Large-scale hypertension program nearly doubled rates of control

A multifaceted hypertension control program applied across a large health care system improved hypertension control compared to state and national averages, a study found.

Researchers included insured patients with hypertension who were enrolled in Kaiser Permanente in Northern California from 2001 to 2009. The hypertension program's key elements included a system-wide registry, development and sharing of performance metrics within the system, development of evidence-based guidelines with algorithms for clinician use, medical assistant visits to measure blood pressure, and prescribing single-pill combination drugs.

The program's patients were compared to insured California patients assessed in the Healthcare Effectiveness Data and Information Set (HEDIS) as part of the National Committee for Quality Assurance (NCQA) quality measure reporting process from 2006 to 2009, and the national mean NCQA HEDIS hypertension control rates from 2001 to 2009.

Results appeared in the Aug. 21 JAMA.

There were 349,937 patients enrolled in Kaiser's hypertension program when it began in 2001, and this figure increased to 652,763 by 2009. Patients who participated in the program had a significant increase in hypertension control compared with state and national rates. The NCQA HEDIS measurement for hypertension control within the Kaiser system increased from 43.6% (95% CI, 39.4% to 48.6%) to 80.4% (95% CI, 75.6% to 84.4%) during the study period (P<0.001 for trend), compared to the national mean increase from 55.4% to 64.1% (P=0.24 for trend) and the California mean increase from 63.4% to 69.4% from 2006 to 2009 (P=0.37 for trend). Hypertension control within the Kaiser system continued to improve after the study ended, from 83.7% in 2010 to 87.1% in 2011.

Use of a single-pill combination drug, lisinopril-hydrochlorothiazide, increased within the Kaiser system from 13 prescriptions per month in 2001 to 23,144 prescriptions per month in 2009, as did single-pill combinations of angiotensin-converting enzyme inhibitor prescriptions, from less than 1% to 27.2%

According to study authors, the following factors aided the program's success:

• The registry helped identify patients for treatment intensification;
• Quarterly and monthly reports identified high-performing medical centers in which successful practices or innovations were found and then disseminated to other centers;
• Evidence-based practice guidelines incorporated new evidence and new treatment options;
• Medical assistant follow-up visits allowed patients greater access by eliminating co-payments, creating more scheduling flexibility, and reducing visit times; and
• Single-pill drugs were included in 2005 and rapidly adopted across the Kaiser system.

An editorial noted that new value-based models of care should encourage more cost-effective, system-wide interventions like this one and that future guidelines might want to address such approaches.