RESISTANT HYPERTENSION - Review of April 2021 POD Meeting - RIPCPC
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Review of
RESISTANT HYPERTENSION
April 2021 POD Meeting
HEDIS Measurement for Controlled Blood Pressure (CBP) Definition: Percentage of patients ages 18–85 who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (
HEDIS Measurement for Controlled Blood Pressure (CBP)
NEW for 2021:
• Palliative care has been added as an exclusion
• Donepezil-memantine to the Dementia Medication list for exclusion criteria (Meds that exclude: donepezil, galantamine, rivastigmine or
memantine)
• Blood pressure readings that take place using appropriate digital device during a telephone visit, e-visit or virtual check-in meet numerator
compliance
• Patient reported blood pressure readings are allowed from an appropriate digital device
UPDATED for 2021:
• The advanced illness exclusion can be identified from a telephone visit, e-visit or virtual check-in
• Blood pressure readings taken on a digital device no longer have to be transmitted from a remote monitoring device
• The two outpatient visits with a diagnosis confirming hypertension must be documented in the first 6 months of the measurement year or
year prior (previously any time during the measurement year or year prior)HEDIS Measures: Integra’s Story
Claims/EHR data thru Claims/EHR data thru Claims/EHR data thru
Medicare Advantage 8/31/2019 8/31/2020 12/31/2020 Cut Points
BLOOD PRESSURE
4 Star 77%
Controlling High Blood Pressure 57% 47% 77.12%
5 Star 84%
Claims/EHR data thru Claims/EHR data thru Claims/EHR data thru
Commercial - Adult 8/31/2019 8/31/2020 12/31/2020 Cut Points
BLOOD PRESSURE
4 Star 72%
Controlling High Blood Pressure 50% 43% 75.98%
5 Star 82%Pseudoresistant Hypertension
Blood pressure that is poorly-controlled and appears resistant to antihypertensives but is due to
other factors:
1. Inaccurate measurement
2. Poor adherence
3. Suboptimal antihypertensives
4. Non-adherence to lifestyle changes
5. White coat hypertension
6. Clinical inertia
Carey RM, et al. Hypertension. 2018 Nov;72(5):e53-e90.Resistant Hypertension
1. Blood pressure that remains above goal while concurrently on >3 antihypertensives from
different classes, with 1 of the 3 agents being a diuretic and all agents must be prescribed at
maximum/maximally tolerated dose
-OR-
2. Blood pressure that is controlled with >4 antihypertensives
Carey RM, et al. Hypertension. 2018 Nov;72(5):e53-e90.Home Blood Pressure Monitoring CPT Code: 99473 • Can be submitted when physician practice staff provide training, device setup and calibration of SMBP devices validated for clinical accuracy for patients, and patients are instructed to properly monitor their BP at home • This code can only be submitted once CPT Code: 99474 • Can be submitted when patients and/or caregivers report their BP readings back to the practice—whether it is done electronically or in person with a SMBP recording log—which then allow the physician to make ongoing treatment decisions based on the average of the patient’s BP readings. • This code can be submitted once a month for ongoing treatment decisions
Clinical Considerations
Comorbidities
Chronic Kidney Disease (CKD)
Obstructive Sleep Apnea (OSA)
Diabetes Mellitus (DM)
Albuminuria
Left Ventricular Hypertrophy
Carey RM, et al. Hypertension. 2018 Nov;72(5):e53-e90.Clinical Considerations
Contributing Factors
Obesity
• Sympathomimetics • Immunosuppressive Alcohol Use
• Estrogen-containing agents
oral contraceptives • Antidepressants (SNRIs)
Dietary Sodium Intake
• NSAIDs Drug-Induced
• Primary aldosteronism • Pheochromocytoma Secondary Causes
• Renal parenchymal • Cushing Syndrome
disease • Coarctation of the
Physical Inactivity
• Renal artery stenosis aorta Sleep Disorders
Carey RM, et al. Hypertension. 2018 Nov;72(5):e53-e90.Diagnosis, Evaluation, Treatment Algorithm
Confirm Treatment Resistance
Exclude pseudoresistance
Identify and reverse contributing lifestyle factors
Discontinue or minimize interfering substances
• Maximize diuretic
Screen for secondary causes of hypertension
• Add MRA
• Add other agent with different
Pharmacological treatment mechanism
• Use loop diuretic in CKD and/or
patients on potent vasodilator
Refer to specialist
Whelton PK, et al. Hypertension. 2018 Jun;71(6):e140-e144.Treatment of RH – Stepwise Approach
Step 1.
