Hypertension Use Case
- Dave Carlson
This implementation guide includes examples that use clinical practice guidelines to manage Hypertension (HTN). Examples are drawn from three sources of published clinical practice guidelines that are freely available (see references below). Primary emphasis is placed on Intermountain Healthcare’s Management of High Blood Pressure guideline that includes care process model algorithms with decision flow diagrams for diagnosis and treatment of high blood pressure.
A small subset of recommendations and clinical data requirements are selected from published guidelines to illustrate and compare use of available standards. This example is first presented from the clinical perspective, independent of alternative implementation standards that are described on this site. Complete, executable examples are then worked out on these pages:
The examples in this implementation guide focus on three aspects of patient care. The linked pages provide specific details from referenced guidelines that are implemented in examples.
Blood pressure screening during primary care visit
Emphasis on clinical workflow, followup scheduling, and criteria for HTN diagnosis.
Recommend therapeutic lifestyle changes (TLC)
Emphasis on patient-centered care planning and shared goals.
Provide educational support, evaluate adherence and progress toward BP target.
TLC elements include weight reduction, the DASH eating plan, sodium reduction, regular physical activity, limiting alcohol, and smoking cessation.
Treat uncontrolled high blood pressure to management target
Emphasis on guideline recommendation for a new or modified care plan intervention.
Initiate treatment with ACE-I (or ARB): lisinopril (or losartan).
Rapid cycle: Evaluate BP every two weeks while titrating or switching meds.
MEASUREMENT & GOALS
As a result of implementing this updated CPM, Intermountain aims to achieve and maintain BP control for Intermountain patients diagnosed with high blood pressure. This goal is designed to assist Intermountain in reducing the rate of serious conditions associated with high BP, such as stroke, chronic kidney disease, and cardiovascular diseases.
The goal is to maintain an acceptable BP through diet, exercise, weight loss, managed blood sugar for diabetics and avoid the complications of high blood pressure as listed above.
Define compelling indications: patients with risk factors and co-morbidities that increase the morbidity and mortality of hypertension (race, sex, diet, weight, cardiovascular disease, diabetes, sedentary lifestyle, etc.) should be in the reference CPG.
Determine what optimize means – maintain a therapeutic BP, i.e. below 140/90 or 130/80 for diabetes/CKD, and medication doses/combinations. Some meds work synergistically so the right combination of 2-3 meds to maintain a therapeutic BP will vary between individuals.
Hypertension Guideline Resources
The National Heart, Lung, and Blood Institute (NHLBI) report on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure clinical practice guideline will be used for examples of recommendations that are developed and published by a professional society.
NHLBI guideline: https://www.nhlbi.nih.gov/files/docs/guidelines/jnc7full.pdf
VA and DoD publish several guidelines for management of chronic disease in primary care. This hypertension guideline will be used as one example for adoption and implementation by a large healthcare provider.
Similar to the VA/DoD guidelines, Intermountain Healthcare publishes a large set of guidelines that are freely available. Of particular interest for this specification, the Intermountain guidelines include decision process “algorithms” that correspond with care pathway models in this IG. Their guideline for Management of High Blood Pressure includes three care process model algorithms with decision flow diagrams. Many published guidelines do not include explicit care pathway decision process algorithms.