This performance measure harmonizes with NCQA HEDIS 2019, ICSI, VHA, NQF Measure 0018, Medicaid, Medicare Physician QPP (formerly PQRS), MSSP, Million Hearts, physician feedback/QRUR, physician VBM, QHP, QRS commonly used in payment programs, public reporting, quality improvement (internal to the specific organization), and regulatory and accreditation programs. National average rates of performance have been consistently <70% for several years for HEDIS. Clinical Recommendations 2017 Hypertension Clinical Practice Guidelines4 1. BP should be categorized as normal, elevated, or stage 1 or 2 hypertension to prevent and treat high BP.27 46 (Class 1, Level of Evidence: B-NR) Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions.47 50 (Class 1, Level of Evidence: ASR ) For adults with confirmed hypertension and known CVD or 10-y ASCVD event risk of 10% or higher, a BP target of less than 130/80 mmHg is (Class 1, Level of Evidence: SBP: B-RSR , DBP: C-EO) For older adults ( 65 y of age) with hypertension and a high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit are reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs. (Class 2a, Level of Evidence: C-EO) Use of the EHR and patient registries is beneficial for identification of patients with undiagnosed or undertreated hypertension.55 57 (Class 1, Level of Evidence: B-NR) Treatment of hypertension with a SBP treatment goal of less than 130 mmHg is recommended for noninstitutionalized ambulatory community-dwelling adults ( 65 y of age) with an average SBP of 130 mmHg or higher.58 (Class 1, Level of Evidence: A) Adults with stage 2 hypertension should be evaluated by or referred to a primary care provider within 1 month of the initial diagnosis, have a combination of nonpharmacological and antihypertensive drug therapy (with 2 agents of different classes) initiated, and have a repeat BP evaluation in (Class 1, Level of Evidence: B-R) In adults with an untreated SBP greater than 130 mmHg but less than 160 mmHg or DBP greater than 80 mmHg but less than 100 mmHg, it is reasonable to screen for the presence of white coat hypertension by using either daytime ABPM or HBPM before diagnosis of hypertension.61 68 (Class 2a, Level of Evidence: B-NR) Resources: 1) Qualified Electronic Health Record,69 2) PCPI National Quality Registry Network (NQRN).70 3) American College of Cardiology Foundation (ACCF) American Heart Association (AHA) Physician Consortium for Performance Improvement (PCPI) Hypertension Performance Measurement Set. 4) NQF Measure 0018 Controlling High Blood Pressure (NCQA).22 Additional note: 2017 Hypertension Clinical Practice Guidelines relies on average BP readings. NCQA HEDIS relies on most recent BP reading: The member is numerator compliant if the BP is <140/90 mmHg. The member is not compliant if the BP is 140/90 mmHg, if there is no BP reading during the measurement year, or if the reading is incomplete (eg, the systolic or diastolic level is missing). If there are multiple BPs on the same date of service, use the lowest systolic and diastolic BP on that date as the representative BP. ABPM indicates ambulatory blood pressure monitoring; ACC, American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; DBP, diastolic blood pressure; EHR, electronic health record; HBP, high blood pressure; HBPM, home blood pressure monitoring; HEDIS, Healthcare Effectiveness Data and Information Set; HF, heart failure; ICSI, Institute for Clinical Systems Improvement; MI, myocardial infarction; MSSP, Medicare Shared Savings Program; NCQA, National Committee for Quality Assurance; NQF, National Quality Forum; PCPI, Physician Consortium for Performance Improvement; QCDR, Qualified Clinical Data Registry; QHP, Qualified Health Plan; QPP, Quality Payment Program; QRS, Quality Rating System; QRUR, Quality and Resource Use Reports; SBP, systolic blood pressure; VBM, Value-Based Payment Modifier; and VHA, Veterans Health Administration. 21 Appendix A. Continued Short Title: PM-1b: ACC/AHA Stage 2 HBP Control SBP <130 mmHg (Enhancing Measure) PM-1b: Percentage of Patients 18 to 85 Years of Age Who Had a Diagnosis of ACC/AHA Stage 2 HBP and Whose SBP Was <130 mmHg During the Measurement Year Measure Description: Percentage of patients with ACC/AHA stage 2 HBP with SBP <130 mmHg (harmonizes with current performance measure Controlling High Blood Pressure in widespread use) Numerator Patients with SBP <130 mmHg Denominator All patients 18 85 y of age with ACC/AHA stage 2 HBP who had at least 1 outpatient encounter with a diagnosis of HBP during the first 6 mo of the measurement year or any time before the measurement period Denominator Exclusions End-stage renal disease, kidney transplantation, pregnancy, BP readings taken during an inpatient stay Denominator Exceptions Documentation of a medical reason (eg, treatment intolerance, significant risk of treatment intolerance, especially for frail patients 65 y of age) Documentation of a patient reason (eg, economic/access issues) Measurement Period 12 mo/measurement year Sources of Data Paper medical record/prospective data collection flow sheet, Qualified Electronic Health Record, QCDR, electronic administrative data (claims), expanded (multiple source) administrative data, electronically or telephonically transmitted BP readings Attribution Healthcare provider (healthcare provider, physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system) Care Setting Outpatient (office, clinic, home, or ambulatory) Rationale Effective management of BP in patients with hypertension can help prevent cardiovascular events, including MI, stroke, and the development of HF, and reduce the risk of death from these complications. This performance measure enhances NCQA HEDIS 2019, ICSI, VHA, NQF Measure 0018, Medicaid, Medicare Physician QPP (formerly PQRS), MSSP, Million Hearts, physician feedback/QRUR, physician VBM, QHP, QRS commonly used in payment programs, public reporting, quality improvement (internal to the specific organization), and regulatory and accreditation programs. Clinical Recommendations 2017 Hypertension Clinical Practice Guidelines4 1. BP should be categorized as normal, elevated, or stage 1 or 2 hypertension to prevent and treat high BP.27 46 (Class 1, Level of Evidence: B-NR) Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions.47 50 (Class 1, Level of Evidence: ASR ) For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher, a BP target of less than 130/80 mmHg is (Class 1, Level of Evidence: SBP: B-RSR , DBP: C-EO) For older adults ( 65 y of age) with hypertension and a high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit are reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs. (Class 2a, Level of Evidence: C-EO) Use of the EHR and patient registries is beneficial for identification of patients with undiagnosed or undertreated hypertension.55 57 (Class 1, Level of Evidence: B-NR) Treatment of hypertension with a SBP treatment goal of less than 130 mmHg is recommended for noninstitutionalized ambulatory community-dwelling adults ( 65 y of age) with an average SBP of 130 mmHg or higher.58 (Class 1, Level of Evidence: A) Adults with stage 2 hypertension should be evaluated by or referred to a primary care provider within 1 month of the initial diagnosis, have a combination of nonpharmacological and antihypertensive drug therapy (with 2 agents of different classes) initiated, and have a repeat BP evaluation in (Class 1, Level of Evidence: B-R) In adults with an untreated SBP greater than 130 mmHg but less than 160 mmHg or DBP greater than 80 mmHg but less than 100 mmHg, it is reasonable to screen for the presence of white coat hypertension by using either daytime ABPM or HBPM before diagnosis of hypertension.61 68 (Class 2a, Level of Evidence: B-NR) Resources: 1) Qualified Electronic Health Record.69 2) PCPI National Quality Registry Network (NQRN).70 3) American College of Cardiology Foundation (ACCF) American Heart Association (AHA) Physician Consortium for Performance