Transcript High blood pressure 442656 - National Forum for Heart Disease and

Controlling High Blood Pressure:
A Public Health Imperative
12th National Forum
November 22, 2014
Eduardo Sanchez, MD,MPH,FAAFP
Deputy Chief Medical Officer
American Heart Association
Top 10 risk factors for health loss in 2010 and the
number of deaths attributable to each
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Dietary risks
Smoking
High blood pressure
High body mass index
Physical inactivity
High blood sugar
High total cholesterol
Ambient air pollution
Alcohol use
Drug use
Institute for Health Metrics and Evaluation (IHME),2013
678,282
465,651
442,656
363,991
234,022
213,669
158,431
103,027
88,587
25,430
Controlling High Blood Pressure
•
•
•
•
•
High blood pressure is a public health issue
Blood pressure greater than or equal to 140/90 should be evaluated in a primary
care setting.
Systems approaches may be the best way to improve blood pressure control in
the clinical setting.
Blood pressure control might be accelerated by linking clinical care and
community-integrated or home-based disease management including blood
pressure monitoring.
Public health should be engaged in addressing other population-based
approaches to reduce blood pressure – sodium reduction in processed or
restaurant foods; reducing the presence of food deserts, activity deserts, and
primary care deserts.
NRC and IOM, January, 2013
Age-adjusted prevalence trends for high blood pressure in adults ≥20 years of age by race/ethnicity,
sex, and survey (National Health and Nutrition Examination Survey: 1988–1994, 1999–2004, and
2005–2010).
Go A S et al. Circulation. 2014;129:e28-e292
Copyright © American Heart Association, Inc. All rights reserved.
Extent of awareness, treatment, and control of high blood pressure by race/ethnicity (National Health
and Nutrition Examination Survey: 2007–2010).
Go A S et al. Circulation. 2014;129:e28-e292
Copyright © American Heart Association, Inc. All rights reserved.
Demographic Shift
2000
2010
2020
2030
2040
2050
Total Pop 282 M
309 M
336 M
364 M
392 M
420 M
White
69.4%
65.1%
61.3%
57.5%
53.7%
50.1%
Hispanic
12.6%
15.5%
17.8%
20.1%
22.3%
24.4%
Black
12.7%
13.1%
13.5%
13.9%
14.3%
14.6%
Asian
3.8%
4.6%
5.4%
6.2%
7.1%
8.0%
census.gov
Hypertension Control in a
Clinical Setting
Improved Blood Pressure Control Associated With a Large-Scale
Hypertension Program – A systems approach
1.Comprehensive hypertension registry
2.Development and sharing of performance metrics
3.Evidence-based guidelines
4.Medical assistants for blood pressure monitoring
5.Simplified pharmacotherapy – single-pill combination
JAMA. 2013;310(7):699-705. doi:10.1001/jama.2013.108769
Blood Pressure Control Advisory
An Effective Approach to High Blood Pressure Control: A Science
Advisory From the American Heart Association, the American
College of Cardiology, and the Centers for Disease Control and
Prevention
– Alan S. Go, MaryAnn Bauman, Sallyann M. Coleman King, Gregg C.
Fonarow, Willie Lawrence, Kim A. Williams and Eduardo Sanchez
Hypertension. published online November 15, 2013;
Hypertension Algorithm
Available for download at: www.heart.org/HBPtoolkit
The Guide to Community Preventive Services
Community Preventive Services Task Force Recommendations
for Cardiovascular Disease CVD) Prevention and Control
– Clinical decision support systems (Apr 2013)
• Patient data (from EHR) to inform clinical care
– Reducing out-of-pocket costs for patients with high blood
pressure and high cholesterol (Nov 2012)
• For medications and lifestyle management services
– Team-based care to improve blood pressure control (Apr
2012)
• True care coordination, for example
thecommunityguide.org
Outcomes of the AHA’s Check. Change. Control.™ Program:
A Multi-Community Hypertension Intervention
Introduction
•
•
Monique L. Anderson, MD*; Emily O’Brien, PhD *; Nancy M. Allen LaPointe, PharmD, MHS*; Rachel Peragallo Urrutia, MD, MSc†; Angel M. Alexander,
MSPH*; Alexander J. Christian, BSPH*; Lisa A. McCoy, MS *; Juliana Crawford, BASc‡; Laura E. Webb, BS*; Paramita Saha-Chaudhuri, PhD*; Patrick
Wayte, MBA‡;
Eric D. Peterson, MD, MPH*
From the *Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; †University of North Carolina at Chapel Hill, Chapel Hill, NC;
‡American Heart Association, Dallas, TX
In 2010, the American Heart Association (AHA) announced
its Strategic Impact Goal: To improve the cardiovascular
(CV) health of all Americans by 20%, while reducing deaths
from CV diseases and stroke by 20% by 2020.
A major focus of this initiative is the development of
prevention education programs.
•
We sought to examine the impact of the AHA’s novel Check.
Change. Control.™ (CCC) program to reduce blood pressure
(BP).
•
The AHA’s CCC program was implemented over a 7-month
period in 18 United States cities.
