Smart AIM:   Improve hypertension control with the following goal: Within three months 60% of patients with hypertension will have a blood pressure less than 140/90 during their most recent office visit.https://jdc.jefferson.edu/patientsafetyposters/1029/thumbnail.jp

Caruso, MD, John

Giordano, MD, Christine

Huelskamp, MD, Stephen

Kloo, MD, Juergen

Knight, MD, Barbara S.

Lee, MD, Albert

Vira, MD, Amit

English

Smart AIM:   Improve hypertension control with the following goal: Within three months 60% of patients with hypertension will have a blood pressure less than 140/90 during their most recent office visit.http://jdc.jefferson.edu/patientsafetyposters/1029/thumbnail.jp

Name not available

Under Pressure: Ambulatory Blood Pressure Control

Jefferson Digital Commons

Thomas Jefferson UniversityJefferson Digital CommonsHouse Staff Quality Improvement and PatientSafety Posters GME Quality and Safety5-31-2017Under Pressure: Ambulatory Blood PressureControlStephen Huelskamp, MDThomas Jefferson University Hospital, Stephen.Huelskamp@jefferson.eduJuergen Kloo, MDThomas Jefferson University Hospital, Juergen.Kloo@jefferson.eduChristine Giordano, MDThomas Jefferson University Hospital, Christine.Giordano@jefferson.eduAmit Vira, MDThomas Jefferson University Hospital, Amit.Vira@jefferson.eduAlbert Lee, MDThomas Jefferson University Hospital, albert.lee@jefferson.eduSee next page for additional authorsFollow this and additional works at: http://jdc.jefferson.edu/patientsafetypostersPart of the Medicine and Health Sciences CommonsLet us know how access to this document benefits youThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inHouse Staff Quality Improvement and Patient Safety Posters by an authorized administrator of the Jefferson Digital Commons. For more information,please contact: JeffersonDigitalCommons@jefferson.edu.Recommended CitationHuelskamp, MD, Stephen; Kloo, MD, Juergen; Giordano, MD, Christine; Vira, MD, Amit; Lee, MD, Albert; Caruso, MD, John; andKnight, MD, Barbara S., "Under Pressure: Ambulatory Blood Pressure Control" (2017). House Staff Quality Improvement and PatientSafety Posters. Poster 29.http://jdc.jefferson.edu/patientsafetyposters/29AuthorsStephen Huelskamp, MD; Juergen Kloo, MD; Christine Giordano, MD; Amit Vira, MD; Albert Lee, MD;John Caruso, MD; and Barbara S. Knight, MDThis poster is available at Jefferson Digital Commons: http://jdc.jefferson.edu/patientsafetyposters/29BACKGROUND • Hypertension (HTN) is the most common reason for a non-pregnant adult to present to their primary care provider.1  • Poor blood pressure control leads to myocardial infarction, stroke, and renal failure with only an estimated 50.1% of hypertensive adults controlled.2 • Jefferson Hospital Ambulatory Practice (JHAP) patients in 2016 showed a hypertension control rate of 47.2% on all clinic days. • The stand-out problem for JHAP was the infrequency of timely follow-up with the primary care provider (PCP). • Using JNC 8 guidelines, our group developed a standardized flow sheet to be followed in any encounter involving a hypertensive patient. • Improve hypertension control with the following goal: Within three months 60% of patients with hypertension will have a blood pressure less than 140/90 during their most recent office visit. SMART AIM METHODS PLAN Beginning in January 2017 we instituted a process for assessing, treating blood pressure and evaluating Tuesday JHAP's hypertensive population.  DO   Methods STUDY  • A thorough chart review was undertaken to review demographics, blood pressure readings, interventions, and follow up visits beginning in October 2016 to April 2017. • Statistical analysis: Descriptive characteristics of patient populations in the pre and post-intervention cohorts were summarized and data were expressed as means ± standard deviations for interval variables and as proportions for categorical variables. Proportion of patients whose hypertension were controlled and patients scheduled for follow-up by visit date were represented graphically.   DISCUSSION 1. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, 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 Feb 5;311(5):507-20. PubMed PMID:24352797.  2. Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. JAMA. 2010 May 26;303(20):2043-50. PubMed PMID: 20501926.  