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Patient Care Module 0.5 Credit CME

Improving Blood Pressure ControlMeasure, Act and Partner (M.A.P.) to help patients control blood pressure and ultimately prevent heart disease.

Team-Based Learning
Learning Objectives:
At the end of this activity, you will be able to:
1. List the three steps that help patients improve blood pressure control
2. State how to measure blood pressure accurately
3. Explain how to rapidly treat blood pressures that are not controlled
4. Describe the importance of partnering with patients, families, and communities

STEPS Forward™ is a practice improvement initiative from the AMA designed to empower teams like yours to identify and attain appropriate goals and tactics well matched to your practice’s specific needs and environment. Wherever you find your team on the practice improvement continuum, the American Medical Association can help you take the next steps – the right steps – to improve your practice. Learn more

How will this module help me control my patients’ blood pressure?

  1. Learn about the evidence-based M.A.P. framework to obtain accurate blood pressure readings, reduce clinical inertia and encourage patient self-management to improve blood pressure control

  2. Identify answers to commonly asked questions

  3. Learn what practices are doing to successfully monitor and control patients’ blood pressure

Introduction
Why is controlling hypertension so vital?

One in three US adults—about 80 million people1—has hypertension. With such a high prevalence of hypertension in the US, it is likely that your practice treats many patients with this condition. Most people with hypertension are aware of their condition, but only about half have their blood pressure under control.1 People with uncontrolled blood pressure may not be aware that it is the leading cause of premature death in the world.2 Clinicians like you need simple and effective ways to tackle hypertension in your patient population.

M.A.P. to improve blood pressure control

The American Medical Association and Johns Hopkins Medicine, in collaboration with clinical care teams from ten practices and health centers, formed an initiative called “Improving health outcomes: Blood pressure,” and created the “M.A.P. to improve blood pressure control.”

M.A.P. stands for:

  1. Measure blood pressure accurately

  2. Act rapidly to manage uncontrolled blood pressures

  3. Partner with patients, families and communities

M.A.P. checklists
The M.A.P. framework addresses common barriers to hypertension control, such as:

  • Poor or inconsistent measurement techniques

  • “White coat effect”

  • Clinical inertia

  • Ineffective care team communication

  • Missing or inconsistent care protocols

  • Poor patient engagement

Benefits:

You and your care team can improve the accuracy of blood pressure measurement through teamwork, improved communication and using standardized protocols. Measuring blood pressure accurately leads to reliable diagnosis and efficient and appropriate treatment.

Evidence–based treatment protocols encourage consistent delivery of care and help formalize the treatment plan, including reassessment schedules. Clinical teams with well-communicated plans will achieve greater success in improving blood pressure control.

Finally, patients who proactively participate in managing their hypertension tend to have better blood pressure control. By committing to lifestyle and behavior changes, taking medications as prescribed and participating in self-measurement of blood pressure, patients can make significant contributions to their overall health and well-being.

“We thought we were doing a good job treating patients with hypertension, however we are more aware of the many patients that are not at goal. We learned a lot from the initiative. It’s been a great experience.”

Practicing physician
Three steps to help patients improve blood pressure control
Step 1Measure blood pressure accurately

When screening patients for high blood pressure (BP) in the office:

  • ✓ Use a validated, automated device to measure BP3

  • ✓ Use the correct cuff size on a bare arm412

  • ✓ Ensure the patient is positioned correctly451321

If the initial office blood pressure is ≥140/90 mm Hg, obtain confirmatory measurements:

  • ✓ Repeat screening steps above

  • ✓ Ensure patient has an empty bladder4,5,23

  • ✓ Ensure patient has rested quietly for at least five minutes4,5,24,25

  • ✓ Obtain the average of at least three BP measurements4,5,26

Box Section Ref ID

Q&A

  • How do I know if the cuff size is correct?

