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Abstract

Objective: Panel management is a system of care that targets groups of patients with similar needs to improve their quality of care. The purpose of this pilot was to determine whether panel management could improve blood pressure control in patients with previously uncontrolled hypertension and to explore how panel management can be integrated in an urban, low-income, primary care setting. Methods: The practice coach model was used to assist a clinical site in forming a quality improvement team to implement panel management. The team created a patient registry to track hypertensive patients over time and to recall patients with uncontrolled hypertension for planned care visits during which evidence-based interventions for hypertension were delivered. Percent of patients gaining control of blood pressure and change in blood pressure were measured between 6 and 9 months after enrollment. Qualitative interviews of clinic staff were completed to explore strengths and weaknesses of program implementation. Results: Forty patients with uncontrolled hypertension were enrolled in the pilot, and 27.5% gained blood pressure control by 9 months after enrollment (P < .001). The average systolic blood pressure decreased by 16 mm Hg from 156.5 to 140.5 mm Hg (P < .001), and the average diastolic blood pressure decreased by 3.8 mm Hg from 85 to 81.2 mm Hg (P = .03). Staff interviews were generally positive; however, several areas for improvement were identified. Conclusion: Panel management for hypertension can be effective and can be implemented in a low-income, urban, primary care clinic setting given appropriate staffing allocation.

Keywords

panel management hypertension primary care practice coach quality improvement

Introduction

Hypertension is a major risk factor for heart disease,¹ which is the number one cause of preventable death in New York City² and the United States.³ Controlling hypertension can reduce this risk, but there are many barriers to adequate treatment. In New York City, more than 30% of patients receiving treatment for hypertension do not have their blood pressure controlled.⁴ Black and Hispanic patients have lower rates of blood pressure control,⁴ which contribute to thousands of excess deaths annually.⁵ Improving hypertension control for these populations could reduce these racial and ethnic disparities.

Panel management, a system of care that allows the targeting of groups of patients with similar needs, has been shown to be an effective way to improve chronic disease management.^6-12 Panel management entails (a) systematic identification of groups of patients at-risk or with gaps in care (usually through a patient registry), (b) outreach to improve follow-up care, (c) implementation of guideline-based interventions, and (d) tracking and monitoring indicators of care delivery and outcomes.

We aimed to determine whether panel management could improve blood pressure control and to explore how it can be integrated into routine practice in an urban community health center serving a low-income, racial and ethnic minority population.

Methods

Selection of the Pilot Site

Prior to this pilot, the New York City Department of Health and Mental Hygiene (Health Department) initiated a project to increase self blood pressure monitoring (SBPM) among hypertensive patients in neighborhoods that are predominantly black and Hispanic, low income, and medically underserved.¹³ Hypertensive patients in clinics in these neighborhoods received blood pressure monitors and training on their use. For this pilot, Health Department staff reached out to medical directors of clinics in the SBPM program that had functioning electronic medical record systems. The Dr Martin Luther King Jr Health Center was chosen because the medical director agreed to commit clinic staff time to this quality improvement effort.

Hypertension Quality Improvement Team

The Health Department provided a practice coach to assist the clinic leadership in sustaining hypertension panel management.¹⁴ The medical director recruited the hypertension quality improvement team (the team), which included a physician leader and representatives from the medical staff, administration, clerical staff, social work, nutrition, information technology support, and nursing. The practice coach provided training in quality improvement methods¹⁵ and in panel management. The physician leader prepared meeting agendas, ensured that the registry was updated, generated reports for monthly team meetings and designated specific tasks to team members.

Team members rotated responsibilities for running meetings and each team member developed protocols in their respective disciplines (eg, the nutritionist developed the nutrition counseling protocol). Resident physicians assisted with data entry, technical support, and generating results for reports from the registry. The registrar tracked and scheduled planned care visits, mailed out reminders to patients overdue for appointments, and flagged patient charts to remind providers that patients were participants in the registry. The social worker directed self-pay patients to low-cost pharmacies and gave information regarding free gym access. The practice manager blocked physician schedules and reserved locations for team meetings. Team huddles were held on a weekly basis to identify any barriers in the work flow and ensure their timely resolution.

Registry

The registry of hypertensive patients was planned as part of the electronic health record with data automatically populated from clinical documentation. However, the information technology department did not have the resources to implement it at the time, and as a result, the team created a registry in Microsoft Excel based on an example from the American Academy of Family Physicians.¹⁶

Development of the Intervention

The clinic physicians identified 42 patients participating in SBPM who still had uncontrolled hypertension after at least 2 months of participation, and nurses contacted them to enroll them in the program in January and February 2011. Inclusion criteria included systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg (or ≥130 or ≥80 mm Hg, respectively, for patients with diabetes or kidney disease), age ≥18 years, documented hypertension for at least 6 months, up-to-date contact information, and previous compliance with the SBPM program.

