(Class 1, Level of Evidence: C-EO) ACC indicates American College of Cardiology; AHA, American Heart Association; BP, blood pressure; CDU, care delivery unit; CVD, cardiovascular disease; GDMT, guideline-directed medical therapy/treatment; HBP, high blood pressure; and RCTs, randomized controlled trials. Appendix A. Continued Table D. Clinician s Steps for the Management of Hypertension Clinician s Sequential Flowchart for the Management of Hypertension Measure office BP accurately Detect white-coat hypertension or masked hypertension by using ABPM and HBPM Evaluate for secondary hypertension Identify target-organ damage Introduce lifestyle interventions Identify and discuss treatment goals Use ASCVD risk estimation to guide BP threshold for pharmacological therapy Align treatment options with comorbidities Account for age, race, ethnicity, sex, and special circumstances in antihypertensive treatment Initiate antihypertensive pharmacological therapy Insure appropriate follow-up Use team-based care Connect patient to clinician via telehealth Detect and reverse nonadherence Use health information technology for remote monitoring and self- monitoring of BP Reproduced with permission from Whelton et al.4 Copyright 2018, American Heart Association, Inc., and American College of Cardiology Foundation. ABPM indicates ambulatory blood pressure monitoring; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; and HBPM, home blood pressure monitoring. Appendix A. Continued 45 Use of Performance Measures to Improve Care for HBP SM-10: Use of Performance and Quality Measures to Improve Quality of Care for Patients With HBP Measure Components The CDU uses performance and quality measures for evaluation and improvement in clinical settings for the diagnosis and management of patients with HBP, which include: Performance measures that are developed according to established ACC/AHA standards. Performance measures that identify key structural components, care processes, and/or outcomes that are highly correlated with important, high-priority patient care goals. Methods to accurately and feasibly collect data in order to assess performance measures. Process to identify appropriate patient groups, healthcare providers, and/or observation periods to be included in the measurement process. Process to include outcomes of performance measurement in quality improvement strategies. Rationale Performance measures are systematic and standardized methods that are aimed at identifying and improving suboptimal medical care and patient outcomes. Performance measures represent one of several potential strategies that can be used, together or alone, to help reduce gaps in the quality of health care. Effective performance measures are those that are associated with meaningful, desirable patient outcomes and include broad sampling from appropriate and related medical domains.2 Performance measure design should follow established standards, as outlined by national organizations,2 and have precise, validated components that are feasible, actionable, and meaningful. Performance measures usually reflect clinical practice guidelines of the highest levels of recommendation and evidence. Given that the identification, treatment, and control of HBP are suboptimal,3,225,226 use of effective performance measures can help improve these gaps in care, as has been shown in 1 observational study from Kaiser Permanente of Northern California.56 No RCTs of HBP performance measures have been published.4 Implementation of Performance Measures 1. Identify performances measures for hypertension that: a. Meet established ACC/AHA standards. b. Include key components that influence the impact and sustainability of hypertension detection, treatment, and control for the target population (medical care, cost of care, patient-reported factors). c. Help address the most pressing gaps in hypertension-related care for the healthcare provider, practice, or system. Coordinate the most feasible and meaningful collection of performance measures data with available data sources (eg, electronic health records, national data registries, administrative databases). Uses of Performance Measures To assess performance of the healthcare provider, practice, or system, identifying and characterizing gaps in quality of hypertension care (based on comparison to a national benchmark standard or based on comparison to previous performance by the same healthcare provider, practice, or system). 2. To be used to design and implement quality improvement plans to help address gaps in quality of hypertension care identified by performance measures. To report the use and outcomes of performance measurement as part of healthcare quality payment programs that are used by organizations to determine reimbursement to healthcare providers, practices, and systems on the basis of achievement and reporting of various performance metrics. Clinical Recommendations 2017 Hypertension Clinical Practice Guidelines4 Recommendation for Performance Measures (Guideline Section 12.4.1) Use of performance measures in combination with other quality improvement strategies at patient-, provider-, and system-based levels is reasonable to facilitate optimal hypertension control.56,227,228 (Class 2a, Level of Evidence: B-NR) ACC indicates American College of Cardiology; AHA, American Heart Association; CDU, care delivery unit; HBP, high blood pressure; and RCT, randomized controlled trial. Appendix A. Continued 46 Appendix B. Author Listing of Relationships With Industry and Other Entities (Relevant) 2019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Donald E. Casey Jr, Chair Thomas Jefferson College of Population Health Adjunct Faculty; Rush Medical College Faculty; University of Minnesota, Institute of Health Informatics Affiliate Faculty; President, American College of Medical Quality; IPO 4 Health Principal and Founder None None None None None None Randal J. Thomas, Vice Chair Mayo Clinic Medical Director, Cardiac Rehabilitation Program None None None None None None Vivek Bhalla Stanford University Medical Center Assistant Professor of Medicine, Nephrology; Stanford Hypertension Center Director