eCQM Title

Controlling High Blood Pressure

eCQM Identifier (Measure Authoring Tool) 165 eCQM Version number 8.5.000
NQF Number Not Applicable GUID abdc37cc-bac6-4156-9b91-d1be2c8b7268
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward National Committee for Quality Assurance
Measure Developer National Committee for Quality Assurance
Endorsed By None
Description
Percentage of patients 18-85 years of age who had a diagnosis of hypertension overlapping the measurement period and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period
Copyright
This Physician Performance Measure (Measure) and related data specifications are owned and were developed by the National Committee for Quality Assurance (NCQA). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2019 National Committee for Quality Assurance. All Rights Reserved. 

Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third party codes contained in the specifications.

CPT(R) contained in the Measure specifications is copyright 2004-2018 American Medical Association. LOINC(R) copyright 2004-2018 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2018 International Health Terminology Standards Development Organisation. ICD-10 copyright 2018 World Health Organization. All Rights Reserved.
Disclaimer
The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
 
Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Measure Scoring Proportion
Measure Type Intermediate Clinical Outcome
Stratification
None
Risk Adjustment
None
Rate Aggregation
None
Rationale
High blood pressure (HBP), also known as hypertension, is when the pressure in blood vessels is higher than normal (Centers for Disease Control and Prevention [CDC], 2016). The causes of hypertension are multiple and multifaceted and can be based on genetic predisposition, environmental risk factors, being overweight and obese, sodium intake, potassium intake, physical activity, and alcohol use. High Blood Pressure is common, according to the National Health and Nutrition Examination Survey (NHANES), approximately 85.7 million adults >= 20 years of age had HBP (140/90 mm Hg) between 2011 to 2014 (Crim, 2012. Between 2011-2014 the prevalence of hypertension (>=140/90 mm Hg) among US adults 60 and older was approximately 67.2 percent (Benjamin et al., 2017). 

HBP, known as the “silent killer,” increases risks of heart disease and stroke which are two of the leading causes of death in the U.S. (Yoon, Fryar, & Carroll, 2015). A person who has HBP is four times more likely to die from a stroke and three times more likely to die from heart disease (CDC, 2012) The National Vital Statistics Systems Center for Disease Control and Prevention reported that in 2014 there were approximately 73,300 deaths directly due to HBP and 410,624 deaths with any mention of HBP (CDC, 20145).Between 2004 and 2014 the number of deaths due to HBP rose by 34.1 percent (Benjamin et al., 2017). Managing and treating HBP would reduce cardiovascular disease mortality for males and females by 30.4 percent and 38.0 percent, respectively (Patel et al., 2015).

The estimated annual average direct and indirect cost of HBP from 2012 to 2013 was $51.2 billion (Benjamin et al., 2017). Total direct costs of HBP is projected to increase to $200 billion by 2030 (Benjamin et al., 2017). A study on cost-effectiveness on treating hypertension found that controlling HBP in patients with cardiovascular disease and systolic blood pressures of >=160 mm Hg could be effective and cost-saving (Moran et al., 2015). 

Many studies have shown that controlling high blood pressure reduces cardiovascular events and mortality. The Systolic Blood Pressure Intervention Trial (SPRINT) investigated the impact of obtaining a SBP goal of <120 mm Hg compared to a SBP goal of <140 mm Hg among patients 50 and older with established cardiovascular disease and found that the patients with the former goal had reduced cardiovascular events and mortality (SPRINT Research Group et al., 2015). 

Controlling HBP will significantly reduce the risks of cardiovascular disease mortality and lead to better health outcomes like reduction of heart attacks, stroke, and kidney disease (James et al., 2014). Thus, the relationship between the measure (control of hypertension) and the long-term clinical outcomes listed is well established.
Clinical Recommendation Statement
The U.S. Preventive Services Task Force (2015) recommends  screening for high blood pressure in adults age 18 years and older. This is a grade A recommendation. 

American College of Cardiology/American Heart Association (2017)
-For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher, a blood pressure target of less than 130/80 mmHg is recommended
-For adults with confirmed hypertension, without additional markers of increased CVD risk, a blood pressure target of less than 130/80 mmHg may be reasonable (Note: clinical trial evidence is strongest for a target blood pressure of 140/90 mmHg in this population. However observational studies suggest that these individuals often have a high lifetime risk and would benefit from blood pressure control earlier in life)

American College of Physicians and the American Academy of Family Physicians (2017):  
-Initiate intensifying pharmacologic treatment in adults aged 60 and older at high cardiovascular risk, based on individualized assessment, to achieve a target systolic blood pressure of less than 140 mmHg (Grade: weak recommendation, quality of evidence: low)
-Initiate intensifying pharmacologic treatment in adults aged 60 and older with a history of stroke or transient ischemic attack to achieve a target systolic blood pressure of less than 140 mmHg to reduce the risk of recurrent stroke (Grade: weak recommendation, quality of evidence: moderate)

American Diabetes Association (2018):
Most patients with diabetes and hypertension should be treated to a systolic blood pressure goal of <140 mmHg and a diastolic blood pressure goal of <90 mmHg (Level of evidence: A)

