Hypertension: Detect, Connect, Control
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Hypertension: Detect, Connect, Control

September 2, 2019

I’m welcoming you to our CDC
Public Health Grand Rounds. Our topic today is Hypertension,
detect and control. I want to bring to your
attention that next month we Won’t have a live session, but a
rerun in a way which is going to Go via our website.
But we will be going live again With cancer screening in July.
We’re right now developing a new Round of sessions for the next
12 months. So I will let you know what
those topics are next time when We meet.
As always, here is a list of Resources I want to bring to
your attention a new feature That we have just started a few
months ago. We call it “Beyond the Data”.
It is a quick video segment Which basically brings home the
key messages in a very simple Manner to the broad audiences.
And you can watch it on our web Page, as well.
Here is a list of selections That accompany our topic, as
always. And I have to say that this
particular session has been one Of those that reminded me of
dancing with the stars. You know how people say that
they always thought it’s simple And then they spend hours and
hours rehearsing this one was Really challenging because it
seemed like everybody and his Brother wanted to put their two
crepts in to make it perfect. And when I usually don’t allow
too much democracy, this time Because of the importance of
topic, we kind of allowed some People to chime in. I really wanted to thank
Judy Hannon for her work with all of our speakers.
This was one of the most fun Sessions to work on.
Some wee hours of the night, as Well.
Now let me introduce our Speakers.
Two of them, Janet and Peter. They have worked extremely hard
and as of now they are going to Be known as Kim and Engel.
The other two speakers, Claudia, Who is not here who is with us
virtually in Philadelphia and Will be joining us by voice, and
Mike, will be known like Kelly and Derrick.
And I think for those of you who Might be living on the moon and
not watching “dancing with the Stars,” Kelly and Derrick are
contenders for the mirror trophy.
So I wanted to say just a couple Of words for those of you who
may be interested in getting a little bit more resources about
the Million Hearts initiative That Janet is going to be
talking about a little bit more detail.
Some of the interesting thing the medical reserve corps
is launching a Million Hearts challenge and engaging their
volunteers to control blood Pressure at the local levels.
Recently we had a speaker who Said that following their
college degree and medical Degree, they wanted to get a
high paying job, so they joined The Medical Reserve Corps and I
was thinking how true. So here is an opportunity to do
something good. The other one is go to the
Million Hearts web page where You can have a number of useful
videos that are how they are Getting more than 80% of their
patients controlling their blood Pressure.
And you will see 80% is a huge Number.
And finally, one that I really Love is how to engage men.
Because we all know that women Are all decision makers at home
and at work and wherever. And so how to engage men in
taking control of their heart Health and at 1:00 p.M. Sunday
eastern on June 3, there is Going to be a state of men’s
hearts webinar where our own Director will be participating.
So I’m encouraging you to join And listen in.
And Dr. Frieden is not with us In person, but he’s with us in
spirit. And we’ll have a couple of tapes
comments.>>Nearly one in three American
adults have high blood pressure. More than half don’t have it
under control. That includes people who have
health insurance and who have seen a doctor at least twice in
the past year. The bottom line is this this.
High blood pressure is out of control for way too many
Americans. There are common lessons for how
to deal with this effectively. First, simple quality measures
reported monthly to every single provider can lead to big
improvements in just one year. Second, Health I.T..
Health Information Technology can be key to success.
Doctors and other health care providers want to provide good
care and I.T. Can make quality improvement much easier.
And third, team based care. So every member of the team does
their part to help manage blood pressure.
The good news is that when Clinicians, health care systems
and patients focus on high blood pressure, they can get it under
control and do so quickly. Large and small practices, in
rural and urban areas, in the private and public sectors, all
can drastically improve the number and proportion of
patients who have their blood pressure under control.
Controlling high blood pressure Is one of the keys to the
Million Hearts initiative which will pre-vent a million heart
attacks and strokes in the next five years.
We’re already seeing results. Today we’ll hear how public
health and clinical care experts can work together to control
blood pressure. Controlling blood pressure can
probably save more lives than any other single clinical
improvement and perhaps even more importantly by getting
systems right to control blood pressure, we learn to improve
care in many other areas. Thank you very much.>>Good afternoon.
I’m executive director of Million Hearts, the HHS initiative you just heard about. My job today is to share with
you how the world of public Health and health care are
coming together to bring the Nation’s blood pressure under
control. We’ll start with some
physiology. As the heart contracts, blood is
ejected out will into the Arteries under force.
That force pressing against the Wall of the artery is known as
blood pressure.Under force. That force pressing against the
wall of the artery is known as Blood pressure.
Blood pressure is expressed as Two numbers.
The top or systolic being the Pressure when the heart squeezes
and the bottom or die stole lick Number when the heart relaxes.
The pressure varies minute to Minute in response to stress,
activity, joy and other factors. But elevated sustained pressures
over time can damage key organs, The brain, heart and kidney.
