HTN in SDC

1
HTN in SDC

• Krista Fajman, M.D.
• February 20, 2008

2
Epidemiology

• Hypertension (HTN) affects over 30 of the US
  population over the age of 18.
• It effects 50 of adults over the age of 65.
• This translates into over 60 million hypertensive
  adults in the US.
• The number of people with hypertension is likely
  to grow as the population ages.
• Currently, over 122 million people in the US are
  overweight or obese and the rise in obesity will
  increase the number of hypertensive individuals.
• 90 of adults have a lifetime risk of HTN.

Pagliei
3
Epidemiology

• The treatment of HTN is the most common reason
  for physician office visits of non-pregnant
  adults in the US for use of prescription drugs.
• Data from NHANES show that only 34 of people
  with HTN have their BP under control, defined as
  below 140/90.
• Uncontrolled HTN is the number one risk factor
  for heart attack and stroke.
• Every 20 mmHg increase in SBP over 115 doubles
  the risk of cardiovascular and cerebrovascular
  disease.
• Approximately 60 of cerebrovascular disease and
  50 of ischemic heart disease is attributable
  directly to HTN.

Pagliei
4
Complications of Uncontrolled HTN

• Premature cardiovascular disease
• Heart failure
• Left ventricular hypertrophy
• Heart failure
• Ventricular arrhythmias
• Death after myocardial infarction
• Sudden cardiac death
• Ischemic stroke
• Intracerebral hemorrhage
• Chronic renal insufficiency/end-stage renal
  disease
• Blindness
• Erectile dysfunction
• Acute, life-threatening emergency
• The higher the blood pressure, the more likely
  the complications from it.

Pagliei
5
Background

• Control of HTN by residents has previously been
  evaluated.
• The Resident Hypertension CQI Review of 2006-2007
  found that 19 of 41 patients (46) with blood
  pressure (BP) readings above goal at follow-up
  visits for HTN did not receive a medication
  intervention to improve their BP control.

N41
Medication changes made at follow up for
patients not at BP goal
no meds changed
46
CV med changed
54
Pagliei
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Initial Data Collection

• Who Jennifer Pagliei, MD, PGY-3 (project
  leader), Nicole Twiddy, RN, Annie Whitney, MS,
  Robb Malone, Pharm. D, CPP
• What Chart review to determine
• 1. If uncontrolled HTN, defined as SBPgt160 and/or
  DBPgt95, was addressed at visit.
• 2. If addressed, did the physician recommend
  titration of existing BP medications or addition
  of a new BP medication if adherence to current BP
  medications was confirmed?
• 3. If BP medications were not titrated or added,
  did the physician cite a reason (e.g. pain) for
  not intervening to improve BP control?
• 4. Did the physician insure appropriate follow-up
  for patients in whom a medication intervention
  was not made?
• When From 10/30/07 through 11/30/07.
• How Review SDC notes in patients with
  uncontrolled HTN.
• How long One month.

Pagliei
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Findings

• There was substantial daily variation in the
  percentage of patients receiving BP medication
  intervention.
• It exceeded 50 on only three of the 22 days
  studied and 90 on only two of the 22 days
  studied.

Pagliei
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Data Analysis Cycle 1

• During the time period from 10/30/07 to 11/30/07,
  there were 87 patients identified in SDC who had
  SBPgt160 and/or DBPgt95.
• Over 22 days this averaged to nearly 4 patients
  per day who met study entry criteria.
• Chart review showed that 31 of the patients
  (36), received a medication intervention to
  improve their BP, while 56 (64) did not.

N87
Pagliei
9
Daily Percentage of Patients Receiving Medication
Intervention
Pagliei
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Findings Cycle 1

• Several reasons were identified for
  non-intervention in the 56 patients (64) who did
  not have a BP medication titrated or added
  despite uncontrolled HTN.
• The reasons included pain, patient
  non-compliance, follow-up with another
  provider, a decrease in BP on recheck,
  recommendation of diet and lifestyle changes, an
  anomalous/isolated elevated BP reading, patient
  refusal to alter medications, cocaine use, lower
  GI bleed, and URI.
• Most commonly, though, the elevated BP was not
  addressed at all by the physician seeing the
  patient (29 of cases).

Pagliei
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Reasons for lack of Medication Intervention
Pagliei
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CQI Model for ImprovementFundamental Questions
for Improvement

• Aim
• Measures
• Changes/Evidence-based strategies

What are we trying to accomplish?
How will we know that changes are an improvement?
What changes can we make that will result in
an improvement?
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Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
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Ryan Sanfords Intervention -Cycle 2

• The problem of missed assessment of uncontrolled
  HTN in the SDC has been clearly identified.
• Implemented a notification system to alert
  providers to BP readings gt 160/95 in Same Day
  Clinic.

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The Intervention

• Placed on all vitals sheets for those gt160/gt95
  and then placed in the door for providers.

Sanford
16
(No Transcript)
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Whats happened since Ryan left?

• Label changes
• Data collection continued to evaluate whether
  label increased medication intervention or
  discussions with the patient (as noted on
  returned vital sign sheets)
• Chart review to determine whether these changes
  were documented in Webcis
• --------------------------------------------------
  ---------
• Some general trends
• Initial high rate of participation that is slowly
  tapering off
• Residents have stopped returning the flagged
  sheets but is this important?
• Residents and attendings are unaware of the
  project

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New Labels

• Medication adjustments restarted previous meds,
  changed dosage or frequency, added new
  medication, changed medications
• Barriers addressed financial, compliance, side
  effects, literacy

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Attention to HTN in Same Day Clinic
100
Meds Adjusted
80
Barriers Addressed
60
with HTN
HTN addressed
40
20
0
2/4-2/8
1/7-1/11
1/28-2/1
12/31-1/4
1/14-1/18
1/22-1/25
2/11-2/15
11/5-11/9
12/3-12/7
2/17-2/22
2/25-2/29
10/30-11/2
11/12-11/16
11/19-11/21
11/26-11/30
12/10-12/14
12/17-12/21
12/26-12/28
Date
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Hypertension Addressed and DocumentedSimilar
trends between Residents and Attendings
14
250
12
200
10
150
8
of patients
6
100
4
50
2
0
0
BP gt 160/95
Webcis documentation
BP gt 160/95
Webcis documentation
Residents
Attendings
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Conclusions

• Easier to see trends over weeks occasionally we
  reach our goal of 90 documentation
• No stability in documentation rates/treatment of
  HTN in SDC
• Similar rates between attendings, residents and
  medical students
• No continuity of providers
• Medications are adjusted more often than barriers
  are addressed
• Are barriers being addressed well enough to
  change patient outcome?

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Our plan for Cycle 3

• We need better stability addressing HTN once a
  month isnt ideal
• Better awareness of the project
• An awareness that there is always a CQI project
  occurring in clinic
• Email to preceptors
• Keep the project visible in SDC
• Bulletin board devoted to the project
• White board
• Nursing staff in SDC
• How do we maintain high levels of participation?
• Yearly or monthly recognition/award to preceptors
  and residents with highest percentage of HTN
  addressed and intervened upon
• Extra freedom pay money?

23
Future Considerations

• Are patients being scheduled for follow up for
  blood pressure control?
• Is blood pressure under better control 6 12
  months following the intervention?
• Should our study inclusion criteria be changed to
  meet the JNC 7 criteria for stage 2 HTN, which is
  classified as SBPgt160 and/or DBPgt100