October 20, 2016
When Dr. David Newman first saw his medical practice’s ranking in the region’s high blood pressure registry, he was shocked. Even though the Brockport physician was active on a hypertension task force, his primary care practice came in last in high blood pressure control.
Seeing that surprising data, Dr. Newman realized hypertension control was “a project that I had to do something about.” He began working with a practice improvement consultant provided by the High Blood Pressure Collaborative, a partnership of the Greater Rochester Chamber of Commerce and Finger Lakes Health Systems Agency.
Two and a half years later, the office’s numbers have steadily improved and the practice now ranks in the middle of the pack.
“We still have work to do, but we’ve made substantial progress getting people under control,” said Dr. Newman. “It’s really all about focus.”
Focusing on high blood pressure control
Dr. Newman’s practice is one of 17 practices that have partnered with a high blood pressure consultant over the past five years as part of an innovative clinical intervention aimed at improving hypertension control in Monroe County. These Practice Improvement Consultants—PICs for short—meet with physicians, nurse practitioners or physician assistants at their office. The consultants offer a convenient way for providers to improve patient outcomes and stay up to date on evidence-based approaches to improving high blood pressure.
For example, Dr. Newman’s consultant, Dr. Mathew Devine, worked with FLHSA staff to identify hypertensive patients who had not had a blood pressure reading in more than a year so they could be called in for a follow up visit. To ensure that blood pressure readings were taken accurately, Dr. Devine also arranged for a nursing instructor from Nazareth College to visit the practice and provide staff with a refresher on best practices.
“To have someone look at your numbers and say, ‘Think about this, and are you doing this,’ was really helpful,” Dr. Newman said.
Fourteen practices that were formerly affiliated with Unity Medical Group took the consultant program further. Each practice selected a practice improvement champion to implement the program, and the champions met regularly. Champions were also encouraged to take initiative to improve their performance by using data and engaging practice teams of clinical and non-clinical staff in innovative ways.
A study through June 2015 of these practices, which are now part of Rochester Regional Health, showed that after adjusting for race/ethnicity and socioeconomic status, hypertensive patients in practices with champions were 35 percent more likely to have controlled hypertension than those in non-participating practices.
Presented in a poster at the National Committee for Quality Assurance’s Patient Centered Medical Home Congress in October, the study showed that practices in the improvement program did a better job of monitoring hypertensive patients, including making sure they had their blood pressure checked at least annually.
The study also attributed improvement in control rates to transparency among providers. Like Dr. Newman, physicians were able to compare their performance to their peers—a powerful motivator for behavior change.
The champions program proved surprisingly effective at addressing health disparities. Black non-Hispanic patients in practices participating in quality improvement efforts had the largest gains in systolic blood pressure control. These patients experienced a 4.7 mmHg lower mean systolic blood pressure, reducing the risk for heart attack, stroke and premature death, according to the poster.
“A quality-driven approach gives every patient a chance to engage,” said Anthony Minervino, who presented the poster and a five-minute oral abstract on the champions program at the Patient Centered Medical Home Congress.
“Clearly there’s something effective about doing care gap reports and making sure that every visit is a blood pressure visit,” added Minervino, the program director of patient-centered medical home for Rochester Regional Health.
Practice champion Dr. Anh Bui of Parkway Family Medicine, one of the fourteen practices studied, said staff throughout her practice were trained to prioritize blood pressure readings.
“We made sure everyone in our office knew this was really important,” Dr. Bui said. “High blood pressure is a major risk factor for heart disease and stroke.”
The practice began a project to monitor patients’ blood pressures in the waiting room to avoid “white coat syndrome,” the artificially high readings that researchers have found often occur in medical settings. Readings are covered so that other waiting patients are not able to see patient information.
The practice also employed a care manager to call in patients with hypertension and provide them with a blood pressure cuff for at-home use and a community health advocate gave patients extra help on diet and lifestyle changes.
To track progress on high blood pressure and other disease markers, the practice uses a dashboard based on electronic medical records.
“That’s nice to have that at our fingertips. We know where we stand. We can trace it month by month,” she said.
The future of quality improvement
As the health care system shifts to value based payment, electronic health records and team approaches to care will help provides meet the demands of the new payment systems. These tools are being incorporated into health systems’ procedures locally as well as being used by doctors in independent practices, said Minervino.
“By 2018, 80 percent of health care payments will be tied to quality,” Minervino said. “A big piece of success in this new model will be tied to practice champions engaging their teams in improvement.”
Minervino said the process improvements that practices have learned in high blood pressure could be applied to quality initiatives on other measures, such as diabetes or screenings. Initiatives that enlist clinicians in improvement within their practices will be crucial to advancing care and meeting new guidelines, he said.