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