    A properly fitted cuff should have a bladder length that is 80 percent of the circumference of the arm, and a width that is at least 40 percent of the circumference of the arm. Measure arm circumference with a tape measure around the mid-arm at the bicep. Although the lines on cuffs for proper fit are correct when the patient’s arm falls in the middle of the range, they are not 100 percent reliable, and less so at the upper and lower limits of what each cuff size allows. See Table 1 for guidance on selecting the appropriate cuff size for your patient.

    Table 1.

    Cuff sizes for accurate blood pressure measurement22

  • Why does taking multiple measurements matter?

    Increasing the number of blood pressure readings may increase diagnostic accuracy. If the initial office blood pressure measured is ≥ 140/90 mm Hg, the chance of a misclassification of hypertension is significantly increased.26 An average of three blood pressure readings is recommended.

  • Why is patient positioning important?

    Several factors must be considered to accurately measure blood pressure, including body positioning (see Table 2). Dangling feet off of an exam table can raise systolic blood pressure by up to 10 mm Hg. Emphasize to your patients that proper technique and body positioning be followed for every blood pressure measurement, both in and out of the office.

    Table 2.

    Common problems that account for inaccurate blood pressure measurement

    Apply these evidence-based tips for correct positioning of the patient to all blood pressure measurements.

    Ensure the patient is seated comfortably and the following conditions are met:

    1. Back supported

    2. Legs uncrossed with feet flat on the floor/supported with a stool

    3. Arm supported with the BP cuff at heart level

    4. No one should be talking during the measurement

    Graphic Jump Location
    Q&A

    Get more tips for measuring blood pressure accurately with this office blood pressure poster for staff.

Step 2Act rapidly to treat blood pressures that are not controlled

To treat uncontrolled blood pressure:

If the patient has blood pressure ≥140/90 mm Hg confirmed:

  • ✓ Use an evidence-based protocol to guide treatment2729

  • ✓ Re-assess patient every two to four weeks until BP is controlled3032

  • ✓ Whenever possible, prescribe single pill combination (SPC) therapy3336

Evidence-based protocols typically include the following tasks:2729

  • Counsel on and reinforce lifestyle modifications

  • Ensure early follow-up to monitor blood pressure and add preferred medications in a step-wise fashion, until BP is controlled

  • For most patients, give preference to the following medication classes:

    • Thiazide diuretics

    • Dihydropyridine calcium channel blockers

    • ACE inhibitors (ACEI)

    • Angiotensin receptor blockers (ARB)

  • Do not prescribe both ACEI and ARB to same patient

  • If BP ≥160/100 mm Hg, start therapy with two medications or a single pill combination

Box Section Ref ID

Q&A

  • What are the benefits of prescribing single pill combination therapy?

    Single pill combination therapies make it easier for patients to fill and take blood pressure prescriptions. From 2001 to 2009, Kaiser Permanente Northern California (KPNC) instituted a comprehensive quality improvement program that resulted in an improvement in control of blood pressure at goal from 44 percent to 80 percent.36 Single pill combination therapy (lisinopril and hydrochlorothiazide, ACEI-HCTZ) was stressed as part of the program. From 2001-2009, the percentage of angiotensin-converting enzyme inhibitor prescriptions dispensed as a SPC (in combination with a thiazide diuretic) increased from < 1 percent to 27.2 percent (see Figure 1).36 During this time period, prescriptions for the lisinopril-hydrochlorothiazide combination pill rose from 13 prescriptions per month to 23,144 prescriptions per month.36 This shift in prescribing habits was a significant contributor to the success of the KPNC program.

Figure 1.

Percentage of angiotensin-converting enzyme inhibitor prescriptions dispensed as single pill combination ACEI-HCTZ combination tablets for Kaiser Permanente Northern California members between 2001 and 2009

Graphic Jump Location
Q&A
Reprinted with permission from JAMA: The Journal of the American Medical Association.
Step 3 Partner with patients, families and communities

Quiz Ref IDTo empower patients to control their blood pressure:

  • ✓ Engage patients using evidence-based communication strategies3739

  • ✓ Help patients to accurately self-measure BP40,41

  • ✓ Direct patients and families to resources that support medication adherence and healthy lifestyles

Table 3.

