Kaiser Permanente Northern California (KPNC) is a not-for-profit, integrated health care delivery system that was founded in 1945 in Oakland, California. KPNC includes a health plan, hospital system, and a physician group practice.1 It is currently the second largest region (by number of members) of the national Kaiser Permanente group.
As of 2013, KPNC cared for more than 2.3 million adult members, with comprehensive inpatient and outpatient care provided through 21 hospitals, 45 medical facilities, and more than 7000 physicians.2
This case study focuses on a comprehensive program that KPNC launched in 2001 to improve hypertension outcomes across their patient population through a number of strategies, which included improving regular medication adherence.
In the late 1990s, fewer than half of Americans diagnosed with hypertension had controlled blood pressure (BP). KPNC recorded their rate of patients with controlled BP at 44% in 2001, when they developed a system-wide, multifaceted program for hypertension management.2,3
The program consisted of five key components:
KPNC created rigorous evidence-based guidelines for the entire system. “A critical characteristic of the hypertension guidelines has been a simplified drug treatment algorithm (protocol),” wrote Drs. Marc Jaffe and Joseph Young, who helped lead the KPNC research group.3 “Instead of listing several potential drug classes or several specific medications as potential options for each step in the protocol, a single specific drug with a recommended dose is advised in nearly all situations. This facilitates the use of fewer drugs, which can lead to improved familiarity, decreased practice variation, and simplification of teaching materials, resulting in increased efficiencies and potentially fewer medical errors.” This strategy captures some of the principles of conservative prescribing discussed earlier in this module. “Importantly, the guideline provides clear advice on how to initiate and escalate both doses and numbers of drugs to achieve blood pressure control but does so in a manner that is not prescriptive and enables clinicians to retain decision-making autonomy,” noted Drs. Abhinav Goyal and William Bornstein in an editorial for JAMA.4 The guidelines are updated every two years and are distributed through many forms throughout the organization.
The results of each medical center were regularly monitored and a central team identified the best performing centers. They contacted teams at those sites and sought to identify best practices, which were then shared with other medical centers throughout the network via training sessions, prepared lectures, email and other methods.
Beginning in 2007, KPNC offered patients medical assistant BP visits, usually scheduled 2 to 4 weeks following a BP medication adjustments. Patients did not need to pay a co-pay for these visits, so they were no-cost to patients. These visits could also be scheduled at flexible times. The medical assistant obtained the BP, and the primary care physician could then direct treatment intensification and follow-up care as needed.
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The results of this systemic approach to improving hypertension treatment were impressive. Over the first 8 years (from 2001 to 2009) the percentage of patients with hypertension who achieved BP control increased from 44% to 80%.2 This was better than national trends in BP control. By 2013, KPNC achieved 90% BP control.3
“In the late 1990s, when uncontrolled blood pressure was the norm, BP control rates of 90% seemed unimaginable,” wrote Drs. Marc Jaffe and Joseph Young.3
Over the same time period, the rate of heart attacks fell 24% and death from stroke declined by 42%.3
“This was and continues to be a team effort – with thousands of physicians, pharmacists, nurses, managers, data analysts, and others who work tirelessly to help our patients maintain healthy BP levels. How far we’ve come in the past 14 years!” wrote Drs. Jaffe and Young in a 2016 editorial.3
