ARGUMENT:
ASSUMING YOU ARE THE VICE PRESIDENT QUALITY OF CARE AND THAT EFFECTIVE PRIMARY CARE FOR HYPERTENSION IS THE EFFECTIVE CONTROL OF ELEVATED BLOOD PRESSURE (BP) TO BELOW SYSTOLIC <140MMHG AND DIASTOLIC < 90MMHG FOR ALL HYPERTENSIVE PATIENTS ON MEDICATION ATTENDING YOUR CLINICS. DESCRIBE HOW YOU WILL CONDUCT A QUALITY ASSESSMENT -BASED PROCESS FOR EFFECTIVELY MANAGING HYPERTENSION IN YOUR CLINIC.
1.Introduction/definition of problem: Effective Quality of care for hypertension in a group practice is provision of healthcare services which will increase the chance of “control of blood pressure (BP) for a hypertensive patient” or population to below 140/90mmHg and is consistent with up-to-date evidence, guideline, or professional knowledge from American College of Cardiology or JNC 7 & 8. 1 Uncontrolled BP in a patient on treatment with poor medication adherence is a quality-of-care problem. Many a patient with a diagnosis of hypertension on treatment reveals during my clinical interaction that they do not take their prescribed medications regularly. Hypertension being an asymptomatic disease, the nature of the medication regimen and extent of their education about the diseases and the medication were major factors patients given for poor adherence. Engaging patients to increase adherence with their prescribed medications should improve control of BP in our patients, therefore, my hypothesis is that the more the number of patients with poor medication adherence (MA) the higher the percentage of patients with uncontrolled BP.
2. Literature/quality indicator information review: Non-adherence to prescribed medication is the topmost cause of poor control of BP. 25% of patients do not fill their initial prescription for BP medications after diagnosis, about the same percent wouldn’t continue treatment beyond a year and only about 1 in 5 keeps adhering over a long term. 2 Despite evidence from studies that adherence to medications controls BP and reduces the risk of long-term complications and death between 50 and 80% of hypertensive patients “shows suboptimal adherence” to their medications leading to poorly controlled BP, increased healthcare cost, end organ damage and poor quality of life.2-5 Major contributing factor to poor adherence is inadequate patient education or awareness about the need to use medication for hypertension, multiple daily dosing regimen, multidrug side effects, cost of medications amongst many other interwoven factors. About 40% of known hypertensives have their BP uncontrolled, largely because of awareness and nature of medication. 6 Higher patient adherence with indirect measures like “proportion of days covered (PDC) or medication possession ratio (MPR)” greater than 80% has been associated with better control of BP, even in resistant hypertension and reduction in death outcomes. 7-9
2. Literature/quality indicator information review:
Non-adherence to prescribed medication is the topmost cause of poor control of BP. 25% of patients do not fill their initial prescription for BP medications after diagnosis, about the same percent wouldn’t continue treatment beyond a year and only about 1 in 5 keeps adhering over a long term. 2 Despite evidence from studies that adherence to medications controls BP and reduces the risk of long-term complications and death between 50 and 80% of hypertensive patients “shows suboptimal adherence” to their medications leading to poorly controlled BP, increased healthcare cost, end organ damage and poor quality of life.2-5 Major contributing factor to poor adherence is inadequate patient education or awareness about the need to use medication for hypertension, multiple daily dosing regimen, multidrug side effects, cost of medications amongst many other interwoven factors. About 40% of known hypertensives have their BP uncontrolled, largely because of awareness and nature of medication. 6 Higher patient adherence with indirect measures like “proportion of days covered (PDC) or medication possession ratio (MPR)” greater than 80% has been associated with better control of BP, even in resistant hypertension and reduction in death outcomes. 7-9
3. Choice of assessment strategy:
The assessment strategy is to assess MA using data from the filling of medication fills/refills from the pharmacy dispensing database. We will evaluate the process of provider-patient education and number of patients on single or multiple daily dosing regimen and its effect on MA. These two clinical processes can be worked upon to improve MA. With patients not commencing, continuing or persisting on prescribed medications, the extent of failure to fill/refill will reveal the degree of non-adherence. The extent is measured using PDC discussed below. Percentage of those with controlled BP will be correlated with the percentage of patients with optimal MA. It is believed that ideal MA should increase the likelihood of blood pressure control. 10-12
4. Method of assessment :
Data is extracted for the total number of patients with a diagnosis of essential hypertension being treated with pharmacotherapy from the medical records over the last 1year. The value of their BP is classified as controlled or not controlled. Other data that were harvested for each patient is the presence of documentation for adequate patient education, number of patients on single or multiple dosing regimen. Pharmacy claims and dispensing data for patients with prescription for BP medication(s) was used to calculate the PDC during the last 1 year. “The rationale is that PDC is one of the most popular methods, more accurate, endorsed and validated by the pharmacy quality alliance (PQA) as a high-quality measure of MA”. 5
5. Assessment level
The assessment level will be at the physician clinic and pharmacy dispensing level. BP measurement, documentation on patient’s education on MA, medication prescription and regimen, and monitoring of filling or refilling of medications is done at these levels.
6. Comparison
Data comparison is done with a similar capacity sister practice. Rationale is that we see patients of comparable (socio-demographics, provider – patient relationship challenges, work force trainings and target internal goal for BP control). One will expect to find from the assessment that optimal MA in our setting and BP control in both practices to be related.