Here you see the range of blood Pressure readings from normal,
less than 120 on the top and Less than 80 on the bottom, to
the abnormal readings, at risk And high.
African americans develop high Blood pressure more often than
caucasians or mexican americans And at an earlier age.
And among african americans, More women than men have the
condition. Cardiovascular disease accounts
for the largest proportion of Inequality in life expectancy
between whites and black, but The take home message is that
one out of every three adult Americans has highly treatable
condition known as high blood Pressure.
The condition which I remind you Is highly treatable is the cause
of death of hundreds of Thousands of americans.
Our friends and our family Members every year.
More commonly than not, people With other serious conditions
like heart attack, stroke and Heart failure have high blood
pressure, as well, doing its Harm in the background.
And that harm extends beyond the Individual to the economy, to
the tune of $47.5 billion spent Annually on direct medical
expenses. Here is the current snapshot of
where we are in the united States in regard to blood
pressure control. Fewer than half of Americans
with hypertension have it under control.
That is defined as less than 140 On the top and less than 90 on
the bottom. And of those 36 million
uncontrolled, 14 million don’t Even know that they have high
blood pressure. And 16 million know they have
it, they’re actually taking Medication for it, and are not
yet under control. You might be surprised to learn
that of the 36 million people with uncontrolled hypertension,
32 million have a usual source Of care and 30 million are
insured. 14 million of those folks are
covered by medicare. And most of the uncontrolled
have been to their usual source Of care more than twice in the
previous 12 months. These numbers represent a ripe
opportunity to improve outcomes And to in fact prevent heart
attack and strokes. Why are we in this fix with
uncontrolled high blood Pressure?
There are many ropes and a few Of them are listed here.
Some relate to the individual With high blood pressure and
others to that person’s health Care or the environment in which
they live. Because hypertension causes no
symptom, people find it hard to Take medication regularly or
find it hard to practice healthy Habits like choosing lower
sodium choices or exercising Daily.
In brief office visit, Clinicians typically address the
most pressing issue for that Individual patient and that’s
often not high blood pressure. Because of the variability of
blood pressure readings really From moment to moment, treatment
decisions need to be based on Not one or two checks in a busy
office visit in an abnormal Environment, but on patterns of
readings. And then finally, our care model
is not really designed to get Out in front.
It’s designed to rescue and Respond.
And we’re just beginning to find Ways to reach out proactively in
a true prevent difference mode To keep these events from
occurring. And then finally, true
resistance is only present this About 9% or 10% of the
population, defined by the Uncontrolled pressures in the
presence of clthree classes, on Of which will is a diruretic.
>>here you see why it’s so Critically important.
It leads to heart attack, Stroke, heart failure and kidney
failure. People are high blood pressure
uncontrolled are four times more Likely to die from stroke and
three times more likely to die From some form of heart disease.
6% of people who have a first Heart attack, 77% of those who
have a first stroke, and 74% With chronic heart failure has
high blood pressure. And cardiovascular disease
remains the number one you came Of preventable deaths for older
americans. But it’s too often the cause in
younger citizens, as well. 800,000 lives lost.
The raw made to families and Communities is devastating.
And the cost to the u.S. Economy Is, as well.
$312.6 billion every year. It’s more than a billion dollars
a day in direct costs and lost Productivity.
A national initiative co-led by Cd c&c ms is focusing the
efforts of federal agencies, State, region, communities and
individuals on the explicit goal To prevent a million heart
attacks and strokes by 2017. The design shown here harnesses
public health and health care to Change both the environment in
which we live and the health Care on this we rely.
Community or population level Work is focused on reducing
exposure to smoke, increasing The availability of lower sodium
choices, food choices, and Eliminating trans fat in the
food supply. Clinical efforts are aimed at
achieving excellence in the abcs Shown here.
Through health I.T., effective Teams and care models that
recognize and reward performance In the abcs.
The abcs were chosen for their Impact in the five year time
fwram frame on outcomes as Demonstrated in the next slide.
Implementing the abcs to their Fullest extent can save
thousands of lives in the u.S. Each year.
You can see the effect of each Of the abcs is impactful, but
please note that blood pressure Control rates of 80% or greater
means more than 60,000 lives Saved each year.
Can such high rates of blood Pressure control actually be
achieved? Yes, it can.
You see on this slide that over The last two decades, the united
states and the united kingdom Have made steady gain, but look
what happens when blood pressure control becomes the focus of
collaborative efforts across public health and health care
sectors. Canada has eclipsed other
nations and in record time. Because of its prevalence, its
impact on health and leading Examples of success like canada,
Million Hearts is focusing first On the goal of control.
Here you see the performance, The leap in performance that
Million Hearts partner, federal, State and local intend to make
by 2017. These goals are audacious, but
they are achievable through the Focused efforts in home,
community, businesses and Clinical settings across the
country. At baseline across the
population, you see that we’re Not achieving even 50% yet on
the acbs. To prevent a million heart
attacks and stroke, they have Set a 65% population wide tar t
target, targets that include People without a usual source of
care. Clinical systems have to get
past 70% in order to achieve That goal.
