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National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP)TTASC | Training and Technical Assistance Support Center
Approaches to Identifying Individuals with Undiagnosed HTN
Evaluation Peer Learning Community: Health Systems and Clinical-Community Linkages
April 20, 2017
2:00-3:00PM EST
Agenda
• Panel Presentation
◦ Wisconsin
◦ Arizona
◦ Los Angeles County
• Group Discussion
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UNDIAGNOSED HYPERTENSION IN WISCONSIN
Mary Pesik, Chronic Disease Prevention Unit Director
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UNDIAGNOSED
HYPERTENSION IN
WISCONSINMary Pesik
Chronic Disease Prevention Program Director
Wisconsin Department of Health Services,
Division of Public Health
April 20, 2017
Today’s Outline: 100 Meter Dash of
Wisconsin’s Experience
Undiagnosed
Hypertension
Basic 5
Intent
Health Plans
Association
of State and
Territorial
Health
Officials
(ASTHO)
Lessons
LearnedChallenges
Federally
Qualified
Health Centers
(FQHCs)
Clinics and
Providers
How it began…
Basic strategy 5 intent and activity modifications
Approach and partnerships to consider
Chronic Disease Quality
Improvement Project: Represents
13 of 17 health plans/payers
MetaStar: Represents the quality
improvement network/regional
extension center
Wisconsin Collaborative for
Healthcare Quality: Represents
about 65% of all physicians
Wisconsin Nurses Association:
Represents over 2,200
nurses/nurse memberships
Pharmacy Society of Wisconsin:
Represents community/clinical
pharmacists and pharmacy chains
(over 3,000 members)
Wisconsin Community Health
Fund: Represents a non-profit
organization/public-private
partnership
Wisconsin Primary Health Care
Association: Represents all 18
FQHCs
ASTHO Million Hearts State
Learning Collaborative September 2015 to present
Overview:
Improve identification of undiagnosed persons with high blood pressure (BP)
Rapid cycle improvement using Plan-Do-Study-Act cycles
Health system in one target population site to identify patients hiding in plain sight (HIPS)
Method:
Measurement Period: April 1, 2015 to March 31, 2016
Numerator: Patients no diagnosis of hypertension (HTN) in problem list or electronic health
record (EHR)
Denominator: During the measurement period, patients a) with at least two BP readings with a
systolic ≥140 mm Hg and a diastolic ≥90 mm Hg and b) that had at least two office visits
Results: Identified 10.04% undiagnosed hypertensive patients (84 out of 837)
Next Steps:
Protocols and workflows developed for staff to connect with patients to return and see provider
for rechecks and assessment
Created EHR prompts to guide staff/providers to address HTN and other chronic diseases
Definitions & Guidance
1) NorthShore University Health System
2) Geisinger Health
3) Palo Alto Medical Foundation
4) University of West Virginia
5) University of Wisconsin
6) National Association of Community Health Centers’
(NACHC) Undiagnosed Hypertension Change Package
FQHCs
Overview:
Wisconsin Primary Health Care Association (WPHCA)
Azara DRVS (Data Reporting & Visualization System)
Method:
NACHC Undiagnosed Hypertension Change Package (3 FQHCs)
Measurement Period: June 2015 to June 2016
Numerator: Patients who had at least one Stage 2 BP reading or at least two Stage 1 BP
readings during the measurement period
Denominator: All patients age 18-85 who do not have a HTN diagnosis (excluding pregnant
and ESRD patients) and had an office visit during the measurement period
Results:
Identified 8.96% undiagnosed hypertensive patients (559 out of 6,238)
Next Steps:
More FQHCs utilizing Azara DRVS
Current FQHCs can utilize the registry and “visit planning” reports for HIPS patient follow-up
Clinics & Providers
Overview:
Wisconsin Collaborative for Healthcare Quality (WCHQ)
Public quality reporting and Repository Based Data Submission tool
Method: Geisinger Health System & Palo Alto Medical Foundation approaches (19 health systems)
Measurement Period: January 1, 2015 to December 31, 2015
Numerator: a) Patients with a problem list diagnosis (active problem), and/or b) encounter file
diagnosis, and/or two elevated BP readings…
Geisinger Only: c) with both systolic ≥140 mmHg or both diastolic ≥90 mmHg
Palo Alto Only: c) with either systolic ≥140 mmHg or diastolic ≥90 mmHg
Denominator: Patients with at least one office visit and has elevated BP (as defined by each
approach) without a diagnosis of HTN in either the problem list or encounter file during the
measurement period
Results:
Geisinger: Identified 21.20% undiagnosed hypertensive patients (167,129 out of 788,315)
Palo Alto: Identified 21.71% undiagnosed hypertensive patients (172,279 out of 788,315)
Next Steps: Explore potential refinements to measurement approach and investigate feasibility of
developing a standardized measure for statewide, public reporting (like NQF 18 and 59)
Challenges & Lessons Learned
Multiple definitions and
algorithms
Acknowledgement of
issue
Buy-in regarding
method/algorithm used
Not a single request
Time
Unable to compare or
cumulate data
Data proves the problem
Constant quality
improvement process
A little can go a long
ways
Challenges Lessons Learned
Mary Pesik, RDN, CD
Chronic Disease Prevention Program Director
608-267-3694
Thank you!
ARIZONA’S EFFORTS WITH IDENTIFYING PATIENTS WITH UNDIAGNOSED HYPERTENSION
Michelle Sandoval-Rosario, Senior Epidemiologist
David Heath, Heart Disease and Stroke Prevention Manager
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Arizona’s Efforts With Identifying Patients with Undiagnosed Hypertension
David Heath, MBA
LCDR Michelle Sandoval-Rosario, MPH, CPH
Overview• Background
• Year 3 Pilot
• Year 4
• Clinical Definitions
• Results
• Challenges
• Lessons Learned
Background• Pre 1305
– 2012 Meaningful Use Analysis of FQHC’s HIT Capacity
• First started evaluating clinic’s capacity to track NQF measures
• Included NQF 13 (HTN x2 Visits per year)
• Multiple vendors; wide range of capacity and training
• Partnerships– Collaborative relationship established with FQHCs, non-FQHC clinics, State QIO
• Leveraging 1305 activities– Integrated the reporting of NQF 18 and 59 into most projects that occur in the
healthcare setting
• CHW projects
• Team based care projects
• Reinforced what was learned in the 2012 capacity analysis – some are ready, some are not
Year 3 Pilot and Year 4• 1305 Year 3 Pilot
– Selected non-FQHC community health center to pilot an EHR enhancement
• Regional Centers for Border Health (RCBH) , Yuma, AZ. Creation of a virtual “portal” to create easy, chronic care management dashboards by patient or by specified patient population. Sorted by provider, condition, etc.
– Results were very good. Clinic optimized information to target high risk patients.
– Selected RCBH to run reports on undiagnosed HTN after providing definitions and parameters.
• 1305 Year 4 – Mirrored EHR portal development with new clinic – St Vincent De Paul
• Portal currently being “built”
– Challenged 5 other 1305 participants to report on undiagnosed HTN through inclusion of “required” performance measure reporting, in addition to their contractually obligated reports on NQF18, self management, etc.