3. Jaffe MG, Lee GA, Young JD, Sidney S, Go AS. Improved blood pressure control associated with a large- scale hypertension program. JAMA. 2013 Aug 21;310(7):699-705. PubMed PMID: 23989679; NIHMSID:  NIHMS531072; PubMed Central PMCID: PMC4270203.  4. Santschi V, Chiolero A, Colosimo AL, et al. Improving blood pressure control through pharmacist interventions: a meta-analysis of randomized controlled trials. J Am Heart Assoc. 2014;3(2):e000718.          Under Pressure: Ambulatory Blood Pressure Control Stephen Huelskamp, Juergen Kloo, Christine Giordano, Amit Vira, Albert Lee, John Caruso, Barbara Knight Department of Medicine, Sidney Kimmel Medical School, Thomas Jefferson University, Philadelphia PA  REFERENCES • Although the effects of our intervention did not reach the level of statistical significance, we are encouraged by the increase in average hypertension control from 57% to 65% during our intervention. • Our intervention led to a nine fold increase in close follow up for patients with untreated hypertension.  • A significant barrier to treatment was that only 48% of patients attended follow up visits. • The complexity of our algorithm led to confusion about proper follow up. • Less familiar follow up methods were under utilized, i.e. clinical pharmacist and phone calls. • Limitations on interpretation of the data includes the small patient cohort, limited time frame studied and inability to randomize or blind which introduced the Hawthorne effect.  In fact, the Hawthorne effect likely had a large role in decreasing provider inertia to change hypertension management.    ¶ HTN Controlled defined as a blood pressure less than 140/90  46 20 15 Interventions Lifestyle ChangeAdditional AntihypertensiveDose IncreaseSTAKEHOLDERS • Stakeholders include patients, resident physicians, medical technicians and the clinical pharmacist. RESULTS Future ACT  • Tuesday JHAP plans on continued active management of our patients' hypertension utilizing a simplified version of our current intervention.  MA's will alert residents verbally when an increased blood pressure is measured, and residents will focus on making interventions with close follow up. • Continued monitoring of performance will be analyzed on a annual basis utilizing the electronic medical record. 0%10%20%30%40%50%60%70%80%Pecentage of Patients with HTN ControlledScheduled for Follow UpVariables, % (n)* Cohorts Pre-Intervention  Post-Intervention Mean Age, Years (±SD) 57.1 (±12.8) 58.0 (±12.0) Sex, Female 59.7 (71) 67.2 (121) Obese 48.7 (58) 62.8 (113) Overweight 29.4 (35) 21.7 (39) Hypertension 93.3 (111) 92.8 (167) Lifestyle Change 15.7 (19) 17.2 (31) Insurance Status No Medicare/Medicaid Others 6.6 (8) 30.6 (37) 57.0 (69) 1.1 (2) 22.8 (41) 75.6 (136) No. of Antihypertensive Meds None One Two Three or more 14.3 (17) 32.8 (39) 32.8 (39) 20.2 (24) 8.3 (15) 34.4 (62) 30.0 (54) 27.2 (49) Table 1. Pre/Post Implementation of Intervention Descriptive Statistics of Patient Population    Implementation of Intervention Variables, % (n)                      Cohorts Pre-Intervention   Post-Intervention  P  value  Patients  N= 119  N= 181  Blood Pressure ¶       <140/90 57.1(68) 65.2(118) 0.07      ≥140/90 42.8(51) 34.8(63) Process Measure     Follow Up  13.7(7)  73.1(68)       Appointment 100(7) 88.2(60)      Phone Call 0(0) 8.8(6)      Clinical Pharmacist  0(0) 2.9(2)      Attended Follow Up Appointment  0 (0)  48.3(29)       Average till Follow Up, week(±SD)  NA 4.3(±2.4)     Interventions ꭍ  28 81 Balance Measures       Complications†      Acute  Kidney Injury      Cough       Orthostatic Hypotension 0(0) 0(0)  0(0) 1.2(1) 1.2(1)  1.2(1) Pre/Post Descriptive Statistics of Patient Population *Less than 1% data were missing thus percent may not add-up to 100%  ¶ Blood pressure taken at most recent clinical visit ꭍ Addition of antihypertensive, Dosage increase or lifestyle change † As reported by resident physician      Yes Yes Yes No Follow Up 2-4 weeks  MA BP> 140/90   Normal visit Follow Up /Phone Call No No Yes Yes BP >140/90 after manual recheck?  Wallet card   On BP medication?  No   Start                     BP med   Greater than 2 BP meds? Tuesday JHAP Hypertension Management Flow Sheet  First Elevated BP?  Adjust HTN management AND Refer to Clinical Pharmacist   No Greater than 2 visits with elevated BP? Continue Medical HTN Management Intervention/study period begins 

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Under Pressure: Ambulatory Blood Pressure Control

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