Here you see the Million Hearts Strategies to achieve blood
pressure control for the nation And this belongs to each of us.
Individuals, public health and Clinical care experts, and the
communities and organizations That we belong to.
Reducing the population’s intake Of sodium will have a profound
impact on blood pressure control Rates.
Better detection and controls Leaving no one up protected from
elevated pressures, and better Self management will ensure a
normal range and a normal Pattern of blood pressures 24/7.
I want to focus now on this Fifth strategy as critically
important to driving progress in Blood pressure control.
The first step to is the Selection of measures that
matter. Standardized measures that are
tightly correlated to the Desired outcomes.
With numerous public and private Partner, millions hearts has
adopted a uniform set of these Measures including the national
quality forum measure listed Here for hypertension.
This measure is now embedded in Multiple programs across the
landscape. Some of which are listed here.
These are programs with reach, Programs that will recognize and
reward performance, and programs That will help prevent heart
attack and stroke. Measures alone of course are not
sufficient to get to the goal. Getting the nation’s blood
pressure under control will take Focus, technology, and teams.
Essential elements that create The in-from a a straukt for
success. Leaders who prioritize blood
pressure control establish the Systems necessary to measure and
provide timely feedback on Progress and sustain that
progress over time by recognizing and rewarding value.
Well designed health I.T. Can serve up action steps for busy
clinicians and their patients so No opportunities are missed and
well informed decisions are Made.
Teams working together across community and clinical settings
operating off a common script Can support the practice of
healthy behaviors, including the Wise use and consistent use of
medications. And those teams can help
patients become the primary managers of their conditions
knowing that help is just a Phone call or e-mail or text
away. Here is the framework for
capturing and building out the Powerful alliance of public
health and health care. You’ve heard the importance of a
population health measure Focusing clinical systems on
high performance. In services, innovative teams
are transforming care delivery. And in drivers, partnerships and
payments and partners are all Aligning to move the needle.
You’re about to hear compelling Examples promising pathways to
blood pressure control for the Company.
Our speakers will show how Focusing on control, deploying
health I.T. And cross sector ral Teams can turn data into action
and action into better Cardiovascular health.
And you’ll see in all three Presentations that the solution
to our national pressure problem Rests in a successful sync of
health and health care.>>good afternoon.
Until last March, I was the vice Claire for quality in the
department of family medicine at North shore university health
system. My talk today is about our
efforts to eliminate undiagnosed Hypertension by providing
detection using electronic Screening.
North shore university health System is located in
metropolitan chicago composed of More than 800 physicians, a
medical group with Multispecialty and primary care,
four community hospitals, and a Research institute.
The principal tipping affiliate Is the university of chicago.
The first question about Hypertension we asked in June of
2010 was is undiagnosed Hypertension a problem in our
system. To answer it, we performed
retrospective analysis looking Back from June of 2006 to may of
2010. Blood pressures at north shore
measured at every office visit. We looked at adult patients in
our system with elevated blood Pressures during three or more
visit, no hypertension diagnosis Who were not prescribed blood
pressure medication. Analysis used data stored in
electric dronic health records Unified database.
As a result, the analysis took Only analysis to complete.
We identified 150,000 adults. 27,000 already had a diagnosis
of hypertension. An additional 3177 patients were
diagnosed with hypertension but Not treated.
In total, we identified more Than 934400 untreated.
Eventually # 8% were diagnosed With hypertension, however from
the time of the third occurrence Of elevated blood pressure,
there were 17,000 missed Opportunities during office
visits to make a diagnosis of Hypertension over the four year
period. Our data was consistent with
data from other medical groups Clearly demonstrating that
physicians miss opportunities to Make the diagnosis.
Will this is not a problem Unique to north shore.
This is happening in most health Care systems on a global scale.
So the next question we asked Was can we eliminate undiagnosed
hypertension in our health care System.
That is what we set out to do. We designed a quality
improvement project that would Lead to a better screening
approach to identify patients at Risk for hypertension, increase
accuracy and reliability of Office blood pressure
measurements, better recognition Of at risk hypertension patients
at the point of care and culture Change around the use of
clinical decision support tools And quality improvement
including administrator, office Staff and clinicians.
The project is called the north Shore undiagnosed hyper tenk
quality improvement project. The pilot study was January
through June of 2011. We included adults age 18 to 79
who were seen by primary care Physicians in the previous 24
months. We used all of the blood
pressure readings taken within One year of the most recent
office visit in both primary Care and specialist offices.
Patients with existing diagnosis Were excluded.
To maximize benefit, we focused On health information
technology. North shore has an integrated
electronic health record system Wise.
We established a dedicated Informatics team to help us
extract data, create point of Care alerts and work flows.
