Data-driven Quality Improvement: The Case of Precise Blood Pressure Measurement

Nikita Stempniewicz1, 2, Elizabeth Ciemins2, Cindy Shekailo2, and John Cuddeback2
, [1] Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, [2] AMGA Analytics


Research Objectives: To determine the degree of rounding in blood pressure (BP) recordings occurring at 16 multi-specialty medical groups and integrated delivery systems across the U.S., share findings, track changes over time, and identify organizations with the largest improvements in the precision of BP recording to better understand drivers of these improvements.

Study Design: Blood pressure readings recorded during an ambulatory visit between 04/01/2013 and 06/30/2013 from a cohort of patients with a diagnosis of hypertension were analyzed. Rounding was quantified using the proportion of patients whose most recently recorded systolic or diastolic BP reading was a multiple of 10 mm Hg, e.g., 100, 110, 120, 130, identified by a last digit of zero. Opportunities for improvement were identified at all 16 organizations.

Population Studied: Office-based BP readings from 425,000 patients, aged 18–85, with a diagnosis of essential hypertension on an insurance claim or electronic health record problem list, representing a cohort of 16 organizations who pool their data as part of a collaborative to improve population health.

Findings: Systolic BP recording varied across organizations from 22–53% of patients with a last digit of zero. Slightly more rounding was observed for diastolic BP readings. Some practices or care teams had as many as 83% of patients with a last digit of zero. After these data were shared, interventions were applied at some organizations, from across-the-board changes at all practices to targeted interventions with specific practices or individual care teams where rounding was most prevalent. A few groups invested in automated BP cuffs; others conducted educational sessions on accuracy of BP measurement and precision of recording. Significant improvements were observed at 88% (14/16) of the participating organizations (p < .001). Improvements in systolic BP recording ranged from 5–45% relative reductions in the proportion of patients with a last digit of zero. A subset of five organizations with the most significant improvements shared their strategies with other collaborative participants. Conclusions: Sharing simple data on BP with medical groups and health systems can lead to improvements in precision with which BP readings are recorded. Stratifying analyses by practice or provider/care team can lead to more efficient quality improvement, by targeting areas where BP rounding is most prevalent. Implications for Policy, Delivery, or Practice: As health care organizations transition from volume to value, productive use of electronic health record (EHR) and other data will become increasingly essential to business operations. Precise recording of blood pressure measurement is important for hypertension management as it enables providers to make timely therapeutic adjustments, and patients to better manage their own disease with accurate information. This example of how EHR data can be evaluated to inform practice improvement and ultimately improve quality of care provides an important instance of data-driven improvement that will be critical for the future of health care in the U.S.