Improvement (PCPI) Hypertension Performance Measurement Set. 4) NQF Measure 0018 Controlling High Blood Pressure (NCQA).22 Additional note: 2017 Hypertension Clinical Practice Guidelines relies on average BP readings. NCQA HEDIS relies on most recent BP reading: The member is numerator compliant if the BP is <140/90 mmHg. The member is not compliant if the BP is 140/90 mmHg, if there is no BP reading during the measurement year, or if the reading is incomplete (eg, the systolic or diastolic level is missing). If there are multiple BPs on the same date of service, use the lowest systolic and diastolic BP on that date as the representative BP. ABPM indicates ambulatory blood pressure monitoring; ACC, American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; DBP, diastolic blood pressure; EHR, electronic health record; HBP, high blood pressure; HBPM, home blood pressure monitoring; HEDIS, Healthcare Effectiveness Data and Information Set; HF, heart failure; ICSI, Institute for Clinical Systems Improvement; MI, myocardial infarction; MSSP, Medicare Shared Savings Program; NCQA, National Committee for Quality Assurance; NMA, National Medical Association; NQF, National Quality Forum; PCPI, Physician Consortium for Performance Improvement; QCDR, Qualified Clinical Data Registry; QHP, Qualified Health Plan; QPP, Quality Payment Program; QRS, Quality Rating System; QRUR, Quality and Resource Use Reports; SBP, systolic blood pressure; VBM, Value-Based Payment Modifier; and VHA, Veterans Health Administration. 22 Appendix A. Continued Short Title: PM-2: ACC/AHA Stage 1 HBP Control SBP <130 mmHg (Harmonizing Measure) PM-2: Percentage of Patients 18 to 85 Years of Age Who Had a Diagnosis of ACC/AHA Stage 1 HBP and Whose SBP Was <130 mmHg During the Measurement Year Measure Description: Percentage of patients with ACC/AHA stage 1 HBP with SBP <130 mmHg (harmonizes with current performance measure Controlling High Blood Pressure for ACC/AHA stage 2 HBP currently in widespread use) Numerator Patients with SBP <130 mmHg Denominator All patients 18 85 y of age with ACC/AHA stage 1 HBP who had at least 1 outpatient encounter with a diagnosis of HBP during the first 6 mo of the measurement year or any time before the measurement period Denominator Exclusions End-stage renal disease, kidney transplantation, pregnancy, BP readings taken during an inpatient stay Denominator Exceptions Documentation of a medical reason (eg, treatment intolerance, significant risk of treatment intolerance, especially for frail patients 65 y of age) Documentation of a patient reason (eg, economic/access issues) Measurement Period 12 mo/measurement year Sources of Data Paper medical record/prospective data collection flow sheet, Qualified Electronic Health Record, QCDR, electronic administrative data (claims), expanded (multiple source) administrative data, electronically or telephonically transmitted BP readings Attribution Healthcare provider (healthcare provider, physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system) Care Setting Outpatient (office, clinic, home, or ambulatory) Rationale Effective management of BP in patients with hypertension can help prevent cardiovascular events, including MI, stroke, and the development of HF, and reduce the risk of death from these complications. This performance measure harmonizes and supplements the existing measure for stage 2 with NCQA HEDIS 2019 (currently in draft form for public comment), ICSI, VHA, NQF Measure 0018, Medicaid, Medicare Physician QPP (formerly PQRS), MSSP, Million Hearts, physician feedback/QRUR, physician VBM, QHP, QRS commonly used in payment programs, public reporting, quality improvement (internal to the specific organization), and regulatory and accreditation programs. There is currently no HEDIS or other standardized measurement of a national average rate of performance for stage 1 HBP. Clinical Recommendations 2017 Hypertension Clinical Practice Guidelines4 BP should be categorized as normal, elevated, or stage 1 or 2 hypertension to prevent and treat high BP.27 46 (Class 1, Level of Evidence: B-NR) Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions.47 50 (Class 1, Level of Evidence: ASR ) For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher, a BP target of less than 130/80 mmHg is (Class 1, Level of Evidence: SBP: B-RSR , DBP: C-EO) For older adults ( 65 y of age) with hypertension and a high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit are reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs. (Class 2a, Level of Evidence: C-EO) Use of the EHR and patient registries is beneficial for identification of patients with undiagnosed or undertreated hypertension.55 57 (Class 1, Level of Evidence: B-NR) Treatment of hypertension with a SBP treatment goal of less than 130 mmHg is recommended for noninstitutionalized ambulatory community-dwelling adults ( 65 y of age) with an average SBP of 130 mmHg or higher.58 (Class 1, Level of Evidence: A) Adults with stage 2 hypertension should be evaluated by or referred to a primary care provider within 1 month of the initial diagnosis, have a combination of nonpharmacological and antihypertensive drug therapy (with 2 agents of different classes) initiated, and have a repeat BP evaluation in (Class 1, Level of Evidence: B-R) In adults with an untreated SBP greater than 130 mmHg but less than 160 mmHg or DBP greater than 80 mmHg but less than 100 mmHg, it is reasonable to screen for the presence of white coat hypertension by using either daytime ABPM or HBPM before diagnosis of hypertension.61 68 (Class 2a, Level of Evidence: B-NR) Resources: 1) Qualified Electronic Health Record.69 2) PCPI National Quality Registry Network (NQRN).70 3) American College of Cardiology Foundation (ACCF) American Heart Association (AHA) Physician Consortium for Performance Improvement (PCPI) Hypertension Performance Measurement Set. 4) NQF Measure 0018 Controlling High Blood Pressure (NCQA).22 Additional note: 2017 Hypertension Clinical Practice Guidelines relies on average BP readings. NCQA HEDIS relies on most recent BP reading: The member is numerator compliant if the BP is <140/90 mmHg. The member is not compliant if the BP is 140/90 mmHg, if there is no BP reading during the measurement year, or if the reading is incomplete (eg, the systolic or diastolic level is missing). If there are multiple BPs on the same date of service, use the lowest systolic and diastolic BP on that date as the representative BP. ABPM indicates ambulatory blood pressure monitoring; ACC, American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; DBP, diastolic blood pressure; EHR, electronic health record; HBP, high blood pressure; HBPM, home blood pressure monitoring; HEDIS, Healthcare Effectiveness Data and Information Set; HF, heart failure; ICSI, Institute for Clinical Systems Improvement; MI, myocardial infarction; MSSP, Medicare Shared Savings Program; NCQA, National Committee for Quality Assurance; NQF, National Quality Forum; PCPI, Physician Consortium for Performance Improvement; QCDR, Qualified Clinical Data Registry; QHP, Qualified Health Plan; QPP, Quality Payment Program; QRS, Quality Rating System; QRUR, Quality and Resource Use Reports; SBP, systolic blood pressure; VBM, Value-Based Payment Modifier; and VHA, Veterans Health Administration. 