Data extracted coupled with Action point of care alerts has
the potential to be a powerful Population health management
tool. We accomplished this using five
unique algorithms. The algorithms were derived
based on accepted clinical Practices, guidelines and
research literature. We call them the north short
hypertension criteria. Here are the five north shore
hypertension al go rithythmrhyt. You can see a few examples.
Whose reading at the most recent Encounter either was or was not
elevated. Another example is algorithm
number four which identified all Patients who had three
encounters greater or equal to 140/90 within the 12 months
prior to the most recent office Visit.
Using all five criteria, we Identified 1586 adults we
suspected had hypertension but Were not diagnosed.
Any patient satisfying at least One of the north shore criteria
is placed on a list for being Notified to come in for
additional blood pressure Measurement.
Primary carry physicians review Their patient list for accuracy
to determine if outreach is Appropriate.
Telephone calls and letters are Used to notify patients they may
be at risk for highway tension And to urge them to schedule a
follow-up appointment. For follow-up appointments, we
use standardized sequence of Automated office blood
pressures. We can did this because manual
office blood pressures are Fraught with error and not
reliable. As a result, office blood
pressures do not correlate well With daytime mean ambulatory
blood pressures. Both observer and patient errors
are reduced using our protocol As well as the white-coat
effect. White-coat effect is blood
pressure elevation that occurs specifically due to the presence
of office staff. We believe it will reduce
clinical hesitation in making diagnosis or modifying treatment
in a patient with hypertension. So what exactly is an Automated
Office Blood Pressure visit? It’s a standardized visit used
for increasing the accuracy of diagnosis. It includes proper siding,
proper positioning, physician and staff trained in proper use,
and patients being left alone in the room during blood pressure
measurements. Six readings are taken at one
minute intervals. The first is discarded and
remaining five are averaged to get the mean which better
correlates to day team Ambulatory blood pressure.
For patients not seen specifically for this visit,
best practice advisory alert Were created.
These clinical decision support Alerts fire in real time during
office visits with primary care Providers for both clinical
staff and physicians. The goal is to better identify
all patients who are at risk for Hypertension during every office
visit. Here a screen shot showing how
clinical staff putting a patient In an exam room are alerted to
measure the patient’s blood Pressure using AOBP.
And here is the alert a Physician would see if a patient
satisfies any of the criteria During an office visit and needs
AOBP testing. We went live with the project
across all north shore primary Care offices in January of 2012.
In the first eight months, 435 Previously undiagnosed and up
treated hypertensive patients Were diagnosed directly related
to the use of algorithm and Confirmatory AOBP readings.
For patients triggering recall, 97% now have a diagnosis.
North shore sees nearly 10,000 New patient as month and in
spite of that growth, the Percentage of diagnoses on the
chart is holding. Most of these newly diagnosed
patients with hypertension have significant blood pressure elevations. As a result, lifestyle Modifications are recommended
and 94% are prescribed Medications.
We now know that screening for Patients with undiagnosed
hypertension using ehr data Combined with electronic alerts
is effective and has potential To permanently eliminate the
problem of undiagnosed Hypertension patients hiding in
plain sight. Physician behavior can be
impacted through identification Of clinical problem, clinical
decision support tools, and Nondisruptive work flows.
Ehrs and electronic screening Can identify silent but
clinically important conditions Efficiently.
Because 72% of office based Physicians in the United States
currently use e will hr systems, There is potential for systems
like the north shore Hypertension criteria and point
of care alerts to be Incorporated across all
organizations using ehrs. Imagine the impact that could
have on this problem. Our next speaker is dr. Peter
bash.>>good afternoon.
I will talk about efforts of a Large health system towards
improving hypertension control. Med star health is the largest
not for profit health system in The maryland/d.C. Region.
It is comprised of research Institute, community hospitals
and academic medical centers, And other health care
facilities. Our more than 5,000 physicians
and 30,000 staff took care of More than 160,000 admitted
patients and 1.5 million drought Patient advice visits in 2012.
Med star health is the largest Provider for graduate medical
education in the region and is a Robust clinical research
environment raking in the top 10% nationally in nih funding.
Our primary care network Consists of providers and
settings ranging from large Urban hospital clinics to rural
small office settings with most Locations in or around
baltimore, maryland or Washington, d.C..
All of our primary care Providers work under the same
enterprise endorsed guidelines For preventive screening and
chronic care management and all Are using the same electronic
health record. Early in 2012, med star health
became the first health system To partner with the department
of health and human services in Their Million Hearts initiative
working to improve adherence to The screening and treatment
guidelines for these abcs of Cardiovascular risk reduction.
