implementation: a systems approach · 2018-10-29 · key elements of successful implementation •...

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Implementation: A Systems Approach

Joel Handler, MDFormer National Hypertension Lead

Kaiser Permanente

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DISCLOSURE OF RELATIONSHIPS

Over the past 12 months

I HAVE NO DISCLOSURES

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Kaiser Permanente – National

7 regions serving 8 states and D.C.

Kaiser Permanente - Nationwide

• 10.2 million members

• 18,000 physicians

• 177,000 employees

• 600-700 residents & fellows

• 619 medical office buildings

• 38 hospitals

• Nation’s largest nonprofit health plan

targetbp.org

targetbp.org

targetbp.org

Key Elements of Successful Implementation

• Hypertension registry

• Expansion of the Medical Home with walk-in no copay BP checks and a triage algorithm

• Regular performance feedback at the team level

• Simple treatment algorithm based on a single pill combination

• Continuous quality improvement for BP measurement accuracy

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Medical Assistant BP Check

• Expands access to the medical home (1500 PMDs for 700,000 pts)

• No copayment

• Triage with no escape; addresses clinical inertia

• Fulfils scope of practice requirements

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HEDIS Controlling High Blood Pressure Measure

November 2015

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Kaiser Permanente Hypertension

Treatment Algorithm Adult Hypertension

If ACEI intolerant or pregnancy potential

Calcium Channel Blocker

Add amlodipine 5 mg X ½ daily � 5 mg X 1 daily � 10 mg daily

Spironolactone

IF on thiazide AND eGFR ≥ 60 ml/min AND K < 4.5 Add spironolactone 12.5 mg daily � 25 mg daily

If not in control

If not in control

If not in control

Thiazide Diuretic

Chlorthalidone 12.5 mg � 25 mg

OR HCTZ 25 mg � 50 mg

If not in control

ACE-Inhibitor 2 / Thiazide Diuretic

Lisinopril / HCTZ (Advance as needed) 20 / 25 mg X ½ daily 20 / 25 mg X 1 daily 20 / 25 mg X 2 daily

Pregnancy Potential: Avoid ACE-Inhibitors 2

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Simple Algorithm: Fixed Dose Combination Based

SIMPLICITY = PERFORMANCE• Fewer steps

• Fewer pills

• Faster control

• Fewer visits/ improved access

targetbp.org

targetbp.org

Ayanian JZ. NEJM 2014; 371: 2288-2297

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targetbp.org

EQUAL CARE EQUITABLE CARE

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Closing AA Disparity Gap

AA HTN Uncontrolled

Lisinopril/HCTZ

underdosed

2601 patients

Thiazide Naïve

2331 patients

No Spironolactone

1180 patients

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Thiazide-naive and Suboptimal Lisinopril/HCTZ Initiatives

2500

2600

2700

2800

2900

3000

3100

3200

3300

3400

Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14

# of

pat

ient

s

Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14# SUBOPTIMAL PRINZIDE 3297 3226 3197 3139 3051 3030 3090# THIAZIDE NAÏVE 3046 2955 2970 2989 2937 2812 2829

AA POINT HTN Patients with uncontrolled or no BP

6% decrease since starting initiative

4% decrease since starting initiative

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Targeted Interventions

Optimize thiazide dose to HCTZ 50 mg or

chlorthalidone 25 mg

Use combo drug with ACEI, then add CCB

Spironolactone 4rth drug, especially if

hypokalemic

Lifestyle improvement, salt reduction