New measures of BP management released by ACC/AHA

The American College of Cardiology and American Heart Association (ACC/AHA) has released new measures to improve treatment and diagnosis of hypertension (high BP) in adults.

The 22 measures are published in the journal Circulation: Cardiovascular Quality and Outcomes. It consists of six performance measures, six process quality measures, and 10 structural quality measures -- the latter being a new category that addresses the U.S. healthcare system's ability to carry out the ACC/AHA's 2017 hypertension guidelines.

Measures are intended to provide practitioners and institutions that deliver cardiovascular services with tools to measure the quality of care provided and identify opportunities for improvement.

One major goal of the document is to offer performance measures for evaluating blood pressure control in adults with stage 1 hypertension (systolic BP, 130–139 mm Hg). Another is to provide new measures for assessing hypertension treatment and monitoring, taking into account lifestyle changes, antihypertensive medication adherence, and home monitoring.

Performance Measures

1. ACC/AHA stage 2 HBP control SBP <140 mm Hg (harmonizing measure) -- Harmonizes with current performance measure “Controlling High Blood Pressure” for ACC/AHA stage 2 HBP currently in widespread use.


2. ACC/AHA stage 1 HBP control SBP <130 mm Hg (harmonizing measure) -- Harmonizes with current performance measure “Controlling High Blood Pressure” for ACC/AHA stage 2 HBP currently in widespread use. Adds emphasis on including the ACC/AHA stage 1 HBP population.


3. ACC/AHA stage 2 and stage 1 HBP control SBP <130 mm Hg (composite measure combining PM-1b and PM-2) -- Harmonizes with current performance measure “Controlling High Blood Pressure” for ACC/AHA stage 2 HBP currently in widespread use. Adds emphasis on including the ACC/AHA stage 1 HBP population and combines both ACC/AHA stage 2 and stage 1 HBP populations.


4. Nonpharmacological interventions for ACC/AHA stage 2 HBP -- Harmonizes with current performance measure “Controlling High Blood Pressure” for ACC/AHA stage 2 HBP currently in widespread use. Adds new emphasis on high-quality evidence and strong recommendation for promoting lifestyle modification, as recommended in the 2017 Hypertension Clinical Practice Guidelines for this population as an important strategy for controlling HBP.


5. Use of HBPM for management of ACC/AHA stage 2 HBP -- Harmonizes with current performance measure “Controlling High Blood Pressure” for ACC/AHA stage 2 HBP currently in widespread use. Adds new emphasis on correct measurement of BP by individuals at home or elsewhere outside the clinic setting, as recommended in the 2017 Hypertension Clinical Practice Guidelines for this population as an important strategy for evaluating control of HBP.

Quality Measures

1. Nonpharmacological interventions for ACC/AHA stage elevated BP -- Adds new emphasis on high-quality evidence and strong recommendation for promoting lifestyle modification, as recommended in the 2017 Hypertension Clinical Practice Guidelines for ACC/AHA elevated BP population as an important strategy for controlling HBP.


2. Nonpharmacological interventions for ACC/AHA stage 1 HBP -- Adds new emphasis high-quality evidence and strong recommendation for promoting lifestyle modification, as recommended in the 2017 Hypertension Clinical Practice Guidelines for ACC/AHA stage 1 population as an important strategy for controlling HBP.


3. Nonpharmacological interventions for all ACC/AHA stages of HBP (composite measure combining PM-4, QM-1, and QM-2) -- Adds new emphasis on high-quality evidence and strong recommendation for promoting lifestyle modification, as recommended in the 2017 Hypertension Clinical Practice Guidelines for all 3 ACC/AHA stages of HBP population as an important strategy for controlling HBP. The composite measure permits assessment of effectiveness for all stages combined.


