Joel Handler, MD Kaiser Permanente

1. Hypertension Control Success in Kaiser Permanente: • Implementology Science Joel Handler, MD Kaiser Permanente

2. I HAVE NO DISCLOSURES Disclosure of Relationships

3. Educational Objectives • Review key elements of a successful approach to hypertension control performance • Construct a simple hypertension treatment algorithm • Define the advantages of population care in an integrated health care system • Use equitable care to close the racial performance gap

4. Kaiser Permanente Nationwide 10.2 million members 18,000 physicians 177,000 employees 600-700 residents & fellows 619 medical office buildings 38 hospitals Nation’s largest nonprofit health plan Kaiser Permanente – National 7 regions serving 8 states and D.C.

5. 4.5 million members 74,290 employees 7,421 physicians 21,167 nurses 15 hospitals 230 medical offices SCPMG: Who we are in 2018 Southern California Permanente Medical Group (SCPMG) • 319,000 hospital discharges • 42,500 babies delivered • 23.2 million outpatient visits • 29 million prescriptions filled • 473,934 home care

6. HEDIS 2016 Top Ten PerformanceMedicare Population Controlling High Blood Pressure

7. HEDIS 2016 Top Ten PerformanceCommercial Population Controlling High Blood Pressure

8. WHY KEEP TALKING ABOUT HTN? • HTN is quantitatively the most important risk factor for premature CVD, being more common than smoking, dyslipidemia and diabetes. • HTN accounts for an estimated 54% of all strokes and 47% of all ischemic heart disease events globally. (Lancet 2008; 371; 1513 – Global Burden of blood pressure related disease 2001). • Increases the risk for CKD, HF, afib and PVD.

9. Treatment WorksNow We Need Implematology! Large scale RCTs show that antihypertensive treatment results in following: • 50% reduction in heart failure • 30-40% reduction in stroke • 20-25% reduction in MI BMJ 2008: BP Lowering Treatment Trialists’ Collaboration

10. SCAL HTN Control 2004 - 2010 % = Controlled No. of Individuals with HTN (1000’s) CSG Performance & CSG Population

12. Key Elements of SuccessfulImplementation • Hypertension registry • Expansion of the Medical Home with walk-in no copay BP checks and a triage algorithm • Regular performance feedback at the team level • Simple treatment algorithm

15. Create a Hypertension Registry

16. Health System-Wide Hypertension Registry

17. Expand the Medical Home

19. Medical Assistant BP Check • Expands access to the medical home (1800 PMDs for 800,000 pts) • No copayment • Triage with no escape; addresses clinical inertia • Fulfils scope of practice requirements

20. Provider Feedback

21. HEDIS Controlling High BP Measure September 2018

22. Hypertension – Standard Deviation and Control Rate May 2005 through August 2008 Handler J, Lackland DT. JASH 2011; 5: 197-207

23. Create a Simple Treatment Algorithm Based on a Single Combination Pill

24. Kaiser Permanente Hypertension Treatment Algorithm

25. Begin with Lisinopril/HCTZ

26. Simplified Treatment Intervention to Control Hypertension Study (STITCH) • Cluster randomization trial in Canada • 93 practices randomized • Compared sequential add-on monotherapy vs 1rst step combination therapy, then add on • Control rate at 6 months: 64.7% vs 52.7% favoring combination therapy Feldman RD. Hypertens 2009; 53: 646-653

27. Simple Algorithm: Fixed Dose Combination Based SIMPLICITY = PERFORMANCE Fewer steps Fewer pills, for adherence Faster control Fewer visits/ improved access

28. Lisinopril/HCTZ Rate vs HTN Performance

29. Amlodipine is Third Drug

30. Spironolactone Preferred Fourth Drug

31. Protocol-Based Treatment of Hypertension • Reduction of clinical variability • Encourages teamwork • Use of treatment algorithm reminders in EHR • Cost efficiency • Facilitates quality of care prioritization Frieden TR JAMA 2014; 311: 21-22

32. Medication Adherence • Adherence ≥80% with prescribed medication is an often used standard for pharmacologic benefit • Provider understanding of medication and messaging makes a difference

33. Thiazide and Quality of Life • TOMHS: 8 QOL domains; chlorthalidone = placebo • ALPINE: no difference in sexual satisfaction thiazide vs candesartan • SHEP: sexual problems, thirst, nocturia chlorthalidone 25mg = placebo

34. Adverse Effect Placebo HCTZ N=168 N=173 Abnormal Urination 3 3 Asthenia 4.9 2.3 Dizziness 1.2-11.8 1-5.9 Fatigue 6 3 Headache 7-17.6 5.9-10.3 Rash 1 1 Stress Reaction 1 3 Frequency (%) of Adverse Effects Weir et al. Am J Med 1996; 101: 835-925

36. Dear Dr. Handler, Again I request another pill to replace “amlodipine” to eliminate the swelling of my ankles. Please!! Summer is coming soon and my capri pants will not cover my swollen ankles. Edith Wins, 100 years old

37. Pathophysiology of Calcium Channel Blocker Related Edema • Not caused by fluid overload • Not responsive to furosemide • CCBs target precapillary arterioles to increase intracapillary pressure • Intracapillary hypertension leads to fluid transudation into soft tissue and edema • Edema is dependent, worse later in day and better in morning

38. Managing Calcium Channel Blocker Related Edema • Always consider other etiologies of edema, ie right heart failure due to sleep apnea, steroids, anegrilide, NSAIDs; heart, kidney, and liver failure • Lisinopril and losartan act on venular side of capillary circuit to reduce intracapillary pressure • Additional antihypertensive agents permit reduction of dose of CCB • Daytime compression stockings, leg elevation • Switch to another calcium blocker: nifedipine XL 30 mg • Reassurance

39. ‘Blast’ Automated Reminder Calls RESULTS

40. Foundation: KP’s widely used communication models - crosswalk

41. Thank You

42. Lifestyle modifications

43. SCHEDULED 2 to 4 WEEK FOLLOW-UP

44. Accurate Measurement is Key

45. “Sir, is this the same technique you use for your home blood pressure readings??” 241/157

46. Common blood pressure errors that raise SBP 5-10 mmHg mmHg too high Cuff too small 5-10 Unsupported arm 5-10 Patient talking 10 Patient actively listening 5 Back unsupported 5-10 Feet not on floor 5-10 Legs crossed 5-10 Full bladder 10 Forearm blood pressure 5-10

47. Instructions Instructions for Blood Pressure Spot Check Team leaders to complete one spot check per day (5 per week), every week, capturing all staff multiple times throughout the year. Important criteria to be assessed: Is the patient’s arm bare? Is the patient’s arm totally supported at heart level? Neither the patient nor the MA/Nurse should be talking during the procedure. Proper size cuff If any of the important criteria is missed, please privately coach the MA/Nurse on the criteria missed. Please return the completed form to the DA/ADA.

48. Blood Pressure Spot Check March 2016 Aggregated Data Received From: Antelope Valley, Baldwin Park, Downey, Fontana, Kern County, Los Angeles, Orange County, Panorama City, Riverside, San Diego, South Bay, West Los Angeles and Woodland Hills Antelope Valley: • Remove clothes from arm • Reminders to pull sleeves of shirt up • Shirt sleeve too tight, advised could take shirt off Fontana: • Patient had to be told to keep feet flat on the floor

50. AOBPM Technique • Oscillometric device • Average of three readings: • Following 5 minutes of rest • Three readings at 1 minute intervals