23 Appendix A. Continued Short Title: PM-3: ACC/AHA Stage 2 and Stage 1 HBP Control SBP <130 mmHg (Composite Measure Combining PM-1b and PM-2) PM-3: Percentage of Patients 18 to 85 years of Age Who Had a Diagnosis of Either ACC/AHA Stage 2 or Stage 1 HBP and Whose SBP Was <130 mmHg During the Measurement Year Measure Description: Percentage of patients with ACC/AHA stage 2 or stage 1 HBP with SBP <130 mmHg (enhances current performance measure Controlling High Blood Pressure in widespread use based on current ACC/AHA guidelines by including patients with ACC/AHA stage 1 HBP) Numerator Patients with SBP <130 mmHg Denominator All patients 18 85 y of age with ACC/AHA stage 2 or stage 1 HBP who had at least 1 outpatient encounter with a diagnosis of HBP during the first 6 mo of the measurement year or any time before the measurement period Denominator Exclusions End-stage renal disease, kidney transplantation, pregnancy, BP readings taken during an inpatient stay Denominator Exceptions Documentation of a medical reason (eg, treatment intolerance, significant risk of treatment intolerance, especially for frail patients 65 y of age) Documentation of a patient reason (eg, economic/access issues) Measurement Period 12 mo/measurement year Sources of Data Paper medical record/prospective data collection flow sheet, Qualified Electronic Health Record, QCDR, electronic administrative data (claims), expanded (multiple source) administrative data, electronically or telephonically transmitted BP readings Attribution Healthcare provider (healthcare provider, physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system) Care Setting Outpatient (office, clinic, home, or ambulatory) Rationale Effective management of BP in patients with hypertension can help prevent cardiovascular events, including MI, stroke, and the development of HF, and reduce the risk of death from these complications. This performance measure harmonizes and supplements the existing measure for stage 2 with NCQA HEDIS 2019 (currently in draft form for public comment), ICSI, VHA, NQF Measure 0018, Medicaid, Medicare Physician QPP (formerly PQRS), MSSP, Million Hearts, physician feedback/QRUR, physician VBM, QHP, QRS commonly used in payment programs, public reporting, quality improvement (internal to the specific organization), and regulatory and accreditation programs. There is currently no HEDIS or other standardized composite measurement of a national average rate of performance for stage 2 and stage 1 HBP combined. Clinical Recommendations 2017 Hypertension Clinical Practice Guidelines4 BP should be categorized as normal, elevated, or stage 1 or 2 hypertension to prevent and treat high BP.27 46 (Class 1, Level of Evidence: B-NR) Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions.47 50 (Class 1, Level of Evidence: ASR ) For adults with confirmed hypertension and known CVD or 10-y ASCVD event risk of 10% or higher, a BP target of less than 130/80 mmHg is (Class 1, Level of Evidence: SBP: B-RSR , DBP: C-EO) For older adults ( 65 y of age) with hypertension and a high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit are reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs. (Class 2a, Level of Evidence: C-EO) Use of the EHR and patient registries is beneficial for identification of patients with undiagnosed or undertreated hypertension.55 57 (Class 1, Level of Evidence: B-NR) Treatment of hypertension with a SBP treatment goal of less than 130 mmHg is recommended for noninstitutionalized ambulatory community-dwelling adults ( 65 y of age) with an average SBP of 130 mmHg or higher.58 (Class 1, Level of Evidence: A) Adults with stage 2 hypertension should be evaluated by or referred to a primary care provider within 1 month of the initial diagnosis, have a combination of nonpharmacological and antihypertensive drug therapy (with 2 agents of different classes) initiated, and have a repeat BP evaluation in (Class 1, Level of Evidence: B-R) In adults with an untreated SBP greater than 130 mmHg but less than 160 mmHg or DBP greater than 80 mmHg but less than 100 mmHg, it is reasonable to screen for the presence of white coat hypertension by using either daytime ABPM or HBPM before diagnosis of hypertension.61 68 (Class 2a, Level of Evidence: B-NR) Resources: 1) Qualified Electronic Health Record.69 2) PCPI National Quality Registry Network (NQRN).70 3) American College of Cardiology Foundation (ACCF) American Heart Association (AHA) Physician Consortium for Performance Improvement (PCPI) Hypertension Performance Measurement Set. 4) NQF Measure 0018 Controlling High Blood Pressure (NCQA).22 Additional note: 2017 Hypertension Clinical Practice Guidelines relies on average BP readings. NCQA HEDIS relies on most recent BP reading: The member is numerator compliant if the BP is <140/90 mmHg. The member is not compliant if the BP is 140/90 mmHg, if there is no BP reading during the measurement year, or if the reading is incomplete (eg, the systolic or diastolic level is missing). If there are multiple BPs on the same date of service, use the lowest systolic and diastolic BP on that date as the representative BP. ABPM indicates ambulatory blood pressure monitoring; ACC, American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; DBP, diastolic blood pressure; EHR, electronic health record; HBP, high blood pressure; HBPM, home blood pressure monitoring; HEDIS, Healthcare Effectiveness Data and Information Set; HF, heart failure; ICSI, Institute for Clinical Systems Improvement; MI, myocardial infarction; MSSP, Medicare Shared Savings Program; NCQA, National Committee for Quality Assurance; NQF, National Quality Forum; PCPI, Physician Consortium for Performance Improvement; QCDR, Qualified Clinical Data Registry; QHP, Qualified Health Plan; QPP, Quality Payment Program; QRS, Quality Rating System; QRUR, Quality and Resource Use Reports; SBP, systolic blood pressure; VBM, Value-Based Payment Modifier; and VHA, Veterans Health Administration. 24 Appendix A. Continued Short Title: PM-4: Nonpharmacological Interventions for ACC/AHA Stage 2 HBP PM-4: Percentage of Adults 18 to 85 Years of Age Who Had a Diagnosis of ACC/AHA Stage 2 HBP Who Have Documentation of a Discussion of Intensive Lifestyle Modification With Their Healthcare Providers During the Measurement Year Measure Description: Percentage of patients with ACC/AHA stage 2 HBP who have a documented discussion of intensive lifestyle modification in 1 visits during the measurement year Numerator Patients who have a documented discussion of intensive lifestyle modification at least once in the performance year and in accordance with ACC/AHA guidelines on nonpharmacological therapy Denominator All patients 18 85 y of age with ACC/AHA stage 2 HBP who had at least 1 outpatient encounter with a diagnosis of HBP during the first 6 mo of the measurement year or any time before the measurement period Denominator Exclusions BP readings taken during an inpatient stay Denominator Exceptions None Measurement Period 12 mo/measurement year Sources of Data Paper medical record/prospective data collection flow sheet, Qualified Electronic Health Record, QCDR, electronic administrative data (claims), expanded (multiple source) administrative data, electronically or telephonically transmitted BP readings Attribution Physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system Care Setting Outpatient (office, clinic, home, or ambulatory) Rationale Nonpharmacological therapy in combination with drug therapy is an integral part of management of ACC/AHA stage 2 hypertension. Prompt and frequent discussion of lifestyle modification among patients with ACC/AHA stage 2 hypertension is important because of the elevated risk of ASCVD events. Dietary modification is a fundamental approach to the prevention and management of hypertension and complements pharmacological management of hypertension. The DASH diet, which is high in fruits, vegetables, potassium, calcium, magnesium, and fiber and low in saturated and total fat, has been demonstrated to be effective in lowering BP. Among those diagnosed with hypertension, the DASH diet produces, on average, overall reductions in SBP and DBP and is particularly effective among black patients.71 Conversely, among blacks, a US Southern-style diet characterized by high intake of fried foods, organ meats, processed meats, added fats, high-fat dairy foods, sugar-sweetened beverages, and bread contributes to the disproportionate burden of and vegetarian dietary patterns77 have been demonstrated to lower BP. There is a strong and dose-dependent association between excessive alcohol consumption (>3 standard drinks per day) and