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Melanie Cole (Host):  Hello and our topic today are the challenges that providers face when they are associated with effectively treating and managing hypertension. My guest is Dr. Robert Healy. He’s the Chief Medical Quality Officer at Carle Foundation Hospital. Dr. Healy what do you see are some of the biggest challenges for providers when they are trying to treat and manage hypertension and tell us about some of the best practices that you are using there at Carle Foundation?

Robert Healy, MD (Guest):  Yeah sure. Great to be with you. One of the challenges I feel of us dealing with hypertension just like any disease that we deal with; is that there is so much that we are doing everyday when we see patients. So, no matter if we are specialists or primary care, we see a patient and as we know they come in with a list of ten different things it seems like. So, focusing on high blood pressure, which if we asked all of us individually, we all know how incredibly important it is to control high blood pressure; we would agree with that, we would agree that we should do things to control it; but practically getting it done can be tricky in our busy lives.

Melanie:  So, what do you want to tell other providers about encouraging monitoring and encouraging healthy living and because monitoring also could be subjective if the patient is doing it themselves and then there are certain changes and variables when they come into the office?

Dr. Healy:  That’s true. And when we look at our data, nationwide, health systems and doctors do probably what we would all say is a pretty poor job of controlling people with high blood pressure. The latest statistics from probably 2016 are that 54% of people with high blood pressure are controlled. So, that means they are below 140/90. At Carle, we do a lot better. We started actually at the beginning of last year at the beginning of 2017, we were at 62% control rate and we are up now to close to 68% control rate. Which at first, might not sound like a lot, but that’s a lot of patients that have their blood pressure controlled now that didn’t before. And really, for our system, it’s a great thing because it will decrease the number of people that develop stroke and develop heart failure and develop atrial fibrillation and all the other comorbidities that go along with having high blood pressure.

Melanie:  What about health disparities and do you see issues with adherence and follow up when you are talking about other populations?

Dr. Healy:  There definitely is data out there and we see it locally of disparities playing an important role in any chronic disease and hypertension is just another example of that. We could look at the medications. Some people are more likely to take certain medications. Some medications have kind of a bad reputation. When we talk about hypertension, people who are given beta blockers, that might scare them because they have heard from other people that might make them feel tired or it might affect their sex drive. So, if we don’t take that into consideration when we are talking about a medication and just write the prescription; there could be groups that aren’t filling that medication. So, that would be more appropriate for or more typical of the males versus the females in this case. Other cases, there is higher copay for medications that are name branded or if people don’t have certain types of insurance; they can be very expensive. So, we will talk about the medicine in the office, we will give them prescription; but they really probably never fill it because it’s so expensive. So, there’s definitely things that we need to keep in mind about different groups, just different socioeconomic classes that really, whether someone has insurance or not, etc. when we are talking about what medicines to use for high blood pressure. One of the nice things is that most of the medicines for high blood pressure have been around a long time. They are all generic or most people can be treated with generic medications so that takes a little bit of that out of the equation, but they are still – we have to keep that in consideration when we are talking to people and how much money it might cost them to get their prescription.

Melanie:  And what about the financial burden of hypertension and uncontrolled high blood pressure on not only the communities, but for you providers to try and manage this and keep track of it?

Dr. Healy:  So, in terms of the nation; there are estimates that we spend about 50 billion dollars, that’s with a B, billion dollars a year. That’s what it costs for people to have uncontrolled high blood pressure. So, it definitely makes sense economically, from a nation, to look at that and to focus on increasing the control rate. At Carle, we have actually tied it to our physician pay, so 2% of our pay is – as part of our performance improvement is tied to us reaching certain metrics in controlling high blood pressure. Last year for 2017, we had a goal of getting to 64% and we got above that. We got it to 65.5% range, so we kind of blew that goal away. This year, we ratcheted it up to 68% and currently, as I look at the dashboard that is actually right in front of me, we are 67.28%. So, we are headed towards reaching the goal this year. So, economically, it impacts us each in our wallet because if we don’t hit that 68%, we would feel a decrease in the amount we get paid and of course, nationally, by decreasing the number of people that are uncontrolled; we will have an impact on our health system as a whole.

