Controlling High Blood Pressure

WCHQ Ambulatory Measure Specification

Controlling High Blood Pressure Performance Measures

Measurement Period 01/01/16 - 12/31/16

Submission Period: 03/06/17 - 04/21/17

Measure Description

The percentage of essential hypertension patients 18 through 85 years of age who had the following during the 12 month measurement period:

1.  A Representative Blood Pressure (BP) in control during the 12-month measurement period. Adequate Control is defined as follows:

·  Less than 140/90 for patients less than 60 years of age or patients of any age with a diagnosis of diabetes and/or chronic kidney disease.

·  Less than 150/90 for patients 60 years of age and older without diabetes or chronic kidney disease.

2.  An eGFR (Estimated Glomerular Filtration Rate) test annually

Disclaimer: Measures reported by WCHQ healthcare organizations represent a specific aspect of care in relation to an evidence-based standard, but are not clinical guidelines and do not establish standards of care. All providers should have an individual care plan established with their patient.

General Information/Rationale

Hypertension (high blood pressure) affects approximately 50 million individuals in the United States. Recent data suggest that individuals who have normal blood pressure (BP) at age 55 have a 90 percent lifetime risk for developing hypertension.

The relationship between BP and risk of cardiovascular disease events is continuous, consistent, and independent of other risk factors. The higher the BP, the greater is the chance of heart attack, heart failure, stroke, and kidney disease. In clinical trials, antihypertensive therapy has been associated with reductions in stroke incidence averaging 35–40 percent; myocardial infarction (heart attack), 20–25 percent; and heart failure, more than 50 percent.

Treatment Goals

·  Less than 140/90 for patients less than 60 years of age or patients of any age with a diagnosis of diabetes and/or chronic kidney disease.

·  Less than 150/90 for patients 60 years of age and older without diabetes or chronic kidney disease.

Approximately 11% of U.S. adults have CKD. The condition is usually asymptomatic until its advanced stages. Most cases of CKD are associated with diabetes or hypertension. Chronic kidney disease is defined as decreased kidney function or kidney damage that persists for at least 3 months. Tests often suggested for screening that are feasible in primary care include testing the urine for protein (microalbuminuria or macroalbuminuria) and testing the blood for serum creatinine to estimate GFR.

Reference: The eighth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Retrieved Feb 5, 2014 from http://jama.jamanetwork.com/article.aspx?articleid=1791497

Reference: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/chronic-kidney-disease-ckd-screening

Definitions

12 Months: Measurement Period

18 Months: First Six Months of Measurement Period + Prior Year.

·  For current specification: 01/01/15-06/30/16

24 Months: Measurement Period + Prior Year

Office Visit: Office visit in an outpatient, non-urgent care setting

PCP: For WCHQ measure purposes, a primary care provider is defined as any General Practice, Internal Medicine, Family Medicine, Pediatrics provider with the following degree types (MD, DO, PA, and NP), and any other practitioners identified by the healthcare system as primary care practitioners. The rationale for the additional practitioner(s) must be documented and must be applied consistently across all preventive care and chronic care measures by the organization.

·  Measure Specific Specialist: As part of the denominator population for this measure visits to a Cardiologist qualify as office visits for the denominator population.

Age Range 18-85: Patients born between 01/01/1931 and 01/01/1998.

Denominator Description

Patients whose age at the beginning of the one year measurement period is at least 18 and whose age at the end of the measurement period is less than 86 and are alive as of the last day of the Measurement Period. Expired patients for whom a specific date of expiration cannot be found are excluded from the denominator population.

The rationale for the denominator population is built from the following criteria (See figure H-1):

[Question 1] – Is this a patient with the disease or condition?

[Question 2] – Is this a patient whose care is managed within the Physician Group?

[Question 3] – Is this a patient currently managed in our system?

For every WCHQ Ambulatory Measure, each organization must calculate total denominator population for this measure, not a sample (see Encounter Data section). If the Denominator for any given measure is less than 50 patients, the organization does not have to report the Numerator for the measure to WCHQ. To allow for appropriate comparisons of performance across organizations, a minimum population of 50 patients ensures a maximum of a 2% incremental scale on proportional measures.