Evidence-based communication strategies37,39

STRATEGYSUGGESTED APPROACH
Begin with open-ended questions about adherence, including recent medication useAVOID: “Are you taking your medicines?”
TRY: “How are your medicines working for you?”
Explore reasons for possible non-adherenceAVOID: “Let me prescribe a different pill that might work better.”
TRY: “What do you think would make it easier?”
Elicit patient views on options and priorities to customize a care plan for each patientAVOID: “Have you considered using a pillbox?”
TRY: “What do you think would work for you?” or “What has worked for you in the past?”
Remain non-judgmental at all timesAVOID educational statements: “It’s really important to take your pills if you want to control your blood pressure.”
TRY supportive statements: “Let’s think about this problem together, maybe we can come up with something that will work for you.”
Use teach-back to ensure understanding of the care planAVOID closed-ended question: “Does this make sense to you?”
TRY: “What is your understanding of what we’ve discussed today?”

Evidence-based tips for patient self-measurement of blood pressure

  • Instruct the patient how to measure blood pressure accurately using a validated, automated home blood pressure monitor and correct positioning

    • Upper arm monitors are recommended

    • All patients should also be instructed to bring in their monitors for testing in your office to make sure they are properly fitted and working properly for best results

  • Ask the patient to record two morning and two evening blood pressure measurements (one minute apart) for at least four consecutive days between office visits (a minimum of 16 measurements)

  • Develop a systematic approach to ensure patients can act rapidly to address elevated blood pressure readings between office visits

  • Counsel patients that self-measured BP ≥135/85 mm Hg is considered elevated

SMBP monitoring program

“It [The M.A.P. Program] forced me to make a point to educate patients about their uncontrolled blood pressure and what they can do about it. It helped me to enlist patients in taking ownership of their BP.”

Practicing physician
Box Section Ref ID

Q&A

  • What are some benefits of implementing a self-measured blood pressure (SMBP) program at home?

    SMBP programs improve blood pressure control, especially if some form of clinical support is provided to the patient.41 Clinical support varies based on your practice’s capabilities, but could include feedback from clinical office staff, feedback through reporting via a secure patient portal and instructing patients how to titrate medications.

    In addition, SMBP improves adherence to antihypertensive therapy.42

Evidence-based lifestyle changes to lower BP

Encourage patients to:

  • Follow the Dietary Approach to Stop Hypertension (DASH) eating plan43

    The DASH plan:

    • Is rich in fruits, vegetables and whole grains

    • Includes low-fat dairy, poultry, fish and plant-based oils

    • Limits sodium, sweets, sugary drinks, red meat and saturated fats

  • Participate in moderate physical activity, such as brisk walking, for 40 minutes a day, at least four days a week.43 Ten minute blocks of walking four times a day counts as 40 minutes of daily exercise

  • Maintain a healthy body mass index (BMI)43

  • Limit alcohol consumption to ≤ 2 drinks per day for men or ≤ 1 drink per day for women43

Access tools to help patients lower their blood pressure: DASH eating plan, A patient guide to lowering your blood pressure

Box Section Ref ID

Q&A

  • Do lifestyle changes have an impact on improving blood pressure?

    Yes, lifestyle changes can have a significant impact on blood pressure control for your patients. Examples are shown in the table below.43

  • What key messages should I use when advising patients about healthy lifestyle choices to lower blood pressure?

    Communicate the following to your patients:

    • Consume no more than 2400 mg of sodium/day by reducing the amount of salt in food and the consumption of processed foods

    • Eat at least five servings of fruits and vegetables per day

    • Choose whole grains products and high-fiber foods over refined grains (avoid white bread, rice and pastas)

    • Gradually build up to 40 minutes of physical activity, like brisk walking, most days of the week

    • Limit calories to meet and not exceed daily needs

    • Use personalized and cultural food preferences (eat the foods you like, just don’t overeat)

  • What does it mean to partner with families and communities in my practice?

