Abstract | November 6, 2020

Improving Hypertension and Diabetes mellitus control by a multidisciplinary approach at BHCC

Presenting Author: Paulo Carvalho, MD, MBA, Family Medicine Department, Borinquen Health Care Center, Miami, FL

Co-authors: Diego Shmuels, MD, MPH, MSN, CHCQM, CQO, DIO, Borinquen Health Care Center, Miami, FL; Joseph Durandis, MD, Program Director, Borinquen Health Care Center, Miami, FL; Sandra Roca, M.D.,MSc., RN, Quality Manager, Borinquen Health Care Center, Miami, FL

Learning Objectives

  1. To understand the challenges faced in the FQHC environment with Hypertension and Diabetes Management.
  2. To identify areas of improvement in Chronic Disease Management.
  3. To identify strategies to address Hypertension and Diabetes management in a patient centered model.

Background: Hypertension and Diabetes mellitus are two chronic diseases that have a tremendous healthcare impact associated to social determinants. Diabetes mellitus affects at least 34 million Americans in 2020, according to the National Diabetes Statistics Report of 2020 and the National Health and Nutrition Examination Survey of 2018. Both Hypertension and Diabetes are risk factors for Cardiovascular Disease (CVD). Lowering blood pressure and controlling serum glucose levels can decrease the incidence of Stroke, Myocardial Infarction (MI), Heart Failure (HF), Chronic Kidney Disease (CKD), and microangiopathies, such as retinal microangiopathy leading to blindness. Many complications can arise from uncontrolled Hypertension and Diabetes, and the main objective of this project is to prevent these complications by improving control through a multidisciplinary approach that include primary care physician (PCP), Nutritionist/dietitian, Clinical pharmacist, Podiatrist, and Behavioral Health support (Patient Care Team). Recommendations and definitions provided by different guidelines, such as the Eight Joint National Committee (JNC-8), American Heart Association (AHA), American Diabetes Association (ADA) were analyzed and followed to design this community project. The Uniform Data System (UDS) of Health Resources and Services Administration (HRSA) is used as a guidance for the establishment of statistical terms, formulas, and threshold values.

Methods/Design: Borinquen Health Care Center (BHCC) is FQHC, PCMH NCQA & AAAHC Accredited, with multiple sites that serving over 44,000 patients (UDS2019) with diverse, multicultural, low income characteristics. BHCC has been implementing actions and updating protocols according to the JNC8, AHA, ADA guidelines to manage Hypertension and Diabetes mellitus. The healthcare providers have been trained on recommended therapeutic options to treat Hypertension and Diabetes mellitus.

As of December 31st, 2019, a total of 3540 patients diagnosed with Essential Hypertension, and 1537 patients with Diabetes mellitus were included in the project. All the existing and newly diagnosed patients are including in the pool of patients throughout 2020, and preliminary quarterly results will be analyzed.

Because patients with both uncontrolled Hypertension and Diabetes mellitus are at a higher risk of developing CVD and deleterious outcomes, stratification of these patients into low-risk and high-risk groups was necessary. On site fundoscopic eye exams have been used as a surrogate ophthalmological exam, to detect patients with retinal complications of Hypertension and/or Diabetes. The high-risk group (e.g. patient with both Hypertension and Diabetes) required focused multidisciplinary attention to attain a satisfactory control of their arterial blood pressure, and serum Glucose level through surrogate measurement of their Hemoglobin A1C. The cut-off levels chosen to determine status of “controlled” and “poorly controlled” are given by the US Department of Health and Human Services – Health Resources and Services Administration (HRSA), as follows:

The objective of the project is achieving a control rate of 75% for Hypertension and 80% for Diabetes mellitus by
December 31st, 2020 by addressing the following goals:

  • By December 31st, 2020, increase control rate of Hypertension (BP < 140/90 mmHg) from 50% (UDS 2019) to
    75%, for patients with active Hypertension (18-85 years);
  • Increase the control rate of Diabetes mellitus (HbA1C ≤ 9%) from 55% (UDS 2019) to 80% for patients with active Diabetes mellitus (18-75 years);
  • Increase patient education on nutrition and compliance to ambulatorial blood pressure monitoring and Hemoglobin A1c follow up in 25% of the non-complaint patients with both Diagnoses;
  • Increase patient participation in decision making process to enhance medication adherence to Antidiabetic, Anti-hypertensive and Lipid-lowering agents, in 25% of the non-Complaint patients with both diagnoses.