1305 Clinical Definitions
• Proportion of adults in the state aware they have high blood pressure (B.5.01): – Numerator: the number of adults who have been diagnosed with HTN
– Denominator: Total number of adults patients with HTN (diagnosed and undiagnosed)
• Embedded algorithms into EHR to identify patients greater than 18 years old at risk for undiagnosed HTN– Definition: two or more non-consecutive blood pressure readings
of >140/90 mm HG who did not have documentation of HTN
Year 3 Pilot Findings
• Between 09/01/2015 – 07/31/2016
– 966 patients identified with HTN (diagnosed and undiagnosed)
– 14% (138) undiagnosed
– 51% Females and 93% Hispanic
– 52% with controlled HTN
Year 4 Findings
• Five additional health systems Health System
(HS)# of patients with 2 or more blood pressure
readings ≥ 140/90
# diagnosed and undiagnosed with
High blood pressure
Percent Undiagnosed
HS 1 77 256 30%
HS 2 92 386 24%
HS 3 159 2218 7%
HS 4 84 1773 5%
HS 5 46 4305 1%
Challenges
• Still need to verify undiagnosed hypertension
• Health System’s EHR capacity or IT support
• Lack of awareness/resources
• Clinical criteria– Undiagnosed HTN
– HTN Self Management Program
• Health system definition
Lessons Learned
Partnerships
Identify EHR capabilities
Establish definition and clinical criteria
Provide on-going technical
assistance and guidance
Develop a plan to address
patients with high blood pressure
Identifying Patients with Undiagnosed HTN
ADDRESSING HYPERTENSION IN LOS ANGELES COUNTY
Tony Kuo, Acting Director
Noel Barragan, Manager
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Addressing Hypertension in Los Angeles County
Thursday, April 20, 2017
Tony Kuo, MD, MSHS
Acting Director
Noel Barragan, MPH
Manager, Special Projects and Strategic Initiatives
Division of Chronic Disease and Injury Prevention
Los Angeles County Department of Public Health
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Los Angeles County
The Landscape• 4,000 square miles
•10 million residents• 23% hypertension• 10% diagnosed diabetes• 40% with prediabetes• 17% poverty
•88 cities •City of Los Angeles ~ 3.5 million residents
•80 schools districts + LACOE
•Opportunity for broad reach
Undertreated or Uncontrolled Hypertension
• Patients ages 18 to 85 years with a diagnosis of hypertension (in EMR or Blood Pressure [BP] registry) who have BP readings >140mmHg SBP or >90mmHg DSP at any one medical visit during the past 12 months, regardless of whether they are on medications or not
Exclusions: pregnancy and end stage renal disease.
Source: Million Hearts – National Association of Community Health Centers
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Undiagnosed Hypertension
• Two or more office visits after an initial screen
• Stage 1: Patients ages 18 to 85 years without a diagnosis of HTN (documented as an ICD‐9 assessment of 401‐405 at an encounter) who have BP readings >140mmHg SBP or >90mmHg DSP at two separate medical visits, including the most recent visit, during the past 12 months
• Stage 2: Patients ages 18 to 85 years without a diagnosis of HTN (documented as an ICD‐9 assessment of 401‐405 at an encounter) who have BP readings >160mmHg SBP or >100mmHg DSP at any one medical visit during the past 12 months
Exclusions: pregnancy and end stage renal disease
Source: Wall et al. JAMA 2014;312(19):1973-1974 28
“Safety Net” Health Systems in Los Angeles
Los Angeles County Department of Health Services
• Second largest municipal health system in the nation
• Annually cares for 670,000 unique patients
• 19 health centers, 4 hospitals, network of community partner clinics
Community Clinics (FQHCs):AltaMed Health Services
• California’s largest non-profit Federally Qualified Health Center
• More than 950,000 annual patient visits
• 43 sites in Los Angeles and greater Southern California
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DPH’s Approach
Provide Technical
Assistance
Engage with Leadership
Provide Funding
Support for Protocol/Tool Development
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Existing Polices and Efforts in California
• California Senate Bill 493
• California Department of Public Health
• LA Barbershop
• American Heart Association, Western States Affiliate Blood Pressure Task Force
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Key Stakeholder Survey
• Opportunities to Align Advanced Community Pharmacy Practice with Unmet Healthcare Needs
• Representatives from: retail chain pharmacies, independent community pharmacies, academia, professional organizations, non-profit organizations, insurance/payers, and local health departments
• Opportunities for pharmacists to meet the chronic disease needs of communities and strategies to scale-up advanced pharmacy practices such a MTM/CMM effectively in LA
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Key Stakeholder Survey: Methods
• All participants were asked to complete a 17-item paper questionnaire
• Closed and open-ended questions that took approximately 10 minutes to complete
• Participant perspectives on priority actions needed to scale-up pharmacist-led patient care activities
• Organizational readiness for implementing such systems or models of practice
• Current barriers to delivering MTM/CMM services
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Key Stakeholder Survey: Results
• 26 of 56 attendees (46%) completed the survey.