Publication on the Website: If the Denominator is less than 50, only the Physician Group Name, Population Size (N), and the following statement will display on www.wchq.org:

·  The patient population is too small (N<50) for purposes of reliably predicting Physician Group performance.

Historical Trend for Low Population Sizes: The historical trend display of Physician Group performance will not include measurement periods with population sizes less than 50. For each measurement period with insufficient data, there will be no display for that period.

Site Level Reporting:

Denominator Minimum: For site level reporting there must be a minimum of 100 patients per clinic in the denominator for each measure. If the clinic denominator for any given measure is less than 100 patients the organization does not publicly report the results for the measure. The results will still be included in the organization level data.

Provider Minimum per Clinic: For site level reporting there are two options as follows:

o  A minimum of 3 providers per clinic who have patients in the measure denominator. There could be a provider or providers in a given clinic who do not get counted because they have no patients in the measure denominator.

o  If an organization desires, they can report site level data for a clinic with fewer than 3 providers as long as the clinic meets the 100 patient threshold. If your organization is planning to report results publicly for clinics with less than 3 providers, all clinics that meet this criteria will need to be reported.

Publication on the Website: Clinics who do not have enough providers or patients to be publicly reported for a given measure or measures will still display on the website by name but without results and with a caveat indicating that data was reported but did not meet the minimum provider or population size.

Provider and /or Clinic Attrition Recommendation:

1.  If a provider or clinic has left the organization prior to the end of the measurement period and if the organization can track the provider termination date, the provider will not be included in the site level reporting results. The provider or clinic is still included in the group level results.

2.  If a clinic closes or is no longer affiliated with a health care system after the end of the measurement period and prior to next year’s data being published a termination date and verbiage will be added next to that clinic’s name on the website. This will require website updating throughout the year.

Assignment of Provider to Clinic:

Organizations can use their current internal site level reporting methodology to assign a provider to a clinic. A provider must be assigned to a “home” clinic. Organizations who are not already doing internal site level reporting can work with WCHQ for assistance.

Assignment of Patient to Provider:

For purposes of WCHQ site level reporting a patient must be attributed to one provider. Organizations can use their own internal algorithm to assign a patient to a provider. Those who are not already doing this can work with WCHQ for assistance.

Patients eligible for inclusion in the denominator include (See Figure H-1):

[Question 1] – Is this a patient with the disease or condition?

a)  Those who had a minimum of two Hypertension coded (including any diagnoses coded for the visit)-(Table H-1) office visits (Table H-2) with any provider (MD, DO, PA, NP) in the Physician Group with different dates of service in an ambulatory setting during the last 24 Months [Measurement Period + Prior Year]

b)  From the patient population identified in “a” above, at least one Hypertension coded (Table H-1) office visit (Table H-2) in Prior Year or first 6-months of Measurement Period to provide an opportunity for the hypertension to be controlled.

c)  The Physician Group should exclude from the eligible population all complicated hypertension patients diagnosed with any of the following:

1.  End Stage Renal Disease (ESRD) meeting one or more of the following definitions:

i.  One ESRD coded office visit (including any diagnoses coded for the visit)- (Table H-4) with any provider in an ambulatory setting during the last 24 months.

ii. One ESRD coded encounter (any type of visit to any service) – (Table H-4) during the last 24 months.

iii.  One ESRD diagnosis from an ICD 9 or 10 diagnosis-based problem list (Table H-4). The problem must be ACTIVE. There is no limit on the look back date, but the date of documentation or onset date must occur prior to the end of the measurement period.

2.  Pregnancy meeting one or more of the following definitions:

i.  One pregnancy coded office visit (including any diagnosis coded for the visit) (Table H-5) with any provider in an ambulatory setting during the measurement period for a female between the ages of 12 and 55.

