Christie Bartels, MD, MS, assistant professor, Rheumatology, is keenly aware of a sobering statistic: people living with rheumatoid arthritis and lupus are 60 percent more likely to develop heart disease at an early age than people without these conditions. A critical factor for preventing stroke and heart attacks in such patients is managing high blood pressure. 

And yet, it is rare that high blood pressure is addressed in specialty visits such as appointments in rheumatology clinics. For example, Dr. Bartels' research found that in a representative cohort study of rheumatology visit EHR information among 1,267 patients with rheumatoid arthritis, even when markedly high blood pressure of ≥160/100 was observed, blood pressure was not discussed in two-thirds of the visits. Only 1 in 10 patients with elevated blood pressure received any documented action steps advising them to follow up with their primary care providers to address hypertension. 

To address this problem, Dr. Bartels and colleagues developed BP Connect, an effective staff protocol to improve follow-up after high blood pressures readings in specialty clinics. 

The protocol is performed by nurses or medical assistants during vitals assessment using a series of electronic health record (EHR) alerts. The protocol advises staff to 1) check or re-measure high blood pressure readings ≥140/90, 2) advise the patient with brief counseling, and 3) connect them to primary care using a simple clickable follow-up order. It was created from an evidence-based primary care hypertension staff protocol, which was then adapted for use in specialty clinics.

"We've been tremendously encouraged by the effectiveness of this protocol,” said Dr. Bartels. “In an implementation study, BP Connect doubled the number of timely primary care follow-up visits after specialty visits with high blood pressures. Blood pressure re-measurement jumped from 2 percent to over 75 percent, and staff orders for primary care follow-up improved from 0 percent to 76 percent averaged over the 6-month pilot, with a peak exceeding 90 percent near the completion of the study." 

The implementation study involved 4,683 pre-implementation and 689 post-implementation rheumatology visits with high blood pressure across three adult rheumatology specialty clinics. Of these visits, 2,789 (57%) were eligible for in-network primary care follow-up as a primary outcome. Rates of timely primary care follow-up doubled post implementation, and when sustained over two years rates of high blood pressures declined clinic-wide from 17 to 9% of visits. 

Importantly as well, specialty clinic staff participating in BP Connect expressed increased confidence in knowing what steps to take after observing a high blood pressure reading, with "very confident" or "extremely confident" ratings increasing from 20 percent to 90 percent. 

Given that the number of visits to specialty clinics in the US equals the number of visits to  primary care, Dr. Bartels sees the protocol as having tremendous potential to control blood pressure and thus reduce cardiovascular disease burden across populations. 

"This is a simple, evidence-based approach that can make a lasting impact. I'm grateful to the incredibly dedicated staff who have worked on developing and implementing this tool," said Dr. Bartels. “We look forward to sharing this BP Connect approach in other specialty clinics.”

Additional co-authors of the implementation study were Edmond Ramly, PhD, Heather Johnson, MD, MS, Diane Lauver, PhD, Daniel  Panyard, Zhanhai Li, PhD, Emmanuel Sampene, PhD, Kristin Lewicki, MD, and Patrick McBride, MD, MPH. Others involved in the project for training, staff engagement, EHR tool development, implementation, or data acquisition include Andrea Gilmore-Bykovskyi, PhD RN, Deb Dunham, Ben Schnapp, Jill Lindwall, Patrick Fergusson, Allie Ziegler, Dave Beam and Amanda Perez. 

The work was supported by funding from a University of Wisconsin (UW) Clinical and Translational Science Award (CTSA), the UW School of Medicine and Public Health’s Wisconsin Partnership Program, the National Institutes of Health National Center for Advancing Translational Sciences, and Independent Grants for Learning and Change.

Resources:

• BP Connect Toolkit
• Bartels, CM, et al. 2018. Connecting Rheumatology Patients to Primary Care for High Blood Pressure: Specialty clinic protocol improves follow-up and population blood pressures. Arthritis Care and Research [Epub ahead of print]