Melanie:  Give us some actionable steps that you want other providers to take and even to integrate the other providers in their offices whether it’s the nurses and the entire healthcare team.

Dr. Healy:  Yeah, so what we have done and what we want people to be really involved with is we’ve said that there are certain doctors, certain groups that we say should be aware of blood pressure and aware of medications and aware of lifestyle modifications that need to be made and talk to their patients about this. So, primary care, the adult medicine doctors, family medicine doctors and pediatricians who have someone above 18 with high blood pressure as well as cardiologists, endocrinologist and nephrologists are all specialties which we assume they will be dealing individually with each patient they see with their blood pressure medication. Other specialists I tend to always pick on orthopedics as my other specialty but if someone is seen in orthopedics, we don’t expect the orthopod to know about different medications and different classes and change medication. What they could do that group is just talk to the patient and say hey we noticed your blood pressure was high today, you really should go back in and see your primary care doctor. The other thing that we do behind the scenes is a message is generated on a patient who is seeing for instance and orthopedics, if they are uncontrolled, a message will go to the scheduling center and they will contact the patient and tell them that we noticed you were in to see Dr. X and your blood pressure was elevated. Your normal doctor Dr. Y would like to see you within 30 days and what we do is set up with that primary care doctor’s team. it is either the doctor or advanced practice provider or a nurse visit, so that’s kind of getting the team involved in a recheck o the blood pressure. Sometimes it’s normal and it was the false alarm that it was high. But sometimes we see people who have persistent high blood pressure and we catch them because they go and see another specialist in our system. They get back to see us and we can adjust their medication, address their lifestyle to get them controlled.

Melanie:  So, give us some tips for implementing a self-management program to help providers teach prevention engagement for their patients.

Dr. Healy:  I think it’s important with blood pressure to tell people to check their blood pressure outside the office. We all know of people who are always high in the office and always fine at home or at Walgreens or CVS or wherever they are checking their blood pressure. So, we really want them to check their blood pressure in the community or at home. People always ask me in my own practice what’s the best blood pressure cuff to get. I can never keep up with the different brands, so I tell them to talk to their pharmacist and get a good arm cuff to measure their blood pressure and see what their blood pressure does. What it helps is that people realize that their blood pressure isn’t just one number, it varies day to day, hour to hour, even minute to minute, but they can get a sense of where they are normally and then when they come in and see us, they can let us know what their blood pressure has been doing. Ideally, they have written it down. We are actually looking at some technology that is out there where you could have a blood pressure cuff that blue tooth’s your information to your computer or your wireless network at home and then sends it into the office. So, there’s a lot of ways that people can be engaged in self-care. Another thing about – I tend to focus on – I’m an internal medicine physician, I tend to focus on medicines, but also by checking their blood pressure at home, people can realize how dietary changes could affect their blood pressure. If they have a high salt meal, they will notice the next day that their blood pressure is higher, so they get to see themselves how a better meal and more exercise etc. can help their blood pressure.

Melanie:  So, wrap it up for us Dr. Healy with the main objective of hypertension treatment and how soon you like to see results once you have identified a patient with hypertension and what you would like other providers to know.

Dr. Healy:  Once we have identified someone with hypertension, which isn’t just a one time you are high and then you have high blood pressure. We, of course, check it a couple of times to make sure it’s real and then check for other things in the person’s life and with their medications that might be affecting their blood pressure. But once we have identified someone and diagnosed them with high blood pressure; we really want to see them controlled within 30 days at the most. So, practically, we would see someone, talk to them about a medication or a diet change and see them back in our office within two to four weeks. And so, there is some special categories if someone is very high with their blood pressure; we would rather see them control it within a couple of days and not four weeks. But for the most part, if we have a return visit in two to four weeks and keep working at each of those visits to explain the importance of diet changes and exercise, but also adjust medications to get them controlled, that’s really the goal.

Melanie:  Thank you so much Dr. Healy for being with us today and sharing your expertise in this very important topic. You’re listening to Expert Insights with Carle Foundation Hospital. For a listing of Carle providers, and to view Carle sponsored educational activities please visit www.carleconnect.com, that’s www.carleconnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole.