ASH Chapter, Clinical HTN Specialists the HTN Initiative

1. ASH Chapter, Clinical HTN Specialists & the HTN Initiative The ASH Model for Hypertension Control and role of ASH Regional Chapters ASH Regional Chapters ASH Clinical HTN Specialists The O’QUIN HTN Initiative BCBS / O’QUIN HTN Initiative QI-P4P Collaborative

2. Controlling BP in 50% of All Hypertensives: Healthy People 2010 Year Aware Treated Rx/C Control 2000 63% 47% 50% 25% 2002 63% 50% 64% 30% 2004 67% 54% 64% 33% 2010 80% 72% 70% 50% All data are age-adjusted. 1Egan, Basile: J Invest Med, 2003. 2Ong, et al: Hypertension, 2007.

3. The ASH Model for Improving Hypertension Control Continuing national leadership role in professional education & research and by developing an educational / interactive website for the lay public Expanding educational influence thru regional ASH Chapters committed to optimizing awareness, Rx, and control of Htn and concomitant CV risk factors. Impacting HTN control locally thru a network of ASH Specialists and others focused on patient / community activation and practice optimization Implementing CQI using a data-driven process.

4. ASH Chapters: 8 Ch; 22 States & DC

5. Rationale for ASH Regional Chapters Patient, provider, community, and systems characteristics vary by region Local and regional solutions require coordinated & active input from local and regional stakeholders Chapters serve as a focal point for stakeholders to identify best public health and practice models & methods for prevention and awareness, Rx & control of hypertension & other CV risk factors Egan, Lackland, Basile: Am J Hypertens 2002;15:372-379.

6. Rationale for ASH Chapters Greater CV risk: More elderly, more minorities, more obesity Feds unlikely to solve problem We can make a difference by: –educating the public, payors and policy makers –promoting implementation of best practices –developing a database to guide CME and CQI Egan, Lackland, Basile: Am J Hypertens 2002;15:372-379.

7. ASH Chapter, Hypertension Specialists and HTN Initiative Commit to excellence in CV risk control Become an active member of ASH, a Regional Chapter (Carolinas-Georgia), and the Initiative ASH: ? www.ash-us.org for information on ASH, ASH Chapters, and ASH Hypertension Specialists Chapter: Contact Dr. Lackland’s office (lackland@musc.edu) for information on the Carolinas-Georgia Chapter. Initiative, TEMR, and VRS project: Contact: Kim Edwards (edwardk@musc.edu); phone 843-792-1715

8. Role of ASH Clinical Hypertension Specialists There are too many uncontrolled Htn Pts to be managed by Specialists, so their expertise must be leveraged through– Education of patients and colleagues Patient Care; referrals of challenging Htn Pts Health Services Research & clinical trials–CMS 7th scope of work; IOM report.

10. American Society of HypertensionClinical Hypertension Specialists South Carolina Top 10% for HTN Specialists / capita Better geographic dispersion of Specialists Majority of Specialists Primary Care Reasons Promote Specialists at all CME program BCBS $5,000 incentive BCBS pays Specialists for consultant service

11. ASH Chapter, Clinical HTN Specialists & the HTN Initiative The ASH Model for Hypertension Control and role of ASH Regional Chapters ASH Regional Chapters ASH Clinical HTN Specialists The O’QUIN HTN Initiative BCBS / O’QUIN HTN Initiative QI-P4P Collaborative

13. DASH for Good Health Southern StyleCookbook Faith-Based Study Guide& Website http://worst2first.musc.edu/dash/files/cookbook2008.pdf

14. Biblical Warning About Eating Royal (Rich) Food Proverbs 23:1-3. Avoid rich (royal) food and gluttony. When you sit to dine with a ruler (royal food), note well what is before you, and put a knife to your throat if you are given to gluttony. Do not crave his delicacies, for that (royal) food is deceptive. Daniel 1:12,15. Please test your servants for 10 days. Give us nothing but vegetables to eat and water to drink. At the end of 10 days they looked healthier and better nourished than the young men who ate the royal food.

15. The Wisdom of Solomon andThe Cost of Deceptive Royal Food HUNGER: Insatiable appetite (Eccl 6:7, Phil 3:18,19) UP WITH: Obesity, Fatigue, Sleep Apnea 3 FREE HIGHS: Blood Pressure, Sugar, Cholesterol ATTACKS & FAILURE of brain, heart, Kidney CANCERS of the Breast, Colon, Esophagus, Kidney, Prostate, Uterus WORN OUT PARTS: Loss of ‘Nature,’ Old Timer’s disease, Arthur(itis)

16. United States: The Revis family of North Carolina Food Cost for 1 Wk $342

17. Italy: The Manzo family of Sicily. Food Costs for 1 Week:  214 Euros $300 

18. Ecuador: The Ayme family of Tingo. Food expenditure for one week: $32

19. Chad: The Aboubakar Family of Breidjing Camp.  Food Costs for 1 Week:  685 CFA Francs or $1.23

21. Hypertension Initiative: Participating Clinical Sites

22. Hypertension Initiative: Analytical Database Variables .

23. Improvement in BP Control 2000 – 2005in 208,547 Hypertensive Patients

24. Change in Control of 3 Risk Factors in 82,442 Diabetic Hypertensives 2000–05

26. O’QUIN Hypertension InitiativeProvider Performance Report

29. DASH BOARD for Dr. John Doe: Lipid Control

30. Multiple Risk Factor Control in Hypertensive, Dyslipidemia Diabetics

31. BP Control in Black and White Men at VA and non-VA Sites in 2003

32. Therapeutic Inertia is a Major Indicator of BP Control

33. Percentage Remaining Normotensive in ~50,000 Pts by SBP Mean at Baseline

34. Hypertension Initiative:Opportunities Database: Guide CME Publications: CVD and non-CVD Preliminary data for grant applications; T2 and T3 research

