HTN MAP principal investigator and Duke Department of Family Medicine and Community Health Chair Anthony Viera, MD, MPH, has been wrestling with these kinds of challenges for years. An expert in the management of hypertension, Viera looks for ways to close stubborn gaps in diagnosis and treatment for the condition.

“We’re trying to address this challenge by making sure that we’re doing all of things we know work, individually and together, to control hypertension,” says Viera. “This means improving the quality of the care we provide and engaging with patients and the community we serve.”

Viera notes that there are already detailed, evidence-based, and continuously updated guidelines for effective, patient-centered approaches to caring for patients with high blood pressure. The next step is to locate and fill the gaps that prevent some patients from getting the kinds of screening, treatment, and follow-up that are known to be effective in controlling hypertension.

“Data in our patient electronic health records is a critical tool for driving improvement,” says Dr. Michael Pignone, who serves as a co-principal investigator for the program and, with Dr. Rick Shannon, as co-lead for Duke’s participation in the HSII program. “When that high-quality data is available and can be used to prompt timely action, whether that relates to diagnosis, treatment, management, or education, we can keep patients from falling through the cracks in the system, and work toward eliminating disparities, both in terms of clinical outcomes and access to the best evidence-based care.”

Pignone is also the director of the Duke Collaborative to Advance Clinical Health Equity, (CACHE), which was the foundation for Duke’s original PCORI-funded capacity-building program whose results helped shape the approach used in HTN MAP. Duke Health will now have three active implementation projects supported by PCORI: appropriate antibiotic prescribing in acute respiratory tract infections in children (ARTIs), implementation of electronic patient reported outcome assessment for patients with advanced cancer (ePROs), and the present work in hypertension (HTN MAP).

“Our pilot studies in hypertension control with CACHE showed some encouraging findings in terms of closing the gaps in quality of hypertension care,” says Pignone, who notes that these gaps often correspond to socioeconomic factors including income, education, and race and ethnicity. These early studies, supported by Duke CACHE, both demonstrated the possibilities of the approach and revealed areas where additional resources could be brought to bear.

David Halpern, MD, MPH, a Duke Primary Care physician who led the earlier pilot studies, agrees.

“Our early results were promising and suggested that this approach could succeed if we spread and scaled our efforts and integrated the clinical services that are best positioned to support patients and families to improve both the diagnosis and control of hypertension.”

A central element of these efforts is Duke Primary Care, a network of more than fifty clinics serving North Carolina’s central and southern piedmont regions.

“Leveraging the Duke Primary Care network offers HTN MAP a built-in advantage,” explains Duke Primary Care Chief Medical Officer Kevin Shah, MD, MBA. “It allows us to bring the intervention to where patients already are and help us improve blood pressure control for patients in the Duke Health system, which is already outstanding, to the next level of excellence.”

HTN MAP support for systematic improvements to the health system will allow patients with hypertension to connect with primary care providers who can provide needed support, education, and follow-up. To accomplish this, the program includes multiple measures aimed not just at patients but also at clinicians, who benefit from automated reminders that prompt physicians to discuss hypertension management with their patients, refer them for additional care as needed, and follow up with them at guidelines-recommended intervals.

Viera explains that the patient-centered approach being used for HTN MAP is a personalized one, in which therapies, treatment plans, visit reminders, and follow-up visits are tailored to a patient’s individual needs and preferences. The program also uses digital tools that enable remote patient monitoring, adjustment of medication, automated reminders, and educational support, reducing the burdens created by the need for repeated visits to clinics or hospitals.

Another key resource for managing HTN MAP also incorporates community-based dimensions, including peer support networks, educational resources, and help for addressing food and housing insecurity.

The HTN MAP implementation project will evaluate success according to health outcomes, such as the amount of time it takes to verify a diagnosis of hypertension and patients’ participation in treatment plans and follow-up. But it will also assess implementation outcomes that measure how well physicians implement guideline-recommended approaches to diagnosis, care, referral, and monitoring.

Ultimately, HTN MAP investigators are planning to enroll approximately 37,000 patients with hypertension in the main program at 54 sites within the Duke Health system; an accompanying pilot program focused specifically on patients with undiagnosed hypertension may enroll around 19,000.

“Hypertension presents a frustrating paradox,” notes Viera. “We have effective tools for identifying and treating it. We know we have the potential to make a real difference in patients’ health and quality of life, but first we’ve got to be able to link up those tools with the patients who need them. With this support from PCORI, we’re moving closer to making that a reality.”