From March to October 2011, patients were monitored and called in for planned-care visits. Patients were seen for follow-up visits at 1 and 2 months after enrollment. During visits, patients received nursing and physician interventions that included medication compliance assessment and counseling along with dietary and exercise counseling. Physicians reviewed and adjusted antihypertensive medications based on the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) hypertension guidelines. Patients were then recalled on a monthly basis if needed.

Data Collection

The registry was used to collect pre- and postimplementation blood pressure, documentation of receipt of the interventions, demographic data, and data on medical co-morbidities.

In September and October 2011, clinic staff members were interviewed using structured in-person interviews. Interviews of team members were designed to assess perceptions of the project, overall time commitment and successes and challenges.

Data Analysis

All 42 patients approached agreed to participate. One patient was unable to continue participation because of cognitive limitations and lack of family support and 1 patient died prior to follow-up. The remaining 40 patients had at least 1 follow-up visit; however, 2 patients had incomplete follow-up with less than 6 months of enrollment. These patients were included in the analysis using their last recorded blood pressure as the outcome measure. The proportion of patients with blood pressure control at baseline and at 6 to 9 months was compared using McNemar’s test. Average systolic and diastolic blood pressure at enrollment and at 6 to 9 months were also compared using paired t tests.¹⁷ Thematic analysis¹⁸ was performed on the data from staff interviews.

Results

Demographic characteristics of the clinic and of participants are shown in Table 1. Fifty percent of the patients were enrolled in either Medicare or Medicaid health maintenance organization, 25% were enrolled in traditional Medicaid, 20% had private insurance, and 5% were uninsured. Recorded comorbidities included diabetes (52.5%), renal disease (17.5%), or both (15.0%). None of the participants had controlled blood pressure at enrollment, and 11 (27.5%) had gained control by the end of the pilot (McNemar’s χ² = 27, P < .001). The average systolic blood pressure decreased by 16 mm Hg from 156.5 to 140.5 mm Hg (P < .001; Figure 1), and the average diastolic blood pressure decreased by 3.8 mm Hg from 85 to 81.2 mm Hg (P = .03; Figure 2).

Table 1.

Demographic Characteristics of Study and Clinic Populations.

Characteristics	Study Panel, n (%)	Clinic Population, n (%)
Male gender	10 (25)	4199 (41)
Average age in years	60	55
Hispanics	17 (42)	3435 (33.5)
African Americans	23 (57)	4628 (45)
Diabetes	21 (52)	1839 (18)
Insured patients	38 (95)	9427 (92)
Total	40	10 247

Figure 1.

Systolic blood pressure at several time points before and after the initiation of the intervention.

Figure 2.

Diastolic blood pressure at several time points before and after the initiation of the intervention.

The mean number of clinic visits between enrollment and follow-up was 6 (range 1-12). Almost all (97.5%) patients received nutrition counseling and 85% received exercise counseling. The majority (72.5%) received medication adjustment, and 40% received medication adherence counseling.

Provider Interviews

All team members were interviewed. One physician who was not on the team was also interviewed to gain perspective on the program’s impact on clinicians without a specific investment in the project. Project successes included improved provider communication, patient education, and patient activation. Challenges centered on scheduling conflicts and use of the registry (Table 2).

Table 2.

Themes and Quotes From Provider Interviews.