[Question 2] – Is this a patient whose care is managed within the physician group? (See Figure H-2):

Patients who had at least two office visits (Table H-2), regardless of diagnosis code, on different dates of service, to a PCP and/or Cardiologist in the past 24 months. If the Cardiologist is not considered a PCP, at least one of the two office visits must be to a PCP.

[Question 3] – Is this a patient current in our system? (See Figure H-2):

Those who had at least one office visit (out of the visits identified in Question 2) (Table H-2), regardless of diagnosis code, with a PCP and/or a Cardiologist during the last 12 Months [Measurement Period]

1.  A Representative Blood Pressure (BP) in control during the 12-month measurement period (Figure H-1)

For patients less than age 60 years of age and for patients of any age with a diagnosis of diabetes and/or chronic kidney disease adequate control is a representative systolic BP <140 mm Hg and a representative diastolic BP <90 mm Hg. For patients 60 years of age and older, without diabetes or chronic kidney disease, adequate control is a representative systolic BP <150 mm Hg and a representative diastolic BP of <90 mm Hg. (BP in the normal or pre-hypertensive range defined by The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure).

1.  Blood Pressure Control

a.  Blood Pressure Selection Criteria: (Figure H-1, continued)

·  Blood Pressure reading must have been obtained during the Measurement Period.

·  Systolic and Diastolic numbers must be from the same BP reading.

·  A controlled BP requires that both the systolic and diastolic readings must be less than the appropriate threshold.

·  Exclusions: Inpatient Stays, Emergency Room Visits, Urgent Care Visits, and Patient Self-Reported BP’s (Home and Health Fair Blood Pressures)

·  Inclusions: Any office visit encounter, including Nurse Only BP Checks, not listed under Exclusions above. NOTE: A BP performed at a patient’s home by a nurse who then inputs the result into an EMR counts as a Nurse Only BP.

·  Select the Blood Pressure from the most recent visit.

·  In the event that multiple Blood Pressures are recorded in the same day of service, select any reading that is controlled. If none are in control, select an uncontrolled reading.

·  If no Blood Pressure is recorded during the Measurement Period, the patient is assumed to be “not controlled”.

Patients Age 60 and Older Without Diabetes or CKD Subset Definition: This subset of patients will be counted in Numerator 1-Blood Pressure Control as adequate control with a threshold of <150/90. Identify denominator patients who meet the following criteria:

1.  Patients Age 60 and older as of the end of the Measurement Period and alive as of the last day of the Measurement Period. Note: The upper age limit for this measure is 85.

·  The Physician Group should exclude the following patients from the subset population (Note: These patients will remain in the overall denominator):

a.  Those with diabetes meeting one or more of the following definitions:

i.  Two diabetes coded office visit (including any diagnoses coded for the visit) - (Table H-6) with any provider in an ambulatory setting during the last 24 months.

ii.  Two Diabetes coded encounter (any type of visit to any service) – (Table H-6) during the last 24 months.

iii.  One diabetes diagnosis from an ICD-9 or ICD-10 diagnosis-based problem list (Table H-6). The problem must be ACTIVE. There is no limit on the look back date, but the date of documentation or onset date must occur prior to the end of the measurement period.

b.  Those with CKD meeting one or more of the following definitions:

i.  One CKD coded office visit (including any diagnoses coded for the visit) - (Tables H-7) with any provider in an ambulatory setting during the last 24 months.

ii.  One CKD coded encounter (any type of visit to any service) – (Tables H-7) during the last 24 months.

iii.  One CKD diagnosis from an ICD-9 or ICD-10 diagnosis-based problem list (Tables H-7). The problem must be ACTIVE. There is no limit on the look back date, but the date of documentation or onset date must occur prior to the end of the measurement period

2.  An eGFR (Estimated Glomerular Filtration Rate) test annually (Figure H-1)

This measure assesses the percentage of patients who had one or more eGFR tests within the last 12 Months [Measurement Period] as demonstrated through any of the following:

1.  Administrative Data, which can include:

a)  Internal or external eGFR tests extracted electronically and requiring Test Date