105. Saving the Most Lives: Blood Pressure

How do you save the most lives? It's a deceptively simple question. Welcome to the final show of season three of the ACO show. Today Josh is joined by three different guests. Dr. Karzad Mostashari, Alladade CEO. Dr. Keisha Davis, Alladade's vice president of health equity and Dr. Keith Winfrey, the chief medical officer at Noella Community Health in New Orleans. Alladade has made controlling hypertension a priority and you'll hear about why. Including how lowering blood pressure may be the single best way to save lives in the healthcare system. The disparity of hypertension in black Americans compared to any other racial or ethnic group and what Alladade is doing about it. This is the ACO show. I'm Josh Israel, a medical director at Alladade and I have the pleasure today to be joined by Alladade CEO Dr. Farzad Mostashari. Hi Farzad. Hey Josh. We're going to talk about blood pressure today. Of all the things Alladade could do we're giving a lot of TLC to blood pressure. Can you talk me through your thinking about why that is? Yeah so this has been something of an obsession for me dating back to my time the 10 years I spent at the New York City Department of Health where in the public health agency we had during that period incredible clarity around what's the question and the question we were focused on was how do we save the most lives? How do you save the most lives? And it's a deceptively simple question and it was shocking to us that it didn't seem to be the North Star that guides decision-making at either public health agencies or healthcare providers. From a public health agency point of view the answer to that question was smoking and so we dedicated you know there's so much going on for you know billions of billions of dollar agency with thousands of employees and that includes you know school nurses and dog catchers and outbreaks and all the TB and STDs and everything else going on but Tom Frieden spent more than 50 percent of his time focused on smoking and made that the priority for the agency because it was clear that that was what would save the most lives. But when it came to healthcare when you ask that same question how can healthcare save the most lives? Of all the hundreds of quality measures and USPSTF you know A, B interventions what would make the biggest difference? And at that time this was in the mid 2000s there was no paper no analysis that answered that question and so we did it ourselves and I think maybe in the show notes you could you could attach a link to that paper what we found was that if you take America's healthcare performance on on those evidence-based clinical measures and you take them from where they are today to where the best institutions and that was often the VA or Kaiser was what we could find to have the best institutions perform what is the delta in terms of the number of lives potentially saved? And the answer was overwhelmingly things that affect cardiovascular disease and in particular hypertension. Hypertension control like by an order of magnitude more than you know other good things to do colonoscopies and mammograms and screenings like those are you know immunizations even right like those are all good things to do don't get me wrong but the amount of attention that we dedicate to hypertension control is nowhere near nowhere near the importance that it potentially has in terms of simply answering that question how do we save the most lives? The other piece of evidence that has become much more top of mind for us since those you know 15 years ago is also its impact on health equity where if you ask the question what accounts for the greatest disparity in deaths among racial minorities it's hypertension control and here's the thing we don't need to discover new mRNA vaccines we don't need new basic science we don't need like we don't need like an incredible amounts of money right like the treatment effective treatments for hypertension you know date back to hydrochlorothiazide for goodness sake we just need to elevate through the the importance of hypertension control compared to everything else if we spend 10 times as much worrying about hypertension control as we do about all this other quality stuff then we would be well in our way. So that paper is not that recent and I know scientific knowledge dissemination takes some time but you're saying we know what to do so why has more not been done is it a matter of incentives that still the system is set up to do extremely well off treating strokes and heart attacks and until now the alignment was not there for the business angle on preventing those things. Yeah I think that's right look it's it's easy to misdiagnose the the problem and the solution to it and I did that for you know 15 years of my career I thought it was an information problem first right I thought oh the the reason why we don't control blood pressure is because we can't just like blood pressure itself five blood pressure it's invisible it's the invisible killer right you don't know what your blood pressure control levels are and the average primary and care practice so of course you're not going to focus on it and you know we measure things to tell us what to focus on and what's important so we spend all this all this time and effort like literally I was in the first you know meaningful use of health IT policy meeting that I was co-chairing we said our goal for meaningful use was going to be to improve blood pressure control and you know 10 years later we have you know near universal adoption of electronic health records with certification to ensure that they collect blood pressure in a systematic way and medications and diagnoses and have decision support and registry functions and they check all those gosh darn boxes and hypertension control in America has not budged one bit in the past 10 years if anything it has gone down so we have the infrastructure the data infrastructure now that we did before but pay for performance and MIPS and all of the you know the other kind of quality industrial complex has not been the way to incentivize movement on blood pressure control in part because the industry turns out more and more and more measures you've recently Josh created a compendium of all the