Development of quality indicators for hypertension, extractable from the electronic health record of the general practitioner. A rand-modified Delphi method. 

Development of quality indicators for hypertension, extractable from the electronic health record of the general practitioner. 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A rand-modified Delphi method. Katrien Danhieux, Marieke Hollevoet, Sien Lismont, Pieter Taveirne, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3957904/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Aug, 2024 Read the published version in BMC Primary Care → Version 1 posted 9 You are reading this latest preprint version Abstract Background: Hypertension, a chronic medical condition affecting millions of people worldwide, is a leading cause of cardiovascular diseases. A multidisciplinary approach is needed to reduce the burden of the disease, with general practitioners playing a vital role. Therefore, it is crucial that GPs provide high-quality care that is standardized and based on the most recent (inter)national guidelines. Quality indicators (QIs) can be used to assess the performance, outcomes, or processes of healthcare delivery and are critical in helping healthcare professionals identify areas of improvement and measure progress towards achieving desired health outcomes. However, QIs to evaluate the care of patients with hypertension in general practice have been studied to a limited extent. The aim of our study is to define quality indicators for hypertension in general practice that are extractable from the electronic health record (EHR) and can be used to evaluate and improve the quality of care for hypertensive patients in the general practice setting. Methods: We used a Rand-modified Delphi procedure. We extracted recommendations from (inter)national guidelines and assembled them into an online questionnaire. An initial scoring based on the SMART principle and extractability from the EHR was performed by panel members, these results were analyzed using a Median Likert score, prioritization and degree of consensus. A consensus meeting was set up in which all the recommendations were discussed, followed by a final validation round. Results: Our study extracted 115 recommendations from (inter)national guidelines on hypertension and was converted into an online questionnaire. After analysis of the questionnaire round and a consensus meeting round, 37 recommendations were accepted and 75 were excluded. Of these 37 recommendations, 9 were slightly modified and 4 were combined into 2 recommendations, resulting in a list of 35 recommendations. All recommendations of the final set were translated to QIs, made up of 7 QIs on screening, 6 QIs on diagnosis, 11 QIs on treatment, 5 QIs on outcome and 6 QIs on follow-up. Conclusions: Our study resulted in a set of 35 QIs for hypertension in general practice. The QIs are extractable from the EHR making them suitable for automated quality assessment. Hypertension Primary care Guideline adherence Healthcare evaluation Health services research Public health Quality indicators Quality of healthcare Figures Figure 1 1. Background Hypertension is a chronic medical condition that affects millions of people worldwide. It is a leading contributor to cardiovascular diseases and a significant risk factor for chronic kidney disease, stroke and heart failure. As a result, it is one of the most common causes of global morbidity and mortality ( 1 ). According to recent statistics from the World Health Organization (WHO), hypertension affects approximately 1.28 billion people globally ( 1 ). In Belgium, hypertension is also a significant health issue, with an estimated prevalence of 17.6% in adults aged 15 and older. The number of people with hypertension has increased over the last decades and is expected to increase even more in the coming years ( 2 ). Despite its high prevalence and seriousness, hypertension often goes undiagnosed and untreated ( 1 , 3 , 4 ). Studies have shown that adequate treatment and follow-up of hypertension can reduce the associated cardiovascular morbidity and mortality ( 5 ). Moreover, early detection of patients at increased risk of developing hypertension allows for age-specific prevention and intervention strategies ( 6 ). A multidisciplinary approach is needed to reduce the burden of disease for the patient and society, in which the general practitioner plays a vital role ( 7 ). To this end it is crucial that GP’s perform high quality care that is standardized and based on the most recent (inter)national guidelines. A way to evaluate this is through the implementation of quality indicators (QIs). QIs refer to quantifiable measures that can be used to assess the outcomes or processes of healthcare delivery. These measures are designed to evaluate and improve the quality of healthcare services and are critical in helping healthcare professionals identify areas of improvement and measure progress towards achieving desired health outcomes ( 8 – 12 ). A good QI is specific, measurable, acceptable, realistic and timely (SMART). ( 13 – 17 ) In addition, extractability from the electronic health record (EHR) must be taken into account. Since the EHR contains structured medical data, it can be used to assess the quality of care and monitor the performance of health care providers. Moreover, it could enable automated quality assessment which is cheap and fast, allowing it to be widely implemented. ( 18 ) QIs to evaluate the care of patients with hypertension in general practice have been studied to a limited extent. A study by Min et al. aimed to identify potential QIs for hypertension care in vulnerable elderly populations which resulted in 14 QIs that covered aspects of care such as blood pressure measurement, medication use, and follow-up. ( 19 ) Various institutions, such as World Health Organization have already published quality indicators for hypertension. ( 20 – 25 ) However, these indicators are mainly based on national guidelines, and except the QIs from Canadian Cardiovascular Outcomes Research Team (CCORT) ( 23 ), not specifically designed for primary care. Moreover, the extractability of these indicators from EHR was not taken into account. The aim of our study was to define quality indicators for hypertension in general practice that are extractable from the EHR and can be used to evaluate and improve the quality of care for hypertensive patients in primary care. 2. Methods 2.1. Study design To develop the QIs for hypertension, we used the RAND-modified Delphi method (13-15, 24-25), as was successfully applied in previous studies (14-15) and contains 5 steps: (I) Extraction of recommendations from (inter)national guidelines and inclusion in a questionnaire. (II) Individual rating of the recommendations by an expert panel, followed by an analysis of the results and a feedback report (questionnaire round). (III) A consensus round to assess the recommendations for their eligibility, with a face-to-face discussion by the expert panel. (IV) Final evaluation of the set of recommendations by the panelists. (V) Transformation of the recommendations into the final set of QIs. 2.2. Study population The expert panel consisted of 12 members: 1 cardiologist, 1 internist in training, 5 general practitioners (GP), 1 GP in training, 2 nurses (1 working in cardiology, 1 working in a GP practice), 1 patient with hypertension, 1 programmer of an EHR software company. All professionals were selected on their expertise with hypertension and were working in Belgium. The patient had the diagnosis of hypertension for 4 years. 2.3. Data collection 2.3.1. Extraction of recommendations We selected the most recent national and international guidelines on hypertension. Guidelines were selected based on language (English and Dutch) and year of publication (after 2011). Non-European guidelines on hypertension were excluded because of geographically different approaches to hypertension. We included the following guidelines: guideline from Domus Medica (2013) (26), guideline from NHG (2019) (27), European guideline (2018) (28) and the NICE guideline (2019) (29). The following commonly used sources in Belgium, based on (inter)national guidelines, were also included: BCFI (2020) (30), Formularium Ouderenzorg (2020) (31). All recommendations were assembled into an online questionnaire consisting of the following categories: screening, diagnosis, treatment (medical & non-medical and choice of antihypertensive agent), outcome (target, therapy-resistant hypertension, blood test at start treatment, start statin, duration treatment) and follow-up. (See Additional File 1). An adapted list was conducted for the patient and the nurses, taking into account their knowledge on the subject and the relevance of the recommendations for each of them. The programmer of the EHR company received the complete list of recommendations. 2.3.2. Questionnaire round An online survey was created using Qualtrics. The panelists were invited to participate by email. Participants were asked to score each recommendation for their capability to measure the quality of hypertension in primary care on a 9- point Likert scale, with 1 being the lowest score and 9 the highest score. More specifically, the panelists were assigned to score the recommendations based on the SMART-principle (specific, measurable, acceptable, realistic and timely), taking into account the benefit for the patient and the EHR extractability. The programmer of the EHR company was asked to rate the recommendations only on EHR extractability. In addition, we asked each panel member to prioritize the recommendations per category in a top-5 (prioritization) on relevance for measuring quality of care. Finally, all participants had the possibility to write down remarks. The median Likert scale score was calculated for each recommendation, ranging from 1 to 9. The prioritization was defined as a percentage, calculated on how the panel ranked the recommendation in the top-5 score. If a recommendation was mentioned first, it received 5 points, the second place received 4 points, , etc. Recommendations that were not included in the top-5 list, received 0 points. These points were then converted into a percentage. The numerator was measured as the sum of the points a recommendation received and the denominator was the maximum score that recommendation could possibly receive ( = 5 times the number of panel members that scored that recommendation). For example, if 3 out of 12 panel members ranked a recommendation first and 7 did not mention it in their top-5, the prioritization percentage was 25% ( = 15/60). “Consensus” was defined as ≥ 70% of the panel members awarding a score of ≥7 to the recommendation. When ≥ 30% of the panel members scored ≥7 AND ≥ 30% scoring ≤3, it was defined as “disagreement”. Other outcomes were interpreted as having “no consensus”. Recommendations were classified into the categories high, uncertain or low potential as quality indicator by two steps. We first preselected, then in a second step we combined the results of the preselection with the degree of consensus to finally reach a conclusion on the classification of each recommendation. Based on these criteria, the recommendations were divided into three categories: having a high, an uncertain or low potential as a quality indicator to measure hypertension care. The preselection was made using the median Likert scale score and the prioritization percentage. Recommendations with a median score on the Likert scale ≥ 7 and a