And now focusing specifically on Hypertension, you have already
heard that most people with Uncontrolled hypertension have
health insurance, a use source Of care, regularly see their
doctor, and that most, 22 Million ultimate off out of 36
also aware of their condition. We have not heard yet were their
providers aware that they were Not at goal or even aware of
what their goal was. Blood pressure goals difference
on co-morbid conditions. Note pete with diabetes, chronic
kidney disease, stroke, have a Higher than average risk of
heart attack and/or stroke and That it typically requires
getting their blood pressure to A goal which will is usually
lower than the goal for Uncomplicated hypertension, less
than 140 over 90. Where patients have more than
one of these conditions, the Lowest goal is typically
applied. And to the point of
individualized goal setting, Note that almost 40% of our
patients with hypertension have A co-morbidity such that their
blood pressure goal is not less Than 140 over 90, but rather one
that is significantly lower. I mentioned earlier that all of
our primary care providers Follow the same guidelines and
use the same ehr. But does their practice reflect
that. We did not have a screening
problem as our adult patients Typically had blood pressures
recorded every visit. Far exceeding the usdftf blood
pressure screening guidelines. However, it was not possible to
tell if we were setting goals as Goals were not being recorded in
the ehr. This lack of goal setting and
the lack of can display of blood Pressure reading compared to
that goal may indeed be the Cause of lack of provider
awareness. And it’s providers typically
inform their patients of their Blood pressure goal and whether
or not they are at goal, it may Also be the cause of lack of
awareness in patients. As mentioned, this is particular
importance to the nearly 40 pus Of our patients with
co-morbidities that give them a Higher risk of heart attack or
stroke. It’s our blood pressuring rates
100%, the primary intent of high Design was to embed automated
blood pressure goal setting and To increase awareness of both
prior and patient when blood Pressure was not at goal.
We wanted to prompt providers Only when necessary to not add
to so-called alert fatigue and Thus only prompt providers if
key information was missing, out Of date but always when blood
pressure was not at goal. However, we also wanted to make
patients aware of their blood Pressure goal and their latest
reading even when they were at Goal.
They felt this was important for Patients to see.
This requirement to not add to Alert ifpha fatigue led to thef.
On the left is one of the Posters on display and on the
right is an example of a patient Specific report card whichever
adult primary care patient Receives at least once a year.
Note that this patient has in This written summary her latest
blood pressure reading, her Blood pressure goal and a clear
statement that she is at goal. Where it’s not, the patient is
advised and given clear advice As to how to get to goal.
And here is what nobody sees. Smart but busy form that opens
in the background of every adult Medicine visit and automatically
determines optimal blood Pressure goal.
It was only rarely being done. By putting the ehr to work as a
member of the care team, blood Pressure goal setting is
automated and more consistently Done.
Here is an example of what they Might view during a typical
office visit. A protocol that needs
addressing, clicking it shows Whatever care opportunities are
unmet which in this case is just One or more goals within our
Million Hearts initiative. Which when launched shows this
Million Hearts global prompt With pertinent information and
which goals are unmet. Launches the specific blood
pressure prompt opens what you See here, apppropriate
information is seen by both Provider and patient and
depending on what the provider Determines to be the course of
action, the provider can take That action and document it very
easily typically with only a few Clicks.
So how are we doing? This provisional report from
early in this calendar year Shows data from our eight
entities. As expected, most of the
patients have blood pressure Recorded and most have blood
pressure goals recorded and thus Provided to the patient.
The preliminary results suggest We have already moved the needle
on the personal of our patients Whose blood pressure is less
than 140/90 but for the first Time we have an indication of
which individual is at their Advised goal and which provider
appears to be more effective Their than peers in managing
hypertension to their Individualized goal.
While we’re a large health System, I believe we’re still to
other health systems and small Practices.
Namely highway tension is very Common and sizable have one or
more company who are b-morbidic. Prior to this, we were not
setting specific goals and thus Not communicating goals and goal
status to our patients. We were able to leverage our ehr
to embed a complex yet highly Usable system such that much of
the background work is automated Including always providing you
understandable information to The patient.
Unanticipated benefit, they are Fully on board with our million
hearts program even though it Adds complexity and time to
their day. Thank you and our next speaker
is claudia segal.>>good afternoon.
I’m the director of health Information and improvement at
the philadelphia department of Public health.
While cardiovascular mortality Continues to decline in
philadelphia and the nation, Philadelphia’s cardiovascular
who aretality rate continues to Exceed that of the nation as in
many cities and counties, Cardiovascular disease is the
leading cause of death in Philadelphia.
We may be similar to many cities And counts with respect to
causes of death, but a recent Study done by the institute for
health metrics and evaluation at The university of washington
showed that among the ten most Populous counties, philadelphia
has the highest rate of Uncontrolled highway tension.
The day is latest data in Southeastern pennsylvania.
Our challenge is to make change In an environment dominant by
fragmented health information Sources.
We have five academics health Centers each with either own
health system including clinics, Hospitals and ehr systems.
Several dominate the market. The medicaid population is under
managed care and split among Four different company that
contract with providers to Provide services.
We have a substantial number of Uninsured, many of whom find
care at the city’s more than 30 Qualified health centers.
So here is what we did. Three years ago, the department
was awarded a cdc cooperative Agreement, one goal was to
improve public health data Infrastructure.
