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