People with cancer often face additional health conditions, or “comorbidities,” that complicate treatment. High blood pressure, or hypertension, is a major comorbidity that affects many cancer patients. Our Curious Dr. George asks Robert E. Matthews, President and CEO of MediSync in Cincinnati, Ohio, about how his company’s tools are helping physicians better manage their patients’ blood pressure.
Curious Dr. George: All physicians and medical organizations know that hypertension is a major attributable cause of many serious and fatal illnesses, such as coronary artery heart disease, heart failure, and stroke. As many as 48% (119 million) of American adults have hypertension. The American Heart Association, the American Medical Association, the American College of Cardiology and hundreds of other organizations have set a new target of 130/80 (revised from 140/90) for blood pressure control and have launched a major initiative to achieve such. Yet, the Centers for Disease Control and Prevention (CDC) reports that fewer than 48% of American patients with hypertension meet even the less stringent historical 140/90 goal.
Your group practice, PriMED Physicians in Ohio, using the MedsEngine AI tool from MediSync and the NICaS (non-invasive cardiac system with impedance cardiography) test coupled with solid clinical leadership reports that its cooperating institutions have consistently exceeded 90 or even 95% blood pressure control for more than 10 years. Exemplary.
Your approach to matching the correct drug or drugs and dosages with each patient’s unique blood pressure pathophysiology would seem to be the key. Why does your organization succeed, and how might others follow your lead to success?
Robert E. Matthews: Helping patients with hypertensive diseases (HTN) reduce blood pressure (BP) to 140/90 or lower has been and remains a struggle for physicians. Since 1999, CDC reports have shown that far more than half of all diagnosed patients fail to achieve this level of BP control. Recent studies strongly suggest an even more stringent BP goal of lower than 130/80 would benefit most patients.
PriMED Physicians in Dayton, Ohio, has a consistent record of achieving >90% BP control across all HTN patients with very slight month-to-month variations. PriMED has a database tracking key quality metrics, including BP for every patient at every visit for over 10 years.
In October 2023, 94% of all of PriMED’s HTN patients; 95% of all the patients with both HTN and diabetes and, remarkably, 96% of all African American patients from socio-economically challenged zip codes had a BP of less than 140/90. These outcomes reflect a different way of providing chronic disease care. You yourself recently encouraged that, now that we know these results are possible, more groups should be using PrIMED’s methods, which are briefly described here:
- PriMED formally established a corporate goal of achieving greater than 90% “control” (control is defined as meeting the evidence-based standard definition of control) for several major chronic diseases in 2002 via a groupwide vote of all physicians. Hypertension was the first disease tackled.
- After surveying non-healthcare companies noted for their consistent quality and discovering that all of them adopted a quality science approach, PriMED and its management partner, MediSync, underwent almost a year of extensive training in the Six Sigma quality science, tools, and statistics.
- Six Sigma instructs that great care be taken to enumerate the challenges to achieving target goals and, further, to discover the root causes of those obstacles. PriMED and MediSync inquired extensively into the challenges of getting 90% of all HTN patients to the target BP. PriMED’s “root cause analysis” of the problems that result in sub-optimal outcomes is enumerated in this talk co-sponsored by The Lundberg Institute and the Commonwealth Club of California.
- Most medical groups conclude that “the patient is the problem” when treating hypertension. PriMED and MediSync recognized that the patient is the smallest part of the challenge. The actions of physicians and other providers are key to success.
- Simplistically described, elevated blood pressure can be the result of several hemodynamic factors, including (1) vasoconstriction, (2) elevated heart rate, (3) elevated stroke index, reflecting a more violent contraction, (4) excessive fluid status, and (5) some combination of 1 through 4. When there are multiple causes, calculating the portion of each cause is very helpful.
- PriMED’s physicians determined that using a simple, Food and Drug Administration-approved, in-office test called Impedance Cardiography (ICG) provides sufficiently accurate analysis of the hemodynamics behind elevated blood pressure. Statistical analysis demonstrated that, when PriMED’s providers used ICG, their outcomes were significantly improved. Without ICG outcomes were worse.
- Over time, PriMED recognized 28 additional demographic and comorbid conditions that can influence provider choices for optimal pharmacotherapy by patient. Given the variables described above, PriMED’s calculations include 50 key variables which, in turn, generate over 240 million permutations.
- All quality sciences prove that doing complex work successfully requires a carefully constructed process. A process is a series of steps designed to achieve the target outcome. If different actors do their work in an individualized manner, quality will be significantly lower.
- PriMED and MediSync first created a “paper and pencil” process to guide providers to select the optimal drugs from the 13 different classes of anti-hypertensive drugs for each patient.
- In 2017, MediSync made available and PriMED adopted an IT application called the MedsEngine that pulls vast amounts of data from any patient’s electronic health record and identifies and calculates the variables to make individualized drug recommendations for the patient. Provider use of this application is highly correlated to outcome success.
- The MedsEngine permitted PriMED to automate more disease calculations for cholesterol, diabetes, and heart failure—diseases for which the group also has excellent outcomes especially by national standards.
Medicine in general and primary care in particular have yet to broadly adopt or embrace the quality improvement techniques and methods that are ubiquitous in virtually all other economic sectors. It is clearly possible and urgently important that primary care does a far better job getting chronic diseases controlled. Once a few medical groups accomplish remarkable goals, there is no further debate about whether it is possible. Hundreds of millions of patients can live longer, healthier lives on average if we meet the challenge of better outcomes.
Mr. Matthews can be reached at firstname.lastname@example.org.
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