Saving Lives Through QI: Improving Blood Pressure Control in Primary Care

The prevalence of hypertension in the United States is staggering, with almost half of adults (119.9 million) meeting the American Heart Association's criteria for the condition — blood pressure (BP) ≥ 130/80 mm Hg or current use of medication to lower BP.¹ Only about one-fourth of those (27 million) have their hypertension under control.¹ Lowering BP significantly reduces cardiovascular (CV) events, stroke, and death with an absolute risk reduction of 28 CV events, 17 strokes, and nine deaths per 1,000 persons treated for five years.²

Due to its profound impact on outcomes, hypertension control is often a target for quality improvement (QI) and pay-for-performance programs. In 2021, our health care system was linking patient panel outcomes on certain quality measures, including hypertension control, to clinician performance pay. Unfortunately, many clinicians were skeptical of data accuracy and patient attribution, and they did not want to be held accountable for factors they could not control, such as medication adherence or measurements obtained in a different setting (e.g., the emergency department). In part because of these barriers, physician engagement in QI efforts was low across our 10 family medicine offices. Our rates of hypertension control were under target, and our approach to improvement was not yielding the desired results.

Recognizing the need for change, we began with the basics of quality improvement — identifying key drivers of hypertension control, developing a protocol with clear roles, defining leading measures, and rewarding our clinicians based on metrics they could understand and influence. After two years of sustained effort, we increased the absolute rate of BP control in our 10-practice family medicine department by 7.5%, to 78%. This exceeded the HEDIS top decile of 75.22% and translated to 1,445 more patients at goal. Using the conservative estimate of one death prevented for every 11 patients at goal over 10 years,³ this means about 130 lives would be saved over the next decade. (See the results.)

We are sharing our experience as a model for other practices to consider when implementing QI work around hypertension and evaluating quality performance incentives.