New AHA/ACC Performance and Quality Statement on Hypertension

Batya Swift Yasgur, MA, LSW

November 15, 2019

The American Heart Association (AHA) and the American College of Cardiology (ACC) have jointly published new clinical and performance quality measures for adults with high blood pressure (HBP).

The comprehensive paper, which focuses on diagnosis and treatment of HBP, includes 22 new measures and expands the existing model of care by focusing not only on BP control targets but also on broader care delivery systems and approaches.

"In the past, we focused mostly on levels of blood pressure, in terms of control, and in the 2017 ACC/AHA guideline we expanded the scope to include other issues, like treating certain subpopulations and correctly measuring and estimating risk," lead coauthor Don Casey, MD, MPH, MBA, president, American College of Medical Quality, told theheart.org | Medscape Cardiology.

The current paper "builds on the 2017 guideline and rethinks the challenge of the problem, in terms of better defining a true system of care, rather than looking only at what an individual provider does," said Casey, who is a faculty member at Rush Medical College and chair of the ACC/AHA Performance Measures Writing Committee for High Blood Pressure Control.

The 2019 ACC/AHA guideline was published online November 12 in Circulation: Cardiovascular Quality and Outcomes.

Staging Process

"One of the goals of this document was to develop new performance measures designed to evaluate the control of patients with Stage 1 HBP," Casey said.

The current measure commonly used by the Centers for Medicare & Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA) for Stage 2 HBP is systolic BP of ≥ 140 mmHg, "but the 2017 guideline redesigned the staging, with 130 to 139 considered to be 'Stage 1' HBP," he said.

"The first four measures focus on control, and 1a is the one in public use right now, but it only captures BP above 140 and misses the change in the guideline, which is reducing the ideal goal of lowering BP for patients with Stage 2 HBP below 140 and below 130 for most — although not all — patients," he added.

To develop the new performance measures, the authors first separately evaluated the control of patients with Stage 1 HBP corresponding to the current measure employed by NCQA and CMS for Stage 2, and then combined the two classifications into a single composite measure.

Table 1. Performance Measures
Measure No. Measure Title/Description
PM-1a ACC/AHA Stage 2: HBP control
Systolic BP < 140 mmHg
PM-1b ACC/AHA Stage 2: HBP control
Systolic BP < 130 mmHg
PM-2 ACC/AHA Stage 1: HBP control
Systolic BP < 130 mmHg
PM-3 ACC/AHA Stage 1 and Stage 2: HBP control
Systolic BP < 130 mmHg (PM-1b + PM-2 composite)
PM-4 Nonpharmacological interventions for ACC/AHA Stage 2 HBP
PM-5 Home BP monitoring for ACC/AHA Stage 2 management

PM-4 is a "new measure we felt important because we wanted to emphasize that some patients need pharmacologic treatment but all need nonpharmacologic treatment," Casey commented.

He noted that nonpharmacological interventions are lifestyle interventions that include weight loss, a healthy diet, reduced sodium intake, enhanced potassium intake, physical activity, and "moderation" in alcohol intake.

New Topics

Casey says the goal of quality measures is to "bring up new topics that haven't been in the public play for what we think are additional important issues to address with measurement."

These quality measures "reflect back to the performance measures," he said.

 

Table 2. Quality Measures
Measure No. Measure Title/Description
QM-1 Nonpharmacological interventions for ACC/AHA elevated BP (defined as systolic BP of 120 mmHg - 129 mmHg)
QM-2 Nonpharmacological interventions for ACC/AHA Stage 1 HBP
QM-3 Nonpharmacological interventions for all ACC/AHA stages of HBP (composite measure combining PM-4, QM-1, and QM-2)
QM-4 ACC/AHA Stage 1 and Stage 2: HBP control
Systolic BP < 130 mmHg (PM-1b + PM-2 composite)
QM-5 Medication adherence to drug therapy for ACC/AHA Stage 1 with atherosclerotic cardiovascular disease risk ≥ 10% and ACC/AHA Stage 2 HBP
QM-6 Home BP monitoring for ACC/AHA Stage 2 HBP

Blueprint for Care

"A major problem with measurement of BP is that it is inconsistent, and a standard protocol should be used to consistently and correctly measure BP," Casey noted.

The "structural quality measures" focus on creating standardized protocols, not at the level of the individual practitioner but rather in "care delivery units."

Casey explained that this "blueprint for HBP care" goes beyond clinical factors, encompassing broader systemic issues and "tries to promote these measures as a standard model for how systems of care should be organized."

Included in the "blueprint" is the importance of taking a patient-centered approach and taking into account social determinants of health.

Additionally, "we can also take advantage of the [electronic health record] to diagnose and assess BP," he said.

Table 3. Structural Measures for the Diagnosis and Management of HBP
Measure No. Measure Title/Description
Diagnosis, Assessment, and Accurate Measurement
SM-1 Standard protocol to consistently and correctly measure BP
SM-2 Standard process for assessing atherosclerotic cardiovascular disease risk
SM-3 Standard process for properly screening all adults ≥ 18 years for HBP
SM-4 Use of an electronic health record to accurately diagnose and assess HBP control
A Patient-Centered Approach for Controlling HBP
SM-5 Use of a standard process to engage patients in shared, tailored decision-making
SM-6 Demonstration of infrastructure and personnel that assess and address social determinants of health in patients with HBP
Implementation of a System of Care for Patients with HBP
SM-7 Use of team-based care better to manage HBP
SM-8 Use of telehealth, m-health, and e-health and other digital technologies to better diagnose and manage HBP
SM-9 Use of a single, standardized plan of care for all patients with HBP
Use of Performance Measure to Improve Care in HBP
SM-10 Use of performance and quality measures to improve quality of care for patients with HBP

"Regardless of your interest in a particular sport, I think we can agree that healthcare is a team sport, and BP treatment is becoming more complex and is rising to the level of not having just one person involved in the patient's care," Casey commented.

He noted that the "blueprint" also includes a focus on digital health, which is "a ubiquitous term that includes e-health, remote monitoring, and an array of other digital technologies."

New Roadmap

Commenting on the study for theheart.org | Medscape Cardiology, Salim Virani, MD, PhD, chair of the ACC's Prevention of Cardiovascular Disease Section and professor of cardiology, Baylor College of Medicine, Houston, Texas, said that the "document puts the patient front and center," with "many performance as well as quality measures that are patient-centric."

Virani, who was not involved with authorship of the paper, noted that the BP targets are "aggressive, at less than 130, and that not all organizations agree with those targets."

Nevertheless, he hopes that "most organizations will find common ground to improve care delivery processes, rather than getting too much into the differences between target BP, because finding the common ground will be the key that will help our patients."

The authors emphasize that new measures "are currently not designed or intended to be used for accountability 'standards' but rather to be used as a roadmap for solo/small physician offices, group practices, health systems, public health sites, accountable care organizations, and clinically integrated networks, etc, in their collective journeys to establish better and more standardized guideline-based systems of care for the many millions of patients with HBP across the United States."

Casey reported being a consultant to the National Committee for Quality Assurance and receiving institutional, organizational, or other benefits from the American College of Medical Quality. The other authors' disclosures are listed online. Virani has disclosed no relevant financial relationships.

Circ Cardiovasc Qual Outcomes. 2019;12:e000057. Full text

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