Improving Blood Pressure Control With Strategic Workflows

 


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Setting a goal, identifying the right patients, and implementing team care can help bring hypertension under control.

Fam Pract Manag. 2016 May-June;23(3):23-28.

Author disclosure: no relevant financial affiliations disclosed.

The Centers for Disease Control and Prevention (CDC) reports that only about 52 percent of the 70 million U.S. adults with high blood pressure have their condition under control. It costs an estimated $46 billion each year to address issues related to hypertension such as health care services, medications, and missed work. Seven to eight out of every 10 people have their first heart attack or stroke or develop congestive heart failure because of uncontrolled blood pressure.1 It is clear that blood pressure control is essential to preventing multiple medical conditions from occurring or worsening. This article discusses how our office of 11 employed physicians, working within an integrated health system, implemented strategic workflows to improve blood pressure control among our 2,800 patients with hypertension.

Getting started

Scripps Health, the integrated health system in San Diego that my site is part of, participates in the “Measure Up/Pressure Down” campaign, a three-year effort created by the American Medical Group Foundation to reduce high blood pressure.2 As part of the campaign, a coalition of local primary care leaders, cardiologists, and nephrologists – including participants from Scripps – reviewed guidelines from the Seventh and Eighth Reports of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 and JNC 8)3,4 and formulated a recommended blood pressure control treatment algorithm and an accompanying list of medications to help manage patients with hypertension. (See “Adult hypertension treatment algorithm” and “Selected generic antihypertensive medications.”)

ADULT HYPERTENSION TREATMENT ALGORITHM

Medication up-titrations are recommended at no greater than 30-day intervals (for most patients) until control is achieved. Consider follow-up labs when up-titrating or adding lisinopril, hydrochlorothiazide, or losartan.

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SELECTED GENERIC ANTIHYPERTENSIVE MEDICATIONS

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View/Print Table

Drug classGeneric nameUsual dosage range

Thiazide-type diuretics

chlorthalidone

12.5 – 25 mg daily

hydrochlorothiazide (HCTZ)

25 – 50 mg daily

Thiazide combinations

lisinopril-HCTZ

10/12.5; 20/12.5; 20/25 mg daily

spironolactone-HCTZ

25/25 mg daily

ACE inhibitors (ACEIs)

lisinopril

10 – 40 mg daily

captopril

12.5 – 50 mg twice daily

Long-acting dihydropyridine calcium channel blockers

amlodipine besylate

2.5 – 10 mg daily

felodipine

2.5 – 10 mg daily

nifedipine ER

30–90 mg daily

Beta-blockers (BB)

atenolol

25 – 100 mg daily

carvedilol

3.125 – 25 mg twice daily

metoprolol tartrate

25 – 100 mg twice daily

metoprolol succinate

25 – 200 mg daily

Aldosterone receptor blocker

spironolactone

12.5 – 25 mg daily

Potassium-sparing diuretics

amiloride hydrochloride or amiloride-HCTZ

About the Author

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Dr. Cuenca is a board-certified family medicine and sports medicine physician and a member of Family Practice Management's editorial advisory board. He formerly served as the site physician lead for Scripps Coastal Medical Center's Oceanside medical offices in Oceanside, Calif. He currently serves as the site physician lead for OptumCare Medical Group in Ladera Ranch, Calif....

He would like to thank Dr. Anthony Chong, CMO for Scripps Coastal Medical Center; Kathy Wright, quality manager of performance improvement for Scripps Medical Foundation; and Malena Leon, medical assistant, for their assistance.

Author disclosure: no relevant financial affiliations disclosed.

 

References

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1. High blood pressure facts. Centers for Disease Control and Prevention. 2015. http://www.cdc.gov/bloodpressure/facts.htm. Accessed March 7, 2016....

2. Measure Up/Pressure Down website. American Medical Group Association. 2012. http://www.measureuppressuredown.com. Accessed Feb 25, 2016.

3. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289(19):2560–2572.

4. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507–520.

5. Pickering TG, Miller NH, Ogedegbe G, et al. Call to action on use and reimbursement for home blood pressure monitoring: a joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. J Cardiovasc Nurs. 2008;23(4):299–323.

6. McCormack T, Krause T, O'Flynn N. Management of hypertension in adults in primary care: NICE guideline. Br J Gen Pract. 2012;62(596):163–164.


 

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