    For you as a clinician, this means that you:

    • Identify and refer your patients to resources available in the community

    • Volunteer at health fairs or blood pressure measuring events in your community

    • Speak in the community on the importance of preventing cardiovascular disease and controlling high blood pressure

    • Lead by example. Modeling a healthy lifestyle is a great example for your patients to follow

    In addition, you should strive to encourage patients and families to participate in healthy lifestyle activities such as:

    • Assisting each other with blood pressure monitoring

    • Offering reminders for when to measure blood pressure and take medications

    • Providing both physical and emotional support

    • Participating in healthy lifestyle choices together, such as physical activity and healthy eating

    • Taking advantage of community resources that offer BP screening and places to exercise together

Box Section Ref ID
Conclusion

Integrate the evidence-based strategies, tools and resources in this module into your workflow to improve your patients’ blood pressure control. Using the M.A.P. framework, and adapting it to meet your practice’s needs, can increase the accuracy of blood pressure measurement, reduce clinical inertia and empower patients to self-manage their blood pressure, leading to improved quality of care.

Glossary Terms

White coat effectWhite coat effect: the alerting reaction that many patients experience when having their blood pressure measured in a health care setting. This effect commonly causes office blood pressures to be higher than out-of-office blood pressures or self-measured blood pressures at home.Clinical inertiaClinical inertia: a lack of treatment intensification at the end of an office visit in a patient with a blood pressure not at goal.

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Where CME credit is designated, the activity is part of the American Medical Association's accredited CME program. The AMA is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
Article Information

Target Audience: This activity is designed to meet the educational needs of practicing physicians.

Statement of Competency: This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice, interdisciplinary teamwork and quality improvement.

Planning Committee:

  • Rita LePard – CME Program Committee, AMA

  • Ellie Rajcevich, MPA – Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA

  • Sam Reynolds, MBA – Director, Professional Satisfaction and Practice Sustainability, AMA

  • Christine Sinsky, MD – Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA

  • Krystal White, MBA – Program Administrator, Professional Satisfaction and Practice Sustainability, AMA

Author Affiliations:

  • Michael Rakotz, MD, FAAFP, Director, Chronic Disease Prevention, Improving Health Outcomes, AMA

Faculty:

  • Romsai Tony Boonyasai, MD, MPH, Assistant Professor of Medicine, Johns Hopkins School of Medicine; Lisa A. Cooper, MD, MPH, James F. Fries Professor of Medicine, Johns Hopkins University School of Medicine; Director, Johns Hopkins Center to Eliminate Cardiovascular Health Disparities; Omar Hasan, MBBS, MPH, Vice President, Improving Health Outcomes, AMA; Linda Murakami, MSHA, RN, Improvement Specialist, Improving Health Outcomes Strategies, AMA; Michael Rakotz, MD, FAAFP, Director, Chronic Disease Prevention, Improving Health Outcomes, AMA; Kathryn Taylor, RN, MPH, Johns Hopkins Medicine, Senior Research Nurse Program Manager, Armstrong Institute for Patient Safety and Quality; Matthew K. Wynia, MD, MPH, Director, Physician and Patient Engagement, Improving Health Outcomes, AMA

About the Professional Satisfaction, Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

About the Improving Health Outcomes Group: The AMA's Improving Health Outcomes area is tackling two of the nation's most prevalent issues: cardiovascular disease and type 2 diabetes. Beginning with a focus on risk factors for these conditions, the AMA is helping physicians and care teams to control high blood pressure and prevent diabetes—two disease burdens that cost the US health care system more than 500 billion dollars annually. With work already underway to engage organized medicine, the private/public sector, the federal government and local communities, the AMA is adding its resources and skill in orchestrating effective collaborative efforts to help improve the health of the nation.

Disclosure Statement: The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.

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