Relypsa, Inc. None None None PyrAmes Health None Yvonne Commodore- Mensah Johns Hopkins School of Nursing Assistant Professor None None None None None None Paul A. Heidenreich Stanford VA Palo Alto Health Care System Professor of Medicine None None None None None None Dhaval Kolte Massachusetts General Hospital and Harvard Medical School International Cardiology Fellow None None None None None None Paul Muntner University of Alabama at Birmingham Professor, Department of Epidemiology None None None None None None Sidney C. Smith Jr University of North Carolina at Chapel Hill Professor of Medicine; Division of Cardiology, Department of Medicine None None None None None None John A. Spertus Washington University School of Medicine in St. Louis Adjunct Professor of Medicine, Cardiovascular Division; Saint Luke s Mid America Heart Institute Director, Health Outcomes Research; University of Missouri-Kansas City Professor, Daniel J. Lauer Missouri Endowed Chair in Metabolism and Vascular Disease Research AstraZeneca* Bayer Healthcare Pharmaceuticals Boehringer Ingelheim* Janssen* Novartis* None None None AstraZeneca UK Limited Novartis* None John R. Windle University of Nebraska College of Medicine Professor, Internal Medicine, Division of Cardiovascular Medicine None None None None None None Gregory D. Wozniak American Medical Association Director, Outcomes Analytics; Northwestern University, Feinberg School of Medicine Adjunct Assistant Professor None None None None None None Boback Ziaeian UCLA David Geffen School of Medicine Assistant Professor; US Department of Veterans Affairs Assistant Professor None None None None None None This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $5000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document or makes a competing drug or device addressed in the document; or c) the person or a member of the person s household, has a reasonable potential for financial, professional or other personal gain or loss as a result of the issues/content addressed in the document. *Significant relationship. No financial benefit. ACC indicates American College of Cardiology; AHA, American Heart Association; UCLA, University of California, Los Angeles; and VA, Veterans Affairs. 47 Appendix C. Reviewer Listing of Relationships With Industry and Other Entities (Comprehensive) 2019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Salary Biykem Bozkurt Official TFPM Lead; TFDS Content Reviewer Baylor College of Medicine Mary and Gordon Cain Chair Professor of Medicine and Director, Winters Center for Heart Failure Research; Michael E. DeBakey VA Medical Center, Cardiology Chief, Cardiology Section Bayer Bristol-Myers Squibb Lantheus Medical Imaging, Inc LivaNova USA Respicardia scPharmaceuticals None None LivaNova USA (DSMB) Abbott None None Nicole L. Lohr Official ACC Medical College of Wisconsin Assistant Professor None None None None Amgen None None Andrea L. Price Official ACC Indiana University Health Director, Quality Databases None None None None ACC Accreditation Foundation Board* None None Brent Egan Official AHA Medical University of South Carolina, Charleston (MUSC) Professor of Medicine and Pharmacology Medtronic Emcure Merck KGaA None None UpToDate None None John M. Flack Official AHA Southern Illinois University School of Medicine, Internal Medicine Professor, Chair, and Chief of Hypertension Specialty Services None None None National Institutes of Health (DSMB) Bayer GlaxoSmithKline Valencia None None Sandra J. Taler Official AHA Mayo Clinic Professor of Medicine None None None None None None None Michael Rakotz Official AMA American Medical Association Vice President, Health Outcomes None None None None AMA None None Cheryl Dennison- Himmelfarb Official PCNA Johns Hopkins School of Nursing Associate Dean for Research, Sarah E. Allison Endowed Professor, and Deputy Director, Institute for Clinical Translational Research None None None Helene Fuld Health Trust* NIH* PCNA None Johns Hopkins University* Nathalie De Michelis Content ACC University of California, Irvine Cardiovascular Program Manager None None None None None None None Eugene Yang Content ACC University of Washington School of Medicine Medical Director and Clinical Associate Professor of Medicine, Division of Cardiology, Carl and Ren e Behnke Endowed Professorship for Asian Health Amgen* RubiconMD* None None None Amgen* Third Party, Firefighter who developed an arrhythmia at work, None Marjorie L. King Content ACC/ AHA Helen Hayes Hospital Chief Medical Officer, Internal Medicine (Cardiology) and Director, Cardiopulmonary, Rehabilitation Island Peer Review Organization* None None None None None None (Continued) 48 Raj Padwal Content AMA University of Alberta Professor of Medicine and Director, Hypertension Dyslipidemia Clinic None None mmHG Inc. None None None None Nancy Houston- Miller Content PCNA The Lifecare Company Associate Director Moving Analytics* None None None None None None This table represents all relationships of reviewers with industry and other entities that were reported at the time of peer review, including those not deemed to be relevant to this document, at the time this document was under review. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $5000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories or additional information about the ACC/AHA Disclosure Policy for Writing Committees. *Significant relationship. No financial benefit. This disclosure was entered under the Clinical Trial Enroller category in the ACC s disclosure system. To appear in this category, the reviewer acknowledges that there is no direct or institutional relationship with the trial sponsor as defined in the ACCF or ACC/AHA Disclosure Policy for Writing Committees. ACC indicates American College of Cardiology; AHA, American Heart Association; AMA, American Medical Association; DSMB, Data Safety and Monitoring Board; HBP, high blood pressure; NIH, National Institutes of Health; PCNA, Preventive Cardiovascular Nurses Association; TFDS, Task Force for Data Standards; and TFPM, Task Force on Performance Measures. Appendix C. Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Salary