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- J Clin Hypertens (Greenwich)
- v.18(4); 2016 Apr
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J Clin Hypertens (Greenwich). 2016 Apr; 18(4): 260–261.
Published online 2016 Mar 3. doi:10.1111/jch.12803
Marc G. Jaffe, MD1 and Joseph D. Young, MD2
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Hypertension is a leading risk for death and disability.1 Nevertheless, in the late 1990s, fewer than half of Americans diagnosed with hypertension achieved controlled blood pressure (BP). This statistic also held true within Kaiser Permanente Northern California (KPNC). In 1999, KPNC organized a task force that included key physicians, administrators, data analysts, pharmacists, nurses, and other clinicians to improve the control of hypertension. A situational analysis was conducted to investigate the challenges that KPNC patients and clinicians faced in achieving BP control. In 2000, after a year of strategic planning, KPNC initiated our program to improve hypertension control. The critical components of the program2 are described below and summarized in the Table.
Key Elements of the Kaiser Permanente Northern California Hypertension Program
|Hypertension registry||Validated and comprehensive|
|Clinic level performance feedback||Facilitates operational and system‐level change, transparent, and widely visible|
|Treatment algorithm||Based on evidence‐based guidelines, simple and implementable|
|Medical assistant visits for blood pressure measurement||Appropriate use of ancillary staff skills and reduced barriers to patients|
|Single‐pill combination therapy||Increased efficiency and increased adherence|
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In order to help monitor and provide feedback on the impact of our program and assess the successes and remaining challenges in achieving BP control, it was necessary to identify people with hypertension and evaluate their progress in the health system. Therefore, a registry (a master list) was created by identifying hypertensive individuals using outpatient visit diagnosis codes, pharmacy data, and hospitalization records. We validated the accuracy of the registry inclusion criteria through random chart reviews. Over time, the registry has grown from 350,000 to more than 650,000 individuals. In 2001, our hypertension registry included roughly 15% of our adult membership. Today, the registry includes roughly 27% of our adult membership.
Evidence‐Based Hypertension Guidelines
To ensure KPNC patients were receiving up‐to‐date evidence‐based treatment, we created and maintained a health system–wide evidence‐based practice guideline. The hypertension guideline is updated every 2 years. To ensure rigor and relevance to primary and specialty care, the guideline development team included primary care and specialty physicians (such as cardiologists, nephrologists, and endocrinologists) as well as pharmacists and evidence‐based methodologists.
A critical characteristic of the hypertension guidelines has been a simplified drug treatment algorithm (protocol). Instead of listing several potential drug classes or several specific medications as potential options for each step in the protocol, a single specific drug with a recommended dose is advised in nearly all situations. This facilitates the use of fewer drugs, which can lead to improved familiarity, decreased practice variation, and simplification of teaching materials, resulting in increased efficiencies and potentially fewer medical errors. Clinicians are encouraged to follow the algorithm unless a specific clinical situation indicates the need for individual variation.
The hypertension guideline was aligned with other organizational guidelines to ensure consistent educational messages. For example, recommendations for BP management in the hypertension guideline were identical in our KPNC diabetes, coronary artery disease, and other guidelines. The guidelines were distributed in many forms, such as printed guideline documents, e‐mail updates, pocket cards, posting to an internet library of online resources, televised videoconferences, and in‐person lectures.
Quality Performance Metrics
The registry and guideline were used to develop quality reports containing BP control data. Initially, a “manual” registry was used prior to KPNC's adoption of an electronic health record (EHR) beginning in 2005 and completed in 2008. Once completed, the EHR enabled more detailed and timely reporting based on a more complete and integrated registry.
In 2000, all KPNC clinic visits were associated with a paper coding form. Physicians were required to mark “bubbles” for diagnostic and procedure‐related codes. These forms were collected locally and sent to a central scanning site where the visit documentation was analyzed. The form was modified to include two new rows, one with six systolic BP ranges and another with six diastolic BP ranges. These data were collected and analyzed centrally. Within 1 year, BP control measurements were available for the majority of people diagnosed with hypertension. This process was used from 2001 to 2008, by which time the EHR was fully implemented including recorded BPs.
