ISQUA18-1984Improving Blood Pressure Screening and Control at University of California Davis Health

Abstract

Objectives: Approximately 80 million adults in the United States have high blood pressure (BP). Although 33% of adults in the United States have hypertension, only 54% have their BP under control. Hypertension is a major risk factor for cardiovascular disease and stroke, and BP control saves more lives than any other preventive medicine intervention. Reducing the average population systolic BP by only 12-13 mm Hg could reduce stroke by 37%, coronary heart disease by 21%, cardiovascular disease deaths by 25%, and deaths from all causes by 13%. Health care settings provide an opportunity to optimize the diagnosis and treatment of hypertension. The goal of the University of California Davis Health Hypertension Quality Improvement Initiative was to improve the diagnosis, management and control of high BP for patients 18-75 years of age. Our aims are: (1) to increase the percentage of patients who are accurately screened for hypertension (2) to increase the percentage of patients with BP < 140/90 mm Hg. Our hypothesis is that QI interventions that include clinician education, patient education, and health system level changes, will improve BP screening and control at UC Davis Health. Method(s): Key stakeholder interviews and physician and nurse surveys were conducted to assess challenges and opportunities for improvement. Clinical processes were mapped and cause-and-effect and key driver diagrams were developed in collaboration with experts and key stakeholders. Plan-Do-Study-Act cycles were used to implement the following evidence-based interventions, based on the Centers for Disease Control and Prevention's Million Hearts Initiative: training clinical support staff to measure BP more accurately, visual reminders at the point-of-care, virtual case-based videoconferences, academic detailing, clinical registries, clinical decision support tools, access to pharmacists for medication comanagement, clinician workflow modifications, patient self-management tools, and access to home BP monitors. Outcomes were assessed through retrospective review of electronic medical records. Result(s): Our needs assessment interviews and surveys identified challenges with clinician variation in BP measurement and documentation, and low patient adherence to lifestyle changes and medications. Opportunities identified were changes to clinic workflow to optimize accurate BP screening, using a team-based approach through engaging pharmacists and nurses, and providing patients with local and online resources for self-management support. Following implementation of interventions in June 2016, accurate screening of BP increased from 14% to 80%. Before the initiative, an average of 62% of our patients had BP < 140/90. Currently 72% of our patients are at this BP goal. Approximately 30% of patients with initial BP > 140/90, had BP under 140/90 after it was re-measured at the same visit following a rest period. Aspects of our intervention that contributed the most significantly to improvements were utilizing a team-based approach, adjusting clinic workflow, and frequent communication of results to staff Conclusion(s): Interventions that optimize team-based care, modification of clinic workflow and engagement of clinic staff can effectively improve BP screening and control, even in large healthcare systems serving complex and high-risk populations. Accurately identifying patients who have "white coat hypertension" helps us prevent over-diagnosis and overtreatment of high blood pressure in this group of patients. It also helps us focus our attention on patients with high BP who would benefit from medication and lifestyle changes.