BP. There is strong evidence that adequate physical activity lowers BP. The average reductions in SBP with aerobic exercise are approximately 2 4 mmHg and 5 8 mmHg in adult patients who are normotensive and hypertensive, respectively. In patients with elevated BP, weight loss has been demonstrated to lower BP, with a dose response relationship of about 1 mmHg per kilogram of weight loss. Among patients who do not achieve weight-loss goals, pharmacological therapy or surgical procedures may be considered, with careful consideration of complications. SDM78,79 between the provider and patient should be considered in selecting specific lifestyle interventions, with consideration of the patient s individual values, preferences, socioeconomic status, associated conditions, and comorbidities to enhance adherence to lifestyle modification. Clinical Recommendations 2017 Hypertension Clinical Practice Guidelines4 A heart-healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet, that facilitates achieving a desirable weight is recommended for adults with elevated BP or hypertension.80 82 (Class 1, Level of Evidence: A) Sodium reduction is recommended for adults with elevated BP or hypertension.83 87 (Class 1, Level of Evidence: A) Potassium supplementation, preferably in dietary modification, is recommended for adults with elevated BP or hypertension, unless contraindicated by the presence of CKD or use of drugs that reduce potassium excretion.88 92 (Class 1, Level of Evidence: A) Adult men and women with elevated BP or hypertension who currently consume alcohol should be advised to drink no more than 2 and 1 standard drinks* per day, respectively.93 98 (Class 1, Level of Evidence: A) Increased physical activity with a structured exercise program is recommended for adults with elevated BP or hypertension.87,99 105 (Class 1, Level of Evidence: Weight loss is recommended to reduce BP in adults with elevated BP or hypertension who are overweight or obese.99,100,106,107 (Class 1, Level of Evidence: A) Effective behavioral and motivational strategies to achieve a healthy lifestyle (ie, tobacco cessation, weight loss, moderation in alcohol intake, increased physical activity, reduced sodium intake, and consumption of a healthy diet) are recommended for adults with hypertension.108,109 (Class 1, Level of Evidence: C-EO) *In the United States, 1 standard drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol). ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CKD, chronic kidney disease; DASH, Dietary Approaches to Stop Hypertension; DBP, diastolic blood pressure; HBP, high blood pressure; QCDR, Qualified Clinical Data Registry; SBP, systolic blood pressure; and SDM, shared decision making. 25 Appendix A. Continued Short Title: PM-5: Use of HBPM for Management of ACC/AHA Stage 2 HBP PM-5: Use of HBPM for Management of ACC/AHA Stage 2 HBP Measure Description: Percentage of patients who had a diagnosis of ACC/AHA stage 2 HBP for whom HBPM is recommended and HBPM data are documented in the patient record Numerator Documentation of home BP readings in the medical record Denominator All patients 18 85 y of age who had a diagnosis of ACC/AHA stage 2 HBP who had at least 1 outpatient encounter with a diagnosis of HBP during the first 6 mo of the measurement year or any time before the measurement period Denominator Exclusions End-stage renal disease, kidney transplantation, pregnancy, BP readings taken during an inpatient stay Denominator Exceptions Documentation of a patient reason (eg, economic issues, refusal, cognitive deficits) Measurement Period 12 mo/measurement year Sources of Data Paper medical record/prospective data collection flow sheet, Qualified Electronic Health Record, QCDR, electronic administrative data (claims), expanded (multiple source) administrative data, electronically or telephonically transmitted BP readings Attribution Healthcare provider (healthcare provider, physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system) Care Setting Outpatient (office, clinic, home, or ambulatory) Rationale HBPM or self-monitoring of BP refers to the regular measurement of BP by an individual at home or elsewhere outside the clinic setting. Home-based measurement has been found to be a better predictor of cardiovascular risk than clinic-based measurement. Evidence also suggests that home-based BP measurement in combination interventions with telemedicine with nurse- or pharmacist-led care may be effective for improving hypertension management. Procedures for Use of HBPM4 Patient training should occur under medical supervision, including: Information about hypertension Selection of equipment Acknowledgment that individual BP readings may vary substantially Interpretation of results Devices: Verify use of automated validated devices. Use of auscultatory devices (mercury, aneroid, or other) is not generally useful for HBPM because patients rarely master the technique required for measurement of BP with auscultatory devices. Monitors with provision for storage of readings in memory are preferred. Verify use of appropriate cuff size to fit the arm. Verify that left/right inter-arm differences are insignificant. If differences are significant, instruct patient to measure BPs in the arm with higher readings. Instructions on HBPM procedures: Remain still: Avoid smoking, caffeinated beverages, or exercise within 30 min before BP measurements. Ensure 5 min of quiet rest before BP measurements. Sit correctly: Sit with back straight and supported (on a straight-backed dining chair, for example, rather than a sofa). Sit with feet flat on the floor and legs uncrossed. Keep arm supported on a flat surface (such as a table), with the upper arm at heart level. Bottom of the cuff should be placed directly above the antecubital fossa (bend of the elbow). Take multiple readings: Take at least 2 readings 1 min apart in morning before taking medications and in evening before supper. Optimally, measure and record BP daily. Ideally, obtain weekly BP readings beginning 2 wk after a change in the treatment regimen and during the week before a clinic visit. Record all readings accurately: Monitors with built-in memory should be brought to all clinic appointments. BP should be based on an average of readings on 2 occasions for clinical decision making. Clinical Recommendation 2017 Hypertension Clinical Practice Guidelines4 Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions.47 50 (Class 1, Level of Evidence: ASR ) ACC indicates American College of Cardiology; AHA, American Heart Association; BP, blood pressure; HBP, high blood pressure; HBPM, home blood pressure monitoring; and QCDR, Qualified Clinical Data Registry. 26 Appendix A. Continued Process Quality Measures Short Title: QM-1: Nonpharmacological Interventions for ACC/AHA Stage Elevated BP QM-1: Percentage of Adults 18 to 85 Years of Age Who Had a Diagnosis of ACC/AHA Stage Elevated BP Who Have a Documented Discussion of Intensive Lifestyle Modification in 1 Visits During the Measurement Year Measure Description: Percentage of patients with ACC/AHA stage elevated BP who have a documented discussion of intensive lifestyle modification in 1 visits during the measurement year Numerator Patients who have a documented discussion of intensive lifestyle modification at least once in the performance year and in accordance with ACC/AHA guidelines on nonpharmacological therapy Denominator All patients 18 85 y of age who had at least 1 outpatient encounter with a diagnosis of HBP during the first 6 mo of the measurement year or any time before the measurement period Denominator Exclusions Pregnancy, BP readings taken during an inpatient stay Denominator Exceptions None Measurement Period 12 mo/measurement year Sources of Data Paper medical record/prospective data collection flow sheet, Qualified Electronic Health Record, QCDR, electronic administrative data (claims), expanded (multiple source) administrative data, electronically or telephonically transmitted BP