Thank you for commenting, the CRP public comment period has closed for measure developer review.

On behalf of The American Heart Association (AHA) and its division, the American Stroke Association (ASA), thank you for the opportunity to provide input on the proposed changes to CMS22, Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented. This is an important measure and we appreciate your reaching out to us to invite our comments.

It’s clear that you have worked very diligently to update and align every aspect of the measure with our 2017 ACC/AHA/AAPA/ABC/ ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. We’re especially pleased to see that you have incorporated the categorization of BP described in the guideline and also specified use of the ACC/AHA Pooled Cohort Equations for estimating CVD risk. Both of these additions to the measure should help clinicians identify those patients likely to benefit from more intensive BP management. We believe it is important for patients to know their own cardiovascular risk and for clinicians to use this information in making antihypertensive treatment decisions. It can also be a valuable tool in shared decision making.

We do have some concerns regarding the feasibility of some aspects of the measure and the availability of the required data in an EHR. For example, it’s very unlikely that the average BP is available in most EHRs. While it appears that this calculation takes place as part of the measure logic and is not pulled directly from the EHR, this does mean that the BP used to determine treatment decisions in the measure may not be readily available to the
clinician providing care. However, we also recognize that including this in the measure may help drive improvements in capture of clinical data in EHRs. This is also true of the Pooled Cohort Equation to estimate CVD risk, which we recognize is not currently routinely used in clinical practice or captured in most EHRs. We, therefore, strongly support the inclusion of averaged BP in the measure not only because it may help drive clinical practice, but also because it may help drive EHR vendors to include this in their products.

The guidelines recommend using an average of ≥2 readings obtained on ≥2 occasions to estimate an individual’s level of BP, however, the measure currently requires only one qualifying encounter to include a patient in the denominator of the measure. This also seems potentially problematic since the value set used to define eligible encounters includes urgent and emergency encounters. We would suggest that CMS consider requiring a minimum of 2 encounters, similar to other measures focused on screening and preventive care. In addition, it’s unclear whether telehealth visits would be considered qualifying encounters for this measure. We also have some reservations about the measure being applied at the individual physician level with the single encounter requirement. It may be more useful at a practice or health plan level as currently specified.

As you note in the Guidance section of the measure, the guideline recommends using clinical judgment and shared decision making involving the team and patient, when determining the risks, benefits and approach to BP reduction and the use of antihypertensive medications for adults > than or = to 65 years old diagnosed with hypertension and comorbid conditions limiting life expectancy. We would recommend that CMS consider expanding the description/examples of medical reason exceptions to address older patients with frailty, limited life expectancy or known symptoms of orthostasis who may be at high risk for adverse events.

Finally, although we understand that it would be challenging to operationalize in the measure logic, the guideline strongly emphasizes the importance of accurate BP measurement. Perhaps the importance of properly preparing the patient and using proper technique (Table 8. In the Guideline) could be addressed in the measure Guidance.

Thank you, again, for the opportunity to comment on this measure. We appreciate the careful work you have done to update the measure to reflect our 2017 guideline. We also recognize the challenges in translating guideline recommendations into feasible measures that will provide meaningful feedback to providers, patients and payers. The ACC/AHA Task Force on Performance Measures is currently updating our Hypertension performance measures, so we are working through the same challenges in trying to operationalize the guideline recommendations into measures. We expect to release our updated measures sometime in 2019.

If you have any questions or require any additional information, please contact Melanie Shahriary, RN, BSN, Senior Manager, Performance Metrics, Quality and HIT, 301-651-7548 or melanie.shahriary@heart.org.

No objections.