Practical Lessons for Improving Care of Patients with High Blood Pressure in Urban Underserved Practices

Research Article

J Fam Med. 2016; 3(1): 1046.

Practical Lessons for Improving Care of Patients with High Blood Pressure in Urban Underserved Practices

Quigley DD¹*, Syltebo TF¹ and Legette-Sobers S²

¹Evaluation & Research Services, 295 Stuyvesant Dr, San Anselmo CA 94960, USA

²Greater Rochester Health Foundation, 150 State Street Ste. 100, Rochester, USA

*Corresponding author: Quigley DD, PhD, Evaluation & Research Services, 295 Stuyvesant Dr, San Anselmo, CA 94960, USA

Received: October 17, 2015; Accepted: January 07, 2015; Published: January 11, 2016


Purpose: Assess impact of multi-component projects to improve care of racially diverse and low-income hypertension patients at three clinics in the Greater Rochester New York area.

Methods: Used multi-method strategy to assess qualitative data on fouryear effort to improve care in a real world underserved setting. We reviewed direct-observation, interview, phone meeting, and patient-level blood-pressure data. To model changes, we used a logistic-regression spline model of 51,654 visits by 12,918 patients, adjusting for patient demographic characteristics and for the clustering of physician and patient.

Results: Clinics that standardized blood-pressure monitoring, redesigned patient flow and scheduling, involved clinical pharmacists, embedded care management into patient flow, had frequent visits for out-of-control patients, and created a culture focusing on individual-patient needs improved control rates from 40.1% to 56.6% (P<0.001 for trend), exceeding national improvements of the time. Logistic-regression spline models confirmed these results and showed statistically significant improvements within the first 6 months and subsequent 2.5 years.

Conclusions: Five themes emerged: 1) Leadership at all levels is necessary. 2) Quality- and process-improvement are integral to sustaining change. 3) Integrating care management into team-based care is critical for patients with hypertension. 4) Frequent follow-up visits are needed when hypertension is not controlled. 5) Daily review of patients on the schedule and periodic reporting of hypertension outcomes raise consciousness. Practical lessons were identified: Changing clinical processes to raise awareness and increase focus can improve control. Medication and treatment-management protocols increasing visit frequency for hypertension patients whose blood pressure is uncontrolled improve patient choices and behaviors. Assessing strategies for improving the management of hypertension, identifying daily solutions and tracking outcomes by patient and doctor help improve control rates in clinics serving low-income populations.

Keywords: Quality improvement; Hypertension; Chronic care management


CMA: Case-Mix Adjustors; EMR: Electronic Medical Record; GRMSA: Greater Rochester Metropolitan Statistical Area; HEDIS: Healthcare Effectiveness Data and Information Set; NCQA: National Committee for Quality Assurance; NHANES: National Health and Nutrition Examination Survey; PDSA: Plan-Do-Study-Act; PPO: Preferred Provider Organization; QI: Quality-Improvement


Hypertension affects one in three U.S. adults [1]. Although substantial knowledge is available regarding its epidemiology, pharmacotherapy, and genetics, many people with hypertension remain under diagnosed and undertreated [2], with National Health and Nutrition Examination Survey (NHANES) 2012 data indicating about half (45.9%) of those with hypertension do not have it controlled [1].

Clinical guidelines for hypertension management emphasize controlling it through healthy lifestyle behaviors and using appropriate medications with integrated clinical systems to sustain adherence [2]. Health systems struggle with identifying hypertension efficiently and delivering care that helps patients bring hypertension under control.

Multi-faceted interventions that include quality-improvement strategies for controlling hypertension can, but do not always, increase control rates [3-9]. One effective intervention is the largescale community-based program at Kaiser Permanente Northern California that uses a multi-faceted approach including a robust quality-improvement and reporting mechanism to increase hypertension control [8]. Key elements of that program include establishing a comprehensive hypertension registry, development and sharing of performance metrics, evidence-based guidelines, medical-assistant visits for blood-pressure measurement, and singlepill combination pharmacotherapy. Another effective intervention is the Community Preventive Services Task Force recommendation to use team-based care to improve blood pressure control (see https://

Efforts to improve hypertension awareness and initiate appropriate treatment remain important to increase blood pressure control, particularly in areas with a high prevalence of hypertension. Primary-care practices increasingly focus on hypertension as part of their quality improvement but questions remain about what can improve control rates.

The Greater Rochester Health Foundation (referred to as the Health Foundation) funded in 2010 projects to improve the quality of clinical care for hypertension patients in the Greater Rochester area, which includes Genesee, Livingston, Monroe, Ontario, Orleans, Seneca, Wayne, Wyoming and Yates counties in New York.

An independent evaluation team used a multi-method evaluation strategy to assess quality-improvement (QI) strategies regarding care of hypertension patients. The analyses below assess how the clinicsite teams implemented multi-faceted intervention strategies with quality-improvement efforts to improve the care of patients with hypertension at three primary-care practices serving low-income and racially diverse patients in the Greater Rochester area. Then we examine the pre- and post-intervention control rate trends for these patients, and compared them to national trends.



The study collected via direct observation, in-depth interviews, and monthly calls with QI-team participants information to describe and assess implementation of the chosen strategies. Pre and postblood- pressure data was also gathered at patient visits to three primary-care practices over four years, allowing for an evaluation of the influence of the chosen strategies on clinic control rates.

Setting and participants

The Greater Rochester Metropolitan Statistical Area (GRMSA) approximates the Greater Rochester area. GRMSA comprises Monroe, Ontario, Wayne, Livingston, and Orleans Counties in New York. Of its 1,128,000 residents, 748,000 live in Monroe County, including the 211,000 in Rochester city limits. The GRMSA features a core, racially diverse and economically disadvantaged central city surrounded by a white, better-educated, and more affluent suburban area (Table 1).