AHA/ACC Aim to Enhance Care of High BP With New Measures

The American Heart Association (AHA) and the American College of Cardiology (ACC) have released a set of 22 new performance and quality measures that they hope will help physicians, care teams, and health systems improve both the detection and treatment of high blood pressure in adults.

Up until now, only one performance measure—the Healthcare Effectiveness Data and Information Set (HEDIS) from the National Committee for Quality Assurance (NCQA)—has been widely used. That standard assesses control of BP to a goal of less than 140/90 mm Hg.

Based primarily on recommendations from the comprehensive hypertension guideline released in 2017 by the ACC, the AHA, and nine partnering organizations, this new document introduces six performance measures, six process quality measures, and 10 structural quality measures.

“Since 2017, we’ve been really trying to promote the guideline, and if you think of the performance measures as being what happens next, the goal of the performance measures is really to create a way to evaluate how well we’re achieving the goals set out by the hypertension guideline,” Donald Casey Jr, MD, MBA (Jefferson College of Population Health, Philadelphia, PA), chair of the writing committee and president of the American College of Medical Quality, told TCTMD.

Importantly, the new measures take into account the updated hypertension classification scheme, which lowers the BP threshold for stage 1 hypertension from 140/90 mm Hg to 130/80 mm Hg. That means the HEDIS measure currently in use does not reflect what is happening with patients who have stage 1 hypertension as defined in the 2017 guideline.

The measures, published online November 12, 2019, ahead of print in Circulation: Cardiovascular Quality and Outcomes, aim to address that gap and also to focus in on other important aspects associated with the delivery of high-quality care for patients with high BP, Casey said.

Performance Measures

Casey noted that the performance and quality measures differ in key ways. “Performance measures are really developed from high-quality evidence and are also designed to be in use for quality payment and reporting programs such as what [the Centers for Medicare & Medicaid Services] and NCQA use,” he explained. Quality measures, on the other hand, are derived using lower ranges in terms of the class of recommendation and level of evidence upon which they’re based. They are meant to be used for quality-improvement initiatives and not for public reporting or pay-for-performance programs.

The six new performance measures, all based on Class I recommendations from the guideline, touch on BP goals, nonpharmacological interventions, and home BP monitoring. One remains similar to the HEDIS standard currently in use, but the idea is really to implement a new benchmark and assess the proportion of patients with ACC/AHA stage 1 or 2 hypertension who have their systolic pressure controlled to less than 130 mm Hg, Casey said.

The writing committee did not want to get into a debate about the optimal BP goal, a discussion that has continued since the updated hypertension scheme was introduced 2 years ago, he pointed out. “We simply said that should you wish to actually lower your target and measure how well you’re doing, you could do that with these new measures and you could also now add in the stage 1 patients.”

In other words, Casey said, “don’t try to solve the debate. Create tools to help people measure in different ways and then let the data help guide the discussion as we continue down this path.”

Quality Measures

The quality measures include six focused on process and 10 focused on structural issues or broader system-level care.

Those addressing process quality look to use of nonpharmacological interventions across the spectrum of high BP and to medication adherence and use of home BP monitoring in patients with stage 2 and high-risk stage 1 hypertension.

Regarding use of interventions like weight loss, healthy diet, reduced sodium intake, increased potassium intake, moderation of alcohol use, and exercise, Casey said. “Not measuring that now is in my mind a mistake, because nonpharmacologic intervention probably has the biggest potential to control a lot more people’s blood pressure that’s high than just treatment with medication.”

Don’t try to solve the debate. Create tools to help people measure in different ways and then let the data help guide the discussion as we continue down this path. Donald Casey Jr

Casey explained that the measures related to structural quality grew out of discussions about some of the other recommendations in the 2017 guideline. They deal with three overarching themes:

• A patient-centered approach to controlling high BP that includes shared decision-making and consideration of social determinants of health
• Diagnosis, assessment, and accurate measurement of high BP
• Implementation of a system of care that includes features like team-based care, use of digital health technology, and a single standardized plan for all patients with high BP

“We designed these [structural measures] to use as a pathway to highlight what we think the key components of an effective system of care should be for people with high blood pressure,” Casey said, “because the guideline does indicate far more complexity in 2017 than it ever did before around these systems changes, largely because we have much better evidence that a lot of these things make a difference, like telehealth and team-based care.”

Unlike the performance and process quality measures, which are targeted to practitioners and health plans, the structural standards are aimed at the level of the “care delivery unit,” which can include anything from a small physician office or group practice to accountable care organizations or clinically integrated networks.

Casey said the TARGET:BP initiative from the AHA and the American Medical Association—which now encompasses more than 1,000 practice sites—is likely to adopt the new structural measures to help instill these system changes. “That points to the fact that there are programs out there, like TARGET:BP and Million Hearts, that are really trying to move the needle in terms of focusing less on just one measure which hasn’t changed and trying to take advantage of the richness of the guideline,” he said.

A Vision to Accomplish

Latching onto existing campaigns is one way to help get the word out about these performance and quality standards, Casey pointed out, saying that “we’re really at the awakening stage.”

“This is really designed to help teams that are out in the care-delivery system focus on this,” he said. “We’ll deal with the health policy changes as it goes along, but we felt it was important to begin to create a new vision for what we really need to accomplish.”

If these measures are widely adopted, Casey said he would hope the medical community would have a better handle on how to design effective systems of care for patients with high BP within the next several years, although he acknowledged that these processes typically move slower than is ideal.

“I would hope that we’d have a better system of care,” he said. “I think that would hopefully result in better improvements in health, lifestyle modification, etc.”

Casey said the next steps involve raising awareness about these new measures, starting with a session at the AHA 2019 Scientific Sessions on Monday, November 18, 2019, and then engaging various stakeholders. “How can we get, for example, the hospital systems involved with thinking that this is a major priority from a public health standpoint? How do we get commercial payers to think this is a major priority that needs a lot more emphasis, right? And also, the government payers,” he said.

Casey predicted that the next year is going to be exciting. “Once you listen to this I don’t see how you can think that there’s any other alternative here to helping move forward,” he said.