quality measures that that that allidate practices have to track how many how many different rows on that worksheet Josh 88 different measures it's bonkers 88 measures right and you know so so yeah if you if you get distracted by that that swarm you're not going to focus on something that matters most and so how do you focus attention I think financial incentives are part of it but I don't want to I don't want to say that I think there's also so much of what happens in medicine gets done because of the ethos and people wanting to do the right thing and it's not just a coin operated world where you know people only do things because they're they're paid to do it and so I think we need to you know it's it's the are the allidate's favorite book on behavior change is switch right we need to appeal to to the brain and and the accountant inside right so that's the the financial calculus has to make sense to spend that extra time with the patient talk about medication adherence that not being seen as a waste of revenue waste of time the second thing has got to be we've got to kill to the heart right the elephant we've got to appeal to the the reason why people just entered medicine in the first place to save lives and here is the way you can do it and think about the tragedy that's a stroke that's a heart attack that's kidney failure think about how you feel when one of your patients who you know has a stroke and you hear about it and then you realize with that sinking dread in your stomach that they had you know blood pressure reading of 160 over 111 the last time you saw them didn't do anything about you didn't change their medications and they didn't come back in 30 days and you lost track of it and then the next thing you hear about they had a stroke how does that feel right feeling is the second and then the third is paving the road right making it easier so that the easiest thing to do is the right thing to do that we overcome clinical inertia that their practice workflows around calling in patients with high blood pressure who've been lost to follow up and measuring blood pressure religiously and changing therapy if it's not working then tracking medication experience and doing all those things around the clinical encounter it's not it's everyone in the practice being engaged not just the physician at the point of care so rider elephant and road all three have to be tapped well dr. Farzad mr. shariant that was a extremely clear why about blood pressure and we'll spend the rest of the show talking about the how thank you thanks so much we're now glad to be joined by a repeat guest dr. kisha davis dr. davis is a family physician and aledade's vice president of health equity welcome back kisha thanks glad to be here you were leading part of our efforts on hypertension so i'd love to talk to you about what aledade's doing to tackle it but let's talk a little bit about the statistics what what's going on in america and that aledade with high blood pressure sure i've you've already heard hypertension in america is a huge phenomenon the single highest area where we can improve lives is to improve our hypertension control almost one in four americans live with hypertension and very few of them have it under control when you look out across your patient panel up to four and ten of your patients might be suffering from uncontrolled hypertension and the health care costs are really astronomical over 131 billion dollars every year is spent related to hypertension and we know not only is hypertension impactful across the country we also know that there is a disparity in hypertension in black americans and we see hypertension being more common in black americans than any other racial or ethnic group hypertension in black americans develops at younger ages and those differences start even as early as age 30 we see higher incidents of stroke high blood pressure related cardiovascular disease as well as end stage renal disease and the mortality rates are two and a half to three times higher in black americans and that spans the rural urban divide and also spans socioeconomic status why is hypertension such a big issue you know if it's known to be a problem if it's known to have such serious health outcomes why is it so poorly controlled you know hypertension is often referred to as the silent killer because people often feel fine when their blood pressure is high and so it's easy to pass it by or or not pay attention to it i think on the patient side and i think even on the medical side as physicians you know hypertension is one of the things that's really core to what we do it's one of the first things that we learn how to treat when we're in medical school and residency but at the same time because patients often feel so well even when their blood pressure is well controlled it's easy for it to get put on the back burner and a patient might come in with a long list of things that they are concerned about or worried about and blood pressure may not be on the list and it's easy for it to get passed aside because of that cold because of that stubbed toe i think another reason is that sometimes we as doctors don't trust the data or you know we don't trust that blood pressure reading if it was done hastily and so the patient may come in and the blood pressure is high and we might write it off because they oh they ran up the stairs or they are stressed out or you know they're worried or their blood pressure is always high in the doctor's office and i would say you know for those patients i would challenge us to not write it off and to really think about okay well let's let them sit and rest a little bit and check that blood pressure again or if their blood pressure is always high in the office let's follow up with them outside of the office you know encourage them to get a blood pressure cuff at home start checking and monitoring those blood pressures to really get a handle on on how how well their blood pressure is controlled or not controlled we can bring to the doctors who work with allidate the information that blood pressure is serious that's a real problem but it's a lot easier to tell somebody about a problem than to help them with it what are we bringing to the table to deal with hypertension yeah you know i