prioritization percentage ≥ 20% were “selected”. The ones with a median score ≥ 7 and prioritization percentage ≥ 1 and ≤ 20% AND the recommendations with a median score <7 and top-5 percentage ≥ 20 were categorized as “discussion”. Other outcomes were defined as “not selected”, see Table 1. Table 1: Preselection and consensus criteria Preselection Median ≥ 7 and Prioritization percentage ≥ 20% Selection Median ≥ 7 and 1% ≤ prioritization percentage ≤ 20% Discussion Median < 7 and Prioritization percentage ≥ 20% Discussion Other No selection Degree of consensus ≥ 70% in highest tertile Consensus ≥ 30% in highest tertile and ≥ 30% in lowest tertile Disagreement Other No consensus The classification of the recommendations was based on the preselection and the degree of consensus. Recommendations that were selected and that had consensus, were ranked as high potential. In case of selection and disagreement or no consensus, or in case of discussion and consensus or disagreement, a recommendation was classified as “uncertain”. In every other case, the recommendation had low potential, see Table 2. Table 2: Classification of recommendations Preselection Degree of consensus Conclusion Recommendation 1 Selection Consensus High potential Recommendation 2 Selection Disagreement Uncertain Recommendation 3 Selection No consensus Uncertain Recommendation 4 Discussion Consensus Uncertain Recommendation 5 Discussion Disagreement Uncertain Recommendation 6 Discussion No consensus Low potential Recommendation 7 No selection Disagreement Low potential Recommendation 8 No selection Consensus Low potential Recommendation 9 No selection No consensus Low potential 2.3.3. Consensus meeting round The results of the analysis were presented to the panel members in a feedback report which contained all recommendations with a color code representing its potential for measuring the quality of care (see Table 2). During the consensus meeting, the recommendations with a high potential were considered as included unless panel members asked for a decision making discussion. Recommendations with a low potential were excluded, unless panel members requested deliberation. Uncertain recommendations were always discussed more comprehensively for exclusion or inclusion. All accepted recommendations were then discussed, adjusted or modified, taking into account the SMART principle, the patient benefit, the recommendations’ EHR extractability and the remarks of the panel members. 2.3.4. Final evaluation The final set of all included recommendations was sent to the panel members for final appraisal. 2.3.5. Translation into quality indicators/ Formulation of the final set QIs The recommendations were transformed into quality indicators as a percentage. For example, “An electrocardiogram should be performed in patients with hypertension” thus became “The percentage of patients with hypertension in whom an electrocardiogram was performed”. The final set of quality indicators was approved by all panel members. 3. Results 3.1. Extraction of recommendations A total of 115 recommendations were extracted from the used (inter)national guidelines. Six recommendations which occurred twice with similar content were combined into 3 recommendations. The final result was a list of 112 recommendations (see additional file 2) which was then converted into an online questionnaire. The adapted list for the nurses consisted of 88 recommendations and the one for the patient of 63. 3.2. Online questionnaire round The doctors and the programmer of the EHR company completed the full questionnaire and scored all of the 112 recommendations. One of the nurses and the patient also filled out the complete questionnaire they received respectively. The other nurse scored only the first 34 recommendations and did not complete the rest of the questionnaire. After analysis of the results, 20 recommendations had high potential, 36 were uncertain and 56 had low potential for measuring quality of care. (see additional file 3) 3.3. Consensus meeting round At the consensus meeting, 5 panelists were able to participate, including three general practitioners from three different general practices, a general internal medicine resident and a software collaborator. Following a comprehensive and detailed discussion, the panel resolved to endorse all 20 recommendations with a high potential, 15 out of 36 recommendations with uncertain potential, and only 2 out of 56 recommendations with low potential. These decisions led to a total of 37 recommendations being accepted while 75 were excluded. Figure 1 illustrates the distribution of these recommendations. Of these 37 recommendations, 9 were slightly modified. Two recommendations related to blood testing and two recommendations related to urine testing were merged into one recommendation each, respectively. Another 24 were accepted literally, which resulted in a final list of 35 recommendations. 3.4. Final appraisal/ evaluation After the consensus meeting, 35 recommendations were sent to the expert panel by email for final approval. Except for the general practice nurse, who dropped out of the study early, every member of the panel agreed on the final list of recommendations. 3.5. Translation into quality indicators/ Formulation of the final set QIs All recommendations of the final set were translated to QIs. The result was a final set of 35 QIs, made up of 7 QIs on screening, 6 QIs on diagnosis, 11 QIs on treatment, 5 QIs on outcome and 6 QIs on follow-up, see Table 3 . Table 3 Quality indicators (QIs) on hypertension care Quality indicators (QIs) on hypertension care. SCREENING Screening 1. Percentage of patients aged 40–70 years whose blood pressure was measured at least every 5 years. 2. Percentage of patients diagnosed with migraine or headache whose blood pressure was measured at the time of diagnosis. 3. Percentage of patients with type 2 diabetes without already diagnosed hypertension or kidney disease whose blood pressure was measured. 4. Percentage of patients prescribed oral contraception for the first time whose blood pressure was measured at the moment of prescription. 5. Percentage of pregnant patients whose blood pressure was measured at least once during pregnancy. Home measurement 6. Percentage of adult patients in whom multiple conventional blood pressures of ≥ 140 mmHg systolic and/or ≥ 90 mmHg diastolic were measured in whom a home measurement was done. Screening for atrial fibrillation 7. Percentage of patients whose pulse regularity was assessed during blood pressure measurement. DIAGNOSIS Assessment of cardiovascular risk factors 8. Percentage of patients diagnosed with hypertension whose smoking status, alcohol consumption and sedentariness were questioned once. 9. Percentage of patients diagnosed with hypertension whose BMI was calculated. 10. Percentage of patients diagnosed with hypertension in whom a cardiovascular risk assessment (using the SCORE table) was done. Blood analysis at diagnosis 11. Percentage of patients diagnosed with hypertension who had a blood test in which hemoglobin, fasting glycemia, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, sodium, potassium, uric acid, creatinine, eGFR and liver function were measured. Urine analysis at diagnosis 12. Percentage of patients diagnosed with hypertension who had a urinalysis in which albumin/creatinine ratio and hematuria were measured. ECG at diagnosis 13. Percentage of patients diagnosed with hypertension who had an electrocardiogram. TREATMENT Non-pharmacological treatment 14. Percentage of patients diagnosed with hypertension in whom lifestyle interventions such as salt restriction, alcohol reduction, healthy diet, exercise, weight control and smoking cessation were advised. Pharmacological treatment 15. Percentage of patients younger than 80 years of age with grade 1 hypertension (conventional blood pressure measurement 140/90–159/100 mmHg and ABPM or HBPM 135/85–149/94 mmHg) and end-organ damage, cardiovascular disease, renal disease, diabetes or cardiovascular risk ≥ 10% who started with antihypertensive medication. 16. Percentage of patients under 80 years of age with grade 1 hypertension (systolic 140–159 mmHg and/or diastolic 90–99 mmHg) who started with antihypertensive medication if blood pressure was not 5% on the SCORE2 table) or organ damage who started with antihypertensive medication. 18. Percentage of patients with very high blood pressure values (systolic > 180 mmHg and/or diastolic > 110 mmHg) in whom antihypertensive medication was immediately initiated, regardless of their cardiovascular risk. 19. Percentage of patients with hypertensive crisis referred to the hospital. Choice of antihypertensive First choice if no comorbidity 20. Percentage of patients who were switched to an Angiotensin-II-receptor blocker if an ACE-inhibitor was not tolerated. First choice if diabetes mellitus type II is present 21. Percentage of patients with type II diabetes mellitus who received a diuretic, calcium antagonist, β-blocker or ACE-inhibitor as the first choice of antihypertensive. First choice if nephropathy is present 22. Percentage of patients with hypertension and nephropathy with proteinuria who receive an ACE-inhibitor as the first choice of antihypertensive. First choice if coronary artery disease is present 23. Percentage of patients with hypertension and stable angina, experienced myocardial infarction, coronary artery disease or atrial fibrillation who received a β-blocker as the first choice of antihypertensive. First choice if heart failure or albuminuria is present 24. Percentage of patients with hypertension and heart failure (including left ventricular dysfunction) or (diabetic and nondiabetic) micro or macroalbuminuria, who received an ACE inhibitor or Angiotensin II receptor blocker as the first choice of antihypertensive. OUTCOME Target blood pressure values 25. Percentage of patients aged 70 years or younger with hypertension where the target is to achieve a systolic blood pressure of < 140 mmHg and a diastolic blood pressure of < 90 mmHg 3 months after initiation of treatment. Treatment Choice if blood pressure is not adequately controlled with current antihypertensive treatment 26. Percentage of patients with hypertension with no adequate response to a single antihypertensive agent who received a combination of low-dose antihypertensive agents instead of the maximum dose of a single agent. Percentage of patients with hypertension with no adequate response to the maximally tolerated dual therapy who received triple therapy. Treatment-resistant hypertension 27. . Percentage of patients with treatment-resistant hypertension who were referred to a specialist. Blood analysis on initiation of antihypertensive medication 28. Percentage of patients in whom a diuretic, an ACE inhibitor or an Angiotensin II receptor blocker was started in which a blood analysis was done prior to the start of these medications with analysis of eGFR, sodium and potassium. Statin treatment 29. Percentage of patients aged 70 years old or younger who are at moderate to high cardiovascular risk (> 5% on the SCORE2 table) and any patient with cardiovascular disease who received a statin. FOLLOW-UP Conventional blood pressure measurement 30. Percentage of patients with hypertension in whom blood pressure has not yet stabilized where blood pressure was measured monthly. 31. Percentage of patients with hypertension where blood pressure was measured at least 6-monthly. 