Report from the Eighth Joint National Committee (2014)
-In the general population younger than 60 years, initiate pharmacologic treatment to lower blood pressure at diastolic blood pressure (DBP) of 90 mmHg or higher and treat to a goal of DBP of lower than 90 mmHg (Grade: A (for ages 30-59), Grade: E (for ages 18-29))
-In the general population younger than 60 years, initiate pharmacologic treatment to lower blood pressure at systolic blood pressure (SBP) to 140 mmHg or higher and treat to a goal of SBP of lower than 140 mmHg (Grade: E)
-In the general population aged 60 years and older, initiate pharmacologic treatment to lower blood pressure at SBP of 150 mmHg or higher or a DBP of 90 mmHg or higher and treat to a goal of SBP lower than 150 mmHg and goal of DBP lower than 90 mmHg
Improvement Notation
Higher score indicates better quality
Reference
American Diabetes Association. (2018). 9. Cardiovascular disease and risk management: Standards of medical care in diabetes 2018. Diabetes Care, 41(Suppl. 1), S86-S104.
Reference
Benjamin, E. J., Blaha, M. J., Chiuve, S. E., et al. (2017). Heart disease and stroke statistics-2017 update: A report from the American Heart Association. Circulation, 135(10), e146-e603.doi: 10.1161/CIR.0000000000000485
Reference
Centers for Disease Control and Prevention. (2012). Vital signs: Getting blood pressure under control. Retrieved from https://www.cdc.gov/vitalsigns/hypertension/index.html
Reference
Centers for Disease Control and Prevention. Division for Heart Disease and Stroke Prevention. (2016). High blood pressure fact sheet. Retrieved from https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htmhttps://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm. 
Reference
Centers for Disease Control and Prevention, National Center for Health Statistics. (2015). Underlying Cause of Death 1999-2013 on CDC WONDER Online Database. Data are from the Multiple Cause of Death Files, 1999-2013, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Retrieved from http://wonder.cdc.gov/ucd-icd10.html
Reference
Crim, M. T., Yoon, S. S., Ortiz, E., et al. (2012). National surveillance definitions for hypertension prevalence and control among adults. Circulation: Cardiovascular Quality and Outcomes. 2012, ;5(3), :343-–351. doi: 10.1161/ CIRCOUTCOMES.111.963439.
Reference
James, P. A., Oparil, S., Carter, B. L., et al (2014). 2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC8). JAMA. 311(5), 507-520. doi:10.1001/jama.2013.284427
Reference
Moran, A. E., Odden, M. C., Thanataveerat, A., et al.Tzong KY, Rasmussen PW, Guzman D, Williams L, Bibbins-Domingo K, Coxson PG, Goldman L. (2015). Cost-effectiveness of hypertension therapy according to 2014 guidelines. [published correction appears in N Engl J. Med. 2015;372:1677]. New England Journal of Medicine,. 2015 ;372, :447-–455. doi:  10.1056/NEJMsa1406751. [published correction appears on page 1677] 
Farley TA, Dalal MA, Mostashari F, Frieden TR. Deaths preventable in the US by improvements in the use of clinical preventive services. Am J Prev Med. 2010;38:600-9.
Reference
Patel, S. A., Winkel, M., Ali, M. K., et al. (2015). Cardiovascular mortality associated with 5 leading risk factors: National and state preventable fractions estimated from survey data. Annals of Internal Medicine, 163(4), :245–253. doi: 10.7326/M14-1753
Reference
Qaseem, A., Wilt, T. J., Rich, R., et al. (2017). Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: A clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Annals of Internal Medicine, 166(6), 430-437.
Reference
SPRINT Research Group,; Wright, J. T., Jr., Williamson,  J. D., et al. (2015). A randomized trial of intensive versus standard blood-pressure control. New England Journal of Medicine, 373(22), 2103–2116.
Reference
U.S. Preventive Services Task Force. (2015). Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 163(10), 778-787.
Reference
Whelton, P. K., Carey, R. M., Aronow, W. S., et al. (2017). Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, . https://doi.org/10.1161/HYP.0000000000000065
Reference
Yoon, S. S., Fryar, C. D., & Carroll, M. D. (2015). Hypertension prevalence and control among adults: United States, 2011-2014. NCHS Data Brief No. 220. Hyattsville, MD: National Center for Health Statistics.
Definition
None
Guidance
In reference to the numerator element, only blood pressure readings performed by a clinician or a remote monitoring device are acceptable  for numerator compliance with this measure. 

Do not include BP readings:
-Taken during an acute inpatient stay or an ED visit
-Taken on the same day as a diagnostic test or diagnostic or therapeutic procedure that requires a change in diet or change in medication on or one day before the day of the test or procedure, with the exception of fasting blood tests.
-Reported by or taken by the member


If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled."

If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading.
Transmission Format
TBD
Initial Population
Patients 18-85 years of age who had a visit and diagnosis of essential hypertension overlapping the measurement period
Denominator
Equals Initial Population
Denominator Exclusions
Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also exclude patients with a diagnosis of pregnancy during the measurement period.

Exclude patients whose hospice care overlaps the measurement period.

Exclude patients 66 and older who are living long term in an institution for more than 90 days during the measurement period. 

Exclude patients 66 and older with advanced illness and frailty because it is unlikely that patients will benefit from the services being measured.
Numerator
Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period
Numerator Exclusions
Not Applicable
Denominator Exceptions
None
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Table of Contents


Population Criteria

Definitions

Functions

Terminology

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables


Measure Set
None