think it's so important you know we don't necessarily need to tell docs how to treat hypertension there's lots of guidelines out there but what i think docs do sometimes need help with is finding those patients that are falling through the cracks and i know i will say myself that i am guilty of this again that patient comes in with a long list of problems and nobody flagged for me that that blood pressure was high and it's you know the end of the day and i'm now charting that note and then i see oh my goodness their blood pressure was high i didn't even recognize it and so one looking at what are those systems you have in place in your office to to find those patients um and make sure before they leave their blood pressure is checked again then there's the patient that you saw them you realized their blood pressure was high you know maybe you made some adjustments in their medications and said come back in a couple weeks or come back in a month and now it's several months later and you're seeing them back in the office and you say what happened here you know why didn't they come in and that person fell through the cracks and we don't have a good way previously to find that person and make sure that they get wrapped into care and so some of the things that we have done in the app to make that a little bit easier the first is a blood pressure tab so in the allidate app you know which is our tool where you can really get information on patients that have contracted with us through allidate in the app on the daily huddle you'll now notice blood pressure tags so a bp mod bpm mod and bp sev for blood pressure severe and those correlate to the last blood pressure reading that we have on file was elevated for that patient so bp mod indicates the blood pressure was 140 to 159 systolic over 90 to 99 diastolic and the blood pressure is severe indicates greater than 160 over greater than 100 and so you'll now see a tag on the daily huddle indicating that the last time they were in their blood pressure was high but the thought being okay let's address that blood pressure when they're in the office today they are here let's find them let's make sure that that blood pressure doesn't fall through the cracks in addition because we have those tags you can also run a report and find those patients that may have fallen through the cracks so using population explorer which is another tool within the app you can choose uncontrolled hypertension so there's a quick pick for hypertension and it will give you all of your patients with a blood pressure moderate or severe and then you can sort that list and look and see oh mrs jones she was in you know three months ago her blood pressure was 165 over 105 what happened to her and then you can you know look in the EHR and say oh she had an appointment but she never followed up or you know she walked out of the office and we didn't get her in or what else do we need to do maybe she didn't get her medications and so there's workflows there and resources to really find and surface those patients who maybe you know maybe have fallen through the cracks we're using a mnemonic to kind of help us remember that and you know calling it treating blood pressure 247 or 247 and so really encouraging you know when a patient comes in and their blood pressure is severe and you've sat them down and let them rest and checked it again and it's still high it's still you know greater than 160 over 100 we'd like to see them back in two weeks that's what the guidelines say the american heart association guidelines and recognize this is different than how some of us were taught so really can we get them back in two weeks for hypertension treatment is for everyone this is really a team affair you know hypertension control doesn't just rest on the backs of the docs and nurse practitioners and pAs who are caring for those patients it's really how are the medical assistants getting involved how are the nursing staff getting involved how is the front desk getting involved you know when that patient has seen the doc and is checking out at the front desk their blood pressure is high and the doc said come back in three months you know encourage the front desk to reach out and say oh the doc said three months but i see that your blood pressure was still high let's get you back in two weeks to to do a blood pressure check and maybe that's to meet with the nurse even or a medical assistant for a blood pressure check and then the last is seven and we're really encouraging doing a seven day follow-up again when that patient everything's been done to try and get their blood pressure down they've rested and repeated the blood pressure and it's still high and they're walking out of the office with that with a severely elevated blood pressure can we get them a follow-up in seven days not not necessarily coming in the office but having somebody call and reach out to them do they have a blood pressure cuff at home have they checked their blood pressures are they feeling okay are they having any problems with the medications that they're taking do they have that follow-up visit scheduled that two-week follow-up visit scheduled so that they can get back in and make sure that everything is okay and so i'll just run through that through those again two four seven two-week follow-up blood pressure control is for everyone and seven-day follow-up outreach to make sure that folks aren't falling through the cracks so it sounds like there's a few hypotheses there one is that physicians and other healthcare providers know how to treat blood pressure but they don't always know who to treat if the the data is not being brought to their attention that sometimes patients aren't being seen frequently enough when this is being addressed and the team-based cares are better way to do it of those hypotheses how's it proving out is it is it working yeah you know especially on the first point of the you know these folks are falling through the cracks we have been hearing some fantastic stories about doctors now that they're seeing the list who are just surprised you know we had one doc and we showed him the list of 30-day follow-up and he got mad rightfully so and in two weeks he had his staff call all of the patients on the list and they improved