RESUMEN
BACKGROUND: Approximately 80% of patients with hypertension in the Internal Medicine Clinic were uncontrolled (BP > 130/80 mmHg), according to the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines, leading to increased morbidity and mortality. The aim of this quality improvement (QI) was to improve BP control <130/80 from the baseline rates of 20%-30% and <140/90 from the baseline rates of 40%-60% between ages of 18-75 years, within 12 months. METHODS: We used the Plan-Do-Study-Act method. A multidisciplinary QI team identified barriers by fish bone diagram. Barriers included: 1) Physicians' knowledge gap and clinical inertia in optimization of medications, and 2) Patients' nonadherence to medication and appointments. The outcome measures were the percentage of patients with BP < 140/90 and < 130/80. Process measures included: 1) attendance rates of physician and nurses at educational sessions, 2) medication reconciliation completion rates and 3) care guide order rates. Key interventions were: 1) physicians and nurses' education regarding ACC/AHA guidelines, 2) patient education and engagement and 3) enhancement of health information technology. Data analysis was performed using monthly statistical process control charts. RESULTS: We achieved 62.6% (n = 885/1426) for BP < 140/90 and 24.47% (n = 349/1426) for BP < 130/80 within 12 months project period. We sustained and exceeded at 72.64% (n = 945/1301) for BP < 140/90 and 44.58% (n = 580/1301) for BP < 130/80 during the 10 months post-project period. CONCLUSIONS: Overcoming physician clinical inertia, enhancing patient adherence to appointments and medications, and a high functioning multidisciplinary team were the key drivers for the success.
RESUMEN
Obstructive sleep apnoea (OSA) is more prevalent in patients with hypertension (HTN), and associated morbidities include stroke, heart failure and premature death. In the Internal Medicine Clinic (IMC), over 70% of the patients had a diagnosis of HTN and obesity. We identified a lack of OSA screening in patients with HTN. The aim of this quality improvement (QI) was to increase OSA diagnosis to 5% from the baseline rate of less than 1% in patients with HTN between the ages of 18 and 75 years over 6 months at IMC. We used the Plan-Do-Study-Act (PDSA) method. The QI team performed root cause analysis to identify materials/methods, provider and patient-related barriers. PDSA cycle included: (1) integration of customised workflow of loud Snoring, Tiredness, Observed apnea, high blood Pressure (STOP)-Body mass index (BMI), Age, Neck circumference, and Gender (BANG) OSA screening tool in the electronic health record (EHR); (2) physician education of OSA and EHR workflow; and (3) completion of STOP survey by patients, which was facilitated by nursing staff. The outcome measure was the percentage of OSA diagnosis in patients with HTN. The process measures included the percentage of patients with HTN screened for OSA and the increase in sleep study referrals in hypertensive patients with STOP-BANG score of ≥3. Increase in patient wait time and cost of sleep study were the balance measures. Data analysis was performed using weekly statistical process control chart. The average increase in OSA screening rate using the STOP-BANG tool was 3.88%. The significant variation seen in relation to PDSA cycles was not sustainable. 32% of patients scored ≥3 on the STOP-BANG tool, and 10.4% had a confirmed diagnosis of OSA. STOP-BANG tool integration in the EHR and a team approach did not result in a sustainable increase in OSA screening. OSA diagnosis was increased to 3.3% in IMC patient population within the 6-month period. The team identified multiple barriers to screening and diagnosis of OSA in the IMC.