Everybody has a hand in blood pressure: applying the evidence-base within a resident clinic

From the 2019 HVPAA National Conference

Dr. Mariah Robertson (Johns Hopkins School of Medicine), Dr. Paul O’Rourke (Johns Hopkins School of Medicine), Dr. Stasia Reynolds (Johns Hopkins School of Medicine), Dr. Heather Agee (Johns Hopkins School of Medicine), Dr. Scott Wright (Johns Hopkins School of Medicine)

Background

Currently based upon NHANES data 46% of all adults 18 and older (108 million adults) have hypertension. This is an epidemic of epic proportions and raises the risks of major adverse cardiac events (MACE) among other things. As a result, many large scale randomized control trials (SPRINT, etc) have identified the importance of a standardized, aggressive approach to blood pressure management as a means of reducing MACE. Within the Johns Hopkins Bayview Internal Medicine resident clinic (RBMG) our residents currently serve 7195 patients of which 3036 carried a diagnosis code of hypertension at the start of the study. Only 54% of these patients had blood pressures that were at goal. This is at odds with the Johns Hopkins institutional goal for its primary care clinics of 68.8% control.

Objectives

  1. To implement an evidence-based, comprehensive blood pressure initiative within the RBMG resident clinic as a means of improving overall control of blood pressure among resident patients, aiming for the institutional goal of 68.8% control across the clinic.
  2. To better capture the number of patients with the diagnosis code of hypertension to ensure we are reaching and targeting blood pressure control in everyone who is affected in our clinic

Methods

Beginning in the summer of 2018 we developed and implemented a clinic-wide initiative to attain improved blood pressure control. This initiative included:

  • Standardized blood pressure measurement (automated blood pressure cuff with rechecks, training of clinical staff in proper measurement, point-of-care prompts)
  • Algorithm for management if elevated:
    • Nutrition education and lifestyle modification (e.g. DASH diet)
    • Evidence-based medication titration plan
    • Standardized, close follow-up for uncontrolled pressure with physician, NP or pharmacist
  • Increased awareness through advertising campaign and regular practice changing pearls and clinical updates

Results

In Figure 1 (attached) you see the trajectory of blood pressure control over the first 9 months of the hypertension initiative within this residency clinic. In December 2017-March 2018 only 54.8% of patients had controlled blood pressure within the clinic, whereas as recently as December 2018, the control is nearing 63%. This marks a nearly 9% increase in control in less than a year. This compares to only 4.4% increase in blood pressure control for Hopkins primary care clinics as a whole over the past 12 months. Additionally, and perhaps even more importantly, from March 2018 to December 2018 we nearly doubled the number of patients who carried the diagnosis code of hypertension, suggesting that while our percent control is going up, we are also reaching more patients through provider identification and appropriate ICD coding.

Conclusions

A standardized, comprehensive approach to blood pressure control within a resident primary care clinic can show great success in both improving the rates of blood pressure control and also the appropriate identification of patients with hypertension.

Clinical implications

Despite the new evidence of even more aggressive control of blood pressure using standardized, algorithmic approaches, very few studies have been conducted to assess ability improve hypertension with traditionally more underserved and resource poor patients such as those served in internal medicine resident clinic. Our initiative has shown that by taking and implementing simple and comprehensive approaches to hypertension management and involving the whole clinic staff we can both improve rates of blood pressure control and total number of patients reached.

Figures

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