Hypertension
Loren Bonner
The American Heart Association (AHA) and the American College of Cardiology (ACC) jointly released a set of performance and quality measures for adults with high blood pressure that closely align with AHA/ACC’s blood pressure guidelines published in late 2017. Like those guidelines, the new measures are centered on team-based care.
A pharmacist who is already working as a member of a health care team has an opportunity to impact most of the new measures, if not all of them, said Mary Ann Kliethermes, PharmD, adjunct professor at Midwestern University Chicago College of Pharmacy.
Formally called the Clinical Performance and Quality (CPQ) Measures, AHA/ACC’s 22 measures for diagnosis and treatment of high blood pressure consist of 6 performance measures, 6 process quality measures, and 10 structural quality measures, which is a new category (see tables).
The performance measures are based on strong evidence and outcomes intended for payment. The quality measures, which have less evidence behind them, are designed for local quality improvement, where it is easier to manage measure issues, said Kliethermes. The structure measures are meant to improve the system and process to make sure hypertension treatment goals are met.
“Which measures a pharmacist actually influence is directly related to the service provided,” said Kliethermes. “As a pharmacist, the measure I would want to influence most is control of blood pressure because that is the ultimate value of my service.”
Like the 2017 blood pressure guidelines, the CPQ measures capture proper blood pressure monitoring, including home monitoring, as well as measures for antihypertensive medication adherence. They also take into account lifestyle changes for individuals who have hypertension, which is now defined as stage 1 hypertension (130–139/80–89 mm Hg). Readings of measures at or above 140/90 mm Hg are considered stage 2 hypertension.
Adopting measures relevant to your practice
The real opportunity with these measures arises for pharmacists who practice with a health care team. Working under a collaborative practice agreement on comprehensive medication management to manage hypertension, a pharmacist would be able to influence measures that achieve blood pressure control, influence lifestyle, manage social issues, improve adherence, or monitor blood pressure remotely, Kliethermes said.
Christina DeRemer, PharmD, BCPS, BCACP, FASHP, a clinical specialist at a rural family medicine clinic in Old Town, FL, said the new measures don’t feel novel to her. As a pharmacist who sees her own set of patients and is treated like a provider at her clinic, she said the new measures validate the goals she sets for her patients who have hypertension.
The quality measures supporting lifestyle changes to improve blood pressure are what stood out to her most with the new measures.
“Advocating for this is something I do as a pharmacist,” she said. But she thinks there is room for improvement, which also means holding patients accountable to lifestyle modifications. “I like seeing this in print—this is the stuff we should be doing.”
The quality measures for lifestyle modifications also have level A evidence—the highest level—supporting them.
Some of the measures specifically mention the value of the pharmacist, particularly those related to home blood pressure monitoring.
In the rationale section of the quality measure on use of home blood pressure monitoring for management of AHA/ACC stage 1 or stage 2 high blood pressure, the guidelines state: “Evidence also suggests that home-based [blood pressure] measurement in combination interventions with telemedicine with nurse- or pharmacist-led care may be effective for improving hypertension management.”
“Pharmacists should adopt the structure measures that are relevant to their practice and support other structure measures less related to their practice,” Kliethermes said.
Collect the data, connect the outcome
Although the new measures make the case for pharmacists to join health care teams to improve patient outcomes, pharmacists will still have to find creative ways to bill, said DeRemer. The current model in her clinic consists of a hybrid billing structure, which creates a sustainable practice while allowing the pharmacist to positively affect outcomes through a team-based approach.
“As pharmacists strive to be recognized as billable providers, we need to be ready through demonstrated understanding of coding and billing in addition to clinical outcomes,” said DeRemer.
Kliethermes said it’s even more important that pharmacists document the service they provide, collect the data, and connect the outcome to a measure.
“I believe it is important for pharmacists to understand that measurement for performance and quality will be critical to sustainability of their practice. If not immediately, it will be soon,” said Kliethermes. She encourages pharmacists and all providers to understand the meaningfulness of the measures, their feasibility, and what they portray as far as value and quality.
“What makes the blood pressure measures important is that this is an area where the evidence is strongest for pharmacists providing patient care,” she said.
The measures, published in the November 2019 issue of AHA’s Circulation: Cardiovascular Quality and Outcomes, are available at https://apha.us/2019BPmeasures.