ASH Chapter, Clinical HTN Specialists & the HTN Initiative

1. ASH Chapter, Clinical HTN Specialists & the HTN Initiative • The ASH Model for Hypertension Control and role of ASH Regional Chapters • ASH Regional Chapters • ASH Clinical HTN Specialists • The O’QUIN HTN Initiative • BCBS / O’QUIN HTN Initiative QI-P4P Collaborative

2. Controlling BP in 50% of All Hypertensives: Healthy People 2010 YearAwareTreatedRx/CControl 2000 63% 47% 50% 25% 2002 63% 50% 64% 30% 2004 67% 54% 64% 33% 2010 80% 72% 70% 50% All data are age-adjusted. 1Egan, Basile: J Invest Med, 2003. 2Ong, et al: Hypertension, 2007.

3. The ASH Model for Improving Hypertension Control • Continuing national leadership role in professional education & research and by developing an educational / interactive website for the lay public • Expanding educational influence thru regional ASH Chapters committed to optimizing awareness, Rx, and control of Htn and concomitant CV risk factors. • Impacting HTN control locally thru a network of ASH Specialists and others focused on patient / community activation and practice optimization • Implementing CQI using a data-driven process.

4. ASH Chapters: 8 Ch; 22 States & DC Rocky Mountains Chapter in Planning PA, DE FLORIDA

5. Rationale for ASH Regional Chapters • Patient, provider, community, and systems characteristics vary by region • Local and regional solutions require coordinated & active input from local and regional stakeholders • Chapters serve as a focal point for stakeholders to identify best public health and practice models & methods for prevention and awareness, Rx & control of hypertension & other CV risk factors Egan, Lackland, Basile: Am J Hypertens 2002;15:372-379.

6. Rationale for ASH Chapters • Greater CV risk: More elderly, more minorities, more obesity • Feds unlikely to solve problem • We can make a difference by: –educating the public, payors and policy makers –promoting implementation of best practices –developing a database to guide CME and CQI Egan, Lackland, Basile: Am J Hypertens 2002;15:372-379.

7. ASH Chapter, Hypertension Specialists and HTN Initiative • Commit to excellence in CV risk control • Become an active member of ASH, a Regional Chapter (Carolinas-Georgia), and the Initiative • ASH:www.ash-us.org for information on ASH, ASH Chapters, and ASH Hypertension Specialists • Chapter: Contact Dr. Lackland’s office (lackland@musc.edu) for information on the Carolinas-Georgia Chapter. • Initiative, TEMR, and VRS project: Contact: Kim Edwards (edwardk@musc.edu); phone 843-792-1715

8. Role of ASH Clinical Hypertension Specialists There are too many uncontrolled Htn Pts to be managed by Specialists, so their expertise must be leveraged through– • Educationof patients and colleagues • Patient Care; referrals of challenging Htn Pts • Health Services Research & clinical trials–CMS 7th scope of work; IOM report.

9. ASH Clinical HTN Specialists in the Carolinas & Georgia Clinical Hypertension Specialists in GA, NC, SC. ASH goal: At least 1 HTN Specialists in every country / parish with 1 Specialist for every 20 primary care physicians

10. American Society of HypertensionClinical Hypertension Specialists South Carolina • Top 10% for HTN Specialists / capita • Better geographic dispersion of Specialists • Majority of Specialists Primary Care Reasons • Promote Specialists at all CME program • BCBS $5,000 incentive • BCBS pays Specialists for consultant service

11. ASH Chapter, Clinical HTN Specialists & the HTN Initiative • The ASH Model for Hypertension Control and role of ASH Regional Chapters • ASH Regional Chapters • ASH Clinical HTN Specialists • The O’QUIN HTN Initiative • BCBS / O’QUIN HTN Initiative QI-P4P Collaborative

12. Mission Statement: To facilitate the tran-sition of the Southeast from a leader in CVD to a model of heart & vascular health Goal: 1. Improve health 2. Cut heart attack & stroke in ½ Strategies: 1. Healthy lifestyles – physical activity & good nutrition 2. Effective health care – access to care & medications

13. DASH for Good Health Southern StyleCookbook Faith-Based Study Guide& Website http://worst2first.musc.edu/dash/files/cookbook2008.pdf

14. Biblical Warning About Eating Royal (Rich) Food Proverbs 23:1-3. Avoid rich (royal) food and gluttony. When you sit to dine with a ruler (royal food),note well what is before you, and put a knife to your throat if you are given to gluttony.Do not crave his delicacies, for that (royal) food is deceptive. Daniel 1:12,15. Please test your servants for 10 days. Give us nothing but vegetables to eat and water to drink. At the end of 10 days they looked healthier and better nourished than the young men who ate the royal food.

