Abstract P1073: Optimizing Blood Pressure Control Strategies with Real-Time Data in Community Health Centers

Introduction: Blood pressure (BP) control in the United States among persons with hypertension (HTN) is less than 50%. Performance and quality measures to improve care and outcomes for patients with high BP were published in 2019. The American Heart Association (AHA) recently completed its federally funded cooperative agreement, the National Hypertension Control Initiative (NHCI) to improve BP control in 350 community health centers (CHCs) with 1.5 million persons with HTN. Hypothesis: Use of a population health management platform can provide CHCs with more actionable, real-time Electronic Health Record (EHR) data to advance quality improvement (QI) efforts and evaluation capabilities. Methods: AHA identified a population health management platform to source EHR-derived data from 38 of 350 CHCs participating in NHCI. The objective was to demonstrate the value of readily accessing and using established measures for BP control in a project and system not already set up to do so. Eighteen clinical measures were used based on established performance and quality measures, aligning with Healthcare Effectiveness Data Information Set (HEDIS) where possible. Data for chosen measures was pulled from CHC EHRs on a monthly, quarterly, and ad hoc basis. This data expanded beyond what is required to be reported by CHCs to the Uniform Data System (UDS). Data sharing agreements were secured from 38 NHCI CHCs and 12 non-NHCI CHCs, as a comparison group, and all measures were made available to participating CHCs and other users. Results: Data was received for 12 quarters (January 2021 through December 2023) from the 50 CHCs on over 4.3 million encounters for 2.8 million patients. Data show a 48.7% relative improvement in the number of CHCs taking a BP reading at each patient encounter from Q1 2021-Q4 2023 (57.4% to 85.4%). Additionally, CHC BP control <140/90 mm Hg and <130/80 mm Hg reached 65.4% and 27.9%, respectively, in Q4 2023, as compared to the UDS reported 2023 BP control rate <140/90 mm Hg of 60.9% for 350 NHCI CHCs. Conclusion: The expanded 18 measures allowed for more timely, frequent, detailed, and potentially actionable data to inform QI efforts. The timeliness and higher frequency of data should enable CHCs to understand the effects of their BP control strategies in real time. Using a population health management platform that emphasizes clinical performance measures based on “real-time” EHR data may strengthen and accelerate BP control QI and evaluation efforts.