• Exclude other causes of hypertension
• Ensure low sodium diet (Treatment – Stepwise Approach
BP not at target
Step 3.
• Add mineralocorticoid receptor antagonist (MRA): spironolactone or
eplerenone**use caution if eGFRTreatment – Stepwise Approach
BP not at target
Step 5.
• Add hydralazine 25 mg TID and titrate up to max dose (300 mg/day);
• Use with beta-blocker and a diuretic
BP not at target
Step 6.
• Substitute minoxidil 2.5 mg TID for hydralazine and titrate upward. If BP is still above goal
consider referral to HTN specialist
Carey RM, et al. Hypertension. 2018 Nov;72(5):e53-e90.Pharmacologic Treatment
THIAZIDE and THIAZIDE-LIKE diuretics
Medication Dose Frequency Considerations Clinical Pearls
Chlorthalidone 12.5-25 mg 1x/day *Preferred Adverse Effects: hyponatremia, hypokalemia, SCr, uric
• Longer half life acid, calcium
• Produces natriuresis
down to eGFR of 30
Hydrochlorothiazide 25-50 mg 1x/day • Unpredictable
natriuresis when eGFR
< 45
Indapamide 1.25-2.5 mg 1x/day
Metolazone 2.5-5 mg 1x/day
Carey RM, et al. Hypertension. 2018 Nov;72(5):e53-e90.
Whelton PK, et al. Hypertension. 2018 Jun;71(6):e140-e144.LOOP diuretics
Medication Dose Frequency Considerations Clinical Pearls
Torsemide 5-10 mg 1x/day • Longest half life Adverse Effects: fluid/electrolyte imbalances
Furosemide 20-80 mg 2x/day • Least bioavailability Conversion:
Bumetanide 1 mg = Torsemide 10-20 mg = Furosemide 40
Bumetanide 0.5-2 mg 2x/day mg
Clinical Considerations:
• For eGFR < 30, loop diuretics should be used
Carey RM, et al. Hypertension. 2018 Nov;72(5):e53-e90.
Whelton PK, et al. Hypertension. 2018 Jun;71(6):e140-e144.ACE inhibitors
Medication Dose Frequency Clinical Pearls
Benazepril 10-40 mg 1-2x/day Adverse Effects: hyperkalemia, angioedema
Captopril 12.5-150 mg 2-3x/day
Clinical Considerations:
Enalapril 5-40 mg 1-2x/day • Do not use in combination with ARB or direct renin inhibitor
Fosinopril 10-40 mg 1x/day due to increased risk of AEs
Lisinopril 10-40 mg 1x/day • Avoid in pregnancy
• SCr: 30-50% increase, consider dose reduction or
Quinapril 10-80 mg 1-2x/day
discontinuation
Ramipril 2.5-20 mg 1-2x/day
Whelton PK, et al. Hypertension. 2018 Jun;71(6):e140-e144.ARBs
Medication Dose Frequency Clinical Pearls
Candesartan 8-32 mg 1x/day Adverse Effects: hyperkalemia, angioedema
Irbesartan 150-300 mg 1x/day
Clinical Considerations:
Losartan 50-100 mg 1-2x/day • Do not use in combination with ACE or direct renin inhibitor
Olmesartan 20-40 mg 1x/day due to increased risk of AEs
Telmisartan 20-80 mg 1x/day • Avoid in pregnancy
• Losartan is the least potent
Valsartan 80-320 mg 1x/day
Carey RM, et al. Hypertension. 2018 Nov;72(5):e53-e90.
