Strategy 3: Increase use of health care extenders in the community in support of self-management of high blood pressure and diabetes (See also the Health Systems Resource Guide)
Interventions: Increase engagement of community pharmacists in the provision of medication/self-management for adults with high blood pressure and adults with diabetes
Short-term:
Proportion of community pharmacists that promote medication-management/self-management for adults with high blood pressure
The purpose of this performance measure is to describe the reach or adoption of community pharmacist interventions to support blood pressure medication-management and blood pressure self-management. Studies show that pharmacist care is associated with significant reductions in systolic/diastolic blood pressure, total cholesterol, low-density lipoprotein cholesterol, and a reduction in the risk of smoking (Santschi, et al., 2011).
Proportion of community pharmacists that promote medication-management/self-management for adults with diabetes
The purpose of this performance measure is to describe the reach or adoption of community pharmacist interventions to support diabetes medication-management or diabetes self-management. Interventions by community pharmacists providing patient self-management services have shown significant improvements in clinical measures while reducing health care costs for employers (Fera, et al., 2009; Cranor, et al., 2003).
Intermediate:
Proportion of patients with high blood pressure in adherence to medication regimens
The purpose of this performance measure is to assess rates of antihypertensive medication (AHM) adherence among adult patients with high blood pressure, as an intermediate effect of interventions to increase implementation of quality improvement processes, team-based care in health systems, and the use of health-care extenders to support self-management. Support for new models of patient care, such as patient-centered medical home (PCMH) and accountable care organizations (ACO), is in part premised upon the potential for these models to encourage improved patient self-management and medication adherence (Bechtel and Ness, 2010.) Better medication adherence to AHMs reduces cardiovascular risk and improves health outcomes (Bitton et al., 2013; Bouchard et al., 2007; Corrao et al., 2011.)
Proportion of patients with diabetes in adherence to medication regimens
The purpose of this performance measure is to assess rates of medication adherence among adult patients with diabetes, as an intermediate effect of interventions to increase implementation of quality improvement processes, team-based care in health systems, and the use of health-care extenders to support self-management, such as community pharmacists and community health workers.
Rigorous reviews have found that adherence among persons with chronic diseases in developed countries averages only 50% (WHO 2003). Estimates for medication adherence rates among people with diabetes vary widely (31% to 98%), but most suggest substantial room for improvement (Cramer 2008, Odegard 2007, Rubin 2005). Nonadherence to diabetes medications is associated with poorer glycemic control and increased hospitalizations, health care costs, and mortality (Ho 2006, Odegard 2007, Salas 2009, Sokol 2005).
In low income populations, competing needs compound the challenges of improving health, including the problem of medication adherence (WHO 2003). Even within an insured population, disparities have been found in rates of cost-related medication underuse, with African Americans and Latinos more likely than whites and Asian/Pacific Islanders to report using less medication because of cost (Tseng 2008). Higher rates of cost-related medication underuse are also found among Medicaid recipients than among those with Medicare or private insurance (Piette 2004).
Proportion of patients with high blood pressure that have a self-management plan (including medication adherence, self-monitoring of blood pressure levels, increased consumption of nutritious food and beverages, increased physical activity, maintaining medical appointments)
The purpose of this performance measure is to assess the change in the proportion of patients with high blood pressure in health care systems/state that have a documented self-management plan to manage their high blood pressure. This change is an expected intermediate effect of interventions to increase implementation of quality improvement processes, team-based care in health systems, and the use of health-care extenders to support self-management of high blood pressure. Patient self-management of chronic hypertension has been shown to encourage lifestyle changes that mediate risks related to high blood pressure including weight loss and weight control, increased physical activity, decreased alcohol intake, and increased medication compliance (Fleischmann, 2004; Zarnke, 1997).
Long-term:
Decreased proportion of people with diabetes with A1C > 9
The purpose of this performance measure is to monitor changes in the proportion of people with diabetes with poor glycemic control (HbA1c > 9%) and at greatest risk of diabetes complications. The Diabetes Control and Complications Trial (DCCT Research Group, 1993), the UK Prospective Diabetes Study Group (Stratton et al., 2000) and subsequent clinical trials (Ismail-Beigi et al., 2010) found increased risk of microvascular complications (retinopathy and nephropathy), with higher HbA1c levels. To reduce the risk of complications the American Diabetes Association recommends a HbA1c < 7% with testing at least two times per year for those in control and quarterly for those not in control to reduce the risk of complications (ADA, 2014).
Proportion of adults with known high blood pressure who have achieved high blood pressure control
The purpose of this performance measure is to ensure enhanced funded states have state-level access to aggregate data in order to quantify the achievement of blood pressure control among patients with known high blood pressure. The performance measure captures the NCQA clinical quality measure identifying the number of adults between the ages of 18-85 years old within the state that have achieved blood pressure control. There is evidence that heart attacks and initiation and recurrence of stroke can be prevented by adequately treating and controlling blood pressure (CDC, 2012).