Therapeutic inertia can affect treatment intensification and get in the way of effective medication treatment patients who are on medication, or just starting medication, for uncontrolled high blood pressure.
If medications are not intensified, patients can end up on suboptimal therapy, Klodiana Myftari, PharmD, the AMA’s director of clinical pharmacy relations, said during an AMA webinar.
This is where AMA MAP™ Hypertension—an evidence-based quality-improvement program that provides a clear path to significant, sustained improvements in BP control—can help. The program’s framework focuses on measure accurately, act rapidly and partner with patients, and it has demonstrated a 10% increase in BP control in six months, with sustained results at one year.
The program is designed to lessen therapeutic inertia using single pill combinations and treatment protocols.
“Implementation of these changes lead to better prescribing, which can be measured by the ‘act rapidly’ process metric,” said Myftari in an AMA interview.
The AMA and Azara Healthcare are collaborating to give organizations access to AMA MAP Hypertension metrics, reports, quality-improvement tools and resources. Azara DRVS is a centralized, scalable data reporting and analytics platform for population-health management and quality improvement. The detailed analytics allow care teams to access a more comprehensive view of their patient population, including the socioeconomic challenges their patients are experiencing.
Intensification leads to better outcomes
A modeling study by researchers at the Centers for Disease Control and Prevention reviewed the impact that three modifiable elements have on blood-pressure control: medication adherence, follow up and treatment intensification. Treatment intensification is the one with the most impact in improving BP control.
Adjusting medications timely in patients with blood pressure above goal drives success in BP control. Treatment intensification at a goal of less than 130/80 mmHg—for most patients—is a strategy that leads not only to better BP control, but also less cardiovascular events and better health outcomes, said Myftari.
Intensifying therapy is difficult, however, mainly because of therapeutic inertia—a lack of treatment intensification when indicated. Such inertia is driven by many factors, including health system, clinician and patient factors such as BP measurement inaccuracy, clinical uncertainty, patient nonadherence and a lack of self-measured BP monitoring.
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AMA MAP’s “act rapidly” goal
The program includes a set of performance measures that can help organizations and practices assess how they're doing with each of the three MAP components—measure accurately, act rapidly and partner with patients—and identify opportunities for improvement.
A medication-intensification measure developed by the AMA represents the percentage of adults with hypertension and uncontrolled BP who receive an additional antihypertension medication class during an office visit.
The recommended “act rapidly” goal for this measure is about 30%. That is because medication intensification may not always be the right call, said Myftari.
“There’s going to be scenarios where the blood pressure may be high, patients may be in acute pain, a new short-term medication is used, and your assessment is going to be that the patient does not need a new medication or a higher dose. And that is completely understandable,” she said.
Actionable steps
Myftari also talked about specific action steps that physician practices, health systems and care teams can take to drive medication intensification. One is to use a combination therapy, preferably as a single pill combination. This means either starting a patient automatically on two medication classes or adding a medication class instead of increasing the dose of the current medication.
Adding a medication from a new class has three times the BP-lowering effect when compared with just increasing the dose of the current medication, she said, noting research “suggesting that in order for us to get our patients to goal, most patients are going to need two or more medications.”
A single pill combination helps support medication adherence, not just from the number of tablets the patient takes, but also from the copay perspective. The patient submits one copay versus two, said Myftari. It also eases the burden of tracking medication refills.
Combination therapy allows us to use two different medication classes which is more effective in lowering systolic blood pressure, therefore it improves BP control and is linked to “better health outcomes, decreased morbidity and mortality,” Myftari said.
A one-page hypertension medication treatment protocol is another step that supports the “act rapidly” metric. The protocol identifies patients who are eligible for treatment, supports prescribing at the point of care and serves as a playbook for the entire care team.
Watch other episodes in the webinar series to learn more about AMA MAP Hypertension and how Azara Healthcare can leverage the program through DRVS.