Our principal strategy is to Gather, house, analyze and share
more and better data for the Entire jurisdiction related to
three areas. Hypertension, cancer screening
and adult immunization. We have started with
hypertension. We established the office of
health information and Improvement within the health
commissioner’s office to build a Relationship and secure the
physical and data related Resources to get the project off
the ground. Here is a list of our diverse
partners working within two Working group, one on policy and
one on data and monitoring. These two groups also meet
together. Because of the diverse
backgrounds of our work group Members, we needed to articulate
and discuss the respective Approaches of public health and
clinical services to the problem Of hypertension.
We needed to achieve a mutual Understanding related to data
needs. First of all, that more and
better data are required than Just vital statistics.
And secondly, if we all agree That hypertension was a problem
that could be handled more Effectively, we had to get
better data related to Prevalence and control, share
the information, and then Construct intervention to
develop policies to complement Our ongoing initiative which
I’ll address in a minute. We used the health impact
pyramid to illustrate where the Department had already begun to
take action, within the area Second from the bottom, clinical
services like those delivered by Some of our partners appear
further up the pyramid. They may involve more individual
effort and have less immediate Population impact over all, but
they are essential. They are also felt more directly
by many of the very people we Would lick to bring to a
healthier status. Where public health and health
services may share interests and Approaches is in the protective
intervention. But this requires shared
information, discussion, and Consensus.
An example about of our Contextual public health
initiative is the dep Get healthy effort which has
turned over 600 corner stores Into healthy corner stores with
fresh fruits and vemabgetables. We’ve increased farmers markets
and allows purchasers to get Even more healthy food at no
additional costs. We’ve expanded walking and
biking paths and assisted Smokers who smoke to connect to
resources that help them to Quit.
Our first meeting, we displayed This slide which shows the end
of the health cascade premature Delt due to cardiovascular
disease. If y
if you plot them against Something vienvironmental like
poverty, you see the multiple Levels of impact.
We plotted premature Cardiovascular mortality 18 to
54 years of age. Most powerful influence on
health, poverty. [ inaudible ]
it is a question of access to Care, healthier living, better
housing? If we were to try to bring down
mortality rates, how should we Go about it.
What can the health department Do and what is the role for our
partners. With a who a
what more do we need to know to Answer the questions and how can
we get the information. These and other questions led us
to develop an information Request.
We asked our partners Information for their total
patient population, along with Numbers that could be identified
as hypertensive and how many had Their hypertension under
control. We were pleasantly surprised
with the quality of the data. The largest number of gaps in
information occurred with the Controlled data, but prevalence
data, there was a straight Correlation that led to us
belieled To us believe that the data was
pretty good. Ultimately swwe received data tt
covered just under 50%. 24.6%, lower than survey data.G.
Ultimately we received data that Covered just under 50%.
24.6%, lower than survey data.Ut Covered just under 50%.
24.6%, lower than survey data.G. Ultimately we received data that
covered just under 50%. 24.6%, lower than survey data.
Controlled gather were who amor Difficult to gather and
interpret. We had to accept a variety of
methods for determining Controls.
The medicare population taken by Itself is the highest prevalence
but also highest control. Provider data covered about
356,000 with average Hypertension prevalence of 17.1%
and control raging from 42.1 to 65.7%.
It opened the prospect of [ inaudible ]
the data when plotted by age had An age related trajectory.
Where do we go from here? We’re completing an sdiincidenc
and the analysis. They’re anticipating additional
analyses using other databases. Well be soliciting our partners
for data again as they decrease More adept at utilizing.
Also well bring new partners Into the group.
Our system is labor intensive But extremely worthwhile.
It pushed us to look beyond the Realm of traditional health and
stimulate our partners to see What they can contribute to
public health information and Outcome.
Thank you.>>the time is now to change
these numbers. And today’s speakers have shown
us how to do so. Health I.T., focus, team based
care, bringing health care and Public health together, optimal
cardios vascular health. What are the lessons learned
from the speakers today? First is sit at the table
together. Health care and public health.
Share data. Set a common goal.
Monitor the progress and Frequently celebrate the
success. Even the small successes along
the way. Because this is arduous work to
do but very rewarding. I’ll leave you with these
thoughts. First, our goal here is to leave
no one uninformed. Help spread the word.
We have no one undetected. Know your numbers.
And leave no one unprotected. Go for the goal of control.
Thank you.>>we’d be dwlelighted now to te
some questions from here in the Room and the airwaves.
Please state your name and also Keep your question short so we
possible. Yes, please.
>>thank you for the nice Presentation.
My question, can you comment on How your clinicians respond to
these proptprompts? I would think they get flooded
with prompts so how do you get Them to pay attention.
>>a great question. This is Peter bash answering.
Certainly one that all of us Need to pay attention to and
system design because one would Think providers would not like
this. They seem to like it.
