A Medicaid Statewide Hypertension Quality Improvement Project: Initial Results

Shari D Bolen; Siran Koroukian; Jackson T Wright Jr; Harry Persaud; Douglas Einstadter; Jordan Fiegl; Adam T Perzynski; Douglas Gunzler; Catherine Sullivan; Jonathan Lever; Michael Konstan; Dushka Crane; Allison Lorenz; Michelle Menegay; Doug Spence; Arun RajanBabu; Wendy Groznik; Tonni Oberly; Xiaokun Qian; Christopher R Jordan; Phyllis Virgil; Sinead Yarberry; Emily Saunders; Alice M Teall; Joyce Zurmehly; Melissa Nance; Stephen Albanese; Donald Wharton; Mary S Applegate

doi:10.7759/cureus.36132

A Medicaid Statewide Hypertension Quality Improvement Project: Initial Results

Cureus. 2023 Mar 14;15(3):e36132. doi: 10.7759/cureus.36132. eCollection 2023 Mar.

Authors

Shari D Bolen^{1

2}, Siran Koroukian³, Jackson T Wright Jr², Harry Persaud³, Douglas Einstadter^{1

2}, Jordan Fiegl¹, Adam T Perzynski^{1

2}, Douglas Gunzler^{1

2}, Catherine Sullivan¹, Jonathan Lever⁴, Michael Konstan⁵, Dushka Crane⁶, Allison Lorenz⁶, Michelle Menegay⁶, Doug Spence⁶, Arun RajanBabu⁶, Wendy Groznik⁶, Tonni Oberly⁶, Xiaokun Qian⁶, Christopher R Jordan⁷, Phyllis Virgil⁸, Sinead Yarberry⁹, Emily Saunders⁹, Alice M Teall⁹, Joyce Zurmehly⁹, Melissa Nance¹⁰, Stephen Albanese¹⁰, Donald Wharton¹¹, Mary S Applegate¹²

Affiliations

¹ Center for Health Care Research and Policy, The MetroHealth Medical Center, Cleveland, USA.
² Medicine, Case Western Reserve University School of Medicine, Cleveland, USA.
³ Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, USA.
⁴ Population Health and Care Management, Better Health Partnership, Cleveland, USA.
⁵ Pediatrics, Case Western Reserve University School of Medicine, Cleveland, USA.
⁶ Public Health, The Ohio Colleges of Medicine Government Resource Center, Columbus, USA.
⁷ Quality Improvement, Chris R. Jordan LLC, Cincinnati, USA.
⁸ Quality Improvement, Phyllis Virgil LLC, Washington DC, USA.
⁹ Nursing, Ohio State University College of Nursing, Columbus, USA.
¹⁰ Quality Improvement, Ohio Department of Medicaid, Columbus, USA.
¹¹ Family Medicine, Ohio Department of Medicaid, Columbus, USA.
¹² Internal Medicine-Pediatrics, Ohio Department of Medicaid, Columbus, USA.

Abstract

Background Hypertension control is critical to reducing cardiovascular disease, challenging to achieve, and exacerbated by socioeconomic inequities. Few states have established statewide quality improvement (QI) infrastructures to improve blood pressure (BP) control across economically disadvantaged populations. In this study, we aimed to improve BP control by 15% for all Medicaid recipients and by 20% for non-Hispanic Black participants. Methodology This QI study used repeated cross-sections of electronic health record data and, for Medicaid enrollees, linked Medicaid claims data for 17,672 adults with hypertension seen at one of eight high-volume Medicaid primary care practices in Ohio from 2017 to 2019. Evidence-based strategies included (1) accurate BP measurement; (2) timely follow-up; (3) outreach; (4) a standardized treatment algorithm; and (5) effective communication. Payers focused on a 90-day supply (vs. 30-day) of BP medications, home BP monitor access, and outreach. Implementation efforts included an in-person kick-off followed by monthly QI coaching and monthly webinars. Weighted generalized estimating equations were used to estimate the baseline, one-year, and two-year implementation change in the proportion of visits with BP control (<140/90 mm Hg) stratified by race/ethnicity. Results For all practices, the percentage of participants with controlled BP increased from 52% in 2017 to 60% in 2019. Among non-Hispanic Whites, the odds of achieving BP control in year one and year two were 1.24 times (95% confidence interval: 1.14, 1.34) and 1.50 times (1.38, 1.63) higher relative to baseline, respectively. Among non-Hispanic Blacks, the odds for years one and two were 1.18 times (1.10, 1.27) and 1.34 times (1.24, 1.45) higher relative to baseline, respectively. Conclusions A hypertension QI project as part of establishing a statewide QI infrastructure improved BP control in practices with a high volume of disadvantaged patients. Future efforts should investigate ways to reduce inequities in BP control and further explore factors associated with greater BP improvements and sustainability.

Keywords: health services research; primary healthcare services; quality improvement projects; racial equity; systemic hypertension.

Grants and funding

Funding for Cardi-OH and the Hypertension QIP is provided by the Ohio Department of Medicaid’s Medicaid Technical Assistance and Policy Program (MEDTAPP), with supplemental funding (cost share) for Cardi-OH by the University of Ohio’s seven medical centers: Case Western Reserve University, Northeast Ohio Medical University, Ohio University, The Ohio State University, University of Cincinnati, University of Toledo, and Wright State University; and associated affiliates: The MetroHealth Medical Center, University Hospitals Cleveland Medical Center, Better Health Partnership, and Ohio State University Wexner Medical Center.