A central physician‐led management team reviewed the quality performance of the medical centers and identified medical centers with superior performance. We contacted the teams at those sites in order to identify best practices, and, in turn, to disseminate these learnings to other medical centers via training sessions, prepared lectures for redistribution and e‐mail communications. Medical center directors (with strict processes to assure confidentiality and data integrity) used the medical center performance data to generate work plans for clinic‐level quality improvement processes, and used individual physician‐level performance metrics to provide clinician‐specific performance improvement activities.
Medical Assistant BP Visits
In 2007, we created medical assistant BP visits as an alternative to the traditional office visit with a physician. These visits were with a medical assistant, usually located in the primary care physician's medical station. Visits were usually scheduled 2 to 4 weeks following a BP medication adjustment. No copayment was charged for these visits. Typically, a medical assistant measured BP and informed the primary care physician, who then directed treatment intensification and follow‐up care as needed. To ensure the accuracy of the BP measurement, medical assistants were trained using standardized materials and underwent periodic assessments of BP measurement technique competency.
Single‐Pill Combination Medications
In 2005, we incorporated a single‐pill combination medication (lisinopril‐hydrochlorothiazide) into our evidence‐based guidelines. This therapy was promoted by developing both patient and physician education materials including e‐mail communications, printed materials, pocket card clinician tools, and system‐wide peer group meetings. From 2001 to 2009, the number of lisinopril‐hydrochlorothiazide prescriptions increased from <20 to more than 23,000 prescriptions per month. During this period, the percentage of angiotensin‐converting enzyme inhibitor prescriptions dispensed as lisinopril‐hydrochlorothiazide increased from <1% to 27%.
In 2015, 14 years after the KPNC hypertension program was launched, the changes in hypertension care are easy to see. From 2001 to 2013, hypertension control in KPNC has increased from 44% to 90%. During approximately the same period of time, the rate of heart attacks has fallen 24%3 and death from stroke has fallen 42%.4 In addition, in our own personal practices, we see the difference in hypertension control every day. Now when we see patients in our offices, the majority have controlled BP. In the late 1990s, when uncontrolled BP was the norm, BP control rates of 90% seemed unimaginable. This was, and continues to be, a team effort—with thousands of physicians, pharmacists, nurses, mangers, data analysts, and others who work tirelessly to help our patients maintain healthy BP levels. How far we've come in the past 14 years!
Acknowledgments and Disclosure
We thank Alan S. Go, MD, Steve Sidney, MD (KPNC Division of Research, Oakland, California), and Grace A. Lee, MD (Virginia Mason Medical Center, Seattle, Washington) for help with the initial study design and evaluation; Laura J. Ransom, MS, Joyce Arango, MPH, DPH, and Genevieve Foti (KPNC Department of Quality and Operation Support, Oakland, California) for regional project management and implementation support for the cardiovascular programs; and Norman R.C. Campbell, MD (University of Calgary, Alberta), MD, and Mark Niebylski, PhD, MBA, MS (World Hypertension League) for editorial assistance and ongoing contributions towards our shared mission on the prevention and control of hypertension. The authors are employees of Kaiser Permanente but have no other conflicts to report.
1. Campbell NR, Lackland DT, Niebylski ML, for the World Hypertension Leagueand the International Society of Hypertension Executive Committee. High blood pressure: why prevention and control are urgent and important: a 2014 fact sheet from the World Hypertension League and the International Society of Hypertension. J Clin Hypertens (Greenwich). 2014;16:551–553 [PMC free article] [PubMed] [Google Scholar]
2. Jaffe MG, Lee GA, Young JD, et al. Improved blood pressure control associated with a large‐scale hypertension program. JAMA. 2013;310:699–705. [PMC free article] [PubMed] [Google Scholar]
3. Yeh RW, Sidney S, Chandra M, et al. Population trends in the incidence and outcomes of acute myocardial infarction. N Engl J Med. 2010;362:2155–2165. [PubMed] [Google Scholar]
4. Sidney S, Jaffe M, Nguyen‐Hyunha M, et al. Closing the gap between cardiovascular and cancer mortality in an integrated health care delivery system, 2000–2008: the Kaiser Permanente Experience. Circulation. 2011;124:A13610.