32. . Percentage of patients with hypertension and type 2 diabetes in whom blood pressure was measured at least 3-monthly. Cardiovascular risk assessment 33. Percentage of patients with hypertension in whom their cardiovascular risk (according to SCORE table) was determined annually. Blood analysis in follow-up 34. Percentage of patients with hypertension and taking a diuretic, ACE-inhibitor or angiotensin-II- receptor blocker in which annual blood tests were done in which creatinine, eGFR, sodium and potassium were measured. 35. Percentage of patients with Spironolactone added to treatment in whom 1 month after the start of this medication a blood test was done with control of sodium, potassium and renal function. 4. Discussion 4.1. Principal findings This study used a RAND-modified Delphi method to develop a list of 35 quality indicators for evaluating the quality of care of patients with hypertension in primary care. The quality indicators on screening demonstrate the importance of being aware of the potential existence of hypertension. Furthermore, the expert panel discussed that when elevated conventional blood pressure measurements were noted multiple times, a home measurement should follow before a diagnosis of hypertension can be made. In patients diagnosed with hypertension, cardiovascular risk factors should be assessed. For this purpose, it is suggested to question smoking status, alcohol consumption and physical activity, calculate the BMI and perform a blood test to measure cholesterol. The panel found it important to redetermine this cardiovascular risk score every year. Performing a blood test, urinalysis and electrocardiogram are key quality indicators to screen for organ damage. Among the various quality indicators related to hypertension treatment, healthcare professionals and patients alike perceived non-pharmacological interventions as the most crucial. Physicians indicated that this is often discussed with the patient, but rarely recorded properly. Panelists questioned whether we should include this quality indicator due to its difficult extractability, but precisely because of the significance of this lifestyle advice, it was deemed necessary to include it anyway. Three quality indicators were selected by the panel concerning the indications for starting medication. The first choice of antihypertensive medication depends on the patient's comorbidities. For example, the panel had different preferences regarding the choice of first initiated antihypertensive in patients with diabetes, chronic renal insufficiency, coronary artery disease and heart failure. For the patient population with hypertension younger than 70 years, the expert panel selected a target blood pressure lower than 140/90 mmHg, which should be achieved no more than 3 months after starting treatment. The experts agreed that if there is insufficient response to antihypertensive treatment, a combination of low-dose antihypertensive drugs is preferable to the maximum dose of a single agent. If blood pressures are not under control with a combination of 3 antihypertensive medications, the hypertension is considered "therapy-resistant" and the patient should be referred to a specialist. Again, the panel cited that this referral to a specialist will rarely be coded correctly in the EHR. Nevertheless, again because of the risks of leaving this untreated, it was opted to include this recommendation anyway, as it could possibly be of value in the future. This is especially true if this could be recorded in a more user-friendly way, if it were more established among physicians to record this and data sharing between primary and secondary care would be improved. In addition to treatment with antihypertensive drugs, treatment with statins was also debated. The experts chose to include the respective recommendation, which says that any patient younger than 70 years and at moderate to high cardiovascular risk (via SCORE2 table) and any patient with cardiovascular disease should be treated with a statin. Because diuretics, ACE inhibitors and Angiotensin II receptor blockers can affect kidney function, sodium and potassium, a blood test verifying these values should be done prior to starting these medications. In any patient with hypertension whose blood pressure has not yet stabilized, blood pressure should be determined monthly. Once blood pressure is stabilized, the frequency of blood pressure follow-up can go to 6-monthly. As mentioned above, there is only a limited amount of research on QIs for hypertension. When comparing our set of QIs to those previously developed, similarities and differences emerge. Our findings align with the QIs defined by the American College of Cardiology/American Heart Association (AHA/ACC) ( 22 ) in certain areas, such as the importance of non-pharmacological treatment, assessing the cardiovascular risk score and treatment based on the grade of hypertension. However, screening is recommended differently, as the AHA/ACC suggest to start screening at 18 years old, with a screening protocol based on blood pressure values, whereas our QI suggest screening to begin at 40 years old and to be performed every 5 years. Furthermore, the use of home blood pressure monitoring (HBPM) is recommended for the follow-up of hypertension and not for screening. Additionally, the AHA/ACC also defined several QIs that are not EHR-extractable in Belgium, including QIs on medication adherence and shared decision-making. Finally, they also have a number of structural quality measures relating to telemedicine, EHR usage and screening protocols, which is not the subject of our study. The 6 QIs identified by NICE ( 21 ) are largely reflected in our QIs, such as screening for target organ damage, target values, assessing cardiovascular risk score annually and referral to a cardiologist for treatment-resistant hypertension. A difference is the recommendation of ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. While ABPM is indeed the most accurate method for confirming the diagnosis of hypertension, our experts preferred a home measurement because this is much more commonly done in practice than an ABPM. In Belgium, ABPM is not reimbursed in primary practice and referral to a specialist is required, whereas home measurements can be easily conducted. The QIs from the CCORT ( 23 ) focus on screening and follow-up and largely overlap with our QIs. A difference is the varying target blood pressure values based on comorbidities. As a next step these quality indicators can be converted into queries to develop an automated audit and feedback intervention to evaluate and improve the quality of care for patients with hypertension by giving practices insight into their strengths and areas of work. Audit and feedback is a strategy used worldwide to encourage professionals to optimize their clinical practice. (32) An audit is a systematic assessment of clinical practice based on explicit criteria/standards. (32) This assessment can include data on a variety of issues, for example process of care, clinical endpoints and number of patients treated correctly according to guidelines. ( 33 ) Using these data to provide feedback to the involved caregiver, as described above, small but significant changes in care delivery can be gained. ( 34 ) 4.2. Strengths and limitations One of the primary strengths of this study is its novelty in developing QIs for hypertension that are extractable from the EHR. This feature enables the QIs to be utilized for monitoring and improving the quality of care for patients with hypertension, through the implementation of audit and feedback interventions. In general, the topics of our QIs overlap with those of other studies. However, our QIs cover all aspects of healthcare (screening, diagnosis, treatment and follow-up) which none of the other sets of QIs do. Within each domain, our QIs are more comprehensive and specific compared to other QIs. Another strength is that a variegated panel of experts that have different viewpoints on the subject was questioned, so in addition to general practitioners, we included 2 specialists (one cardiologist and one resident in internal medicine), 2 nurses (one nurse from the general practice and one nurse working in the internal medicine department) and a patient. To gain better insight into the extractability of the QIs, we also included a software programmer specialized in electronic medical records. One of the limitations of this study is that there were some absentees at the consensus meeting and thus only a relatively small group could discuss with each other. Since both the cardiologist, the nurses and the patient were absent during the consultation moment, it was mainly the general practitioners and the resident in internal medicine who engaged in discussion with each other. Also one nurse started the survey but did not complete it and decided to drop out of the study early. Additionally, we chose guidelines based on geography, which meant that some major guidelines such as the American ACC/AHA guidelines ( 35 ) were not included. 5. Conclusion This study used a RAND-modified Delphi method to identify a set of 35 EHR-extractable QIs to measure the quality of primary care for patients with hypertension. These QIs could be used in an automated audit and feedback intervention and cover all aspect of primary hypertension care. Abbreviations GP: General Practitioner QIs: Quality Indicators SMART: Specific, Measurable, Achievable, Relevant, Timely EHR: Electronic Health Record WHO: World Health Organization CCORT: Canadian Cardiovascular Outcomes Research Team NICE: National Institute for Health and Care Excellence NHG: Nederlands Huisartsen Genootschap (Dutch College of General Practitioners) BCFI: Belgisch Centrum voor Farmacotherapeutische Informatie (Belgian Center for Pharmacotherapeutic Information) ACC/AHA: American College of Cardiology/American Heart Association HBPM: Home Blood Pressure Monitoring ABPM: Ambulatory Blood Pressure Monitoring Declarations Ethics approval and consent to participate The research project was presented to the KU Leuven ethics committee and was granted approval with a positive final decision under the reference number MP018005 on 18-01-2022. Informed consent was given by all participants. Consent for publication Not applicable Availability of data and materials The dataset(s) supporting the conclusions of this article are included within the article and its additional files. Competing interests The authors declare that they have no competing interests. Funding The authors did not receive any funding. Authors' contributions BV and SVdB contributed to the conceptualization of the study. KD, MH, SL, PT, LVV, BV and SVdB contributed to the design of the study. Data collection and analysis was performed by MH, SL, PT, LVV and supervised by KD, BV and SVdB. KD, MH, SL, PT, LVV, BV and SVdB contributed to the final manuscript. KD and SVdB are the guarantors of this work. Acknowledgements We thank all panel members for contributing. Authors ’ information KD is a general practitioner and PhD researcher. MH, SL, PT and LVV were residents in general practice during the study. 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Last updated: 2015 Available from: https://www.nice.org.uk/guidance/qs28 Casey Jr D.E., Randal J.T., Vivek B., et al. 2019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circ:Cardiovascular Quality and Outcomes. 