I said this is overengineering, But they said this is perfect
because it helps us to capture Nondisruptive work flow.
So it helped to support them. So the other part of it, because
I have had some clinicians Comment I don’t want to see
another prompt last thing I do. I said you know what, if you set
a goal for your blood pressure Mf-for your patient’s blood
pressure and you try your Hardest to keep to goal, you’ll
never see it. Our prompts only appear when
there is an unmet opportunity. So we see it as something to
help our docs and we tell them Your goal is not to respond to
the prompts, but to respond to The patient.
Use these prompts in a way that Helps you and your patients.
>>we had a similar experience. One of the things that I think
physicians, they’re overoverwhe, Short on time.
First thing we did several years Ago when the quality promise was
wrapping up was turn off all the Alerts because they were being
ignored. When we brought them back one at
a time, we brought them back With evidence with academic
detailing from physicians oig to Explain to them why this was
clinically useful. And to make the alerts,able and
useful in clinical practice to Help them diagnose a patient
with hypertension. Physicians still have a hard
time believing that office blood Pressures aren’t accurate or
reliable. But once you show them the
evidence and they go how can the Whole plannic being doing this
wrong, they see the data. They realize maybe there is a
better way. You show them the better way,
you give them the appropriate Alert, you give them the data to
back it up and they like it. But you have to go very slow and
you have to have some wins Before you can start rolling out
alert after alert. So I think that’s one of the
key, as well.>>and let me add one other
point. Before I built our system, I
made sure we had the clinical Buy d
buy-in as what are the goals That you want your doctors to
achieve. Is it just volume, just the
chief complaint? No, we are signed on as a part
they are with Partner which means we will try
our hardest. Every adult primary care patient
will have their abcs addressed. So I said okay.
And in that case, it’s in Support of their new clinical
mission. I’m glad to see that our
clinicians see it that way.>>I don’t know how many people
in the office are clinical, but I have to say one thing, that if
every primary care physician can Did everything that they’re
required to do by guidelines and Task force guidelines, the
estimate is that it would take Approximately 20 hours a day 7
days a week to get these things Done.
So if you use these alerts Appropriately to help them, if
ehrs and computers can help Physicians instead of hinder
them, it’s really going to take Hold, I think.
But we have to be very careful About how we go about doing it.
>>you can tell we’re passionate About this.
We could spend the rest of the Day on this question.
>>but we won’t.>>I spent part of my career at
cdc working on another chronic Disease, tuberculosis, which is
where tom frieden got his start In public health.
And tom did a spectacular job Controlling tb in new york city
and he brought in one of the World’s experts.
The doctor said how many Patients did you cure.
And I think what tom was getting Getting at is how many patients
actually have their blood Pressure under control, not just
at a doctor’s office, but Permanently.
And with due webettertuberculos Compliance.
It looks like you’re able to Push to 70%.
I guess I have two questions. One is how do you do quality
control in terms of can you go On a sin set ubset of these pato
their homes and do measurements Of their blood pressure and
secondly what tools are you u Useing or what additional tools
could be used. I would expect to get the befab
70% you have to get into Compliance issues.
>>it’s a great question and I Think there are many aspects to
that question. I think a key one with
hypertension is if those of us Who remember one of the first
public health campaigns about Blood pressure, the silent
killer, this is part of the Awareness issue that we try and
present to our patients. Which is the reason doctor we
have separate patient education. All patients regardless of
whether blood pressure is Elevated or not receive
information about the importance Of knowing blood pressure and if
they have hypertension Controlling blood pressure.
So it’s part of a visit making Sure patients understand the
issue. I think that because we are
fortunate that most of our Patients also have a consistent
relationship with their primary Care doctor, they’re monitored
over time and part of what we Consider routine primary care
now is addressing not just why You’re here today, but multiple
chronic conditions which in our Patient population typically 60%
of our patients have Hypertension, diabetes, so
forth, so we have to deal with Issues of diet, exercise, self
monitoring, can you afford your Medicines, are you taking them
every day. This has now become part of the
visit. There are other tools that we’re
beginniing to use, but I’ll say Beginning to because these are
not accurate on their own such As electronic medication
adherence data. But certainly can give a
suggestion of medication Adherence.
>>I’ll just say quickly that Physicians need to do a much,
much better job at explaining to Their patients about
medications. Approximately 20% of patients
don’t fill the first Prescription that we write for
them for blood pressure and Other medicines.
And up to 40% don’t fill the Second prescription.
And the average amount of time The typical physician spends
explaining medication use to Their patients is between 20 and
30 seconds. So a lot of the responsibility
falls on physicians to do a Better job at this.
But also I think in the future a Lot of responsibility needs to
fall on the patients, as well, And the communities to help the
patients better understand and Better adhere with the task at
hand. And I think home blood pressure
monitoring and out of office Blood pressure monitoring will
play a much bigger role down the Road in communities.
>>can I interject something?>>please.