readings Attribution Physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system Care Setting Outpatient (office, clinic, home, or ambulatory) Rationale Effective management of elevated BP requires intensive lifestyle modification. In those diagnosed with elevated BP, nonpharmacological therapy is useful in preventing ACC/AHA stage 1 or 2 hypertension. Dietary modification is a fundamental approach to the prevention and management of elevated BP and complements pharmacological management of hypertension. The DASH diet, which is high in fruits, vegetables, potassium, calcium, magnesium, and fiber and low in saturated and total fat, has been demonstrated to be effective in lowering BP. Among those diagnosed with hypertension, the DASH diet produces, on average, overall reductions in SBP and is particularly effective among black patients.71 Conversely, among blacks, a US Southern-style diet characterized by high intake of fried foods, organ meats, processed meats, added fats, high-fat dairy foods, sugar-sweetened beverages, and bread contributes to the disproportionate burden of hypertension.72 and vegetarian dietary patterns77 have been demonstrated to lower BP. There is a strong and dose-dependent association between excessive alcohol consumption (>3 standard drinks per day) and BP. There is strong evidence that adequate physical activity lowers BP. The average reductions in SBP with aerobic exercise are approximately 2 4 mmHg and 5 8 mmHg in adult patients who are normotensive and hypertensive, respectively. In patients with ACC/AHA elevated BP, weight loss has been demonstrated to lower BP, with a dose response relationship of about 1 mmHg per kilogram of weight loss. Among patients who do not achieve weight-loss goals, pharmacological therapy or surgical procedures may be considered, with careful consideration of complications. SDM78,79 between the provider and patient should be considered in selecting specific lifestyle interventions, with consideration of the patient s individual values, preferences, socioeconomic status, associated conditions, and comorbidities to enhance adherence to lifestyle modification. Clinical Recommendations 2017 Hypertension Clinical Practice Guidelines4 A heart-healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet, that facilitates achieving a desirable weight is recommended for adults with elevated BP or hypertension.80 82 (Class 1, Level of Evidence: A) Sodium reduction is recommended for adults with elevated BP or hypertension.83 87 (Class 1, Level of Evidence: A) Potassium supplementation, preferably in dietary modification, is recommended for adults with elevated BP or hypertension, unless contraindicated by the presence of CKD or use of drugs that reduce potassium excretion.88 92 (Class 1, Level of Evidence: A) Adult men and women with elevated BP or hypertension who currently consume alcohol should be advised to drink no more than 2 and 1 standard drinks* per day, respectively.93 98 (Class 1, Level of Evidence: A) Increased physical activity with a structured exercise program is recommended for adults with elevated BP or hypertension.87,99 105 (Class 1, Level of Evidence: A) Weight loss is recommended to reduce BP in adults with elevated BP or hypertension who are overweight or obese.99,100,106,107 (Class 1, Level of Evidence: A) Effective behavioral and motivational strategies to achieve a healthy lifestyle (ie, tobacco cessation, weight loss, moderation in alcohol intake, increased physical activity, reduced sodium intake, and consumption of a healthy diet) are recommended for adults with hypertension.108,109 (Class 1, Level of Evidence: C-EO) Adults with an elevated BP or stage 1 hypertension who have an estimated 10-y ASCVD risk less than 10% should be managed with nonpharmacological therapy and have a repeat BP evaluation within 3 to 6 months.59,60 (Class 1, Level of Evidence: B-R) *In the United States, 1 standard drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol). ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CKD, chronic kidney disease; DASH, Dietary Approaches to Stop Hypertension; HBP, high blood pressure; QCDR, Qualified Clinical Data Registry; SBP, systolic blood pressure; and SDM, shared decision making. 27 Appendix A. Continued Short Title: QM-2: Nonpharmacological Interventions for ACC/AHA Stage 1 HBP QM-2: Percentage of Adults 18 to 85 Years of Age Who Had a Diagnosis of ACC/AHA Stage 1 HBP Who Have a Documented Discussion of Intensive Lifestyle Modification in 1 Visits During the Measurement Year Measure Description: Percentage of patients with ACC/AHA stage 1 HBP who have a documented discussion of intensive lifestyle modification in 1 visits during the measurement year Numerator Patients who have a documented discussion of intensive lifestyle modification at least once in the performance year and in accordance with ACC/AHA guidelines on nonpharmacological therapy Denominator All patients 18 85 y of age with ACC/AHA stage 1 HBP who had at least 1 outpatient encounter with a diagnosis of HBP during the first 6 mo of the measurement year or any time before the measurement period Denominator Exclusions Pregnancy, BP readings taken during an inpatient stay Denominator Exceptions None Measurement Period 12 mo/measurement year Sources of Data Paper medical record/prospective data collection flow sheet, Qualified Electronic Health Record, QCDR, electronic administrative data (claims), expanded (multiple source) administrative data, electronically or telephonically transmitted BP readings Attribution Physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system Care Setting Outpatient (office, clinic, home, or ambulatory) Rationale Effective management of ACC/AHA stage 1 hypertension requires intensive lifestyle modification. Among patients with ACC/AHA stage 1 hypertension with ASCVD risk 10%, nonpharmacological therapy should be used in addition to pharmacological therapy as first-line therapy. Lifestyle modification is also a fundamental approach to prevention and management of ACC/AHA stage 1 BP and complements pharmacological management of hypertension. The DASH diet, which is high in fruits, vegetables, potassium, calcium, magnesium, and fiber and low in saturated and total fat, has been demonstrated to be effective in lowering BP. Among those diagnosed with hypertension, the DASH diet produces, on average, overall reductions in SBP and is particularly effective among Conversely, among blacks, a US Southern-style diet characterized by high intake of fried foods, organ meats, processed meats, added fats, high-fat dairy foods, sugar-sweetened beverages, and bread contributes to the disproportionate burden of hypertension.72 low- and vegetarian dietary patterns77 have been demonstrated to lower BP. There is a strong and dose-dependent association between excessive alcohol consumption (>3 standard drinks per day) and BP. There is strong evidence that adequate physical activity lowers BP. The average reductions in SBP with aerobic exercise are approximately 2 4 mmHg and 5 8 mmHg in adult patients who are normotensive and hypertensive, respectively. In patients with elevated BP, weight loss has been demonstrated to lower BP, with a dose response relationship of about 1 mmHg per kilogram of weight loss. Among patients who do not achieve weight-loss goals, pharmacological therapy or surgical procedures may be considered, with careful consideration of complications. SDM78,79 between the provider and patient should be considered in selecting specific lifestyle interventions, with consideration of the patient s individual values, preferences, socioeconomic status, associated conditions, and comorbidities to enhance adherence to lifestyle modification. Clinical Recommendations 2017 Hypertension Clinical Practice Guidelines4 A heart-healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet, that facilitates achieving a desirable weight is recommended for adults with elevated BP or hypertension.80 82 (Class 1, Level