their 30-day follow-up rate by 80 in just a couple weeks which is just amazing you know another thing that we've been finding are there are patients on that list that didn't have a diagnosis of hypertension and so practices are surprised and so again because the focus wasn't on hypertension that patient came in for you know a stubbed toe and then they came in for a cold and then they came in for a stomach ache and their blood pressure was high each of those times but it was chalked up to something else each time but when they look over the aggregate they're like oh this but this person does have hypertension and we've been missing it because we were focusing on other things so you know keeping folks from falling through the cracks there has really already starting to show some improvement the team-based care is also really important one of our docs has shown that when everybody on the team understands and gets involved and invested in hypertension or other and any other preventive care work for that matter it really helps them feel like they are making a difference for that patient and brings them closer to the work and gives them satisfaction too so they are involved they're not going to let that patient walk out of the door they feel invested and involved in the care and patients really appreciate that too. Dr. Kesha Davis thanks as always for joining the ACO show. Thanks again Dr. Israel always a pleasure. Now joined by Dr. Keith Winfrey who is a specialist in internal medicine and preventive medicine and the chief medical officer at Noella Community Health in New Orleans welcome Dr. Winfrey. Thank you for having me glad to be here. When I've asked around about who's doing good work in blood pressure a couple different people mentioned your health center and you how have you been approaching hypertension in your practice? We approach hypertension like many of the other chronic diseases in the area more to team-based approach we have adopted the patient center medical home model for our way of delivering care and so the way we address hypertension is much like the other chronic diseases in that we have the primary provider we have medical assistance in a team of care coordinators that work with them. Allidate has recently introduced blood pressure tags in the app the app is the population health platform that we put in front of physicians and it indicates when patients may need a little extra attention on their blood pressure how have you used that in your practice? It's worked great and that's allowed our care coordinators to really be more efficient when they're searching out hypertension patients particularly those involved the ACO they were a part of. It allows them to directly identify patients that need more of their time and attention and then they've made it kind of prioritize them and giving them in to meet with their providers. Given the outreach that you're doing can you say any more about what kind of results you've been seeing? Yes the results have been positive we're one being to quickly identify patients who are following that range you know one six over a hundred or the extreme blood pressure range and so it's allowed our care coordinator to spend more time with them ensuring that they are using their home blood pressure monitor correctly if they're getting that data back to our staff and then getting back in front of our providers and so we have noticed that she's made it give those patients in a lot faster than we've done in the past. That's great so she uses the Allidate app if I understand correctly to generate a list of patients who need outreach? She does absolutely and she used that list to kind of prioritize her work and then from there really work to get those patients in the office in front of their providers. What kind of learnings have there been about patients whose blood pressure right of control you know any surprises once patients were contacted? Surprisingly no I mean the patient has been very open to to coming back in and having to address many patients report that you know they get nervous when they come in to see their providers and so they bleed as a white coat syndrome effect and so we just ensure that all the patients have a home automated blood pressure one that's been calibrated and maybe they should they bring those readings with them when they come in. We have health coaches within the clinic and so we schedule these patients with their health coaches depending on their interests and their blood pressure and the health coaches are able to spend a little more time than our care coordinators really delving into aspects of hypertension like lifestyle modification, stressors, diet, physical activity to really help round out their their hypertension management and so I think that has also been helpful for us to get our patients making the right choices to have improved their blood pressure. Now before the Allidate Population Health Platform put this data in front of your practice, were there ways to generate sort of simple lists of which of your patients needed attention on their blood pressure? There are yes our QI director would run monthly reports on all of our patients just looking at our overall hypertension control rates and from there he would provide those lists to our team to to work on but prior to the Allidate work it was really left up to our primary care teams to address meaning the primary care provider in their own MOA. With the Allidate app we're now bringing our care coordinator to focus her efforts on reaching out seven days after the visit makes your patients are getting back in within 30 days and that they're plugged in with the health coach if they haven't done so already. Well great Dr. Keith Winfrey glad you're taking such good care of your patients and I'm glad we can be some small part of it. Great thanks for having me. This episode was produced by Brittany Barnes and also by the irreplaceable Hannah Posner. Though after this show we have to somehow try to replace her as she moves on to the next phase of her career. Thank you Hannah. The ACO show will be taking a short break and we will be back in the fall with a new season of great shows about all the things in value-based healthcare. From all of us we wish you a great summer. ACO Show