By David C. Dugdale, M.D.
Department of Medicine
University of Washington School of Medicine

 


Introduction

The University of Washington Medicine health system encompasses 32 outpatient primary care practice sites with a strong tradition of clinical excellence, covering 226,721 enrolled primary care patients. To deliver high value care to populations with elevated blood pressure (BP), we created an ambulatory clinical pathway for the diagnosis and management of hypertension.

Methods
The hypertension pathway creation process began in April 2017. First, the hypertension pathway team surveyed the peer-reviewed literature for relevant clinical guidelines (1-3). It then created a draft guideline and process change framework, including lead and lag metrics for the pathway implementation. Operational leaders, including medical directors, nurses, pharmacists, care managers and administrative leaders reviewed and revised multiple drafts to create the final guideline that was approved in December 2017. Core elements of the pathway are:

1. Establish a BP target. BP <140/90 if age < 60 years or diabetic; <150/90 if age >=60 and not diabetic, in absence of contraindications.
2. Measure BP using a standard and validated technique (3). Recheck the BP if the first measurement is above target.
3. Follow up with patients with elevated BP within 1 month and adjust the treatment plan at each visit. Use the pathway’s pharmacotherapy algorithm to overcome clinical inertia and intensify therapy for patients whose BP is not at target.

Pathway implementation
The pathway team identified 6 sites for phase 1 of our system implementation. Team members gave multiple presentations to clinical leaders about pathway elements and related performance metrics and assisted with spreading this information to site clinicians and staff. Site leaders received semi-monthly reports of pathway metric performance. The pathway team convened monthly webinars with site leaders to solicit information about pathway implementation, share data about the pathway performance metrics, and summarize and disseminate “lessons learned” to all sites. After a 5 month period, 8 sites began phase 2 of the pathway implementation, which followed the structures and processes used during phase 1, with modifications based on experience.

Results
BP recheck rate. At baseline, the phase 1 sites had a 28% BP recheck rate that increased to 71% after 5 months. Subsequently, their rate rose further to 78%. The phase 2 sites had a 32% baseline BP recheck rate that rose to 74% (Figure 1).

Hypertension control rate. At baseline, the phase 1 sites had a 61% hypertension control rate that increased to 72% after 5 months. Subsequently, their control rate rose further to 74%. The phase 2 sites had a 61% hypertension control rate at baseline that also rose to 74%. The phase 1 sites’ control rate rose earlier than the phase 2 sites, likely due to the differing timing of the pathway implementations.

Discussion
In addition to improving our control rate of hypertension, this work created several valuable lessons about care transformation. First, the pathway effort underscored the need for substantial assessment and planning related to primary care clinic work flows and work flow changes. For example, the BP recheck rate depended on specific steps performed by medical assistants, such as how they recorded data in the EMR. These tasks had to be coordinated with those of clinicians in order to avoid unintended consequences (e.g., delays and decreased patient throughput). For sites where performance lagged, meticulous dissection of workflow issues often unearthed deviations from standard processes that led to better results when corrected.

Second, the planning process emphasized the importance of carefully selecting and preparing implementation sites. We deliberately included 2 sites with resident physicians in order to examine how they would perform under the pathway. Given early challenges faced by these 2 sites, we implemented more intensive communication and training that helped improve their performance.

Third, the implementation showed the importance of iterative, detailed performance assessment in determining which processes were “working” and which needed modification.

Fourth, the pathway implementation demonstrated that clinicians and clinic staff engaged more actively when they received individual quantitative feedback. Providing such feedback facilitated efforts to troubleshoot sites with slower progress and supported improvements observed under the pathway.

Conclusion
The design and implementation of an ambulatory hypertension pathway allowed our academic health care system to successfully improve processes related to BP measurement and improve the hypertension control rate from 61% to 74%.

Notes:
Support: This project described was supported by Funding Opportunity Number CMS-331-44-501 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services.

Conflicts of Interest Statement: None declared. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

References
1. Qaseem A, et al. Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2017;166(6):430-437.

2. James P, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520.

3. Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127-e248.

David Dugdale is a practicing general internist at the University of Washington School of Medicine and is the Medical Director for Hypertension Population Health. He is trained in the comprehensive primary care of adults and the diagnosis and managementof complex medical problems. He enjoys partnering with patients to help them make the health care choi ces that are best for them. He can be reached at dugdaled@uw.edu

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