of Evidence: A) 2. Sodium reduction is recommended for adults with elevated BP or hypertension.83 87 (Class 1, Level of Evidence: A) Potassium supplementation, preferably in dietary modification, is recommended for adults with elevated BP or hypertension, unless contraindicated by the presence of CKD or use of drugs that reduce potassium excretion.88 92 (Class 1, Level of Evidence: A) Adult men and women with elevated BP or hypertension who currently consume alcohol should be advised to drink no more than 2 and 1 standard drinks* per day, respectively.93 98 (Class 1, Level of Evidence: A) Increased physical activity with a structured exercise program is recommended for adults with elevated BP or hypertension.87,99 105 (Class 1, Level of Evidence: A) Weight loss is recommended to reduce BP in adults with elevated BP or hypertension who are overweight or obese.99,100,106,107 (Class 1, Level of Evidence: A) Effective behavioral and motivational strategies to achieve a healthy lifestyle (ie, tobacco cessation, weight loss, moderation in alcohol intake, increased physical activity, reduced sodium intake, and consumption of a healthy diet) are recommended for adults with hypertension.108,109 Level of Evidence: C-EO) Adults with an elevated BP or stage 1 hypertension who have an estimated 10-y ASCVD risk less than 10% should be managed with nonpharmacological therapy and have a repeat BP evaluation within 3 to 6 months.59,60 (Class 1, Level of Evidence: B-R) Adults with stage 1 hypertension who have an estimated 10-y ASCVD risk of 10% or higher should be managed initially with a combination of nonpharmacological and antihypertensive drug therapy and have a repeat BP evaluation in 1 month.59,60 (Class 1, Level of Evidence: B-R) *In the United States, 1 standard drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol). ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CKD, chronic kidney disease; DASH, Dietary Approaches to Stop Hypertension; HBP, high blood pressure; QCDR, Qualified Clinical Data Registry; SBP, systolic blood pressure; and SDM, shared decision making. 28 Appendix A. Continued Short Title: QM-3: Nonpharmacological Interventions for All ACC/AHA Stages of HBP (Composite Measure Combining PM-4, QM-1, and QM-2) QM-3: Percentage of Adults 18 to 85 Years of Age Who Had a Diagnosis of Any ACC/AHA Stage of HBP (Elevated BP, Stage 1 HBP, or Stage 2 HBP) Who Have a Documented Discussion of Intensive Lifestyle Modification in 1 Visits During the Measurement Year Measure Description: Percentage of patients with any ACC/AHA stage of HBP (elevated BP, stage 1 HBP, or stage 2 HBP) who have a documented discussion of intensive lifestyle modification in 1 visits during the measurement year Numerator Patients who have a documented discussion of intensive lifestyle modification at least once in the performance year and in accordance with ACC/AHA guidelines on nonpharmacological therapy Denominator All patients 18 85 y of age with any ACC/AHA stage of HBP (elevated BP, stage 1 HBP, or stage 2 HBP) who had at least 1 outpatient encounter with a diagnosis of HBP during the first 6 mo of the measurement year or any time before the measurement period Denominator Exclusions BP readings taken during an inpatient stay Denominator Exceptions None Measurement Period 12 mo/measurement year Sources of Data Paper medical record/prospective data collection flow sheet, Qualified Electronic Health Record, QCDR, electronic administrative data (claims), expanded (multiple source) administrative data, electronically or telephonically transmitted BP readings Attribution Physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system Care Setting Outpatient (office, clinic, home, or ambulatory) Rationale Effective management of HBP requires intensive lifestyle modification. Dietary modification is a fundamental approach to prevention and management of elevated BP and complements pharmacological management of hypertension. The DASH diet, which is high in fruits, vegetables, potassium, calcium, magnesium, and fiber and low in saturated and total fat, has been demonstrated to be effective in lowering BP. Among those diagnosed with hypertension, the DASH diet produces, on average, overall reductions in SBP and is particularly effective among black patients.71 Conversely, among blacks, a US Southern- style diet characterized by high intake of fried foods, organ meats, processed meats, added fats, high-fat dairy foods, sugar-sweetened beverages, and bread contributes to the disproportionate burden of hypertension.72 and vegetarian dietary patterns77 have been demonstrated to lower BP. There is a strong and dose-dependent association between excessive alcohol consumption (>3 standard drinks per day) and BP. There is strong evidence that adequate physical activity lowers BP. The average reductions in SBP with aerobic exercise are approximately 2 4 mmHg and 5 8 mmHg in adult patients who are normotensive and hypertensive, respectively. In patients with elevated BP, weight loss has been demonstrated to lower BP, with a dose response relationship of about 1 mmHg per kilogram of weight loss. Among patients who do not achieve weight-loss goals, pharmacological therapy or surgical procedures may be considered, with careful consideration of complications. SDM78,79 between the provider and patient should be considered in selecting specific lifestyle interventions, with consideration of the patient s individual values, preferences, socioeconomic status, associated conditions, and comorbidities to enhance adherence to lifestyle modification. Clinical Recommendations 2017 Hypertension Clinical Practice Guidelines4 A heart-healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet, that facilitates achieving a desirable weight is recommended for adults with elevated BP or hypertension.80 82 (Class 1, Level of Evidence: A) Sodium reduction is recommended for adults with elevated BP or hypertension.83 87 (Class 1, Level of Evidence: A) Potassium supplementation, preferably in dietary modification, is recommended for adults with elevated BP or hypertension, unless contraindicated by the presence of CKD or use of drugs that reduce potassium excretion.88 92 (Class 1, Level of Evidence: A) Adult men and women with elevated BP or hypertension who currently consume alcohol should be advised to drink no more than 2 and 1 standard drinks* per day, respectively.93 98 (Class 1, Level of Evidence: A) Increased physical activity with a structured exercise program is recommended for adults with elevated BP or hypertension.87,99 105 (Class 1, Level of Evidence: A) Weight loss is recommended to reduce BP in adults with elevated BP or hypertension who are overweight or obese.99,100,106,107 (Class 1, Level of Evidence: A) Effective behavioral and motivational strategies to achieve a healthy lifestyle (ie, tobacco cessation, weight loss, moderation in alcohol intake, increased physical activity, reduced sodium intake, and consumption of a healthy diet) are recommended for adults with hypertension.108,109 (Class 1, Level of Evidence: C-EO) Adults with an elevated BP or stage 1 hypertension who have an estimated 10-y ASCVD risk less than 10% should be managed with nonpharmacological therapy and have a repeat BP evaluation within 3 to 6 months.59,60 (Class 1, Level of Evidence: B-R) Adults with stage 1 hypertension who have an estimated 10-y ASCVD risk of 10% or higher should be managed initially with a combination of nonpharmacological and antihypertensive drug therapy and have a repeat BP evaluation in 1 month.59,60 (Class 1, Level of Evidence: B-R) *In the United States, 1 standard drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol). ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CKD, chronic kidney disease; DASH, Dietary Approaches to Stop Hypertension; HBP, high blood pressure; QCDR, Qualified Clinical Data Registry; SBP, systolic blood pressure; and SDM, shared decision making. 