Whelton PK, et al. Hypertension. 2018 Jun;71(6):e140-e144.Dihydropyridine CCBs
Medication Dose Frequency Considerations Clinical Pearls
Amlodipine 2.5-10 mg 1x/day Clinical Considerations:
• Dose-related pedal edema (women > men)
Felodipine 2.5-10 mg 1x/day
Nicardipine SR 60-120 mg 2x/day
Nifedipine LA 30-90 mg 1x/day • Preferred in pregnancy
Carey RM, et al. Hypertension. 2018 Nov;72(5):e53-e90.
Whelton PK, et al. Hypertension. 2018 Jun;71(6):e140-e144.ALDOSTERONE antagonists
Medication Dose Frequency Considerations Clinical Pearls
Spironolactone 25-100 mg 1x/day • Associated with Adverse Effects: hyperkalemia (w/ eGFR < 45 or baseline
gynecomastia (9% serum K+ > 4.5)
occurrence at usual
doses) Monitoring:
Eplerenone 50-100 mg 1-2x/day • 4x more expensive • K+ within 1 week of initiation or dose titration
Clinical Considerations:
• Preferred in RH
• Avoid use with K+ supplements or K+ sparing diuretics
Whelton PK, et al. Hypertension. 2018 Jun;71(6):e140-e144.ALPHA-1 blockers
Medication Dose Frequency Considerations Clinical Pearls
Doxazosin 2-4 mg 1x/day • IR formulation used in Adverse Effects: orthostatic hypotension
HTN
• May be used for BPH
Prazosin 1-5 mg 2x/day • May be used for PTSD-
related nightmares and
sleep disturbances
Terazosin 1-5 mg 1x/day • May be used for BPH
Whelton PK, et al. Hypertension. 2018 Jun;71(6):e140-e144.Central ALPHA-2 agonists
Medication Dose Frequency Clinical Pearls
Clonidine 0.1-0.2 mg 2x/day • Available as weekly patch; more expensive
• Onset of action for the patch is delayed
• Risk for rebound HTN with abrupt discontinuation (risk >
for PO)
• Do NOT stop abruptly
Guanfacine 1-3 mg 1x/day • IR formulation only
Methyldopa 250-500 mg 2-3x/day • Currently unavailable
Whelton PK, et al. Hypertension. 2018 Jun;71(6):e140-e144.Direct arterial vasodilators
Medication Dose Frequency Clinical Pearls
Hydralazine 100-400 mg 3-4x/day • Associated with reflex tachycardia and fluid retention
• Consider combining with beta-blocker and/or diuretic
• Some dosage forms contain propylene glycol
Minoxidil 5-10 mg 5-10x/day • Rarely used
• Consider combining with beta-blocker and/or diuretic to
prevent reflex tachycardia and fluid retention
• Maximum doses of a diuretic and 2 additional anti-HTN
agents should be used prior to use of minoxidil
• Boxed Warning: may cause pericardial effusion
Whelton PK, et al. Hypertension. 2018 Jun;71(6):e140-e144.2021 Pharmacy Quality Incentive Program
Stars Related Measures
Data Source
Measure (frequency) Description 100% Variance Weight
Additional information
1. Adherence: Diabetes Percent of Medicare Part D beneficiaries ≥18 who adhere to their prescribed drug therapy across
classes of diabetes medications.
90.0% +/- 2.0% 3
OutcomesMTM Platform
2. Adherence: RAS Percent of Medicare Part D beneficiaries ≥18 who adhere to their prescribed drug therapy for RAS
Quality Index (CSAR Monthly) antagonists.
92.0% +/- 2.0% 3
Acumen (Final)
3. Adherence: Lipids Percent of Medicare Part D beneficiaries ≥18 who adhere to their prescribed drug therapy for statin
cholesterol medications.
90.0% +/- 2.0% 3
4. Statin Use in Patients OutcomesMTM Platform This measure is defined as the percentage of Medicare Part D beneficiaries between 40 and 75 years
with Diabetes Quality Index (Monthly) old who received at least two diabetes medication fills and also received a statin medication during 89.0% +/- 2.0% 5
the measurement period.
