Improving Blood Pressure Control for Hypertensive Patients at a University of Utah Family Medicine Residency Clinic: A Continuous Quality Improvement Project

Uncontrolled home blood pressure is associated with increased risk for cardiovascular events, stroke, and all-cause mortality, independent of office BP [USPSTF]. By implementing a process for initiating home blood pressure monitoring (HBPM), we hope to improve BP control for our hypertensive patients, thereby improving overall health and quality of life and decreasing health care costs. As of January 2016, only 67.73% of Madsen Family Medicine adult patients (ages 18-85 years) with hypertension had a controlled BP at their most recent clinic visit. At that time, 18.45% of our hypertensive patients had MyChart HBPM ordered (a flowsheet through our EMR Patient Portal). Of those patients, 9.1% had submitted at least one blood pressure reading. AIM: To improve the proportion of hypertensive adult patients (ages 18 to 85) at Madsen Family Medicine with controlled blood pressure by 15% over the three month period from February 3, 2016 to May 3, 2016. Conclusion: Improvement in BP control was statistically significant at the end of the post-intervention period (p < 0.0001 by chi- square and Fisher exact test) but not by our goal of 15%. Increase in MyChart HBPM orders and utilization were both statistically significant (both p < 0.0001 by chi-square and Fisher exact test). Our intervention was associated with improved BP control, likely due to patient involvement in reaching their goal, earlier recognition of poor control, and more values available for providers at follow up visits.

Improving Blood Pressure Control for Hypertensive Patients at a University of Utah Family Medicine Residency Clinic: A Continuous Quality Improvement Project Erin Helms, MD, Sakineh Najmabadi, MPH, Victoria Prince, MD, PhD, Marlana Li, MD, Ana Ortiz, Lisa Langell, Jovana Boutet, Jacob Miller, MD, Brian Hill, MD, Jessica Jones, MD, MPH Background Uncontrolled home blood pressure is associated with increased risk for cardiovascular events, stroke, and all-cause mortality, independent of office BP [USPSTF]. By implementing a process for initiating home blood pressure monitoring (HBPM), we hope to improve BP control for our hypertensive patients, thereby improving overall health and quality of life and decreasing health care costs. Methods INTERVENTION: We designed an EPIC Smart Set (order set) that an MA can pend for provider signature. The features of our Smart Set include: • Patient-centered instructions for HBPM and lifestyle tips to lower BP (pictured below) • Prescription for a blood pressure cuff • Visit diagnosis of elevated blood pressure • Order for MyChart HBPM PROBLEM: As of January 2016, only 67.73% of Madsen Family Medicine adult patients (ages 18-85 years) with hypertension had a controlled BP at their most recent clinic visit. At that time, 18.45% of our hypertensive patients had MyChart HBPM ordered (a flowsheet through our EMR Patient Portal). Of those patients, 9.1% had submitted at least one blood pressure reading. According to JNC-8 and HEDIS, BP control is defined as BP: • < 140/90 for patients under age 60 or with diabetes at any age, and • < 150/90 for patients over age 60 without diabetes AIM: To improve the proportion of hypertensive adult patients (ages 18 to 85) at Madsen Family Medicine with controlled blood pressure by 15% over the three month period from February 3, 2016 to May 3, 2016. TEAM: • Family medicine faculty physicians • Family medicine residents • Sports medicine fellow • Medical assistants • Public health student Methods WORKFLOW: • MA records elevated BP in EMR • MA places green sign on the computer screen to draw attention to elevated BP (result of previous CQI intervention) • MA pends Smart Set order • Provider signs (or deletes) Smart Set prior to closing chart • Patient picks up blood pressure cuff from pharmacy and inputs home BP values into MyChart • MyChart BP flowsheet released to ordering provider inbox and patient record after 14 days or 7 values • Provider can use these values at next appointment or opt to call patient for earlier appointment or medication changes Results FIGURE 5: Process Measure Discussion Results FIGURE 2: Smart Set Screenshot PUBLICIZING: • Announcement at Clinic Quality Meeting • Email to all providers • Reminders at MA huddle • Bulletin board announcement with all ongoing CQI projects • Poster in each patients room INVESTIGATION: • Brainstorming • Process map • Fishbone diagram Table 1: Baseline Hypertensive Patient Characteristics Number Percent Gender Male 634 54.37% Female 532 45.63% Age (years) Under 60 651 55.83% 60 and over 515 44.17% Diabetes Diagnosis Yes 150 12.86% No 1016 87.14% Total 1166 100.00% FIGURE 4: Outcome Measure CONCLUSIONS • Improvement in BP control was statistically significant at the end of the post-intervention period (p < 0.0001 by chisquare and Fisher exact test) but not by our goal of 15% • Increase in MyChart HBPM orders and utilization were both statistically significant (both p < 0.0001 by chi-square and Fisher exact test) • Our intervention was associated with improved BP control, likely due to patient involvement in reaching their goal, earlier recognition of poor control, and more values available for providers at follow up visits LIMITATIONS: • Only three months to measure effects, however a new PDSA cycle begins July 2016 • Some staff unsure of when to initiate intervention • Only about half of patients enrolled in MyChart HBPM entered BP values FUTURE DIRECTIONS: • EPIC prompt to increase rate of use of our intervention • Alternative uses for our Smart Set including identifying "white coat" or over-treated hypertension and confirming hypertension diagnoses • Incentives to encourage more patient participation • Utilizing EPIC's new features involving home BPs References and Acknowledgements Thank you to the staff at Madsen Family Medicine for implementing this intervention into their daily clinic flow, Ken Gondor and Nicole Edwards for assistance with our hypertensive patient registry, Mandy Johnson for assistance with poster design, and Melissa Briley for assistance with Smart Set design. Thank you to the staff at Madsen Family Medicine FIGURE 1: Fishbone Diagram FIGURE 3: Patient Instructions Final Recommendation Statement: High Blood Pressure in Adults: Screening. U.S. Preventive Services Task Force. November 2015. http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/high-blood-pressure-in-adults-screening