15. The Wisdom of Solomon andThe Cost of Deceptive Royal Food HUNGER: Insatiable appetite (Eccl 6:7, Phil 3:18,19) UP WITH: Obesity, Fatigue, Sleep Apnea 3 FREE HIGHS: Blood Pressure, Sugar, Cholesterol ATTACKS & FAILURE of brain, heart, Kidney CANCERS of the Breast, Colon, Esophagus, Kidney, Prostate, Uterus WORN OUT PARTS: Loss of ‘Nature,’ Old Timer’s disease, Arthur(itis)

16. United States: The Revis family of North Carolina Food Cost for 1 Wk $342

17. Italy: The Manzo family of Sicily. Food Costs for 1 Week:  214 Euros $300 

18. Ecuador: The Ayme family of Tingo. Food expenditure for one week: $32

19. Chad: The Aboubakar Family of Breidjing Camp.  Food Costs for 1 Week:  685 CFA Francs or $1.23

20. Mission Statement: To facilitate the tran-sition of the Southeast from a leader in CVD to a model of heart & vascular health Goal: 1. Improve health 2. Cut heart attack & stroke in ½ Strategies: 1. Healthy lifestyles – physical activity & good nutrition 2. Effective health care – access to care & medications

21. Hypertension Initiative: Participating Clinical Sites The HTN Initiative includes >280 practices in the Southeast including ~150 with EMRS & >1,600,000 patients that provide recurring data. The Initiative returns confidential reports to physicians designed to facilitate quality improvement in Rx and control of HTN, hyperlipidemia and diabetes.

22. Hypertension Initiative: Analytical Database Variables Patients Patient ID (Masked) Birth Date (mo/yr) Race / Ethnicity Sex Insurance Status Zip Code / RUCA Visits Patient ID (Masked) Date of Visit Site of visit (Masked) Provider Seen (Masked) Weight (kg); Height (m) Systolic , Diastolic BP Medications Patient ID (Masked) Drug ID (FDA ID/NDID) Start, End Date Dose Unit Frequency . ICD9s / CPT codes Patient ID (Masked) ICD9 / Problem List CPT codes Dates Labwork Patient ID (Masked) Date of Lab Lab Name Lab Result, Unit Outcomes(SC only) ER visits, Dx, Cost Hosp, Dx, Cost Prescriptions filled (Medicaid)  Available in limited data set with IRB approval

23. Improvement in BP Control 2000 – 2005in 208,547 Hypertensive Patients BP control in patients among practices in the Initiative. In >200,000 patients with at least 5 visits in different 6 month intervals, BP control to <140/<90 improved from 49% to 66% in the 5-year period from 2000 - 2005. Egan, et al. J ClinHypertens, 2006.

24. Change in Control of 3 Risk Factors in 82,442 Diabetic Hypertensives 2000–05 Multiple risk factor control for >80,000 diabetic patients with hypertension and hyperlipidemia who had at least 5 visits over the 5-year period 2000 - 200s. Egan, et al. J ClinHypertens, 2006.

25. Time Trends in Application of Evidence-Based Therapies: The ASH Carolinas-Georgia Chapter Database Diabetics on ACEI HF Pts on -B HF Pts on ,-B

26. O’QUIN Hypertension InitiativeProvider Performance Report

28. Hypertension Indicators for Dr. John Doe

29. DASH BOARD for Dr. John Doe: Lipid Control

30. Multiple Risk Factor Control in Hypertensive, Dyslipidemia Diabetics

31. BP Control in Black and White Men at VA and non-VA Sites in 2003 Initiative data use f evaluation of racial and healthcare system differences in CV risk factor treatment and control. At the VA, BP control was better for black men and the racial disparity was less. Rehman S, et al: Arch Int Med 2005;165:1041–1047.

32. Therapeutic Inertia is a Major Indicator of BP Control Okonofua E, et al: Hypertension 2006;47:1–7.

33. Percentage Remaining Normotensive in ~50,000 Pts by SBP Mean at Baseline <110 110-119 120-129 130-139 500 1000 1500 2000 2500 Time (Days)

34. Hypertension Initiative:Opportunities Network: Quality improvement —CV, diabetes —most chronic disease — CME Clinical Trials: T2 and T3 research incl genetic epi, pharmacogenomics Database: Guide CME Publications: CVD and non-CVD Preliminary data for grant applications; T2 and T3 research

35. Quality Improvement Strategies in Hypertension Management Walsh, et al: Med Care 2006. Fahey, et al. Cochrane Rev 2009 Self-monitoring* Patient education Physician education Nurse or Pharmacist care* Organizational interventions (too much heterogeneity) • Provider education • Provider reminders • Audit & feedback • Facilitated relay • Patient education • Pt self-management • Patient reminders • Team Change* * Interventions with largest effect size

36. Barriers to Dissemination of EBM: Efficacy vs Effectiveness; Cost & Complexity • Intervent’n Characteristics • High cost • Time intensive • High level staff expertise • Not well packaged • Ignore user needs • Not self-sustaining • Setting specific • Not ‘customizable’ • Target Setting Limitations • Competing demands • Client needs • Outside program • Limited resources/support • Established work patterns • Inadequate incentives • Low-quality implementation • Research Design • Not relevant • Not representative of patients and practices • Fail to evaluate cost, RE-AIM, sustainability • Interactions among intervention, setting, and design barriers • Given participation barriers, program reach and/or participation are low • Interventions are inflexible, inappropriate for target population • Staffing not matched to intervention needs/requirements • Practice setting organization and intervention team philosophies misaligned • Practice setting unable to implement intervention as designed Glasgow RE, Emmons KM. Ann Rev Publ Health. 2007;28:413–433.