2019;12:e000057 FI Burge, K Bower, W Putnam, JL Cox. Quality indicators for cardiovascular primary care. Can J Cardiol 2007;23(5):383-388 Dalkey N, Helmer O. An Experimental Application of the DELPHI Method to the Use of Experts. Manag Sci. 1963;9(3):458–67 Kotter T, Blozik E, Scherer M. Methods for the guideline-based development of quality indicators--a systematic review. Implement Sci. 2012;7:21. De Cort P, Christiaens T, Philips H, Goossens M, Van Royen P. Aanbeveling voor goede medische praktijkvoering: Hypertensie. Huisarts Nu 2009;38:340-61. NHG Cardiovasculair risicomanagement [Internet]. Utrecht: NHG; 2019 Jun [cited 2023 Apr 28]. Available from: https://richtlijnen.nhg.org/standaarden/cardiovasculair-risicomanagement. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). Eur Heart J. 2018 Sep 1;39(33):3021-3104. doi: 10.1093/eurheartj/ehy339. National Institute for Health and Care Excellence (NICE). Hypertension in adults: diagnosis and management [Internet]. Published 28 August 2019 [updated 18 March 2022; cited 28 April 2023]. Available from: https://www.nice.org.uk/guidance/ng136. Belgian Centre for Pharmacotherapeutic Information (BCFI). Cardiovasculair stelsel, Hypertensie, Folia maart 2014 and Folia maart 2019. Belgian Centre for Pharmacotherapeutic Information (BCFI). Formularium ouderenzorg, Arteriële hypertensie, Literatuur geraadpleegd tot: 14/04/2020. R. Busse, N. Klazinga, D. Panteli, W. Quintin. Improving healthcare quality in Europe: Characteristics, effectiveness and implementation of different strategies. Health policy series 2019; 53 R Foy, MP Eccles, G Jamtvedt, J Young, JM Grimshaw, R Baker. What do we know about how to do audit and feedback? Pitfalls in applying evidence from a systematic review. BMC Health Serv Res. 2005; 5: 50. vers N, Jamtvedt G, Flottorp S, et al. Audit and feedback : effects on professional practice and healthcare outcomes (Review). Cochrane database Syst Rev. 2012;6(6):CD000259. Whelton PK, Carey RM, Aronow WS, et al. 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: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:e13–e115. DOI: 10.1161/HYP.0000000000000065 Additional Declarations No competing interests reported. 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Development of QIs for hypertension by the RAND-modified Delphi method (N = number).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3957904/v1/1744bb86b993917b042a9b34.png"},{"id":63071018,"identity":"1309d9b6-9c45-4935-9755-736631cdb85e","added_by":"auto","created_at":"2024-08-22 20:02:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":824267,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3957904/v1/b91ad04f-6eb2-4f5a-ad93-0ed364030ce4.pdf"},{"id":51330897,"identity":"ba3b0daa-985a-4f0b-8d83-6ee46188dd4f","added_by":"auto","created_at":"2024-02-19 17:50:58","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":77596,"visible":true,"origin":"","legend":"","description":"","filename":"DevelopmentofqualityindicatorsforhypertensionAdditionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-3957904/v1/a76fb2eaea995e4954b3659c.docx"},{"id":51332284,"identity":"ecd2a002-5d4b-4721-aa0b-f2590551d36f","added_by":"auto","created_at":"2024-02-19 17:59:01","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":29544,"visible":true,"origin":"","legend":"","description":"","filename":"DevelopmentofqualityindicatorsforhypertensionAdditionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-3957904/v1/28f6bd420d54485466ad7361.docx"},{"id":51330898,"identity":"8b944c52-c72a-411b-81cf-a60e403f9e25","added_by":"auto","created_at":"2024-02-19 17:50:59","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":38997,"visible":true,"origin":"","legend":"","description":"","filename":"DevelopmentofqualityindicatorsforhypertensionAdditionalfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-3957904/v1/5c56863611b91a4606ddb2a4.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development of quality indicators for hypertension, extractable from the electronic health record of the general practitioner. A rand-modified Delphi method. ","fulltext":[{"header":"1. Background","content":"\u003cp\u003eHypertension is a chronic medical condition that affects millions of people worldwide. It is a leading contributor to cardiovascular diseases and a significant risk factor for chronic kidney disease, stroke and heart failure. As a result, it is one of the most common causes of global morbidity and mortality (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to recent statistics from the World Health Organization (WHO), hypertension affects approximately 1.28\u0026nbsp;billion people globally (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In Belgium, hypertension is also a significant health issue, with an estimated prevalence of 17.6% in adults aged 15 and older. The number of people with hypertension has increased over the last decades and is expected to increase even more in the coming years (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite its high prevalence and seriousness, hypertension often goes undiagnosed and untreated (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Studies have shown that adequate treatment and follow-up of hypertension can reduce the associated cardiovascular morbidity and mortality (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Moreover, early detection of patients at increased risk of developing hypertension allows for age-specific prevention and intervention strategies (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA multidisciplinary approach is needed to reduce the burden of disease for the patient and society, in which the general practitioner plays a vital role (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e7\u003c/span\u003e). To this end it is crucial that GP\u0026rsquo;s perform high quality care that is standardized and based on the most recent (inter)national guidelines. A way to evaluate this is through the implementation of quality indicators (QIs).\u003c/p\u003e \u003cp\u003eQIs refer to quantifiable measures that can be used to assess the outcomes or processes of healthcare delivery. These measures are designed to evaluate and improve the quality of healthcare services and are critical in helping healthcare professionals identify areas of improvement and measure progress towards achieving desired health outcomes (\u003cspan additionalcitationids=\"CR9 CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e12\u003c/span\u003e). A good QI is specific, measurable, acceptable, realistic and timely (SMART). (\u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e17\u003c/span\u003e) In addition, extractability from the electronic health record (EHR) must be taken into account. Since the EHR contains structured medical data, it can be used to assess the quality of care and monitor the performance of health care providers. Moreover, it could enable automated quality assessment which is cheap and fast, allowing it to be widely implemented. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eQIs to evaluate the care of patients with hypertension in general practice have been studied to a limited extent.\u003c/p\u003e \u003cp\u003eA study by Min et al. aimed to identify potential QIs for hypertension care in vulnerable elderly populations which resulted in 14 QIs that covered aspects of care such as blood pressure measurement, medication use, and follow-up. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eVarious institutions, such as World Health Organization have already published quality indicators for hypertension. (\u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24\" citationid=\"CR21\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e25\u003c/span\u003e) However, these indicators are mainly based on national guidelines, and except the QIs from Canadian Cardiovascular Outcomes Research Team (CCORT) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e23\u003c/span\u003e), not specifically designed for primary care. Moreover, the extractability of these indicators from EHR was not taken into account.\u003c/p\u003e \u003cp\u003eThe aim of our study was to define quality indicators for hypertension in general practice that are extractable from the EHR and can be used to evaluate and improve the quality of care for hypertensive patients in primary care.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e2.1. Study design\u003c/p\u003e\n\u003cp\u003eTo develop the QIs for hypertension, we used the RAND-modified Delphi method (13-15, 24-25), as was successfully applied in previous studies (14-15) and contains 5 steps: (I) Extraction of recommendations from (inter)national guidelines and inclusion in a questionnaire. (II) Individual rating of the recommendations by an expert panel, followed by an analysis of the results and a feedback report (questionnaire round). (III) A consensus round to assess the recommendations for their eligibility, with a face-to-face discussion by the expert panel. (IV) Final evaluation of the set of recommendations by the panelists. (V) Transformation of the recommendations into the final set of QIs.\u003c/p\u003e\n\u003cp\u003e2.2. Study population\u003c/p\u003e\n\u003cp\u003eThe expert panel consisted of 12 members: 1 cardiologist, 1 internist in training, 5 general practitioners (GP), 1 GP in training, 2 nurses (1 working in cardiology, 1 working in a GP practice), 1 patient with hypertension, 1 programmer of an EHR software company. All professionals were selected on their expertise with hypertension and were working in Belgium. The patient had the diagnosis of hypertension for 4 years.\u003c/p\u003e\n\u003cp\u003e2.3. Data collection\u003c/p\u003e\n\u003cp\u003e2.3.1. Extraction of recommendations\u003c/p\u003e\n\u003cp\u003eWe selected the most recent national and international guidelines on hypertension. Guidelines were selected based on language (English and Dutch) and year of publication (after 2011). Non-European guidelines on hypertension were excluded because of geographically different approaches to hypertension.\u0026nbsp;We included the following guidelines: guideline from Domus Medica (2013) (26), guideline from NHG (2019) (27), European guideline (2018) (28) and the NICE guideline (2019) (29). The following commonly used sources in Belgium, based on (inter)national guidelines, were also included: BCFI (2020) (30), Formularium Ouderenzorg (2020) (31).\u003c/p\u003e\n\u003cp\u003eAll recommendations were assembled into an online questionnaire consisting of the following categories: screening, diagnosis, treatment (medical \u0026amp; non-medical and choice of antihypertensive agent), outcome (target, therapy-resistant hypertension, blood test at start treatment, start statin, duration treatment) and follow-up. (See Additional File 1).\u003c/p\u003e\n\u003cp\u003eAn adapted list was conducted for the patient and the nurses, taking into account their knowledge on the subject and the relevance of the recommendations for each of them. The programmer of the EHR company received the complete list of recommendations.\u003c/p\u003e\n\u003cp\u003e2.3.2. Questionnaire round\u003c/p\u003e\n\u003cp\u003eAn online survey was created using Qualtrics. The panelists were invited to participate by email. Participants were asked to score each recommendation for their capability to measure the quality of hypertension in primary care on a 9- point Likert scale, with 1 being the lowest score and 9 the highest score. More specifically, the panelists were assigned to score the recommendations based on the SMART-principle (specific, measurable, acceptable, realistic and timely), taking into account the benefit for the patient and the EHR extractability. The programmer of the EHR company was asked to rate the recommendations only on EHR extractability. In addition, we asked each panel member to prioritize the recommendations per category in a top-5 (prioritization) on relevance for measuring quality of care. Finally, all participants had the possibility to write down remarks.