Articles from The Journal of Clinical Hypertension are provided here courtesy of Wiley-Blackwell
What is Kaiser HTN guidelines? ›
For adults aged 60 and older without diabetes or CKD, treat to a goal systolic blood pressure (SBP) <150 mmHg and goal diastolic blood pressure (DBP) <90 mmHg. For all adults aged under 60, treat to a goal SBP <140 mmHg and goal DBP <90 mmHg. Screen all adults aged 18 and older for hypertension.What is control program for hypertension? ›
The Hypertension Management Program (HMP) aims to improve the quality and management of patient care, and decrease the number of patients with uncontrolled hypertension.What are the new guidelines for hypertension? ›
The AAFP strongly recommends a standard blood pressure target of less than 140/90 mm Hg to reduce the risks of all-cause and cardiovascular mortality. The AAFP also recommends that clinicians consider a blood pressure target of less than 135/85 mm Hg to reduce the risk of myocardial infarction.What is the golden standard for hypertension? ›
The diagnostic threshold for hypertension remains 140/90 mmHg on clinic blood pressure (BP).
Most U.S. adults with hypertension report being advised to reduce their dietary sodium intake (82%), increase their physical activity (79%), and lose weight (66%), whereas only 31% were advised to reduce their alcohol consumption.
- Limiting salt and alcohol.
- Limiting use of NSAIDs for pain relief (acetaminophen can be used instead).
- Doing at least 30 minutes a day of aerobic activity several days a week.
- Treating sleep apnea with continuous positive airway pressure.
- Lose extra pounds and watch your waistline. Blood pressure often increases as weight increases. ...
- Exercise regularly. ...
- Eat a healthy diet. ...
- Reduce salt (sodium) in your diet. ...
- Limit alcohol. ...
- Get a good night's sleep. ...
- Reduce stress. ...
- Monitor your blood pressure at home and get regular checkups.
Blood pressure categories in the new guidelines are: Normal: 120/80 mm Hg or lower. Elevated: This used to be called “prehypertension.” The top number (systolic) is between 120 and 129 and the bottom number (diastolic) is 80 or lower.What is the first drug of choice for hypertension? ›
The first choice is usually a thiazide diuretic.What are the new vs old blood pressure guidelines? ›
Under the updated AHA/ACC guidelines, if you have systolic blood pressure rates of 130 and higher you are considered to have high blood pressure. The old guidelines set high blood pressure rates at 140 or higher.
What is the disability rating for hypertension? ›
The VA uses the following criteria to rate hypertension: 60% rating is given if your diastolic pressure is 130 or higher. 40% rating is given if your diastolic pressure measures between 120 and 129. 20% rating is given if your diastolic pressure is 110-119, or your systolic pressure is 200 or higher.What is hypertension to senior citizen? ›
High blood pressure, or hypertension, is a major health problem that is common in older adults. Your body's network of blood vessels, known as the vascular system, changes with age. Arteries get stiffer, causing blood pressure to go up. This can be true even for people who have heart-healthy habits and feel just fine.What is the CDC recommendation for hypertension? ›
Talk with your health care team about eating a variety of foods rich in potassium, fiber, and protein and lower in salt (sodium) and saturated fat. For many people, making these healthy changes can help keep blood pressure low and protect against heart disease and stroke.What are 2 signs of hypertension? ›
- severe headaches.
- chest pain.
- difficulty breathing.
- blurred vision or other vision changes.
Hypertensive patients should perform at least 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity aerobic exercise, and muscle-strengthening activities at least 2 days per week, in the absence of specific contraindications.What are the top 3 ways to reduce blood pressure? ›
- Regular physical activity. ...
- Keep to a healthy weight. ...
- Eat a healthy balanced diet. ...
- Cut down on salt. ...
- Don't drink too much. ...
- Take your medicines as prescribed.
