NEW YORK CITY, NY — A quality-improvement initiative that actively engaged churches, barbershops, and businesses as part of an outreach program to improve the treatment of hypertension reported significant improvements in blood-pressure control over a recent four-year period[1].

The results of the project, which is part of the Network for Regional Healthcare Improvement and designed to address gaps in blood-pressure control in Monroe County in western New York State, were presented today here at the American Society of Hypertension (ASH) 2014 Annual Scientific Meeting .

Speaking during the meeting, lead investigator Dr Howard Beckman (Finger Lakes Health Systems Agency, Rochester, NY) reported that in 2010, when the program was first established, 62.7% of those with hypertension had their blood pressure under control. By 2013, there was a significant increase in the percentage of individuals at target, with 71.3% meeting the goal of <140/90 mm Hg.

"Everyone has increased their control rates over time, but the gap is still widening for African Americans and for those with lower socioeconomic status," said Beckman. "Even though we've made what I think is a really concerted effort to try to reduce disparities, we have a lot more work to do."

Good Control in Poorer Neighborhoods

The population of Monroe County is 589 788, and based on national estimates, the researchers assumed that approximately 30% of these individuals had high blood pressure. To date, 114 000 individuals with high blood pressure have been included in the registry, which they believe is about 65% of all Monroe Country residents with hypertension. The project involved 65 clinical practices in the county, including 115 family physicians, 185 internists, 49 nurse practitioners, and 204 residents.

Beckman said they were concerned poorer neighborhoods had lower control rates, so they investigated whether family practices in these communities were underperforming. However, when they examined these, to their surprise, the practice in one of the poorest neighborhoods had the highest control rate. Even many of the practices in the mid-range of socioeconomic status performed considerably better than those with wealthier populations.

"It really challenges the notion of using sociodemographics as the major contributor in practices," he said. "We're going to spend a lot of time—it turns out that Jefferson Family Medicine, which is a safety-net practice in our community that has the highest blood-pressure–control rate—trying to figure out what those folks are doing. It would have a significant impact on other practices that do safety-net work."

He added that physicians should be able to treat everybody effectively, regardless of socioeconomic status. Also, if the program is truly successful, there should be decreases in hospitalizations for MI, stroke, initiation of dialysis, and heart failure. The researchers are working on assessing long-term clinical outcomes and hope to report such findings in the future.

Dr Keith Ferdinand (Tulane University School of Medicine, New Orleans, LA), who was not affiliated with the study, said that community-based research can be difficult and praised the investigators for their efforts.

He noted there tends to be a lot of front-end enthusiasm for such projects but "fatigue" among the project's volunteers in the barbershops, churches, and workplaces can set in. He wondered whether the group revisited the community workers to assess how well they were performing. Beckman said the project includes a community-engagement officer who visits the sites for this purpose and that there is an active public-relations campaign to help prevent fatigue from occurring.

Kaiser Permanente Algorithm Boosts BP Control

Dr Joseph Young (Kaiser Permanente Northern California, San Francisco) also reported the results of an initiative in hypertension control in their healthcare system, one that includes 21 hospitals and 45 facilities with more than 7000 physicians[2]. Hypertension control increased from 44% in 2001 to 86% in 2012, rates that are significantly higher than control rates achieved across the US and in California (63% and 69%, respectively).

In presenting the Kaiser Permanente data, Young explained the research was also designed to identify interventions associated with improvements in care.

One of the key interventions was the creation of an "easy-to-read and easy-to-implement" treatment algorithm based on the clinical guidelines. These recommendations have evolved over time and include multiple steps physicians should take when treating patients. In the latest iteration, a thiazide diuretic, with or without an ACE inhibitor, is the first step. This is then followed by an ACE inhibitor if it hasn't been added, a calcium-channel blocker as the third step, and a beta-blocker or spironolactone as fourth or fifth drugs.

Despite the algorithm, Young explained that one of best successes they have had is with the implementation of medical assistants who are trained to take blood pressure. These assistants can be accessed by the patient with very little waiting, and the results are transmitted to the physician. Other metrics that have contributed to their success include better feedback loops and an increased use of single-pill polypharmacy with the combination of hydrochlorothiazide and ACE inhibitor.

The Rochester Business Alliance cosponsored the Monroe County project and $1.4 million in funding was provided by the Wegmans Family Foundation. Young reports no disclosures.


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