\u003c/p\u003e\n\u003cp\u003eThe median Likert scale score was calculated for each recommendation, ranging from 1 to 9. The prioritization was defined as a percentage, calculated on how the panel ranked the recommendation in the top-5 score. If a recommendation was mentioned first, it received 5 points, the second place received 4 points, , etc. Recommendations that were not included in the top-5 list, received 0 points. These points were then converted into a percentage. The numerator was measured as the sum of the points a recommendation received and the denominator was the maximum score that recommendation could possibly receive ( = 5 times the number of panel members that scored that recommendation). For example, if 3 out of 12 panel members ranked a recommendation first and 7 did not mention it in their top-5, the prioritization percentage was 25% ( = 15/60).\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Consensus\u0026rdquo;\u0026nbsp;was defined as\u0026nbsp;\u0026ge;\u0026nbsp;70% of the panel members awarding a score of\u0026nbsp;\u0026ge;7 to the recommendation. When\u0026nbsp;\u0026ge;\u0026nbsp;30% of the panel members scored\u0026nbsp;\u0026ge;7 AND\u0026nbsp;\u0026ge;\u0026nbsp;30% scoring\u0026nbsp;\u0026le;3, it was defined as\u0026nbsp;\u0026ldquo;disagreement\u0026rdquo;. Other outcomes were interpreted as having\u0026nbsp;\u0026ldquo;no consensus\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003eRecommendations were classified into the categories high, uncertain or low potential as quality indicator by two steps. We first preselected, then in a second step we combined the results of the preselection with the degree of consensus to finally reach a conclusion on the classification of each recommendation.\u003c/p\u003e\n\u003cp\u003eBased on these criteria, the recommendations were divided into three categories: having a high, an uncertain or low potential as a quality indicator to measure hypertension care.\u003c/p\u003e\n\u003cp\u003eThe preselection was made using the median Likert scale score and the prioritization percentage. Recommendations with a median score on the Likert scale\u0026nbsp;\u0026ge;\u0026nbsp;7 and a prioritization percentage\u0026nbsp;\u0026ge;\u0026nbsp;20% were\u0026nbsp;\u0026ldquo;selected\u0026rdquo;. The ones with a median score\u0026nbsp;\u0026ge;\u0026nbsp;7 and prioritization percentage\u0026nbsp;\u0026ge;\u0026nbsp;1 and\u0026nbsp;\u0026le;\u0026nbsp;20% AND the recommendations with a median score \u0026lt;7 and top-5 percentage\u0026nbsp;\u0026ge;\u0026nbsp;20 were categorized as\u0026nbsp;\u0026ldquo;discussion\u0026rdquo;. Other outcomes were defined as\u0026nbsp;\u0026ldquo;not selected\u0026rdquo;, see Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 1: Preselection and consensus criteria\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.729684908789388%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003ePreselection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.22885572139303%\" valign=\"top\"\u003e\n \u003cp\u003eMedian\u0026nbsp;\u0026ge;\u0026nbsp;7 and\u003c/p\u003e\n \u003cp\u003ePrioritization percentage\u0026nbsp;\u0026ge;\u0026nbsp;20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.041459369817577%\" valign=\"top\"\u003e\n \u003cp\u003eSelection\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.41004184100419%\" valign=\"top\"\u003e\n \u003cp\u003eMedian\u0026nbsp;\u0026ge;\u0026nbsp;7 and\u003c/p\u003e\n \u003cp\u003e1%\u0026nbsp;\u0026le;\u0026nbsp;prioritization percentage\u0026nbsp;\u0026le;\u0026nbsp;20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.589958158995817%\" valign=\"top\"\u003e\n \u003cp\u003eDiscussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.41004184100419%\" valign=\"top\"\u003e\n \u003cp\u003eMedian \u0026lt; 7 and\u003c/p\u003e\n \u003cp\u003ePrioritization percentage\u0026nbsp;\u0026ge;\u0026nbsp;20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.589958158995817%\" valign=\"top\"\u003e\n \u003cp\u003eDiscussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.41004184100419%\" valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.589958158995817%\" valign=\"top\"\u003e\n \u003cp\u003eNo selection\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.729684908789388%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eDegree of consensus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.22885572139303%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ge; 70% in highest tertile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.041459369817577%\" valign=\"top\"\u003e\n \u003cp\u003eConsensus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.41004184100419%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;\u0026nbsp;30% in highest tertile and\u0026nbsp;\u0026ge;\u0026nbsp;30% in lowest tertile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.589958158995817%\" valign=\"top\"\u003e\n \u003cp\u003eDisagreement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.41004184100419%\" valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.589958158995817%\" valign=\"top\"\u003e\n \u003cp\u003eNo consensus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe classification of the recommendations was based on the preselection and the degree of consensus. Recommendations that were selected and that had consensus, were ranked as high potential. In case of selection and disagreement or no consensus, or in case of discussion and consensus or disagreement, a recommendation was classified as\u0026nbsp;\u0026ldquo;uncertain\u0026rdquo;. In every other case, the recommendation had low potential, see Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2: Classification of recommendations\u003c/em\u003e\u003c/p\u003e\n\u003ctable style=\"width: 4.5e+2pt;margin-left:6.15pt;border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.25pt;border: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: 1pt solid black;border-right: 1pt solid black;border-bottom: 1pt solid black;border-image: initial;border-left: none;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003ePreselection\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: 1pt solid black;border-right: 1pt solid black;border-bottom: 1pt solid black;border-image: initial;border-left: none;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eDegree of consensus\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111.75pt;border-top: 1pt solid black;border-right: 1pt solid black;border-bottom: 1pt solid black;border-image: initial;border-left: none;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eConclusion\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eRecommendation 1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eSelection\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eConsensus\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(147, 196, 125);padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eHigh potential\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eRecommendation 2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eSelection\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eDisagreement\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(246, 178, 107);padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eUncertain\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eRecommendation 3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eSelection\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eNo consensus\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(246, 178, 107);padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eUncertain\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eRecommendation 4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eDiscussion\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eConsensus\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(246, 178, 107);padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eUncertain\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eRecommendation 5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eDiscussion\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eDisagreement\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(246, 178, 107);padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eUncertain\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eRecommendation 6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eDiscussion\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eNo consensus\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(224, 102, 102);padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eLow potential\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eRecommendation 7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eNo selection\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eDisagreement\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(224, 102, 102);padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eLow potential\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eRecommendation 8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eNo selection\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eConsensus\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(224, 102, 102);padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eLow potential\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116.25pt;border-right: 1pt solid black;border-bottom: 1pt solid black;border-left: 1pt solid black;border-image: initial;border-top: none;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eRecommendation 9\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eNo selection\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: white;padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eNo consensus\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111.75pt;border-top: none;border-left: none;border-bottom: 1pt solid black;border-right: 1pt solid black;background: rgb(224, 102, 102);padding: 4pt;height: 14pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-indent: 0in;line-height:normal;font-size:13px;font-family:\"Calibri\",sans-serif;color:black;border:none;text-align:justify;'\u003e\u003cspan style=\"font-size:13px;color:#242424;\"\u003eLow potential\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e2.3.3. Consensus meeting round\u003c/p\u003e\n\u003cp\u003eThe results of the analysis were presented to the panel members in a feedback report which contained all recommendations with a color code representing its potential for measuring the quality of care (see Table 2). During the consensus meeting, the recommendations with a high potential were considered as included unless panel members asked for a decision making discussion. Recommendations with a low potential were excluded, unless panel members requested deliberation. Uncertain recommendations were always discussed more comprehensively for exclusion or inclusion. All accepted recommendations were then discussed, adjusted or modified, taking into account the SMART principle, the patient benefit, the recommendations\u0026rsquo;\u0026nbsp;EHR extractability and the remarks of the panel members.\u003c/p\u003e\n\u003cp\u003e2.3.4. Final evaluation\u003c/p\u003e\n\u003cp\u003eThe final set of all included recommendations was sent to the panel members for final appraisal.