Presented by:Presented by:

National Forum for Heart Disease and Stroke Prevention

Improving Hypertension ControlThe Kaiser Permanente Hypertension Control Project: How a large health care organization improved blood pressure control from 44% to 80% in 8 years

Marc Jaffe, MDClinical Leader,

Kaiser Permanente Northern California Cardiovascular Risk Reduction Program

Associate Clinical Professor of Medicine, UCSFOctober 17, 2012

2Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/11/2023

Kaiser Permanente Northern California (KPNC)

3.3 million members2.7 million adults>5,000 MDs17 medical centers35 outpatient

facilities

3Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/11/2023

KPNC Hypertension Implementation Timeline

1995 1997 1999 2001 2003 2005 2007 2009

1995GuidelineCreated, updatedevery 2 yrs

2002Performance Measures Distributed

Successful practices disseminated

2005 Single Pill Combination Promoted

2007 Non-MDBP Visits

2000HTNRegistry developed

4Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/11/2023

Evolution of the Hypertension Guideline

Year 2001* 2003 2005 2007 2009

Step 1

TD or BB TD TD or TD + ACEI

TD or TD + ACEI

TD or TD + ACEI

Step 2

TD + BB TD + ACEIor TD + BB

TD + ACEI TD + ACEI TD + ACEI

Step 3

TD + BB +ACEI

TD + BB +ACEI

TD + ACEI +BB

TD + ACEI +BB

TD + ACEI+ DCCB

Step 4

TD + BB +ACEI +DCCB

TD + BB +ACEI +DCCB

TD + BB +ACEI +DCCB

TD + BB +ACEI +DCCB

TD + ACEI +DCCB +BB or Spir

TD=Thiazide Diuretic, BB=Beta Blocker, ACEI=Angiotensin Converting Enzyme Inhibitor, DCCB=Dihydropyridine Calcium Channel Blocker, Spir=Spironolactone *1995-2001 No Significant changes after step 2

5Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/11/2023

Evolution of the Hypertension Guideline

Year 2001* 2003 2005 2007 2009

Step 1

TD or BB TD TD or TD + ACEI

TD or TD + ACEI

TD or TD + ACEI

Step 2

TD + BB TD + ACEIor TD + BB

TD + ACEI TD + ACEI TD + ACEI

Step 3

TD + BB +ACEI

TD + BB +ACEI

TD + ACEI +BB

TD + ACEI +BB

TD + ACEI+ DCCB

Step 4

TD + BB +ACEI +DCCB

TD + BB +ACEI +DCCB

TD + BB +ACEI +DCCB

TD + BB +ACEI +DCCB

TD + ACEI +DCCB +BB or Spir

TD=Thiazide Diuretic, BB=Beta Blocker, ACEI=Angiotensin Converting Enzyme Inhibitor, DCCB=Dihydropyridine Calcium Channel Blocker, Spir=Spironolactone. *1995-2001 No Significant changes after step 2

BB not 1st

ACEI or BB 2nd

SPC OK 1st

ACEI 2nd

BB 3rd DCCB 3nd

BB OK 4th BB OK 1st BB OK 2nd BB 3rd BB still 3rd

BB OK 4th

6Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/11/2023

Hypertension Registry Development

Outpatient Coding

HTN Registry:Lab ResultsMedicationsDemographicsComorbid ConditionsBP MeasurementsVisit Information

Hospital

Pharmacy

Membership Data

Clinical Laboratory

Outpatient EMR

7Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/11/2023

Hypertension Registry Definition

Hypertension (HTN) Registry Population: 2 visits for HTN in the past 2 yrs No age limits Designed to be very inclusive

8Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/11/2023

Hypertension Control Definition

Hypertension Control Rate Age 18-85 yrs with an encounter diagnosis of

Hypertension (46-85 before 2006) in the 1st 6 months of the reporting year

Blood Pressure at last clinic visit <140/90 (≤140/90 before 2006)

Exclusions: End Stage Renal Disease, Renal Transplant, pregnancy, or blood pressure measurements during hospitalization, Emergency Department visit, diagnostic test, or surgical procedure.

9Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/11/2023

Medical Center Hypertension Control 2001

Performance Reports Distributed to Medical Directors

Quarterly Report 2001-2007, Monthly after 2007

High Performing sites identified and practices shared

HTN Control Rate 2001

0%

10%

20%

30%

40%

50%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Medical Center

HT

N C

on

tro

l

10Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/11/2023

Evolution of Single Pill Combination Therapy in KPNC

1995 1997 1999 2001 2003 2005 2007 2009

Not generally advised Advised

Optional

11Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/11/2023

1/4 of ACEI Rx’s dispensedas Single Pill Combination Therapy

0%

20%

40%

60%

80%

100%

2001 2002 2003 2004 2005 2006 2007 2008 2009

% O

f A

ll A

CE

I R

xs

ACEI OnlyTabletACEI +HCTZ Tablet

12Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/11/2023

Non-MD Blood Pressure Check

BP at goal

Doctor clinic visit

BP over goal

Follow upnon-MD visit

Treatmentintensification

BP check

Advantages Shorter visit for patient No charge for visit Scheduling flexibility Improves access to MD

13Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/11/2023

Hypertension Control Rates 2001-2009

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

% C

on

tro

lled

Commercial Rate asreported to HEDIS

44%

80%

14Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/11/2023

Hypertension Control Rates 2001-2010in Kaiser Permanent Northern California

17

2

22

2

25

2

30

2

42

8

43

5

47

7

51

2

53

1

22

2

20

2

23

3

22

8

13

5

15

8

14

8

12

5

13

0

0

200

400

600

800

2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

HT

N P

atie

nts

(100

0s)

Uncontrolled BP

Controlled BP

Commercial Rate asreported to HEDIS

15Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/11/2023

Hypertension Results 2001-2009

From 2001 to 2009 in KPNC HTN control rate nearly doubled from 44% to 80% HTN registry increased by 167% Controlled HTN tripled from 171,000 to 531,000 359,00 more people had controlled HTN

6 care processes implemented Evidence Based Guideline development HTN Registry creation Performance measure distribution Successful practice dissemination Single Pill Combination therapy promotion Non-physician BP visit creation

16Marc Jaffe, MD • The Permanente Medical Group, Inc. • Oakland, CA • 04/11/2023

Heart Attack Rates are declining in KPNC

16