How Maine is Operationalizing High Blood Pressure Control Indicator 1.8.1

1. How Maine is Operationalizing High Blood Pressure Control Indicator 1.8.1 Ruth Dufresne, MS September 15, 2010 The findings and conclusions in this presentation are those of the presenters and do not necessarily represent the views of the Maine Center for Disease Control and Prevention/DHHS, Maine Cardiovascular Health Program or collaborators (Maine Center for Public Health, Medical Care Development , Maine Health Management Coalition, and the University of New England).

2. Project Overview Maine Cardiovascular Health Program healthcare systems intervention to improve the detection and control of high blood pressure among adults with high blood pressure Phase 1: establish a Blood Pressure Master Trainer (BPMT) Training and provide a forum where BPMTs can share successful quality improvement efforts with other healthcare systems and primary care practices.

3. Intervention elements: Accurate measurement Treatment guideline adherence Participation in hypertension or heart disease and stroke public reporting or recognition programs such as National Committee for Quality Assurance (NCQA) or Bridges to Excellence (BTE) or the Maine Health Management Coalition�s Pathways to Excellence (PTE) Care Team Integration and Quality Improvement Strategies Patient self-management support

4. Indicator 1.8.1 1.8.1 Proportion of adults who have achieved blood pressure control

5. Stakeholder Involvement Clinical Improvement Specialist, Program coordinator, stakeholders from intervention Ongoing assistance from Pathways to Excellence staff, CDC HDSP and CoP A work in progress � adapting to change

6. Background Work Reviewed existing state clinical data sources: 2007 and 2008 PTE Ischemic Vascular Disease (IVD) and Office Systems Survey data Reviewed existing national clinical data sources: NCQA Heart/Stroke Recognition Program and Bridges to Excellence Cardiac Care Link and Hypertension care Link Cannot get state estimates for NHANES CoP

7. Data Source Maine does NOT have NHANES Maine does have Maine Health Management Coalition�s (MHMC) Pathways to Excellence (PTE) data (clinical quality improvement data similar to NCQA, Bridges to Excellence data Chose to use existing PTE data for several reasons (primarily reduces time, cost and reporting burden for primary care practices) Did have a formal agreement in place (MOU/MOA with MHMC, PTE) to have permission to use data and contract with Maine Health Information Center (now called OnPoint Health Data) to analyze the data

8. Background on Key Partners Maine Practice Improvement Network (MPIN) Maine Patient Centered Medical Home Pilot (PCMH) Maine Health Management Coalition (MHMC)

9. MPIN reaches over 300 + primary care practices state-wide. MCVHP staff serves as quality advisor, team leader and on executive committee. MPIN members advised on development of MCVHP BP intervention and helped spread throughout the healthcare systems in state.

10.  Maine Quality Forum (MQF), Quality Counts, and the Maine Health Management Coalition are leading the Maine Patient Centered Medical Home (PCMH) Pilot. 26 primary care practices implementing PCMH - first step in achieving statewide implementation. Pilot includes all major private and public payers & provides an alternative reimbursement model that recognizes the infrastructure and system investments needed to deliver care in PCMH model, and rewards practices for demonstrating high quality and efficient care.

11.  MHMC brings diverse views together on how to improve healthcare quality and safety. Maine employers, doctors, health plans, and hospitals all have a stake in improving the safety and quality of healthcare. They work together to: Collect accurate, reliable data to measure how we�re doing Evaluate the data to assign quality ratings Present the data in a way that�s easy to understand and use. MHMC supports healthcare providers, purchasers, and consumers.

12. Background on MHMC, PTE May 2009, MHMC began switching to national rating systems results of care for heart disease & stroke (NCQA or BTE). MHMC gives blue ribbons to Maine practices in which at least 80% of patients are treated by doctors who have earned national quality ratings. Green ribbons are made in Maine quality ratings based on: Quality care data submitted by medical practices without enough patients to be rated by national systems. Practices that tried for national rating (NCQA or BTE) but didn�t earn the required 75 points. These practices earned a green ribbon when they earned between 60 and 75 points. Received a blue ribbon in 2007 and 2008 based on PTE rating.

13. Background on NCQA & BTE NCQA: national group that rates the quality of a doctor�s care based on certain standards. Doctors submit reports about the care they give patients which are checked to be sure they are correct and truthful. Doctors can earn NCQA awards for excellence in office systems and care for patients with diabetes, heart/stroke and spine conditions. BTE: another national group that rates the quality of a doctor�s care in a similar way and also gives quality awards to practices that earn NCQA awards.

14. Example of Clinical Quality Measures

15. Concepts Defined Based on treatment/management recommendations from JNC7, NCQA, AHA/ASA

16. Intended Population Maine adults with hypertension served by primary care practices participating MCVHP BP interventions (MPIN and BPMT) and partner initiatives (QC, AF4Q, PCMH) Non-institutionalized, patients aged 18-80 years old with IVD for at least 12 months (per AHA/ASA/NCQA) seen at primary care practices participating in PTE In 2008, 160 out of 416 primary care practice locations participated in and submitted IVD data to the PTE program (38% response rate).

17. Recommended Measures Crude proportions of all PTE primary care practice sites (Phase 1, once achieved will begin looking at possibility of Phase 2 measures) Stratify by primary care practice sites participating in MCVHP interventions and sites participating in partner activities (Phase 2)

18. Numerator and Denominator (PTE) Numerator definition Non-institutionalized, patients aged 18-80 years old with IVD for at least 12 months seen at primary care practices participating in Pathways to Excellence who (a) had one or more blood pressure checks within the past year and (b) whose most recent BP value was less than 140/90 mmHg Denominator definition Non-institutionalized, patients aged 18-80 years old with IVD for at least 12 seen at primary care practices participating in Pathways to Excellence who had one or more blood pressure checks within the past year

19. Periodicity Dependent upon Maine Health Management Coalition, Pathways to Excellence IVD data collected in 2007 & 2008. Discontinued in 2009 as planned to switch to BTE or NCQA. PTE IVD data is being collected in 2010, but do not know if will still be able to get actual BP values or composite score.

20. Data Caveats (PTE) Does not capture hypertensives who are seen by practice sites that do not participate in PTE Does not capture hypertensives who do not have IVD Does not capture IVD patients that were not seen in the past year or who did not have the blood pressure measured in the past year Does not capture undiagnosed hypertensives Survey data, self-report, response bias

21. Challenges Complex and dynamic, if switch to national results may gain comprehensive care indicator, but loose detail or individual measures such as BP as may get some practices that are certified for heart/stroke care rather than BP Rapidly changing healthcare environment (health care reform, electronic health records) Time and cost Privacy for both practices and patients

22. Benefits/Facilitators Being part of the CoP very helpful Maine is one of few states doing state-level recognition, fortunate to have two years of IVD clinical data

23. References Maine Health Management Coalition http://www.mhmc.info/ Bridges to Excellence http://www.bridgestoexcellence.org/ National Committee for Quality Assurance (NCQA) http://www.ncqa.org/

24. Contact Info Ruth M. Dufresne, MS Telecommute Phone: 207-799-1959 Cell: 207-615-1288 Fax: 207-799-1959 email: dufresne@maine.rr.com