\u003c/p\u003e\n\u003cp\u003e2.3.5. Translation into quality indicators/ Formulation of the final set QIs\u003c/p\u003e\n\u003cp\u003eThe recommendations were transformed into quality indicators as a percentage. For example, \u0026ldquo;An electrocardiogram should be performed in patients with hypertension\u0026rdquo; thus became \u0026ldquo;The percentage of patients with hypertension in whom an electrocardiogram was performed\u0026rdquo;. The final set of quality indicators was approved by all panel members.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Extraction of recommendations\u003c/h2\u003e \u003cp\u003e A total of 115 recommendations were extracted from the used (inter)national guidelines. Six recommendations which occurred twice with similar content were combined into 3 recommendations. The final result was a list of 112 recommendations (see additional file 2) which was then converted into an online questionnaire. The adapted list for the nurses consisted of 88 recommendations and the one for the patient of 63.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Online questionnaire round\u003c/h2\u003e \u003cp\u003eThe doctors and the programmer of the EHR company completed the full questionnaire and scored all of the 112 recommendations. One of the nurses and the patient also filled out the complete questionnaire they received respectively. The other nurse scored only the first 34 recommendations and did not complete the rest of the questionnaire. After analysis of the results, 20 recommendations had high potential, 36 were uncertain and 56 had low potential for measuring quality of care. (see additional file 3)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Consensus meeting round\u003c/h2\u003e \u003cp\u003eAt the consensus meeting, 5 panelists were able to participate, including three general practitioners from three different general practices, a general internal medicine resident and a software collaborator.\u003c/p\u003e \u003cp\u003eFollowing a comprehensive and detailed discussion, the panel resolved to endorse all 20 recommendations with a high potential, 15 out of 36 recommendations with uncertain potential, and only 2 out of 56 recommendations with low potential. These decisions led to a total of 37 recommendations being accepted while 75 were excluded. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the distribution of these recommendations.\u003c/p\u003e \u003cp\u003eOf these 37 recommendations, 9 were slightly modified. Two recommendations related to blood testing and two recommendations related to urine testing were merged into one recommendation each, respectively. Another 24 were accepted literally, which resulted in a final list of 35 recommendations.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Final appraisal/ evaluation\u003c/h2\u003e \u003cp\u003eAfter the consensus meeting, 35 recommendations were sent to the expert panel by email for final approval. Except for the general practice nurse, who dropped out of the study early, every member of the panel agreed on the final list of recommendations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.5. Translation into quality indicators/ Formulation of the final set QIs\u003c/h2\u003e \u003cp\u003eAll recommendations of the final set were translated to QIs. The result was a final set of 35 QIs, made up of 7 QIs on screening, 6 QIs on diagnosis, 11 QIs on treatment, 5 QIs on outcome and 6 QIs on follow-up, see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuality indicators (QIs) on hypertension care\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eQuality indicators (QIs) on hypertension care.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSCREENING\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eScreening\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients aged 40\u0026ndash;70 years whose blood pressure was measured at least every 5 years.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients diagnosed with migraine or headache whose blood pressure was measured at the time of diagnosis.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients with type 2 diabetes without already diagnosed hypertension or kidney disease whose blood pressure was measured.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients prescribed oral contraception for the first time whose blood pressure was measured at the moment of prescription.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of pregnant patients whose blood pressure was measured at least once during pregnancy.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHome measurement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of adult patients in whom multiple conventional blood pressures of \u003cb\u003e\u0026ge;\u003c/b\u003e\u0026thinsp;140 mmHg systolic and/or \u003cb\u003e\u0026ge;\u003c/b\u003e\u0026thinsp;90 mmHg diastolic were measured in whom a home measurement was done.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eScreening for atrial fibrillation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients whose pulse regularity was assessed during blood pressure measurement.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDIAGNOSIS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAssessment of cardiovascular risk factors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients diagnosed with hypertension whose smoking status, alcohol consumption and sedentariness were questioned once.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients diagnosed with hypertension whose BMI was calculated.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients diagnosed with hypertension in whom a cardiovascular risk assessment (using the SCORE table) was done.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood analysis at diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients diagnosed with hypertension who had a blood test in which hemoglobin, fasting glycemia, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, sodium, potassium, uric acid, creatinine, eGFR and liver function were measured.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUrine analysis at diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients diagnosed with hypertension who had a urinalysis in which albumin/creatinine ratio and hematuria were measured.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eECG at diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients diagnosed with hypertension who had an electrocardiogram.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTREATMENT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNon-pharmacological treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients diagnosed with hypertension in whom lifestyle interventions such as salt restriction, alcohol reduction, healthy diet, exercise, weight control and smoking cessation were advised.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePharmacological treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients younger than 80 years of age with grade 1 hypertension (conventional blood pressure measurement 140/90\u0026ndash;159/100 mmHg and ABPM or HBPM 135/85\u0026ndash;149/94 mmHg) and end-organ damage, cardiovascular disease, renal disease, diabetes or cardiovascular risk\u0026thinsp;\u003cb\u003e\u0026ge;\u003c/b\u003e\u0026thinsp;10% who started with antihypertensive medication.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients under 80 years of age with grade 1 hypertension (systolic 140\u0026ndash;159 mmHg and/or diastolic 90\u0026ndash;99 mmHg) who started with antihypertensive medication if blood pressure was not \u0026lt;\u0026thinsp;140 mmHg systolic and/or 90 mmHg diastolic after 3\u0026ndash;6 months of lifestyle interventions.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients under 80 years of age diagnosed with hypertension and a high cardiovascular risk (\u0026gt;\u0026thinsp;5% on the SCORE2 table) or organ damage who started with antihypertensive medication.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients with very high blood pressure values (systolic\u0026thinsp;\u0026gt;\u0026thinsp;180 mmHg and/or diastolic\u0026thinsp;\u0026gt;\u0026thinsp;110 mmHg) in whom antihypertensive medication was immediately initiated, regardless of their cardiovascular risk.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients with hypertensive crisis referred to the hospital.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChoice of antihypertensive\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFirst choice if no comorbidity\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients who were switched to an Angiotensin-II-receptor blocker if an ACE-inhibitor was not tolerated.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFirst choice if diabetes mellitus type II is present\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients with type II diabetes mellitus who received a diuretic, calcium antagonist, β-blocker or ACE-inhibitor as the first choice of antihypertensive.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFirst choice if nephropathy is present\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients with hypertension and nephropathy with proteinuria who receive an ACE-inhibitor as the first choice of antihypertensive.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFirst choice if coronary artery disease is present\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients with hypertension and stable angina, experienced myocardial infarction, coronary artery disease or atrial fibrillation who received a β-blocker as the first choice of antihypertensive.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFirst choice if heart failure or albuminuria is present\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients with hypertension and heart failure (including left ventricular dysfunction) or (diabetic and nondiabetic) micro or macroalbuminuria, who received an ACE inhibitor or Angiotensin II receptor blocker as the first choice of antihypertensive.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOUTCOME\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTarget blood pressure values\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients aged 70 years or younger with hypertension where the target is to achieve a systolic blood pressure of \u0026lt;\u0026thinsp;140 mmHg and a diastolic blood pressure of \u0026lt;\u0026thinsp;90 mmHg 3 months after initiation of treatment.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTreatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eChoice if blood pressure is not adequately controlled with current antihypertensive treatment\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients with hypertension with no adequate response to a single antihypertensive agent who received a combination of low-dose antihypertensive agents instead of the maximum dose of a single agent. Percentage of patients with hypertension with no adequate response to the maximally tolerated dual therapy who received triple therapy.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTreatment-resistant hypertension\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e27. .\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients with treatment-resistant hypertension who were referred to a specialist.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBlood analysis on initiation of antihypertensive medication\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e28.