NUR 8200 Module 2 Care Gap Paper: Hypertension Control Data, a Registry Program and the Barbershop Trial Example

Forty-Six Percent Controlled: Using System Data to Close the Hypertension Gap in a Newark Health System

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Doctor of Nursing Practice, Thomas Edison State University

NUR-8200: Integrating and Evaluating Population Health in Advanced Nursing Practice

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Month Day, Year

Forty-Six Percent Controlled: Using System Data to Close the Hypertension Gap in a Newark Health System

The Gap in Our Data

Newark's system in this paper is invented, a teaching hospital and fourteen primary care sites in Newark and nearby cities serving about 120,000 adults, more than half of whom are Black or Hispanic. Its population health team built a hypertension registry from the electronic record, including every adult with a diagnosis code, two elevated readings or a blood pressure medicine. The registry holds 31,400 patients. Using the most recent reading in the past year and a threshold of below 140 over 90, 46 percent are controlled.

The data show deeper gaps. Control is 39 percent among Black men, 44 percent among Hispanic adults and 54 percent among white adults. Patients without a visit in the past year make up a fifth of the registry, and a third of uncontrolled patients are on only one medicine. Nearly a quarter of readings are recorded as a single measurement without a repeat when the first is high.

The registry itself needed work before it could be trusted. An early version counted patients with a single elevated reading at an urgent care visit, inflating the hypertension count by about 3,000 people who did not have the condition. The team narrowed the definition, checked a random sample of 200 charts by hand and found the revised registry correctly identified hypertension in 94 percent of cases. That validation step is reported in the paper because a care gap drawn from a flawed registry can send effort in the wrong direction.

The National Picture

Muntner et al. (2020) analyzed national survey data on 18,262 adults with hypertension across ten survey cycles from 1999-2000 to 2017-2018. The age-adjusted share with controlled blood pressure rose from 31.8 percent in 1999-2000 to 48.5 percent in 2007-2008, held near 53.8 percent in 2013-2014 and then fell to 43.7 percent in 2017-2018. Control was less likely among younger adults, those without a usual source of care or health insurance, and non-Hispanic Black adults. Our system's 46 percent, then, sits near the national level, but the national trend is moving in the wrong direction.

What Worked at Scale

Jaffe et al. (2013) described Kaiser Permanente Northern California's hypertension program from 2001 to 2009. The program built a registry of every member with hypertension, which nearly doubled over eight years to more than 650,000 members, shared control rates with each medical center, used a simplified treatment algorithm that encouraged single-pill combination medicines, and added medical assistant visits for blood pressure checks without a copay. On the HEDIS control measure, Kaiser members went from 43.6 to 80.4 percent, while the national average crept from 55.4 to 64.1.

The paper draws four elements from this program for our system: a registry with performance feedback to each site, a standard treatment algorithm, combination pills to reduce the pill burden, and nurse or medical assistant blood pressure visits between physician visits.

Reaching People Outside the Clinic

Victor et al. (2018) recruited 319 Black men whose top number was 140 or more through 52 Black-owned barbershops around Los Angeles in a cluster-randomized trial. In the pharmacist arm, barbers steered customers to pharmacists trained in hypertension care, who wrote prescriptions on site under collaborative practice agreements with the men's physicians. Barbers in comparison shops promoted healthier habits and urged men to see their doctors. By month six, men in the pharmacist shops had dropped their systolic readings by 27.0 points, against 9.3 points in the advice-only shops, and 63.6 percent of intervention participants reached below 130 over 80 compared with 11.7 percent.

For our system, where Black men have the lowest control and many have no recent visit, the barbershop model offers a way to reach patients the clinic misses. The paper proposes a pilot with ten barbershops in Newark's South and West Wards, staffed by the system's clinical pharmacists under a collaborative practice agreement permitted by New Jersey regulation.

The pilot is designed with the barbers, not only for them. Two barbershop owners who already host health fairs join the planning group and help choose the other eight shops. Barbers are paid a small fee for each customer they refer, as in the trial. Pharmacists visit each shop on fixed evenings and Saturdays, carry automated cuffs and a laptop connected to the record, and send each prescription to the patient's preferred pharmacy. The men's own physicians receive a note after every visit, so care stays coordinated.

The Program

The program has five parts. A registry dashboard shows each site's control rate by race, ethnicity, sex and age each month. A standard algorithm, approved by the system's medical leadership, moves patients to combination pills and adds a medicine when two readings are above target. Repeat readings are required when the first is high, with automated cuffs in every room. Nurse-led blood pressure visits are offered without a copay where insurance allows. A barbershop pilot with clinical pharmacists reaches Black men.

Measures

Control across the registry, broken out by group, is the headline measure. Secondary measures include the share on combination pills, how often a high first reading is rechecked, the share with a visit in the past year and, in the barbershop pilot, mean change in systolic pressure. A balancing measure, falls and fainting episodes among patients over 70, protects against overtreatment.

Limits

The Kaiser program operated in an integrated system with its own insurance, so the paper adapts rather than copies it. The barbershop trial was in Los Angeles and may differ in Newark. Registry data depend on accurate readings and coding, which the repeat reading rule improves.

Conclusion

The system's hypertension control rate of 46 percent sits near a national rate that is falling, and its registry shows the gap is widest for Black men and patients without recent visits. A registry with feedback, a standard algorithm with combination pills, repeat readings and nurse visits draw on the Kaiser program's success, and a barbershop pilot draws on a trial that brought pharmacist care to Black men where they are. Measures by group will show whether the gap closes.

References

Jaffe, M. G., Lee, G. A., Young, J. D., Sidney, S., & Go, A. S. (2013). Improved blood pressure control associated with a large-scale hypertension program. JAMA, 310(7), 699-705. https://doi.org/10.1001/jama.2013.108769

Muntner, P., Hardy, S. T., Fine, L. J., Jaeger, B. C., Wozniak, G., Levitan, E. B., & Colantonio, L. D. (2020). Trends in blood pressure control among US adults with hypertension, 1999-2000 to 2017-2018. JAMA, 324(12), 1190-1200. https://doi.org/10.1001/jama.2020.14545

Victor, R. G., Lynch, K., Li, N., Blyler, C., Muhammad, E., Handler, J., Brettler, J., Rashid, M., Hsu, B., Foxx-Drew, D., Moy, N., Reid, A. E., & Elashoff, R. M. (2018). A cluster-randomized trial of blood-pressure reduction in Black barbershops. New England Journal of Medicine, 378(14), 1291-1301. https://doi.org/10.1056/NEJMoa1717250