A Technology-Based Quality Innovation to Identify Undiagnosed Hypertension Among Active Primary Care Patients

Abstract

PURPOSE The goal of this study was to develop a technology-based strategy to identify patients with undiagnosed hypertension in 23 primary care practices and integrate this innovation into a continuous quality improvement initiative in a large, integrated health system. METHODSIn phase 1, we reviewed electronic health records (EHRs) using algorithms designed to identify patients at risk for undiagnosed hypertension. We then invited each at-risk patient to complete an automated office blood pressure (AOBP) protocol. In phase 2, we instituted a quality improvement process that included regular physician feedback and office-based computer alerts to evaluate at-risk patients not screened in phase 1. Study patients were observed for 24 additional months to determine rates of diagnostic resolution. RESULTSOf the 1,432 patients targeted for inclusion in the study, 475 completed the AOBP protocol during the 6 months of phase 1. Of the 1,033 at-risk patients who remained active during phase 2, 740 (72%) were classified by the end of the follow-up period: 361 had hypertension diagnosed, 290 had either white-coat hypertension, prehypertension, or elevated blood pressure diagnosed, and 89 had normal blood pressure. By the end of the follow-up period, 293 patients (28%) had not been classified and remained at risk for undiagnosed hypertension.CONCLUSIONS Our technology-based innovation identified a large number of patients at risk for undiagnosed hypertension and successfully classified the majority, including many with hypertension. This innovation has been implemented as an ongoing quality improvement initiative in our medical group and continues to improve the accuracy of diagnosis of hypertension among primary care patients.

CDC Grand Rounds: A Public Health Approach to Detect and Control Hypertension

“…NorthShore's Ambulatory Primary Care Innovations Group and clinical informatics team developed an enterprise-wide hypertension surveillance system within the EHR, which included point-of-care alerts for both clinic staff and physicians. Data were queried from the EHR using several unique algorithms to identify patients meeting the criteria for elevated blood pressure, and who might have hypertension (8). These algorithms, called NorthShore hypertension criteria, were derived from accepted clinical practices, guidelines, and research literature.…”

Patients With Undiagnosed Hypertension

“…Of the 520 patients who were identified by the algorithms and had a subsequent visit during which an AOBP was measured, 246 (47%) were found to have hypertension and another 185 (36%) were determined to have “white coat” hypertension, prehypertension, or elevated blood pressure (all based on International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes). Rakotz and colleagues 3 also reviewed 50 randomly selected patient charts from the cohort identified by the algorithms to validate that patients had undiagnosed hypertension and not undocumented hypertension. Of the 50 patients, 2 patients (4%) had physician notes that mentioned hypertension; only 1 of those 2 patients and an additional patient (4%) received antihypertensive medications despite not having a hypertension-related diagnosis code.…”

“…These patients are less likely to receive treatment 3, 5 and remain at increased risk for myocardial infarction, stroke, and kidney or heart failure. Moreover, because performance measures for blood pressure control typically rely on the use of ICD-9-CM codes to generate measure denominators, hypertensive patients without a diagnosis code are excluded from quality metrics, resulting in a potentially inaccurate and inflated blood pressure control rate for the population.…”

Evaluating models of healthcare delivery using the Model of Care Evaluation Tool (MCET)

“…Patients were contacted and scheduled a visit to discuss the blood pressure readings, obtain current readings, and increase patient awareness of the concerns. The description of the technology‐based strategy to provide a new service was extensive, and would allow replication in other practices (Rakotz et al., ).…”