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients in whom a diuretic, an ACE inhibitor or an Angiotensin II receptor blocker was started in which a blood analysis was done prior to the start of these medications with analysis of eGFR, sodium and potassium.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStatin treatment\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients aged 70 years old or younger who are at moderate to high cardiovascular risk (\u0026gt;\u0026thinsp;5% on the SCORE2 table) and any patient with cardiovascular disease who received a statin.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFOLLOW-UP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConventional blood pressure measurement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients with hypertension in whom blood pressure has not yet stabilized where blood pressure was measured monthly.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients with hypertension where blood pressure was measured at least 6-monthly.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e32. .\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients with hypertension and type 2 diabetes in whom blood pressure was measured at least 3-monthly.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCardiovascular risk assessment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e33.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients with hypertension in whom their cardiovascular risk (according to SCORE table) was determined annually.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood analysis in follow-up\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e34.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients with hypertension and taking a diuretic, ACE-inhibitor or angiotensin-II- receptor blocker in which annual blood tests were done in which creatinine, eGFR, sodium and potassium were measured.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage of patients with Spironolactone added to treatment in whom 1 month after the start of this medication a blood test was done with control of sodium, potassium and renal function.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Principal findings\u003c/h2\u003e \u003cp\u003e This study used a RAND-modified Delphi method to develop a list of 35 quality indicators for evaluating the quality of care of patients with hypertension in primary care.\u003c/p\u003e \u003cp\u003eThe quality indicators on screening demonstrate the importance of being aware of the potential existence of hypertension. Furthermore, the expert panel discussed that when elevated conventional blood pressure measurements were noted multiple times, a home measurement should follow before a diagnosis of hypertension can be made. In patients diagnosed with hypertension, cardiovascular risk factors should be assessed. For this purpose, it is suggested to question smoking status, alcohol consumption and physical activity, calculate the BMI and perform a blood test to measure cholesterol. The panel found it important to redetermine this cardiovascular risk score every year. Performing a blood test, urinalysis and electrocardiogram are key quality indicators to screen for organ damage. Among the various quality indicators related to hypertension treatment, healthcare professionals and patients alike perceived non-pharmacological interventions as the most crucial. Physicians indicated that this is often discussed with the patient, but rarely recorded properly. Panelists questioned whether we should include this quality indicator due to its difficult extractability, but precisely because of the significance of this lifestyle advice, it was deemed necessary to include it anyway. Three quality indicators were selected by the panel concerning the indications for starting medication. The first choice of antihypertensive medication depends on the patient's comorbidities. For example, the panel had different preferences regarding the choice of first initiated antihypertensive in patients with diabetes, chronic renal insufficiency, coronary artery disease and heart failure. For the patient population with hypertension younger than 70 years, the expert panel selected a target blood pressure lower than 140/90 mmHg, which should be achieved no more than 3 months after starting treatment. The experts agreed that if there is insufficient response to antihypertensive treatment, a combination of low-dose antihypertensive drugs is preferable to the maximum dose of a single agent. If blood pressures are not under control with a combination of 3 antihypertensive medications, the hypertension is considered \"therapy-resistant\" and the patient should be referred to a specialist. Again, the panel cited that this referral to a specialist will rarely be coded correctly in the EHR. Nevertheless, again because of the risks of leaving this untreated, it was opted to include this recommendation anyway, as it could possibly be of value in the future. This is especially true if this could be recorded in a more user-friendly way, if it were more established among physicians to record this and data sharing between primary and secondary care would be improved. In addition to treatment with antihypertensive drugs, treatment with statins was also debated. The experts chose to include the respective recommendation, which says that any patient younger than 70 years and at moderate to high cardiovascular risk (via SCORE2 table) and any patient with cardiovascular disease should be treated with a statin. Because diuretics, ACE inhibitors and Angiotensin II receptor blockers can affect kidney function, sodium and potassium, a blood test verifying these values should be done prior to starting these medications. In any patient with hypertension whose blood pressure has not yet stabilized, blood pressure should be determined monthly. Once blood pressure is stabilized, the frequency of blood pressure follow-up can go to 6-monthly.\u003c/p\u003e \u003cp\u003eAs mentioned above, there is only a limited amount of research on QIs for hypertension. When comparing our set of QIs to those previously developed, similarities and differences emerge. Our findings align with the QIs defined by the American College of Cardiology/American Heart Association (AHA/ACC) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e) in certain areas, such as the importance of non-pharmacological treatment, assessing the cardiovascular risk score and treatment based on the grade of hypertension. However, screening is recommended differently, as the AHA/ACC suggest to start screening at 18 years old, with a screening protocol based on blood pressure values, whereas our QI suggest screening to begin at 40 years old and to be performed every 5 years. Furthermore, the use of home blood pressure monitoring (HBPM) is recommended for the follow-up of hypertension and not for screening. Additionally, the AHA/ACC also defined several QIs that are not EHR-extractable in Belgium, including QIs on medication adherence and shared decision-making. Finally, they also have a number of structural quality measures relating to telemedicine, EHR usage and screening protocols, which is not the subject of our study. The 6 QIs identified by NICE (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e21\u003c/span\u003e) are largely reflected in our QIs, such as screening for target organ damage, target values, assessing cardiovascular risk score annually and referral to a cardiologist for treatment-resistant hypertension. A difference is the recommendation of ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. While ABPM is indeed the most accurate method for confirming the diagnosis of hypertension, our experts preferred a home measurement because this is much more commonly done in practice than an ABPM. In Belgium, ABPM is not reimbursed in primary practice and referral to a specialist is required, whereas home measurements can be easily conducted. The QIs from the CCORT (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e23\u003c/span\u003e) focus on screening and follow-up and largely overlap with our QIs. A difference is the varying target blood pressure values based on comorbidities.\u003c/p\u003e \u003cp\u003eAs a next step these quality indicators can be converted into queries to develop an automated audit and feedback intervention to evaluate and improve the quality of care for patients with hypertension by giving practices insight into their strengths and areas of work. Audit and feedback is a strategy used worldwide to encourage professionals to optimize their clinical practice. (32) An audit is a systematic assessment of clinical practice based on explicit criteria/standards. (32) This assessment can include data on a variety of issues, for example process of care, clinical endpoints and number of patients treated correctly according to guidelines. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) Using these data to provide feedback to the involved caregiver, as described above, small but significant changes in care delivery can be gained. (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.2. Strengths and limitations\u003c/h2\u003e \u003cp\u003eOne of the primary strengths of this study is its novelty in developing QIs for hypertension that are extractable from the EHR. This feature enables the QIs to be utilized for monitoring and improving the quality of care for patients with hypertension, through the implementation of audit and feedback interventions.\u003c/p\u003e \u003cp\u003eIn general, the topics of our QIs overlap with those of other studies. However, our QIs cover all aspects of healthcare (screening, diagnosis, treatment and follow-up) which none of the other sets of QIs do. Within each domain, our QIs are more comprehensive and specific compared to other QIs.\u003c/p\u003e \u003cp\u003eAnother strength is that a variegated panel of experts that have different viewpoints on the subject was questioned, so in addition to general practitioners, we included 2 specialists (one cardiologist and one resident in internal medicine), 2 nurses (one nurse from the general practice and one nurse working in the internal medicine department) and a patient. To gain better insight into the extractability of the QIs, we also included a software programmer specialized in electronic medical records.\u003c/p\u003e \u003cp\u003eOne of the limitations of this study is that there were some absentees at the consensus meeting and thus only a relatively small group could discuss with each other. Since both the cardiologist, the nurses and the patient were absent during the consultation moment, it was mainly the general practitioners and the resident in internal medicine who engaged in discussion with each other. Also one nurse started the survey but did not complete it and decided to drop out of the study early. Additionally, we chose guidelines based on geography, which meant that some major guidelines such as the American ACC/AHA guidelines (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) were not included.