Theme	Quote
Successes
Patient education	“Calling noncompliant patients in multiple times helps make them realize that you have to be really serious.”—Physician
Patient education	“Educating the patient more and having the patient look at the blood pressure every day helps them to understand.”—Physician
Patient activation	“It increases efficiency by increasing patient involvement . . . it makes the doctor’s work easier.”—Physician
Patient activation	“It makes patient more proactive and responsible.”—Nurse
Provider communication	“Communication with other team workers increases efficiency. You don’t worry about whether to call someone or not [about specific patient issues]. You just call.”—Physician
	“It helped to communicate with other team members and to try to do specific things like gym membership.”—Registrar
	“Team meetings were useful to get a chance to sit down and converse. It keeps everyone abreast and keeps social work and nutrition involved.”—Nurse
Teamwork	“The team functioned well, worked well, and showed motivation.”—Physician
Teamwork	“We worked as a team together. Everyone worked on their different parts.”—Nutritionist
Practice coach model	“It helped us to focus. Otherwise we would be blind.”—Physician
Challenges
Meeting scheduling	“Meetings sometimes interfered with daily work. The patient schedules were not blocked by administration and patients had to wait.”—Physician
	“We needed better assistance in organizing meetings to set locations and block schedules.”—Physician
	“There was poor attendance at some meetings . . . [Administrators] could have been useful with patient scheduling.”—Physician
	“Meetings were difficult to schedule because MDs were seeing patients.”—Nurse
Health information technology	“It was very cumbersome to enter data manually. You had to go back and forth between Excel and the electronic health record. Support from IT [information technology] was not there. The registry through the electronic record never materialized.”—Physician
	“The registry needs to be computerized.”—Registrar
	“It was difficult to train others to maintain and use the registry.”—Physician
	“We didn’t have a warning [flag] in the system. You didn’t know that you were seeing a patient in the group. One of the administrators was flagging them [by hand].”—Physician
	“We need to have patients flagged in the computer.”—Registrar

Two physicians estimated that they spent 1.5 to 2 hours per week during the first few weeks on the project followed by 1.5 to 3 hours per month afterward. A third resident physician spent 4 to 5 hours per month on the project. Two nurses each spent 0.5 to 1 day twice a month on the project, and the registrar spent 1 to 1.5 hours per week on the project. All other respondents indicated that the project did not appreciably increase their workload or detract from their other duties.

Discussion

The results of this pilot project indicate that panel management can improve blood pressure control in a difficult-to-reach population with limited resources. We found similar improvements compared to other hypertension quality improvement projects. Walsh et al,¹⁹ in a systematic review of 82 quality improvement studies, found a 16.2% increase in patients with blood pressure control, 4.5 mm Hg improvement in systolic blood pressure and 2.1 mm Hg improvement in diastolic blood pressure.¹⁹

In general, this approach was well accepted by clinic staff. Information on specific staffing requirements for implementing panel management is lacking in the literature. This pilot generated estimates of the number of hours each staff member contributed. Taken as a whole, these results suggest that in order to be viable on a larger scale, health information technology needs to be used more efficiently and management and administrative support for scheduling need to be strong and consistent.

Limitations of this pilot include the pre-post design that lacked a control group for comparison. Also, we used a convenience sample of patients enrolled in the SBPM program who were selected to be likely to comply with frequent follow-up. The most vulnerable patients with financial barriers to treatment and poor follow-up were not captured in this sample. Finally, clinic staff member interviews may have been biased due to courtesy bias.

Primary care practices, with appropriate staff supports, could use this model to improve their own clinical practice. Even providers without access to an electronic health record–based registry can create a registry using commercially available software to track patients and improve care.* Functional, user-friendly registries that populated automatically from the electronic medical record could substantially improve the efficiency for panel management.

Footnotes

Acknowledgements

The authors would like to thank Angela Aguasvivas, Minerva Calderon, Dr Shadi Chamany, Dr Ellen Cohen, Grace Cruz, Victoria Foster, Dr Jayanthi Loganathan, Dr Andrea Lyman, Dr Suresh Nayadu, Kinjal Patel, Dr Amparo Ramirez, Dr Venkat Sahasranaman, Dr Abayomi Salako, Kendall Sims, Stella Yi, Susan Leung Yuen, and the staff of the Dr Martin Luther King Jr clinic for their contributions to this work.

Authors’ Note

At the time of this study, Dr Chuang was a resident in Public Health and Preventive Medicine at the New York City Department of Health and Mental Hygiene, Drs Alvi and Yandrapu were residents in Internal Medicine at Bronx-Lebanon Hospital, and Dr Dalal was the Medical Director of Quality Improvement in the Bureau of Chronic Diseases at the New York City Department of Health and Mental Hygiene.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

*

Low-cost registry software that may be useful for small practices can be found through i2iSystems at http://www.i2isys.com/products-detail/646710-i2i-tracks. A review of various free access and low-cost registry software programs can be accessed through the California Healthcare Foundation at .

Author Biographies

Elizabeth Chuang, MD, MPH, is an assistant professor at the Albert Einstein College of Medicine in the department of Family Medicine, and is an attending physician in palliative care at Montefiore Medical Center. She earned an MD from New York University School of Medicine and an MPH from the Columbia Mailman School of Public Health. Her interests include quality improvement in healthcare and health systems research.