Acumen (Final)
5. Statin Use in Patients OutcomesMTM Platform The percentage of Medicare Part D beneficiaries 21-75 (males) and 40-75 (females) years of age who
with Cardiovascular Disease Quality Index (Monthly) were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and were dispensed at 89.0% +/- 2.0% 5
least one high-intensity or moderate intensity statin medication during the measurement year.
SPC Report (Final)
6. Comprehensive This measure is defined as the percent of Part D beneficiary MTMP enrollees who met targeting
OutcomesMTM Platform
Medication Review criteria who received a CMR during the reporting period. Additional bonus payout of $100 per 93.0% +/- 2.0% 5
Quality Index (Monthly) targeted CMR completed above 95% threshold.2021 Pharmacy Quality Incentive Program
Ancillary Measures
Data Source
Measure (frequency) Description 100% Variance Weight
Additional information
7. Polypharmacy Composite percent of Medicare Part D beneficiaries ≥65 with concurrent use of multiple unique CNS
(Lower is Better) or unique ACH medications
OutcomesMTM Platform • CNS: 1) antipsychotics 2) benzodiazepines & nonbenzo sedative/hypnotics 3) opioids, 4) SSRI &
Quality Index (Monthly) tricyclic antidepressants 3.8% +/- 1.0% 1
Acumen (Final) • ACH: 2) antihistamines 2) antiparkinsonian 3) skeletal muscle relaxants 4) antidepressants 5)
antipsychotics 6) antiarrhythmics 7) antimuscarinics (urinary incontinence) 8) antispasmodics 9)
antiemetics
8. Case Review Percent of case reviews provided for members targeted for possible intervention.
Targeted Lists • Specific targets provided by BCBSRI on an adhoc basis for an assortment of programs and/or
95.0% +/- 5.0% 3
(ad hoc, primarily via email) needs
• 1 OutcomesMTM claims/month per funded pharmacist for FEP members (+/- 0.5)
9. Total Cost Avoidance The sum of the AIM value in OutcomesMTM for services rendered and logged on the platform during
OutcomesMTM Platform +/-
the reporting period for Medicare and Commercial members with a Status of “Approved-Paid” or $1M/RPh 3
(MTM Claims with AIM Value) “Approved-Not Paid’ divided by the number of funded pharmacists for the site. $500K/RPh
10. Program Development Develop an initiative that impacts one or more of the overall goals of the PCPP (reduce drug spend,
improve member health, improve quality scores, reduce medical costs, increase engagement). Develop
Self Reported and implement a workflow, document how success is measured, and share results with the group.
100.0% +/- 50.0% 3
Replicability and/or adoption for future P4P goals exceeds expectations.2021 Pharmacy Quality Incentive Program
2 0 2 1 D i s p l ay M e a s u r e s
Data Source
Measure (frequency) Description
Additional information
11. Display: Adherence: HIM OutcomesMTM Platform Composite percent of Health Insurance Marketplace beneficiaries ≥21 who adhere to their prescribed drug therapies across classes of diabetes
Composite Quality Index (Monthly) medications, RAS antagonists, statin cholesterol medications.
CCAR (Final)
12. Display: Opioid OutcomesMTM Platform Composite percent of Medicare Part D beneficiaries without Cancer, 18 years or older, receiving prescriptions for opioids:
Composite • High dosage (average daily MME ≥90mg for ≥90 days)
Quality Index (Monthly) • Multiple providers (≥4 prescribers & ≥4 pharmacies ≤180 days)
Acumen (Final) • At a high dosage AND from Multiple ProvidersNew for 2021: StatinUseinPatientswithDiabetes(UHCandBCBS) Definition: • Percentage of Medicare members with diabetes ages 40–75 who receive at least one fill of a statin medication in the measurement year • Members with diabetes are defined as those who have at least two fills of diabetes medications during the measurement year. Exclusions: The following exclusions have been added for the measure and must be coded annually within the first 12 codes • Persons with rhabdomyolysis or myopathy • Pregnancy, lactation or fertility • Liver disease • Pre-diabetes • Polycystic ovary syndrome (PCOS) • Persons who use hospice services or elect to use a hospice benefit, regardless of when the services began in the measurement year • End-stage renal disease (ESRD)
Thank you! Questions?
You can also read
