Measure Description: Percentage of patients with ACC/AHA stage 2 or stage 1 HBP with SBP <130 mm Hg (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 mm Hg
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
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)
2. 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)
3. 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 mm Hg is recommended.46,51–54 (Class 1, Level of Evidence: SBP: B-RSR, DBP: C-EO)
4. 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)
5. 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)
6. Treatment of hypertension with a SBP treatment goal of less than 130 mm Hg is recommended for noninstitutionalized ambulatory community-dwelling adults (≥65 y of age) with an average SBP of 130 mm Hg or higher.58 (Class 1, Level of Evidence: A)
7. 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 1 month.59,60 (Class 1, Level of Evidence: B-R)
8. In adults with an untreated SBP greater than 130 mm Hg but less than 160 mm Hg or DBP greater than 80 mm Hg but less than 100 mm Hg, 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 mm Hg. The member is not compliant if the BP is ≥140/90 mm Hg, 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.