4. Medication adherence to drug therapy for ACC/AHA stage 1 with ASCVD risk ≥10% or ACC/AHA stage 2 HBP -- Adds new emphasis on high-quality evidence and strong recommendation for assessing and promoting medication adherence, as recommended in the 2017 Hypertension Clinical Practice Guidelines for the combined ACC/AHA stage 1 with ASCVD risk ≥10% and ACC/AHA stage 2 HBP population as an important strategy for controlling HBP.


5. Use of HBPM for management of ACC/AHA stage 1 HBP -- Harmonizes with new performance measure PM-5 for ACC/AHA stage 2 HBP. Adds new emphasis on correct measurement of BP by individuals at home or elsewhere outside the clinic setting, as recommended in the 2017 Hypertension Clinical Practice Guidelines for this population as an important strategy for evaluating control of ACC/AHA stage 1 HBP and ASCVD risk ≥10%.


6. Use of HBPM for management of ACC/AHA stage 1 or ACC/AHA stage 2 (composite measure combining PM-5 and QM-5) -- Harmonizes with new measures PM-5 and QM-5 and adds new emphasis on correct measurement of BP by individuals at home or elsewhere outside the clinic setting, as recommended in the 2017 Hypertension Clinical Practice Guidelines for this population as an important strategy for evaluating control of ACC/AHA stage 2 and stage 1 HBP and ASCVD risk ≥10%. Composite measure permits assessment of effectiveness for these 2 stages combined.

Structural Quality Measures

1. Use of a standard protocol to consistently and correctly measure BP in the ambulatory setting -- Accurate measurement and recording of BP are essential to categorize level of BP, ascertain BP-related CVD risk, and guide management of high BP. Office BP measurement is often unstandardized, despite the well-known consequences of inaccurate measurement. Errors are common and can result in a misleading estimation of an individual’s true level of BP if staff are not trained and a protocol is not followed.


2. Use of a standard process for assessing ASCVD risk -- To facilitate decisions about preventive interventions, it is recommended to screen for traditional ASCVD risk factors and apply the race- and sex-specific PCE (ASCVD Risk Estimator) to estimate 10-year ASCVD risk for asymptomatic adults 40–79 years of age.


3. Use of a standard process for properly screening all adults ≥18 y of age for HBP -- The evidence on the benefits of screening for HBP is well established. In 2007, the USPSTF reaffirmed its 2003 recommendation to screen for HBP in adults ≥18 y of age.


4. Use of an EHR to accurately diagnose and assess HBP control --A growing number of health systems are developing or using registries and EHRs that permit large-scale queries to support population health management strategies to identify undiagnosed or undertreated HBP.


5. Use of a standard process to engage patients in shared decision-making, tailored to their personal benefits, goals, and values for evidence-based interventions to improve control of HBP -- Decisions about primary prevention should be collaborative decisions made between a clinician and a patient.


6. Demonstration of infrastructure and personnel that assess and address social determinants of health of patients with HBP -- It is important to tailor advice to an individual’s socioeconomic and educational status, as well as cultural, work, and home environments.


7. Use of team-based care to better manage HBP -- RCTs and meta-analyses of RCTs of team-based HBP care involving nurse or pharmacist intervention demonstrated reductions in SBP and DBP and/or greater achievement of BP goals when compared with usual care.


8. Use of telehealth, m-health, e-health, and other digital technologies to better diagnose and manage HBP -- Meta-analyses of RCTs of different telehealth interventions have demonstrated greater SBP and DBP reductions and a larger proportion of patients achieving BP control than those achieved with usual care without telehealth.


9. Use of a single, standardized plan of care for all patients with HBP -- Studies demonstrate that implementation of a plan of care for HBP can lead to a sustained reduction of BP and attainment of BP targets over several years.


10. Use of performance and quality measures to improve quality of care for patients with HBP -- A large observational study showed that a systematic approach to HBP control, including the use of performance measures, was associated with significant improvement in HBP control compared with historical control groups.

"2019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures," is published in the journal Circulation: Cardiovascular Quality and Outcomes.

DOI: https://doi.org/10.1161/HCQ.0000000000000057