7. Description of data sources
Direct method of sourcing data is more expensive and complex to achieve. Our data source is an indirect method. Administrative Claims record would be the source of all medical data for our patient cohort. This may have some incomplete records on medication fill as it depends on the pharmacy unit filling all details required to calculate PDC, which isn’t always so. Pharmacy dispensing database, which has all details, will be our source. We have easy access because it’s in-house. This pharmacy records also adapts to hypertensive care where medications may be changed easily.
8. Data collection
Pharmacy staff who are already trained in handling the medication dispensing and events monitoring system will collect data from fill/refill records for the 12months period. This is to ensure high-quality data from pharmacy records. First day of medication initiation is determined, Initial filling of medication is confirmed, refill rates are gotten, pill counts with days of supply information, and total number of days will provide figures for the calculation of PDC per patients. Few patients’ direct clinical response or questionnaires may be used to improve the reliability of these data by confirming the actual usage of the medications during the study period. Administrative claims data can also be used, since it’s more standardized to collect, but it will depend on complete details filled from the pharmacy unit. This can be used to cross check.
Medical records abstraction will be done for the 12 months period for blood pressure readings by using computer-based tool in the EHR by trained personnel. Data on documentation for patient education and regimen of medication will be harvested as well for analysis. This will ensure high quality data is extracted and with minimal human efforts. This will provide measurement figures for numerator and denominator for the calculation of percentage of BP control.
9. Key audience/stakeholders
Local Hospital Leaders will be engaged with all data to stimulate a strategic direction for effective management of Hypertension. For the physicians and other members of the care team, comparative percentage of adherence with control of BP will be presented. Presence of data showing patients education with adherence and comparing single dosing with multiple dosing regimen will help to set a goal for improvement and drive team-based effort for achievement of MA. Administrators will have data analyzed for the purpose of allocation of resources towards improving adherence such as training of the healthcare staff. Percentage of medication adherence would be discussed with all patients and the provider-patient target for improvement will be discussed to improve education and get buy in of the patients. Policy makers will be engaged with data to stimulate public awareness.
10. Analysis
The data will be analyzed to percentage level. The analyzed data will show the degree of association between two identified causes of medication adherence – Provider-patient education and dosing regimen with % PDC. Furthermore, medication adherence data will be correlated with BP control as seen in the table below. Tables and Charts will be crafted to convey the message for the identified causal factor of MA, % MA association with BP control, for different stakeholders.
| BP < 140/90 mmHg | BP > 140/90 mmHg | Incomplete BP record | |
|---|---|---|---|
|
PDC > 80 |
64% |
32% |
4% |
|
PDC < 80 |
11% |
81% |
8% |
If the hypothesis is true, our data will show a relationship between medication adherence and the likelihood of BP control and even poorer BP figures is likely for patients with low PDC. We also found that increase in documentation of patient education in medical records increases the likelihood of patients’ adherence and achievement of better BP control. We found also that the percentage of patients who had single daily dosing regimen had higher percentages of achieving PDC of 80% and above than those with multiple dosing, which is in keeping with findings from other studies. These create the need for all stakeholders to support interventions to improve medication adherence by improving provider-patient engagement and single daily dosing regimen for BP control.
REFERENCES
1. Understanding quality measurement. http://www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/understand/index.html. Accessed Nov 11, 2020.
2.2017ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Journal of the American College of Cardiology. 2018;71(19):e127-e248. https://www.jacc.org/doi/10.1016/j.jacc.2017.11.006. Accessed Nov 16, 2020. doi: 10.1016/j.jacc.2017.11.006.
3. Vrijens B, Antoniou S, Burnier M, Sierra Adl, Volpe M. Current situation of medication adherence in hypertension. . 2017;8. http://hdl.handle.net/2445/120874. doi: 10.3389/fphar.2017.00100.
4. Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of A medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich). 2008;10(5):348-354. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2562622/. Accessed Nov 16, 2020.
5. 2019 AHA/ACC clinical performance and quality measures for adults with high blood pressure. Journal of the American College of Cardiology. 2019;74(21):2661-2706. https://www.jacc.org/doi/10.1016/j.jacc.2019.10.001. Accessed Nov 9, 2020. doi: 10.1016/j.jacc.2019.10.001
6. Asch SM, McGlynn EA, Hiatt L, et al. Quality of care for hypertension in the united states. BMC cardiovascular disorders. 2005;5(1):1. https://www.ncbi.nlm.nih.gov/pubmed/15638933. doi: 10.1186/1471-2261-5-1.
7. Simpson SH, Eurich DT, Majumdar SR, et al. A meta-analysis of the association between adherence to drug therapy and mortality. BMJ. 2006;333(7557):15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1488752/. Accessed Nov 16, 2020. doi: 10.1136/bmj.38875.675486.55.
8. Burnier M. Is there a threshold for medication adherence? lessons learnt from electronic monitoring of drug adherence. Front Pharmacol. 2019;9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6334307/. Accessed Nov 16, 2020. doi: 10.3389/fphar.2018.01540.
Summarized By Dr.Joshua Kolawole
(MD, MBA, MASc., FISQua, CPHQ, PMP)
Agile Program Manager & Transformational Leadership Expert, Valdymas Intelligence LLC, Grand Prairie, Texas, USA.
valdymas@valdymasintelligence.org