Recently, HHS' Million Hearts initiative recognized nine public and private medical practices and health systems across the United States for achieving excellent rates of high blood pressure control. Solo family physician Jen Brull, M.D., of Plainville, Kan., was on that list.
Family physician Jen Brull, M.D.
"I was very excited to be selected as a Hypertension Control (Challenge) Champion by the CDC this year," Brull told AAFP News. "I think some of that excitement stems from the fact that I was selected as a rural, solo family physician alongside the likes of Kaiser (Permanente) and the (U.S. Department of Veterans Affairs). But I think that proves that it doesn't matter who you are, as far as your corporate structure. It matters more what you do every day for your patients."
According to a CDC news release(www.cdc.gov) announcing the winners, nearly one in three American adults has hypertension. Yet, fewer than half of those with the condition have it under control and, thus, are at risk of having heart disease or a stroke, two of the leading causes of death and disability among Americans.
Million Hearts is a national initiative HHS launched in September 2011 with the goal of preventing 1 million heart attacks and strokes by 2017. CDC and CMS co-lead the Million Hearts initiative. The Million Hearts Hypertension Control Challenge(millionhearts.hhs.gov) is designed to identify practices, clinicians and health systems that have worked with their patients to successfully reduce high blood pressure and improve heart health.
- HHS' Million Hearts initiative recently named family physician Jen Brull, M.D., and her solo rural practice as one of nine Hypertension Control Challenge Champions for 2013.
- The challenge is designed to identify practices, clinicians and health systems that have worked with their patients to successfully reduce high blood pressure and improve heart health.
- Brull credits the accomplishment to a combination of work at both the patient and population levels.
Little Fish, Big Pond
The 2013 Hypertension Control Challenge Champions, who together care for more than 8.3 million adult patients, are
- Broadway Internal Medicine P.C. in Queens, N.Y.;
- Jen Brull, M.D., of Plainville, Kan.;
- Cheshire Medical Center/Dartmouth-Hitchcock Keene in Keene, N.H.;
- Kaiser Permanente, Northern California Division;
- Nilesh Patel, M.D., of Audubon, Pa.;
- Pawhuska Indian Health Center (U.S. Indian Health Service) in Pawhuska, Okla.;
- River Falls Medical Clinic in River Falls, Wis.;
- ThedaCare in Appleton, Wis.; and
- the Veterans Health Administration (U.S. Department of Veterans Affairs).
Brull said she became involved with the Million Hearts initiative while working as a health IT fellow for the Office of the National Coordinator for Health Information Technology. When the CDC recommended that all of the fellows apply for the Hypertension Control Challenge if their clinic numbers for blood pressure control met the threshold, Brull did just that.
Her small rural practice achieved a blood pressure control rate of more than 85 percent among its patients with hypertension, which Brull credited to "a combination of work at the patient level -- making sure that each hypertensive patient, when they come in, has a controlled blood pressure, or appropriately adjusting medications and having them come back if they don't."
But, Brull noted, achieving and maintaining control also requires work at the population level. "We have a group of patients who are hypertensive," she said, "and one of the things we do is make sure that they are getting in at regular intervals to have their blood pressure checked, and that they are getting labs completed. And also that they know they are part of the team that is controlling their blood pressure."
The 2013 champions achieved control rates ranging from 73 percent to more than 90 percent by using a variety of proven approaches, according to the news release. These approaches included
- making high blood pressure control a priority at every visit;
- using evidence-based guidelines;
- working as a team -- physicians, nurses, nurse practitioners, pharmacists, care coordinators and patients -- to achieve blood pressure control;
- using health IT to track blood pressure readings over time, cue team members to talk about blood pressure with patients and adjust medications in a timely way to safely achieve control;
- staying engaged with patients by offering free blood pressure checks, in-home nurse visits and medication checks by pharmacists; and
- publicly recognizing or using financial incentives to reward high-performing clinicians or teams.
Each of the nine champions was able to demonstrate it had helped patients achieve control by using either the National Quality Forum (NQF)-endorsed 0018 (controlling blood pressure) measure or a similar measure that could be validated. The NQF 0018 measure captures the percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (i.e., to less than 140/90) during the measurement year, excluding patients with end-stage renal disease, patients who were pregnant or those admitted to a nonacute inpatient setting during the measurement year.
Scaling It Up Successfully
Juxtaposed with Brull's solo office in a Kansas town that boasts only about 1,900 souls, fellow champion Kaiser Permanente Northern California (KPNC) serves more than 3.4 million members in the region. Joseph Young, M.D., leads the hypertension control program for the region and said that the Million Hearts program aligns well with KPNC's PHASE (Prevent Heart Attacks and Strokes Everyday) program. Controlling high blood pressure is one of the pillars of PHASE, he said.
"Within KPNC, over the last decade, stroke mortality has fallen by 42 percent, and the (incidence of the) worst kind of heart attacks has fallen by 62 percent," Young said. "Being recognized as a Million Hearts (Hypertension) Control (Challenge) Champion will help us to help other health plans share in our success."
Young said he believes the program can be replicated in other health care settings, and that was one of the goals of publishing "Improved Blood Pressure Control Associated With a Large-Scale Hypertension Program"(jama.jamanetwork.com) in the Journal of the American Medical Association in August 2013. The paper describes the KPNC hypertension program and explains how the organization used electronic health records (EHRs) to establish a hypertension registry and support medication adherence, as well as how it treated patients aggressively, including through use of single-pill combination pharmacotherapy and medical assistant followup after medication adjustments.
FP Wins Hypertension Control Challenge
ThedaCare, another Hypertension Control Challenge Champion, serves about 150,000 patients in Wisconsin. Mark Hallett, M.D., said high blood pressure affects 17,000 patients in ThedaCare and is the most common chronic disease that the health system treats. He said that the company's culture of continuous improvement lends itself well to enhancing care efforts and communication about managing chronic diseases, such as hypertension, and focusing more on population health.
"As we continue to evolve our care toward population health, Million Hearts was a logical next step because it is population health for our largest population of patients with chronic disease," Hallett told AAFP News. "We wanted to use it as a platform to show our teams what population health looks like and see how we compared to others nationally."
Based on ThedaCare's experience, Hallett offered several tips on how other facilities could achieve higher rates of hypertension control.
- Make all clinicians' results transparent, and tie modest amounts of clinician compensation to achieving reasonable improvement targets.
- Focus on and stabilize basic care processes.
- Close the care loop by scheduling patients' follow-up visits before they leave the current visit.
- Use registries to catch all patients who have fallen through the cracks of the care processes, and produce them for the care teams to work on a regular basis.
- Focus initially on the results of "bright spot" clinicians instead of lower performers.