Valli Ganti, MD, MPH, is a Board Certified Internal Medicine Physican and a member of the American College of Physicians. After completing medical school at Andhra Medical College in India and residency at Bronx Lebanon Hospital Center, she joined the Department of Primary care and Preventive Medicine, Bronx Lebanon Hospital as an attending and is an instructor with the Albert Einstein College of Medicine. Dr Ganti specializes in adult health care, including the diagnosis and management of acute and chronic medical illness from teens to adult and prioritizes delivery of quality health care.

Afshan Alvi, MD, graduated from Punjab Medical College, Pakistan and completed an internal medicine residency and chief residency at Bronx Lebanon Hospital in 2012. Dr. Alvi is currently an attending physician in the Pre-surgical testing Clinic at Bronx Lebanon Hospital and will start cardiology fellowship in July 2014.

Harathi Yandrapu, MD, MS, is an assistant professor of internal medicine at the Texas Tech University Health Sciences Center and is actively involved in the academic appointments and research projects. She plays a key role in the clinical management of critical care, telemetry and acute medical care units. She is a physician champion of quality improvement and active leader of “computer provider order entry” program, and was awarded a certificate of circle of excellence in clinical management.

Mehul Dalal, MD, MSc, MHS, is currently the Chronic Disease Director at the Connecticut Department of Public Health. He was previously the Medical Director of Quality Improvement at the New York City Department of Health and Mental Hygiene’s Cardiovascular Disease Prevention and Control Program. He completed a primary care internal medicine residency at New York University/Bellevue Hospital and was a Robert Wood Johnson Foundation Clinical Scholar at the Yale University School of Medicine.

References

Chobanian

Bakris

Black

. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252.

Schwartz

. Summary of Vital Statistics 2004: The City of New York. New York: New York City Department of Health and Mental Hygiene; 2004.

Heron

Hoyert

Murphy

Kochanek

Tejada-Vera

. Deaths: Final Data for 2006. Hyattsville, MD: National Center for Health Statistics; 2009.

Angell

Garg

Gwynn

Bash

Thorpe

Frieden

. Prevalence, awareness, treatment and predictors of control of hypertension in New York City. Circ Cardiovasc Qual Outcomes. 2008;1:46-53.

Fiscella

Holt

. Racial disparity in hypertension control: tallying the death toll. Ann Fam Med. 2008;6:497-502.

Thomas

Stroebel

. Use of a registry-generated audit, feedback and patient reminder intervention in an internal medicine resident clinic—a randomized trial. J Gen Intern Med. 2007;22:1740-1744.

Dinneen

Bjornsen

Bryant

. Towards an optimal model for community-based diabetes care: design and baseline data from the Mayo Health System Diabetes Translation Project. J Eval Clin Pract. 2000;6:421-429.

Pollard

Bailey

Petitte

Baus

Swim

Hendryx

. Electronic patient registries improve diabetes care and clinical outcomes in rural community health centers. J Rural Health. 2009;25:77-84.

East

Krishnamurthy

Freed

Nosovitski

. Impact of a diabetes electronic managment system on patient care in a community clinic. Am J Med Qual. 2003;18:150-154.

10.

Smith

Murphy

Huschka

. Impact of a diabetes electronic management system on the care of patients seen in a subspecialty diabetes clinic. Diabetes Care. 1998;21:972-976.

11.

Grant

Hamrick

Sullivan

. Impact of population managment with direct physician feedback on care of paitents with type 2 diabetes. Diabetes Care. 2003;26:2275-2280.

12.

Shojania

Ranji

McDonald

. Effects of quality improvement strategies for type 2 diabetes on glycemic control. JAMA. 2006;296:427-440.

13.

Angell

Guthartz

Dalal

. Integrating self blood pressure monitoring into the routine management of uncontrolled hypertension: translating evidence to practice. J Clin Hypertens. 2013;15:180-185.

14.

Agency for Healthcare Research and Quality. Integrating Chronic Care Business Strategies in the Safety Net: A Toolkit for Primary Care Practices and Clinics (Publication No. 08-0104-EF). 2008. http://www.ahrq.gov/populations/businessstrategies. Accessed December 22, 2011.

15.

Langley

Nolan

Noan

Norman

Provost

. The Improvement Guide: A Practical Approach to Enhancing Organizational Perormance. 2nd ed. San Francisco, CA: Jossey-Bass; 2009.

16.

Ortiz

. Using a simple patient registry to improve your chronic disease care. Fam Pract Manag. 2006;13(4):47-52.

17.

Fleiss

Levin

Paik

. Statistical Methods for Rates and Proportions. 3rd ed. Hoboken, NJ: Wiley; 2003.

18.

Braun

Clarke

. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77-101.

19.

Walsh