Data-driven Quality Improvement: The Case of Precise Blood Pressure MeasurementNikita Stempniewicz; Elizabeth Ciemins PhD, MPH, MA; Cindy Shekailo; and John Cuddeback, MD, PhD | AMGA Analytics, Alexandria, Virginia

About AMGA Analytics

Objective

Methods

Results• AMGArepresentsmultispecialtymedicalgroupsandintegratedhealthcaredeliverysystems—450memberorganizations,mediansize150FTEphysicians

• InpartnershipwithOptum,AMGAconductsalearningcollaborativeformemberswhousetheOptum™Onepopulationhealthanalyticsplatform

• Optumextracts,maps,andnormalizesclinicaldatafromEHRsandoutgoingclaimsdata,toenablemeaningfulcomparisonsacrossmedicalgroups,identifyinggroupswithsuperiorperformance

• Wefocusonambulatorycareforpatientswithchronicconditions• Datadetermineswhattoimprove;sharedlearningfocusesonhowtoimprove

Why Investigate Precise BP Measurement?• Hypertension(HTN)isamajorriskfactorforcardiovasculardisease1

• Areductionaslittleas2mmHgcanleadtoasubstantialreductionintheincidenceofdeath,stroke,heartdisease,orothervascularoutcomes2

• Recordingprecisebloodpressure(BP)measurementsisfundamentaltomanagingHTNandallowsproviderstomaketimelytreatmentadjustments

• AssumingBPvaluesaremeasuredaccuratelybutroundedtothenearest10mmHg:

•Reductionof2mmHgcouldbeinterpretedasareductionof10mmHg,e.g.,146(roundedto150)to144(roundedto140)

•Reductionof8mmHgcouldbeinterpretedasnochange,e.g.,164(roundedto160)to156(alsoroundedto160)

• Establishthedegreeofprecisiontowhichbloodpressureismeasuredintheambulatorysetting

• DetermineifdatasharingonprecisionofBPmeasurementleadstoimprovement• IdentifyinterventionsassociatedwithimprovementsintheprecisionofBPmeasurement

Study Population:• 1,200,000patients• Aged18–85• DxHTN(insuranceclaimorproblemlist)• Receivedcareat22AMGAmemberorganizations

Study Design• PrecisionofBPmeasurementwasquantifiedusingtheproportionofpatientswhosemostrecentlyrecordedsystolicordiastolicBPreadingwasamultipleof10mmHg,e.g.,100,110,120,130,identifiedbyalastdigitofzero

• Baselinereportsweredistributedtoorganizationsin2013Q2including:

• PrecisionofsystolicanddiastolicBPmeasurementonallpatients

• StratificationbydegreeofHTN,i.e.,patientswithBP≥134/84,andbysiteofcare

• Improvementsweretrackedquarterlyforthedurationofa3-yearHTNcampaign

• Organizationswiththelargestimprovementssharedsuccessstories

Figure 1: Quantifying Precise Blood Pressure Measurement

• OntheleftisadistributionofsystolicBP,eachcolorrepresentsadifferentlastdigit

• ThestackedbarchartontherightshowstheproportionofpatientsgroupedbytheirlastdigitofsystolicBP,e.g.,17%hadlastdigit8,11%lastdigit6

• Lightercolorsrepresentevennumbers,darkercolorsoddnumbers

• IfBPwerepreciselymeasuredandrecordedtothenearest

•1mmHg,eachdigitwouldaccountforapproximately10%ofpatients

•2mmHg,evennumbereddigitswouldaccountforabout20%ofpatients

• Overall,32%ofpatientshada0asthelastdigitoftheirmostrecentsystolicBP(blue);suggestingalackofprecisioninBPmeasurementandanopportunityforimprovement

• MostorganizationshaveopportunitiesforimprovementinpreciseBPmeasurement

• SharingsimpleBPdatawithorganizationscanleadtoimprovements

• Stratifyinganalysesbypracticeorprovider/careteamcanleadtomoreefficientqualityimprovement,bytargetingareaswiththeleastprecision

• Interventionsleadingtoimprovementsvariedinbreadthandresourceutilization

• Ashealthcareorganizationstransitionfromvolumetovalue,productiveuseofEHRandotherdatawillbecomeincreasinglyessentialtobusinessoperations

• PreciseBPmeasurementisimportantasitenablesproviderstomaketimelytherapeuticadjustments,andpatientstobettermanagetheirowndiseasewithaccurateinformation

• Data-driveninterventionsarecriticalforefficientuseoflimitedresources,andthefutureofhealthcareintheU.S.

1Mozaffarian,D.,etal.(2016).“HeartDiseaseandStrokeStatistics-2016Update:AReportFromtheAmericanHeartAssociation.”Circulation133(4):e38-60.

2Lewington,S.,etal.(2002).“Age-specificrelevanceofusualbloodpressuretovascularmortality:ameta-analysisofindividualdataforonemillionadultsin61prospectivestudies.”Lancet360(9349):1903-1913.

Conclusions

Implications

Bibliography

• Overall,32%ofpatientshadalastdigitof0fortheirmostrecentsystolicBP

•Thisvariedacrossorganizationsfrom22%–55%

• SlightlylessprecisionwasobservedindiastolicBPreadings(36%with0)

• InpatientswithBP≥134/84,28%hadalastdigitof0forsystolicBP,31%fordiastolic

• Somepracticesorcareteamshadasmanyas83%ofpatientswithalastdigitofzero

Figure 2: Last Digit of Systolic (top) and Diastolic (bottom) BP

• DistributionoflastdigitofsystolicanddiastolicBPduringthebaselineperiod(2013Q1):

•Thisisshownbothoverall(left),andforindividualorganizations(right)

• BluerepresentstheproportionofpatientswithazeroasthelastdigitofBP

• Bytheendofthe3-yearcampaign,significantimprovementswereobservedat91%(20/22)oftheparticipatingorganizations(p<.001)

• Relativereductionsintheproportionofpatientswithalastdigitofzerorangedfrom3–62%

• SimilarimprovementswereachievedforbothsystolicanddiastolicBP

• AsubsetoforganizationswiththemostsignificantimprovementssharedstrategieswithotherAMGAmembers,suchas:

•Applyingacross-the-boardchangesatallpractices•Targetinginterventionswithspecificpracticesorindividualcareteamswiththeleastprecision

•ImplementingautomatedBPmonitors•Providingeducationalsessionstostaff

Blood Pressure:• Readingsrecordedduringanambulatoryvisit

Figure 3: Improvements in Precise Systolic BP Measurement

• ImprovementsintheprecisemeasurementofsystolicBPreadingsatthreeorganizationsoverthecourseofthreeyears

• Eachbarisaquarterrangingfrom2013Q1to2015Q4• AreductioninthebluesegmentrepresentsimprovementsinpreciseBPmeasurement