35. Quality Improvement Strategies in Hypertension Management Walsh, et al: Med Care 2006. Provider education Provider reminders Audit & feedback Facilitated relay Patient education Pt self-management Patient reminders Team Change* Fahey, et al. Cochrane Rev 2009 Self-monitoring* Patient education Physician education Nurse or Pharmacist care* Organizational interventions (too much heterogeneity)

36. Barriers to Dissemination of EBM: Efficacy vs Effectiveness; Cost & Complexity

37. ASH Chapter, Clinical HTN Specialists & the HTN Initiative The ASH Model for Hypertension Control and role of ASH Regional Chapters ASH Regional Chapters ASH Clinical HTN Specialists The O’QUIN HTN Initiative BCBS / O’QUIN HTN Initiative QI-P4P Collaborative

38. Healthcare Quality Improvement Collaborative What’s wrong with the current reimbursement system P4P: Definition, objectives, measures Brief review CMS QI Roadmap AHA translation and QI principles QI-P4P key design elements Previous experience; early adopters

39. What’s Wrong with the Current Healthcare Payment System? Provider’s standpoint Providers are paid the same amount regardless of outcome. From an economic standpoint, there is no incentive to improve “quality” (clinical outcomes). The current system also does not incentivize providers and practices to: Expand preventive services Enhance patient safety and satisfaction

40. What’s Wrong with the Current Healthcare Payment System? Insurers’ standpoint Health insurers want to account for the quality and the economy of medical services. They recognized the financial benefits of improving the health of their subscribers

41. The What and Why of P4P? Defining P4P: “Pay-for-performance (P4P) programs offer financial incentives to physicians for achieving specific, measurable patient safety, quality, satisfaction or efficiency objectives. P4P programs generally base a portion of physician payment on quantitative measures. These may include patient care process and/or outcome measures and/or patient satisfaction scores.” Any P4P program should have as its central purpose to improve the quality of patient care, satisfaction and clinical outcomes.

42. P4P Measures Most P4P programs focus primarily on clinical outcomes and patient satisfaction Utilize the Health Plan Employer Data and Information Set (HEDIS) measures from the NCQA. Half also include efficiency measures (e.g., the number of inpatient admissions or rate of prescribing generic medications) More programs are measuring the use of Information Technology Typically, the incentive is weighted among the different measures

43. CMS’ Quality Improvement Roadmap ? Make care: ? Safe ? Effective ? Efficient ? Patient-centered ? Timely ? Equitable

44. AHA: TRIP and P4P Principles TRIP: Scientific discovery Disseminate discoveries Evidence-based guidelines Performance measures Develop clinical decision support and QI tools Directed-cause campaigns QI P4P: Promote safe, effective, patient-centered, timely, efficient care Use rigorous methods; risk-adjust, standardize, EBM Promote quality-of care systems & infrastructure Evaluate if goals reached, unintended effects occur

45. P4P: 5 Key Design Elements

46. Effects of P4P Quality of Care in England; Comparison of Unintended Consequences In 2004, P4P on 136 clinical indicators began. Quality of care for asthma, diabetes and heart disease was increasing before P4P incentives. “Between 2003 and 2005, the rate of improvement in quality indicators increased for asthma and diabetes but not heart disease. By 2007, the rate of improvement slowed for all three; quality of care for services not associated with an incentive declined. Continuity (seeing same doc) declined promptly after P4P began English doctors happier than California doctors with QI / P4P; less resentment/frustration, more motivated, greater change English doctors more chart data (vs claims); can remove difficult patients from denominator

47. P4P Learning Curve: Where are early adopters now? “Our findings suggest that leading-edge sponsors of P4P have expanded the reach of their efforts, particularly with regard to specialists, and increasingly are focused on outcome and cost-efficiency measures, rather than clinical outcome measures alone.” Rosenthal, et al: Health Affairs 2007: Nov-Dec 1674 – 1682.

48. QI / P4P: A Developing BCBS / O’QUIN HTN Initiative Program Inaugural meeting of the ‘Healthcare Quality and Reimbursement (HQR) Advisory Board’, comprised of key opinion leaders from 12 practices. Three ‘domains’ were identified as essential to a successful collaboration. Quality indicators. Thoughtful selection of high impact process and outcome indicators that can be clearly defined and rigorously measured across practice settings. Quality improvement. Develop, share, refine best practices to ensure productive encounters and attain goals of the process and outcome indicator selected. Reimbursement/incentives. Define & implement incentives that compensate for time and resources invested to meet goals of process and outcome indicators.

49.  Quality Indicators: Hypertension: JNC 7 – 2003; ACC/AHA – 2009.

50. Quality Indicators:Diabetes: ADA – 2008.

51. Hypercholesterolemia/Lipidemia. NCEP – ATP III, 2001; Update 2004; ACC/AHA Performance Measures 2009

52. ASH Chapter, Clinical HTN Specialists & the O’QUIN HTN Initiative The ASH Model for Hypertension Control and role of ASH Regional Chapters ASH Regional Chapters ASH Clinical HTN Specialists The O’QUIN HTN Initiative BCBS / O’QUIN HTN Initiative QI-P4P Collaborative