Still, you can make lifestyle changes to bring your blood pressure down. Something as simple as keeping yourself hydrated by drinking six to eight glasses of water every day improves blood pressure. Water makes up 73% of the human heart,¹ so no other liquid is better at controlling blood pressure.Does coffee raise blood pressure? ›
Some research suggests coffee can lower the risk for high blood pressure, also called hypertension, in people who don't already have it. But drinking too much coffee has been shown to raise blood pressure and lead to anxiety, heart palpitations and trouble sleeping.What is stroke level blood pressure? ›
Call 911 or emergency medical services if your blood pressure is 180/120 mm Hg or greater and you have chest pain, shortness of breath, or symptoms of stroke. Stroke symptoms include numbness or tingling, trouble speaking, or changes in vision.What is the best natural remedy for hypertension? ›
- Regular Physical Activity Helps Improve Health. It's no secret that regular physical activity helps to keep you in good health. ...
- Eat Less Salt. ...
- Add More Potassium to Your Diet to Reduce High Blood Pressure. ...
- Limit Your Alcohol Consumption. ...
- Reduce Your Stress to Lower Your Blood Pressure.
What foods prevent hypertension? ›
The more salt you eat, the higher your blood pressure. Aim to eat less than 6g (0.2oz) of salt a day, which is about a teaspoonful. Eating a low-fat diet that includes lots of fibre, such as wholegrain rice, bread and pasta, and plenty of fruit and vegetables also helps lower blood pressure.Do bananas lower blood pressure? ›
Bananas. These are rich in potassium, a nutrient shown to help lower blood pressure, says Laffin. One medium banana provides about 375 milligrams of potassium, about 11 percent of the recommended daily intake for a man, and 16 percent for a woman.What is HTN guidelines over 65? ›
The 2017 American College of Cardiology/American Heart Association guidelines indicate that a BP <130/80 mm Hg should be targeted after the age of 65 years. The 2018 guidelines propose a BP goal of <140/90 mm Hg for individuals older than 65 years.What is first line in HTN guidelines? ›
There are three main classes of medication that are usually in the first line of treatment for hypertension: 1. Calcium Channel Blockers (CCB) 2. Angiotensin Converting Enzyme inhibitors (ACE inhibitors or ACE-I) and Angiotensin Receptor Blockers (ARBs) 3. Diuretics.What are the latest JNC guidelines for hypertension? ›
According to JNC 7, the general BP goal is to lower systolic BP to less than 140 mm Hg and diastolic BP to less than 90 mm Hg. This recommendation is supported by many clinical trials. A more aggressive goal of less than 130/80 mm Hg is advised for patients with diabetes or chronic kidney disease.Is 140 90 normal BP for seniors? ›
A higher target BP for adults aged 60 or older.
The recommended goal BP is now less than 150/90, instead of less than 140/90 (which was the target recommended in prior guidelines, published in 2003).
Normal blood pressure for most adults is defined as a systolic pressure of less than 120 and a diastolic pressure of less than 80.What is the first choice drug for hypertension? ›
The first choice is usually a thiazide diuretic.What is the best hypertension medication? ›
- the ACE inhibitor lisinopril (Prinivil, Zestril) tops the list,
- followed by amlodipine besylate (Norvasc),
- a calcium channel blocker, and.
- generic hydrochlorothiazide (HCTZ).
Low-dose thiazide diuretics remain first-line therapy for older patients. Beta blockers, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and calcium channel blockers are second-line medications that should be selected based on comorbidities and risk factors.
What are the best practices for hypertension management? ›
Lifestyle changes are recommended for all patients: weight loss, exercise, decreased sodium intake, Dietary Approaches to Stop Hypertension (DASH) diet, and moderation of alcohol consumption.What is the threshold for hypertension treatment? ›
However, in practice, blood pressure readings often drive treatment decisions. Medication is usually started when someone's blood pressure is above a standard threshold (of 140/90 mm Hg).What are the guidelines for Stage 2 hypertension? ›
The recommended action for a patient with stage 2 hypertension—BP readings at or above 140/90 mm Hg—is both nonpharmacological therapy and BP-lowering medication. Patients' blood pressure should be reassessed after one month. If the blood pressure goal has been met, reassess in three to six months.