat
ient
s (1
000s
)
Uncontrolled BP
Controlled BPCommercial Rate asreported to HEDIS
15Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/22/2023
Hypertension Results 2001-2009
From 2001 to 2009 in KPNC HTN control rate nearly doubled from 44% to 80% HTN registry increased by 167% Controlled HTN tripled from 171,000 to 531,000 359,00 more people had controlled HTN
6 care processes implemented Evidence Based Guideline development HTN Registry creation Performance measure distribution Successful practice dissemination Single Pill Combination therapy promotion Non-physician BP visit creation
16Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/22/2023
Heart Attack Rates are declining in KPNC
16