37. ASH Chapter, Clinical HTN Specialists & the HTN Initiative • The ASH Model for Hypertension Control and role of ASH Regional Chapters • ASH Regional Chapters • ASH Clinical HTN Specialists • The O’QUIN HTN Initiative • BCBS / O’QUIN HTN Initiative QI-P4P Collaborative

38. Healthcare Quality Improvement Collaborative • What’s wrong with the current reimbursement system • P4P: Definition, objectives, measures • Brief review CMS QI Roadmap • AHA translation and QI principles • QI-P4P key design elements • Previous experience; early adopters

39. What’s Wrong with the Current Healthcare Payment System? • Provider’s standpoint • Providers are paid the same amount regardless of outcome. • From an economic standpoint, there is no incentive to improve “quality” (clinical outcomes). • The current system also does not incentivize providers and practices to: • Expand preventive services • Enhance patient safety and satisfaction

40. What’s Wrong with the Current Healthcare Payment System? • Insurers’ standpoint • Health insurers want to account for the quality and the economy of medical services. • They recognized the financial benefits of improving the health of their subscribers •  Employers’ standpoint • There is a strong need to control health care costs / premiums • Productivity suffers when employees have medical problems / issues

41. The What and Why of P4P? Defining P4P: • “Pay-for-performance (P4P) programs offer financial incentives to physicians for achieving specific, measurable patient safety, quality, satisfaction or efficiency objectives. • P4P programs generally base a portion of physician payment on quantitative measures. These may include patient care process and/or outcome measures and/or patient satisfaction scores.” • Any P4P program should have as its central purpose to improve the quality of patient care, satisfaction and clinical outcomes.

42. P4P Measures • Most P4P programs focus primarily on clinical outcomes and patient satisfaction • Utilize the Health Plan Employer Data and Information Set (HEDIS) measures from the NCQA. • Half also include efficiency measures (e.g., the number of inpatient admissions or rate of prescribing generic medications) • More programs are measuring the use of Information Technology • Typically, the incentive is weighted among the different measures

43. CMS’ Quality Improvement Roadmap Vision: The right care for every person every time  Make care:  Safe  Effective  Efficient  Patient-centered  Timely  Equitable Strategies  Work through partnerships  Measure quality and report comparative results  Value-Based Purchasing: improve quality and avoid unnecessary costs  Encourage adoption of effective health information technology  Promote innovation and the evidence base for effective use of technology

44. AHA: TRIP and P4P Principles TRIP: • Scientific discovery • Disseminate discoveries • Evidence-based guidelines • Performance measures • Develop clinical decision support and QI tools • Directed-cause campaigns QI P4P: • Promote safe, effective, patient-centered, timely, efficient care • Use rigorous methods; risk-adjust, standardize, EBM • Promote quality-of care systems & infrastructure • Evaluate if goals reached, unintended effects occur AHA Special Report. Circulation 2008;118:687–696. AHA Policy Recommendation. Circulation 2006;113:1151–1154.

45. P4P: 5 Key Design Elements JAMA 2007;297:740 – 744.

46. Effects of P4P Quality of Care in England; Comparison of Unintended Consequences • In 2004, P4P on 136 clinical indicators began. • Quality of care for asthma, diabetes and heart disease was increasing before P4P incentives. “Between 2003 and 2005, the rate of improvement in quality indicators increased for asthma and diabetes but not heart disease. • By 2007, the rate of improvement slowed for all three; quality of care for services not associated with an incentive declined. • Continuity (seeing same doc) declined promptlyafter P4P began • English doctors happier than California doctors with QI / P4P; less resentment/frustration, more motivated, greater change • English doctors more chart data (vs claims); can remove difficult patients from denominator NEJM 2009;361:368–378. Ann Fam Med 2009;7:121–127.

47. P4P Learning Curve: Where are early adopters now? “Our findings suggest that leading-edge sponsors of P4P have expanded the reach of their efforts, particularly with regard to specialists, and increasingly are focused on outcome and cost-efficiency measures, rather than clinical outcome measures alone.” Rosenthal, et al: Health Affairs 2007: Nov-Dec 1674 – 1682.

48. QI / P4P: A Developing BCBS / O’QUIN HTN Initiative Program Inaugural meeting of the ‘Healthcare Quality and Reimbursement (HQR) Advisory Board’, comprised of key opinion leaders from 12 practices. Three ‘domains’ were identified as essential to a successful collaboration. • Quality indicators. Thoughtful selection of high impact process and outcome indicators that can be clearly defined and rigorously measured across practice settings. • Quality improvement. Develop, share, refine best practices to ensure productive encounters and attain goals of the process and outcome indicator selected. • Reimbursement/incentives. Define & implement incentives that compensate for time and resources invested to meet goals of process and outcome indicators.

49.  Quality Indicators: Hypertension: JNC 7 – 2003; ACC/AHA – 2009.

50. Quality Indicators:Diabetes: ADA – 2008.