29 Appendix A. Continued Short Title: QM-4: Medication Adherence to Drug Therapy for ACC/AHA Stage 1 With ASCVD Risk 10% or ACC/AHA Stage 2 HBP QM-4: Percentage of Adults 18 to 85 Years of Age Who Had a Diagnosis of ACC/AHA Stage 1 HBP With ASCVD Risk 10% or ACC/AHA Stage 2 HBP With 1 Prescriptions for BP Medication Who Had 80% Adherence to BP Medication(s) During the Measurement Year Measure Description: Percentage of patients with ACC/AHA stage 1 HBP and ASCVD risk 10% or ACC/AHA stage 2 HBP who had 80% adherence to prescribed BP medication(s) during the measurement year Numerator Patients with 1 prescriptions for BP medication(s) who met the PDC threshold of 80% during the measurement year Denominator All patients 18 85 y of age with ACC/AHA stage 1 HBP and ASCVD risk 10% or ACC/AHA stage 2 HBP who had at least 1 outpatient encounter with a diagnosis of HBP and had 1 or more prescriptions for BP medications during the first 6 mo of the measurement year or any time before the measurement period Denominator Exclusions End-stage renal disease, kidney transplantation, pregnancy, BP readings taken during an inpatient stay, patients solely on nonpharmacological therapy Denominator Exceptions Documentation of a medical reason (eg, treatment intolerance, significant risk of treatment intolerance, especially for frail patients 65 y of age) Documentation of a patient reason (eg, economic/access issues) Measurement Period 12 mo/measurement year Sources of Data Medicaid claims data, commercial claims data, Medicare claims data, Tricare claims data Attribution Physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system Care Setting Outpatient (office, clinic, home, or ambulatory) Rationale Adherence to drug therapy lowers BP and reduces the risk of cardiovascular events and death.110 112 As many as 50% to 80% of patients prescribed antihypertensive medications demonstrate suboptimal adherence.113 Adherence to drug therapy is influenced by several interrelated factors, including large pill burden, complex drug regimen, cost of medications, side effects of multidrug antihypertensive regimens, poor patient provider relationship, and clinical No single strategy has been found to be more effective than others in improving adherence, but rather, a combination of patient-level, provider-level, and system-level strategies is likely to be the most effective. Medication adherence is highest with once-daily dosing and declines within increasing dosing Medication adherence tools, such as the Hill-Bone Compliance to HBP Therapy Scale,117 may be used to identify barriers to medication adherence, in combination with other more objective methods, such as pill counts and data on medication refills. PDC is one of the most popular methods to calculate medication adherence and is endorsed and validated by the PQA as a high-quality measure of medication adherence.118,119 * Clinical Recommendations 2017 Hypertension Clinical Practice Guidelines4 In adults with hypertension, dosing of antihypertensive medication once daily rather than multiple times daily is beneficial to improve adherence.115,116,120 (Class 1, Level of Evidence: B-R) Adults initiating a new or adjusted drug regimen for hypertension should have a follow-up evaluation of adherence and response to treatment at monthly intervals until control is achieved.59,60,121 (Class 1, Level of Evidence: B-R) Use of BP-lowering medications is recommended for secondary prevention of recurrent CVD events in patients with clinical CVD and an average SBP of 130 mmHg or higher or an average DBP of 80 mmHg or higher, and for primary prevention in adults with an estimated 10-y atherosclerotic cardiovascular disease (ASCVD) risk of 10% or higher and an average SBP 130 mmHg or higher or an average DBP 80 mmHg or higher.29,37,42,43,46,122 125 (Class 1, Level of Evidence: SBP: A, DBP: C-EO) Use of BP-lowering medication is recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-y ASCVD risk <10% and an SBP of 140 mmHg or higher or a DBP of 90 mmHg or higher.39,125 128 (Class 1, Level of Evidence: C-LD) Initiation of antihypertensive drug therapy with 2 first-line agents of different classes, either as separate agents or in a fixed-dose combination, is recommended in adults with stage 2 hypertension and an average BP more than 20/10 mmHg above their BP target. (Class 1, Level of Evidence: C-EO) Use of combination pills rather than free individual components can be useful to improve adherence to antihypertensive therapy.129 132 (Class 2a, Level of Evidence: B-NR) Initiation of antihypertensive drug therapy with a single antihypertensive drug is reasonable in adults with stage 1 hypertension and BP goal <130/80 mmHg with dosage titration and sequential addition of other agents to achieve the BP target. (Class 2a, Level of Evidence: C-EO) *We encourage stratification by clinically relevant subsets, such as stage 1 with ASCVD risk 10, or stage 2, for quality improvement efforts. ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; DBP, diastolic blood pressure; HBP, high blood pressure; PDC, proportion of days covered; PQA, Pharmacy Quality Alliance; and SBP, systolic blood pressure. 30 Appendix A. Continued Short Title: QM-5: Use of HBPM for Management of ACC/AHA Stage 1 HBP QM-5: Use of HBPM for Management of ACC/AHA Stage 1 HBP Measure Description: Percentage of patients 18 85 y of age who had a diagnosis of ACC/AHA stage 1 HBP for whom HBPM is recommended and HBPM data are documented in the patient record Numerator Documentation of home BP readings in the medical record Denominator All patients 18 85 y of age with ACC/AHA stage 1 HBP who had at least 1 outpatient encounter with a diagnosis of HBP during the first 6 mo of the measurement year or any time before the measurement period Denominator Exclusions End-stage renal disease, kidney transplantation, pregnancy, BP readings taken during an inpatient stay Denominator Exceptions None Measurement Period 12 mo/measurement year Sources of Data Paper medical record/prospective data collection flow sheet, Qualified Electronic Health Record, QCDR, electronic administrative data (claims), expanded (multiple source) administrative data, electronically or telephonically transmitted BP readings Attribution Healthcare provider, physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system Care Setting Outpatient (office, clinic, home, or ambulatory) Rationale HBPM or self-monitoring of BP refers to the regular measurement of BP by an individual at home or elsewhere outside the clinic setting. Home-based measurement has been found to be a better predictor of cardiovascular risk than clinic-based measurement. Evidence also suggests that home-based BP measurement in combination interventions with telemedicine with nurse- or pharmacist-led care may be effective for improving hypertension management. Recommended procedures for the collection of HBPM data are as follows4 : Patient training should occur under medical supervision, including: Information about hypertension Selection of equipment Acknowledgment that individual BP readings may vary substantially Interpretation of results Devices: Verify use of automated validated devices. Use of auscultatory devices (mercury, aneroid, or other) is not generally useful for HBPM because patients rarely master the technique required for measurement of BP with auscultatory devices. Monitors with provision for storage of readings in memory are preferred. Verify use of appropriate cuff size to fit the arm. Verify that left/right inter-arm differences are insignificant. If differences are significant, instruct patient to measure BPs in the arm with higher readings. Instructions on HBPM procedures: Remain still: Avoid smoking, caffeinated beverages, or exercise within 30 min before BP measurements. Ensure 5 min of quiet rest before BP measurements. Sit correctly: Sit with back straight and supported (on a straight-backed dining chair, for example, rather than a sofa). Sit with feet flat on the floor and legs uncrossed. Keep arm supported on a flat surface (such as a table), with the upper arm at heart level. Bottom of the cuff should be placed directly above the antecubital fossa (bend of the elbow). Take multiple readings: Take at least 2 readings 1 min apart in morning before taking medications and in evening before supper. Optimally, measure and record BP daily. Ideally, obtain weekly BP readings beginning 2 wk after a change in the treatment regimen and during the week before a clinic visit. Record all readings accurately: Monitors with built-in memory should be brought to all clinic appointments. BP should be based on an average of readings on 2 occasions for clinical decision making. Clinical Recommendation 2017 Hypertension Clinical Practice Guidelines4 Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions.47 50 (Class 1, Level of Evidence: ASR ) ACC indicates American College of Cardiology; AHA, American Heart Association; BP, blood pressure; HBP, high blood pressure; HBPM, home blood pressure monitoring; and QCDR, Qualified Clinical Data Registry. 