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Page 1: Henry Ford Hospital

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2008-2009 Best Practices 2008-2009 Best Practices in Managing Hypertension in Managing Hypertension

Sponsored by AMGA and Daiichi Sankyo.Sponsored by AMGA and Daiichi Sankyo.

Wrap-Up MeetingWrap-Up Meeting November 18-20, 2009 November 18-20, 2009

San Diego, CASan Diego, CA

Henry Ford Health System

Division of Nephrology and Hypertension

An Effective Approach to Lowering Blood Pressure in Chronic Kidney Disease

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Overview

Large urban sub-specialty clinic within the Division of Nephrology and Hypertension

located at a 903-urban academic medical center NP managed CKD clinic

• Upon referral to the clinic many of the patients are considered “resistant”

• 85.4% of patients noted with CKD stages 3 and 4

• Patient characteristics• Older ( mean age = 71)• Predominately AA• Highly complex ( significant co-

morbidities)

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Overview

• Real time data submitted into a dedicated queryable CKD database (Web-enabled, FM Pro 8 software)

-matrixed to accommodate multiple CKD variables

-facilitates report generation- ongoing maintenance provided by

systems analyst• Patient data directly submitted into

corporate electronic health record system (Careplus)

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Team CompositionTeam Composition

Naima Ogletree, MSN-APN-BC (chair) Schawana Thaxton, MSN, NP-C (co-chair) Jerry Yee, MD (lead physician) Collaborative Relationships

• Pharmacy• Dietitian• Lead CSR• Nursing staff (RN, MA)• IT personnel (software engineer)

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HTN Algorithm

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Project Overview

Total engagement of nursing staffImproved design and

implementation of the BP follow up clinic

Develop and distribute BP report card

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Project Overview

Applied various modes of delivery of health education information– Shared medical group visits

• Curriculum development (Hypertension and the CKD patient)

• PharmD lecture on medication management– Provision of HTN-specific educational

materials– Increased community awareness via

outreach• BP screening• Educate the community on HTN and its

associated risk in the development of CKD

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Project GoalsProject Goals

Aim 1: determine whether an algorithmic approach to treating HTN could achieve a 60% and 40% attainment rate at a SBP cut point of <140 and <130, respectively

Target achievement rates increased to 65% and 45% for SBP thresholds of<140 and <130 mmHg, respectively

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Project Goals

Aim 2: determine whether success of anti-hypertensive treatment achieved ANPs using an algorithmic anti-hypertensive treatment strategy equaled that of nephrologists who treated HTN in non-protocolized fashion

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NP vs MD Data

Data

Period

05/09 – 07/09

No. Patients

(N)

Mean SBP

(mmHg)

Patients who

Achieved SBP <130

(N)

Patients who

Achieved BP target

(%)

NP 229 134 98 43%

MD 49 132 22 45%

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NP vs MD Data

No.

Patients

(N)

Mean SBP

(mmHg)

No. Patients w/ SBP <130

(N)

Patients who

Achieved Target

(%)

NP N = 229 134 N = 98 43%

MD N = 49 132 N = 22 45%

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Modifications/EnhancementsModifications/Enhancements

Aggressive BP therapeutic approach High utilization of CCB and anti-RAAS agents

Employed non-pharmacologic strategies in managing HTN

Routine referral to the RD Encouragement of physical activity

Referral to system weight loss programs Distribution of ‘staying active’ educational handouts

Ongoing education Increased percentage of patients who

achieved BP targets Deferred development of educational

resource nook

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Goal Attainment

Time IntervalTotal no. of

patientsMean SBP

(mmHg)

Patients who met target SBP < 130

(%)

12/01/08 – 01/31/09 206 135 44%

02/01/09 – 03/31/09 192 134 47%

04/01/09 – 05/31/09 314 131 50%

06/01/09 – 07/31/09 196 131 52%

08/01/09 – 09/30/09 229 134 43%

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Discussion

Outcomes• Consistently met the specified BP target of

SBP <130 over three quarters• Last period assumed care of patients followed

by the graduating fellows

• Departmental QA data consistently exceeded specified BP targets throughout collaborative

• Underscores the importance of the accessibility and availability of a BP follow up clinic

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Percent of patients reaching SBP Target: SBP < 130

YearQ1

(Jan thru Mar)

(N)

Q2(Apr thru Jun)

(N)

Q3(Jul thru Sept)

(N)

Q4(Oct thru Dec)

(N)

200745%

170

56%

157

48%

263

55%

250

200842%

286

46%

364

42%

330

44%

355

200947%

323

48%

343

50%

375

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Measuring SuccessMeasuring Success

Performed a literature review and compared published data to our patient population

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Literature Review

SBP <130

mmHg

BP

<130/80

(%)

Mean SBP

(mmHg)

J Hypertens 24:395-402

N = 2501 24% 17% 141 ± 20

AJKD 46:18-25

N =186 21% 136 ± 18

Kidney Int 69:538-545;

N = 1058 21% 12%

Hypertens 45:1119-1124

N = 3213 37%

Am J Med 121: 332-340;

N = 10,813 13.2%

NDT 1-6

N = 113 137 ± 15

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Results

HFHSPatients who

Achieved

BP <130/80

(%)

Mean SBP

(mmHg)

Patients who Achieved

SBP <130

(%)

12/01/08 – 01/31/09 39% 135 44%

02/01/09 – 03/31/09 134 47%

04/01/09 – 05/31/09 131 50%

06/01/09 – 07/31/09 131 52%

08/01/09 – 09/30/09 134 43%

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Mean SBP Data

YearQ1

(Jan – Mar)

Q2

(Apr – Jun)

Q3

(Jul – Sept)

Q4

(Oct – Dec)

2007133mmHg

N = 170

130mmHg

N = 157

132mmHg

N = 263

131mmHg

N = 250

2008136mmHg

N = 286

133mmHg

N = 364

134mmHg

N = 330

134mmHg

N = 355

2009133mmHg

N = 323

132mmHg

N = 343

130mmHg

N = 375

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Challenges?Challenges?

Underinsured/Uninsured Solutions:

Refer to MSW for temporary medication relief Referral to community assistance programs Prescribe generic medications

Shared group visits Generates low revenue Poor participation

– Invited 60 patients – 36% or 22 said yes– 31% or 7 attended

Solutions: Improve marketing of class throughout clinic Integrate method into standard clinic

schedule

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Celebrating AccomplishmentsCelebrating Accomplishments

Embrace team philosophy Appoint head nurse as liaison Provide feedback of progress during staff

meetings

Recipient, NKFM Champion of Hope award that acknowledges innovative programs aimed at improving the management of CKD

Display AGMA award in clinic area Acknowledgement in organization newsletter

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Future StepsFuture Steps

Continue aggressive BP strategy Expand outreach opportunities

Continued community screening and health counseling

Partner with HMO Ongoing collaboration with IM / FP Improve awareness among highest

risk patients

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Lessons LearnedLessons Learned

Development and adherence to BP protocol Use holistic approach

Consider co-morbidities Routine CQI

Give providers feedback Improve access for adequate follow-up Engage the patient

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Questions for the Group Questions for the Group

Have any members had experience using direct renin inhibitors (aliskerin) in their management of HTN?