>>I think one of the reasons –>>thank you very much for the
very informative presentations. We come from the world of
vaccine where it’s easier to Control disease.
You get the impact. So on the previous question, I
see you with the interventions You have addressed a lot of what
can be done on the clinical, Both on the health care side and
on the public health side. F
going back to the patient’s Side, we all know that just
education and increasing Awareness is not enough.
And I think the example of Smoking program are very good on
how policies have actually had Most of the impacts on
addressing the issue. I was wondering, we didn’t
really talk much about policies. What do you think about the
roles of the various policies That have been discussed lately,
the issue of an salt control in Diet and the issues of how much
can you ask restaurants and fast Food businesses, et cetera.
And along this line, I was Actually curious about the
experience and how much of it Was policy and different medical
system in canada versus clinical Intervention.
Thank you.>>if it’s okay with you guy,
I’ll ask claudia to weigh in on That.
>>I heard the question, but I’m On mute.
I can’t get in.>>we can hear you.
>>all right. We have embarked on a low salt
campaign and we’re working with Our chinese restaurants in town
to lower the salt content of Some of the meals since chinese
takeout food is very prevalent In low income neighborhoods here
in philadelphia. I think also in response to the
earlier observation, one of the Reasons we are working with
pharmacists is that we agree That — I mean, adherence and
control are burdens on the Physicians and burdens on the
patient. But we need to pay more
attention in the public health Department to community support
and what we could be devising in Concert with our partners that
will help to support the efforts Of physicians and the attempts
by patients to adhere to their Medication regiment.
I’m not certain that we know What all of those interventions
might look like just yet.. I’m not certain that we know
what all of those interventions Might look like just yet.
But one of the things we’re Trying is to find out what those
hi Might be.
>>thank you. One more question.
>>patricia griffin here at cdc. I hear the same people saying
that clinicians don’t have time, That they can’t get it all done.
And I think you’re also saying Physicians need to do a better
job of educating people. And I’m in a field where we
don’t have vaccines and patient Education is helpful and I’m
also a clinician and when I’m Taking care of patients, I don’t
have time to give the messages That I advocate giving.
So I want to know in your health Care systems what are you doing
for other ways to educate Patients?
If you have a new hypertension Patient curriculum where they go
in, maybe seeded a video, talk Health care personnel who
answers their question, Something other than the
physician encounter, it could be Supported by the clinician, they
could say I’ll ask that you did It, what else are you doing to
really educate patients?>>when you hear the term team
based care, a lot of people Don’t understand what that
means. It means different things at
different institutions. But the dream of that kind of
chronic team management is Nutritionist who can do the kind
of counseling you’re talking About with diet, exercise fi
physiologist, pharmacists are Critical, they manage highway
tension, they work at the top of Their license, do as much as
they can. And physicians are left to treat
patients, make a diagnosis and Then hand off to other skilled
people on the team. I think that’s the real future.
We all want to have rooms with Videos and educators in our
offices. I think we’re in it our infancy
in that area right now. Part of the problem is we don’t
always get reimbursed for that. A lot of the practice based
research that’s going on and the Grants that are being taken for
there are trying to figure out How we can do this cost
effectively.>>and terrific question.
I think it really frames what at Least in my judgment we need to
go through. And I believe we are in terms of
making for a better health care System.
Which is understanding the role Of payment policy, care delivery
innovation which includes team Based care, thoughtful use of
health I.T., and one could Think, well, how do we effect
the space time continuum. When we look at time studies,
doctors waste a lot of time Doing things they shouldn’t be
doing. And there are very thoughtful
ways of not just using the ehr As a team member, using the
patient and family members as Team members, but thinking about
pushing various pieces of Information to patients so it’s
not just structured around a Visit.
If our goals as a country which I think it is to connect and
control hypertension, we 23r5i78 Our health care delivery a
little bit differently. I think we’re making great
strides there and I think one of The things I’m proud to say
we’re involved in is as this new Paradigm is evolving, we can
step up to the plate. As Janet said, if we do a
consistent and throughooughtful Application of existing
knowledge, we can make a huge Difference.
We don’t have to wait for a Perfect scenario.
>>we have to move it from the Physician office only into the
community where we can do it in A more cost effective way.
>>claudia, would you like to Weigh in on that last point?
>>well, I can only concur. I think it’s really important to
involve every possible area of Support in the community to did
did exactly what has been Discussed.
And again, I’m not certain we Know all of the ways in which
that can happen. It’s a matter of exploring and
finding out what works and what Doesn’t and bringing people into
the conversation to see what They can contribute.
>>Fantastic. Thank you.
Thank you all. I would actually ask now for a
round of applause for our Fearless brilliant leader, Dr.
Tanja Popovic.>>Thank you so much.
And I have to say I’m amazed We’re six minutes over and
people haven’t left. This must have been really
mesmerizing for people. Thank you for coming.
Thank you for good questions. And I hope to see you in a month
and then in two months live again.
Thank you very much.

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