• About half reported their level of experience as at least 11 years or more (n=13)
• More than 40% self-identified as a pharmacists or members of pharmacy leadership in California (n=11)
• Rated the following as top priority actions:
• Improve reimbursement procedures or options among private insurers
• Advance federal policy at the Centers for Medicare and Medicaid Services to expand coverage of pharmacists’ services
• Increase healthcare provider awareness of and receptivity to pharmacists’ services
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Key Stakeholder Survey: Results
• Barriers associated with the scale-up and spread of pharmacist-led patient care services
• Reimbursements for most services remain siloed based on health plan policies which are generally physician-centric
• There is a lack of interoperable electronic medical record systems that facilitate seamless pharmacist-physician communications
• Standard clinic workflows do not readily integrate pharmacists into the healthcare team
• Lack of awareness and support by prescribing physicians for MTM/CMM services
• Perceived limited public acceptance of non-physician extenders as a treating provider
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Public Opinion Internet Panel Survey: Methods
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• Internet panel survey of adult residents living in LA
• Awareness of having access to MTM at usual healthcare facility?
• Potential interest in receiving MTM services if made available to them?
Public Opinion Internet Panel Survey: Results
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• 1,014 completed the survey
• Adjusted response rate = 58%
• Demographics
• Ages of 25-64 (71%)
• Female (51%)
• Hispanic (43%), White (30%)
• Some college education (56%)
• Excellent/very good health (56%)
• Overweight/obese (54%)
• At least two chronic conditions (35%)
Public Opinion Internet Panel Survey: Results
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• Approximately 9% reported knowledge of having access to MTM services where they usually go for care
• 2% had used MTM
• 41% expressed interest in using MTM services, regardless of what was currently available
• Among participants who expressed interest in using MTM, 51% were female, 54% reported excellent to very good health, and 86% said they were generally comfortable speaking to a pharmacist.
Public Opinion Internet Panel Survey: Results
• Predictors of interest in MTM (binary logistic model)
• Older age (65+) positively predicted interest, p=0.02
• Awareness of access to MTM services negatively predicted interest, p<0.00
• Comfort speaking with a pharmacist negatively predicted interest, p<0.00
• Results speak to the challenges of developing client interest in MTM services and the complexities of patient decision-making
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Continuing Medical Education Module
• Sponsored the development and launch of a continuing medical education module to increase physician understanding of MTM/CMM and its potential benefit to the healthcare team.
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White Paper/Toolkit
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• Collaborated with AltaMed to develop a toolkit for incorporating MTM/CMM in clinical practice
• Algorithms for patient identification and treatment, clinic workflows, patient scripts
Lessons Learned…
• Public awareness
• Provider buy-in
• Full program development versus incremental but across system investment
• Implementation barriers – reimbursement, length of time to change healthcare provider behaviors, issue of patient adherence, system incentives, lack of coordinating infrastructure, EHR
• Language translation needs, cultural competency, health literacy
• Health equity
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Next Steps…
• Work with local clinic and pharmacy partners to pilot these protocols and workflows, and to evaluate their impact
• Included in the evaluation will be measures to study patient interest in and receptivity to these services
• Disseminate toolkit and expand access to CME module
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Breakout Discussion
• What has your experience been with identifying individuals with undiagnosed or undertreated HTN?
• For 1305 grantees, how have you identified state-wide systems?
◦ How do you approach this using a state wide definition of health system?
• How do you define undiagnosed HTN? Undertreated HTN?
• What stakeholder groups have you engaged in your efforts?
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Thank you!
• Want to talk further with your peers? Email or visit the Google Group!
◦https://groups.google.com/d/forum/eplc-hs-ccl
• Have a question for our community administrators? Contact us at [email protected]
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