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study used a RAND-modified Delphi method to identify a set of 35 EHR-extractable QIs to measure the quality of primary care for patients with hypertension. These QIs could be used in an automated audit and feedback intervention and cover all aspect of primary hypertension care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eGP: General Practitioner\u003c/p\u003e\n\u003cp\u003eQIs: Quality Indicators\u003c/p\u003e\n\u003cp\u003eSMART: Specific, Measurable, Achievable, Relevant, Timely\u003c/p\u003e\n\u003cp\u003eEHR: Electronic Health Record\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organization\u003c/p\u003e\n\u003cp\u003eCCORT: Canadian Cardiovascular Outcomes Research Team\u003c/p\u003e\n\u003cp\u003eNICE: National Institute for Health and Care Excellence\u003c/p\u003e\n\u003cp\u003eNHG: Nederlands Huisartsen Genootschap (Dutch College of General Practitioners)\u003c/p\u003e\n\u003cp\u003eBCFI: Belgisch Centrum voor Farmacotherapeutische Informatie (Belgian Center for Pharmacotherapeutic Information)\u003cbr\u003e\u0026nbsp;ACC/AHA: American College of Cardiology/American Heart Association\u003c/p\u003e\n\u003cp\u003eHBPM: Home Blood Pressure Monitoring\u003c/p\u003e\n\u003cp\u003eABPM: Ambulatory Blood Pressure Monitoring\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research project was presented to the KU Leuven ethics committee and was granted approval with a positive final decision under the reference number MP018005 on 18-01-2022. Informed consent was given by all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset(s) supporting the conclusions of this article are included within the article and its additional files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive any funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBV and SVdB contributed to the conceptualization of the study. KD, MH, SL, PT, LVV, BV and SVdB contributed to the design of the study. Data collection and analysis was performed by MH, SL, PT, LVV and supervised by KD, BV and SVdB. KD, MH, SL, PT, LVV, BV and SVdB contributed to the final manuscript. KD and SVdB are the guarantors of this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all panel members for contributing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003cstrong\u003e\u0026rsquo;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003einformation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKD is a general practitioner and PhD researcher.\u003c/p\u003e\n\u003cp\u003eMH, SL, PT and LVV were residents in general practice during the study. The research presented served as their master\u0026apos;s thesis in order to obtain the degree of Advanced Master of Family Medicine.\u003c/p\u003e\n\u003cp\u003eBV is general practitioner and professor in general practice.\u003c/p\u003e\n\u003cp\u003eSVdB is general practitioner and postdoctoral researcher.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO Fact sheet on Hypertension. Last updated 16th March 2023 World Health Organization. Available from: https://www.who.int/news-room/fact-sheets/detail/hypertension\u003c/li\u003e\n\u003cli\u003ePoulter NR, Prabhakaran D, Caulfield M. Hypertension. Lancet. 2015 Sep 5;386(9995):801-12.\u003c/li\u003e\n\u003cli\u003eVan der Heyden J., Nguyen D., Renard F. et al, Belgian Health Examination Survey. 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BMC Fam Pract. 2020;21:131. doi:10.1186/s12875-020-01197-8.\u003c/li\u003e\n\u003cli\u003eBaker R, Fraser RC. Development of review criteria: linking guidelines and assessment of quality. BMJ. 1995;311:370\u0026ndash;373\u003c/li\u003e\n\u003cli\u003eBrook RH, McGlynn EA, Cleary PD. Quality of health care. Part 2: measuring quality of care. N Eng J Med. 1996;335:966\u0026ndash;970\u003c/li\u003e\n\u003cli\u003eDonabedian A. Evaluating the quality of medical care (1966) Milbank Q. 2005;83:691\u0026ndash;729\u003c/li\u003e\n\u003cli\u003eMainz J. Quality indicators: essential for quality improvement. Int J Qual Health Care. 2004;16:i1\u0026ndash;i2\u003c/li\u003e\n\u003cli\u003eMcGlynn EA, Asch SM. Developing a clinical performance measure. Am J Prev Med. 1998;14:14\u0026ndash;21 \u003c/li\u003e\n\u003cli\u003eSmets M, Smeets M, Van den Bulck S, Janssens S, Aertgeerts B, Vaes B. Defining quality indicators for heart failure in general practice. Acta Cardiol. 2019 Aug;74(4):291-298\u003c/li\u003e\n\u003cli\u003eVan den Bulck SA, Vankrunkelsven P, Goderis G, Broekx L, Dreesen K, Ruijten L, Mpoukouvalas D, Hermens R: Development of quality indicators for type 2 diabetes, extractable from the electronic health record of the general physician. A rand-modified Delphi method. Primary Care Diabetes 2019.\u003c/li\u003e\n\u003cli\u003eVan den Bulck, S.A., Vankrunkelsven, P., Goderis, G. et al. Developing quality indicators for Chronic Kidney Disease in primary care, extractable from the Electronic Medical Record. A Rand-modified Delphi method. BMC Nephrol 2020; 21:161 \u003c/li\u003e\n\u003cli\u003eDoran GT. There\u0026apos;s a S.M.A.R.T. way to write management\u0026apos;s goals and objectives. Manage Rev. 1981;35-36.\u003c/li\u003e\n\u003cli\u003eTichelaar J, Uil den SH, Antonini NF, van Agtmael MA, de Vries TPGM, Richir MC. A \u0026apos;SMART\u0026apos; way to determine treatment goals in pharmacotherapy education. Br J Clin Pharmacol. 2016;82:280-284.\u003c/li\u003e\n\u003cli\u003eCampanella P, Lovato E, Marone C, Fallacara L, Mancuso A, Ricciardi W, Specchia ML. The impact of electronic health records on healthcare quality: a systematic review and meta-analysis. Eur J Public Health. 2016;26:60-64.\u003c/li\u003e\n\u003cli\u003eMin L.C., Mehrota R., Fung C.H., Quality indicators for the care of hypertension in vulnerable elders. JAGS 2007;55:S359-S365\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. HEARTS Technical package for cardiovascular disease management in primary health care: systems for monitoring. Geneva: World Health Organization; 2018. (WHO/NMH/NVI/18.5 Version 1.1). Licence: CC BY-NC-SA 3.0 IGO.\u003c/li\u003e\n\u003cli\u003eNational Institute for Health and Care Excellence. Hypertension in adults: quality standard [Internet]. 2013. Last updated: 2015 Available from: https://www.nice.org.uk/guidance/qs28\u003c/li\u003e\n\u003cli\u003eCasey Jr D.E., Randal J.T., Vivek B., et al.\u003cu\u003e \u003c/u\u003e2019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circ:Cardiovascular Quality and Outcomes. 2019;12:e000057\u003c/li\u003e\n\u003cli\u003eFI Burge, K Bower, W Putnam, JL Cox. Quality indicators for cardiovascular primary care. Can J Cardiol 2007;23(5):383-388\u003c/li\u003e\n\u003cli\u003eDalkey N, Helmer O. An Experimental Application of the DELPHI Method to the Use of Experts. Manag Sci. 1963;9(3):458\u0026ndash;67\u003c/li\u003e\n\u003cli\u003eKotter T, Blozik E, Scherer M. Methods for the guideline-based development of quality indicators--a systematic review. Implement Sci. 2012;7:21.\u003c/li\u003e\n\u003cli\u003eDe Cort P, Christiaens T, Philips H, Goossens M, Van Royen P. Aanbeveling voor goede medische praktijkvoering: Hypertensie. Huisarts Nu 2009;38:340-61.\u003c/li\u003e\n\u003cli\u003eNHG Cardiovasculair risicomanagement [Internet]. Utrecht: NHG; 2019 Jun [cited 2023 Apr 28]. Available from: https://richtlijnen.nhg.org/standaarden/cardiovasculair-risicomanagement.\u003c/li\u003e\n\u003cli\u003eWilliams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). Eur Heart J. 2018 Sep 1;39(33):3021-3104. doi: 10.1093/eurheartj/ehy339.\u003c/li\u003e\n\u003cli\u003eNational Institute for Health and Care Excellence (NICE). Hypertension in adults: diagnosis and management [Internet]. Published 28 August 2019 [updated 18 March 2022; cited 28 April 2023]. Available from: https://www.nice.org.uk/guidance/ng136.\u003c/li\u003e\n\u003cli\u003eBelgian Centre for Pharmacotherapeutic Information (BCFI). Cardiovasculair stelsel, Hypertensie, Folia maart 2014 and Folia maart 2019.\u003c/li\u003e\n\u003cli\u003eBelgian Centre for Pharmacotherapeutic Information (BCFI). Formularium ouderenzorg, Arteri\u0026euml;le hypertensie, Literatuur geraadpleegd tot: 14/04/2020.\u003c/li\u003e\n\u003cli\u003eR. Busse, N. Klazinga, D. Panteli, W. Quintin. Improving healthcare quality in Europe: Characteristics, effectiveness and implementation of different strategies. Health policy series 2019; 53\u003c/li\u003e\n\u003cli\u003eR Foy, MP Eccles, G Jamtvedt, J Young, JM Grimshaw, R Baker. What do we know about how to do audit and feedback? Pitfalls in applying evidence from a systematic review. BMC Health Serv Res. 2005; 5: 50.\u003c/li\u003e\n\u003cli\u003evers N, Jamtvedt G, Flottorp S, et al. Audit and feedback : effects on professional practice and healthcare outcomes (Review). Cochrane database Syst Rev. 2012;6(6):CD000259.\u003c/li\u003e\n\u003cli\u003eWhelton PK, Carey RM, Aronow WS, et al.\u003c/li\u003e\n\u003cli\u003eACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:e13\u0026ndash;e115. DOI: 10.1161/HYP.0000000000000065\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hypertension, Primary care, Guideline adherence, Healthcare evaluation, Health services research, Public health, Quality indicators, Quality of healthcare","lastPublishedDoi":"10.21203/rs.3.rs-3957904/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3957904/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eHypertension, a chronic medical condition affecting millions of people worldwide, is a leading cause of cardiovascular diseases. A multidisciplinary approach is needed to reduce the burden of the disease, with general practitioners playing a vital role. Therefore, it is crucial that GPs provide high-quality care that is standardized and based on the most recent (inter)national guidelines. Quality indicators (QIs) can be used to assess the performance, outcomes, or processes of healthcare delivery and are critical in helping healthcare professionals identify areas of improvement and measure progress towards achieving desired health outcomes. However, QIs to evaluate the care of patients with hypertension in general practice have been studied to a limited extent. The aim of our study is to define quality indicators for hypertension in general practice that are extractable from the electronic health record (EHR) and can be used to evaluate and improve the quality of care for hypertensive patients in the general practice setting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe used a Rand-modified Delphi procedure. We extracted recommendations from (inter)national guidelines and assembled them into an online questionnaire. An initial scoring based on the SMART principle and extractability from the EHR was performed by panel members, these results were analyzed using a Median Likert score, prioritization and degree of consensus. A consensus meeting was set up in which all the recommendations were discussed, followed by a final validation round.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOur study extracted 115 recommendations from (inter)national guidelines on hypertension and was converted into an online questionnaire. After analysis of the questionnaire round and a consensus meeting round, 37 recommendations were accepted and 75 were excluded. Of these 37 recommendations, 9 were slightly modified and 4 were combined into 2 recommendations, resulting in a list of 35 recommendations. All recommendations of the final set were translated to QIs, made up of 7 QIs on screening, 6 QIs on diagnosis, 11 QIs on treatment, 5 QIs on outcome and 6 QIs on follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Our study resulted in a set of 35 QIs for hypertension in general practice. The QIs are extractable from the EHR making them suitable for automated quality assessment.\u003c/p\u003e","manuscriptTitle":"Development of quality indicators for hypertension, extractable from the electronic health record of the general practitioner. A rand-modified Delphi method. 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