Preliminary Results: The data was calculated using definitions provided by Uniform Data System (UDS) Resources of HRSA, and results are compiled as a monthly cumulative result depicted on Table 1, and as monthly non-cumulative trend depicted on Graph 1.

The total number of patients each month is to illustrate the burden of Hypertension and Diabetes in the BHCC
community assigned to this project, which is summarized as semi-annual report on Table 2.

Results/Findings:

  • Controlled Hypertension – Patients age 18 – 85 years:
    • Patients whose most recent blood pressure is adequately controlled during the measurement period – systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg during the measurement period.
  • Poorly controlled Diabetes mellitus patients age 18-75 years:
    • Hemoglobin A1C > 9% in the measurement period (Conversely, “controlled” diabetes is considered HbA1C ≤ 9%)

Patients with both uncontrolled Hypertension and poorly controlled Diabetes mellitus are at a higher risk of CVD and they may benefit from a multidisciplinary holistic approach, based on patient education to increase access to care and medication adherence; nutrition counseling, smoking cessation and statin therapy compliance.

Graph 1: Due to the novel COVID-19 pandemics, patient health management and follow-up have been negatively affected, despite the availability of Telehealth visits, starting in March 2020. Patients have reported more sedentarism and weight gain during this period, which could account for a decrease in the percentual cases of controlled Hypertension during the period of March – May 2020. Similarly, data shows that during the same period, there was a percentual decrease in controlled Diabetes cases. This could be a reflect of lower number of visits of diabetic patients, either presential, or via Telehealth. The goal of reporting data in a quarterly basis is to guide interventional strategies to achieve the community project goals. Once negative impact of the COVID-19 pandemics starts declining, it is expected a further improvement in controlling Hypertension and Diabetes mellitus, as the trend of outpatient office visits, and daily physical activity by patients should increase, which will enable BHCC to continue efforts in patient and caregiver education to achieve the community project goals by December 31st, 2020.

ConclusionsT; he burden caused by Essential Hypertension and Diabetes mellitus is relevant, particularly when it comes to all potential complications that may arise. Nevertheless, as a starting point, patients have been encouraged to adhere to a strict control of their blood pressure and glucose levels, in order to prevent these latent complications. BHCC is not only committed to improving control of Hypertension and Diabetes for its patients, but also preventing the potentially lethal complications. The realization that only this multidisciplinary approach can achieve an adequate control of Hypertension and Diabetes, allows a crucial selection and allocation of appropriate existing resources, maximizing clinical and financial outcomes. A shift in the caregivers’ mindset and access to care management culture was a positive outcome observed from the implementation of this project. Despite the fact these benefits were not originally contemplated during this project design, not only patients have benefited from this holistic approach, but the organization, caregivers and the Healthcare system also draw numerous benefits from it.

Graphs and Figures

References and Resources

  1. SPRINT Research Group, Wright JT Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 373(22):2103–16. 2015.
  2. National Center for Health Statistics. National Health and Nutrition Examination Survey (NHANES): Physician examination procedures manual.pdf icon
  3. Centers for Disease Control and Prevention. National Center for Health Statistics. Underlying Cause of Death 1999–2017 on CDC WONDER Online Database, 2018. Accessed at http://wonder.cdc.gov/ucd icd10.html on Oct 10, 2019.
  4. Eight Joint National Committee – JNC-8, online at http://thepafp.org/website/wp-content/uploads/2017/05/2014-JNC-8-Hypertension.pdf
  5. UDS Health Resources and Services Administration – HRSA, online http://bphc.hrsa.gov/datareporting/reporting/index.html
Posted in: Cardiovascular Disease7 Endocrinology, Diabetes, and Metabolism12 Hypertension1 Diabetes Mellitus2