31 Appendix A. Continued Short Title: QM-6: Use of HBPM for Management of ACC/AHA Stage 1 or ACC/AHA Stage 2 (Composite Measure Combining PM-5 and QM-5) QM-6: Use of HBPM for Management of ACC/AHA Stage 1 HBP or ACC/AHA Stage 2 HBP (Composite Measure Combining PM-5 and Process QM-5) Measure Description: Percentage of patients 18 85 y of age who had a diagnosis of either ACC/AHA stage 1 HBP or ACC/AHA stage 2 HBP for whom HBPM is recommended and HBPM data are documented in the patient record Numerator Documentation of home BP readings in the medical record Denominator All patients 18 85 y of age who had a diagnosis of either ACC/AHA stage 1 HBP or ACC/AHA stage 2 HBP who had at least 1 outpatient encounter with a diagnosis of HBP during the first 6 mo of the measurement year or any time before the measurement period Denominator Exclusions End-stage renal disease, kidney transplantation, pregnancy, BP readings taken during an inpatient stay Denominator Exceptions None Measurement Period 12 mo/measurement year Sources of Data Paper medical record/prospective data collection flow sheet, Qualified Electronic Health Record, QCDR, electronic administrative data (claims), expanded (multiple source) administrative data, electronically or telephonically transmitted BP readings Attribution Healthcare provider (healthcare provider, physician group practice, accountable care organization, clinically integrated network, health plan, integrated delivery system) Care Setting Outpatient (office, clinic, home, or ambulatory) Rationale HBPM or self-monitoring of BP refers to the regular measurement of BP by an individual at home or elsewhere outside the clinic setting. Home-based measurement has been found to be a better predictor of cardiovascular risk than clinic-based measurement. Evidence also suggests that home-based BP measurement in combination interventions with telemedicine with nurse- or pharmacist-led care may be effective for improving hypertension management. Recommended procedures for the collection of HBPM data are as follows4 : Patient training should occur under medical supervision, including: Information about hypertension Selection of equipment Acknowledgment that individual BP readings may vary substantially Interpretation of results Devices: Verify use of automated validated devices. Use of auscultatory devices (mercury, aneroid, or other) is not generally useful for HBPM because patients rarely master the technique required for measurement of BP with auscultatory devices. Monitors with provision for storage of readings in memory are preferred. Verify use of appropriate cuff size to fit the arm. Verify that left/right inter-arm differences are insignificant. If differences are significant, instruct patient to measure BPs in the arm with higher readings. Instructions on HBPM procedures: Remain still: Avoid smoking, caffeinated beverages, or exercise within 30 min before BP measurements. Ensure 5 min of quiet rest before BP measurements. Sit correctly: Sit with back straight and supported (on a straight-backed dining chair, for example, rather than a sofa). Sit with feet flat on the floor and legs uncrossed. Keep arm supported on a flat surface (such as a table), with the upper arm at heart level. Bottom of the cuff should be placed directly above the antecubital fossa (bend of the elbow). Take multiple readings: Take at least 2 readings 1 min apart in morning before taking medications and in evening before supper. Optimally, measure and record BP daily. Ideally, obtain weekly BP readings beginning 2 wk after a change in the treatment regimen and during the week before a clinic visit. Record all readings accurately: Monitors with built-in memory should be brought to all clinic appointments. BP should be based on an average of readings on 2 occasions for clinical decision making. Clinical Recommendation 2017 Hypertension Clinical Practice Guidelines4 Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions.47 50 (Class 1, Level of Evidence: ASR ) ACC indicates American College of Cardiology; AHA, American Heart Association; BP, blood pressure; HBP, high blood pressure; HBPM, home blood pressure monitoring; and QCDR, Qualified Clinical Data Registry. 32 Appendix A. Continued Structural Quality Measures The Structural Quality Measure domain should be considered to be at the CDU level (can be a physician group practice, accountable care organization, clinically integrated network, health plan, or integrated delivery system), as opposed to the specific patient or physician/clinician level. The goal will be to guide and motivate CDUs to implement and evaluate these specific guideline recommendations to improve the various and necessary evidence-based components of a guideline-driven system of care and accompanying infrastructure needed for effective identification and management of patients with HBP. Diagnosis, Assessment, and Accurate Measurement SM-1: Use of a Standard Protocol to Consistently and Correctly Measure BP in the Ambulatory Setting Measure Components The CDU uses a standard process/protocol for properly measuring BP consistently and correctly, including: Adoption and implementation of a protocol for accurate measurement and documentation of BP. Availability of staff who are trained in measurement and documentation of BP. Documentation of staff assessment of correct BP measurement skill. Elements Protocol includes preassessment tools, checklists, and metrics to assess gaps in care. Certification of staff in correct BP measurement skills. Recommended Protocol 2017 Hypertension Clinical Practice Guidelines.4 Blood Pressure Assessment in Adults in Clinical Practice and Clinic-Based Research.133 Documentation Documenting the implementing protocols may impose additional burdens on HCOs. Potential options to consider: Attestation, self-reported information External auditor/rater Competency testing Rationale Accurate measurement and recording of BP are essential to categorize level of BP, ascertain BP-related ASCVD risk, and guide management of high BP. Office BP measurement is often unstandardized, despite the well-known consequences of inaccurate measurement. Errors are common and can result in a misleading estimation of an individual s true level of BP if staff are not trained and a protocol is not followed. The use of automated office BP measurements should be considered as part of the protocol for accurate measurement.134 Checklist for Accurate Measurement of BP135,136 Key Steps for Proper BP Measurements Specific Instructions: Step 1: Properly prepare the patient 1. Have the patient relax, sitting in a chair (feet on floor, back supported) for >5 min. 2. The patient should avoid caffeine, exercise, and smoking for at least 30 min before measurement. 3. Ensure patient has emptied his/her bladder. 4. Neither the patient nor the observer should talk during the rest period or during the measurement. 5. Remove all clothing covering the location of cuff placement. 6. 