•
•
•
Sites: Birmingham/Montgomery, AL; Los
Angeles, CA; San Francisco, CA;
Washington, DC; Miami, FL; Atlanta, GA;
Chicago, IL; Baltimore, MD; Detroit, MI; St.
Louis, MO; Charlotte, NC; New York, NY/NJ;
Cleveland, OH; Philadelphia, PA; Memphis,
TN; Dallas/Fort Worth, TX; Houston, TX;
Richmond, VA
Local AHA staff partnered with local
community organizations and businesses
Methods
to train volunteer health mentors (VHM) to
develop and implement a program
We evaluated three outcomes of interest (all calculated
from
centered on the use of Heart360® health
Heart360 BP data):
information technology, health education
• participant enrollment
and events, and support to participants to
• participant engagement (8 BPs uploaded over 4 months)
monitor and reduce BP.
• BP change (comparing first and last recorded BP for systolic and
diastolic [not shown])
•
Calculated at the participantand site-level
•
Association between number of uploads and BP change was
examined using Spearman correlation coefficients.
•
We then examined program factors associated with program
success via mixed-methods research.
•
Qualitative and quantitative surveys,
phone interviews with AHA staff, and
review of grant applications, determined
program characteristics.
•
Clinical characteristics were compared by
program outcomes performance.
•
Programs were divided based
on performance for each
outcome into Lowest (25th),
Middle (50th), and Highest
(25th) percentiles.
Results
• From 1/1/2013 to 7/31/2013, n=4069 participants were enrolled in the
program across 18 geographically-distinct communities.
Table 2. Program-Level Characteristics and Outcomes by Lowest, Middle, and Highest
Performing Groups
Program Characteristics
• Mean age was 50.7 (6.2), 74.5% were women, and 36.0% were
specified as black race.
• Mean number of patients enrolled at each site was 226 (standard
deviation [SD] 106) over a 3-month period.
• Participant engagement ranged from 0% to 52.8%.
• Among all participants, systolic BP decreased by a mean of -7.5 mmHg (SD
20.1 mmHg, p<0.0001) and diastolic BP by -3.3 mmHg (SD 11.2 mmHg,
p<0.0001) (Table 1).
• At the site level, mean BP decrease was -4.7 mmHg (SD 7.2 mmHg) (Table
2).
• Increasing number of BP uploads was associated with larger declines in
systolic (r=-0.27, p<0.0001) and diastolic (r=-0.17, p<0.0001) BP.
• Among the 18 programs, there was significant program level variation in
systolic (+7.7 to -29.3 mmHg) and diastolic (+1.84 to -9.89 mmHg) BP.
Table 1. Participant Outcomes of Enrollment, Engagement, and BP Change Overall and By Site
Number
Enrolled
Number
Expected
% Enrolled
Overall
4209
9980
40.8
20.7
-7.5
Site A
Site B
Site C
Site D
Site E
Site F
Site G
Site H
Site I
Site J
Site K
Site L
Site M
Site N
Site O
Site P
Site Q
Site R
74
116
217
154
281
91
118
150
211
166
176
206
322
304
356
329
376
422
800
1200
1150
730
1150
350
350
350
450
350
350
350
500
450
400
350
350
350
9.3
9.7
18.9
21.1
24.4
26.0
33.7
42.9
46.9
47.4
50.3
58.9
64.4
67.6
89.0
94.0
107.4
120.6
1.4
17.2
7.4
15.6
0.0
5.5
25.4
2.7
15.6
9.0
0.6
2.4
46.3
8.9
15.2
2.4
25.0
52.8
-1.0
-3.1
-2.5
-4.1
-1.0
-9.3
-2.5
-7.8
-2.6
-1.3
7.7
-2.3
-29.3
-5.5
-2.6
-5.7
-4.1
-8.4
Campaign
Overall
(n=18)
Group 1
Lowest 25th
(n=4)
BP change*, systolic, mmHg, mean (SD)
Engagement mechanism
Hypertension management classes, %
Incentives community partner, %
Communication to participants
Phone call, %
Text, %
Volunteer leads to oversee program, %
Group 3
p-value
Middle
Highest 25th
50th
(n=4)
(n=10)
-3.5 (1.3) -13.7 (10.4) 0.001
-4.7 (7.2)
1.1 (4.4)
33.3
22.2
0
25
30
0
75
75
0.09
0.01
61.1
16.7
16.7
25
0
0
60
10
10
Middle
50th
(n=10)
100
50
50
0.10
0.13
0.13
Lowest 25th
(n=4)
Program enrollment*, mean % (n)
51.8 (226)
Recruitment location
Senior living complex/service
organizations
55.6
Churches
88.9
Worksite wellness
44.4
Enrollment education events
Hypertension management classes
33.3
Kick-off events, ≥7 events
25.0
Community partners, both new and existing
partnerships
55.6
% Engagement Change in Systolic
Group 2
Highest 25th
(n=4)
14.7 (140) 46.2 (202) 114.0 (371) 0.001
0
100.0
100.0
70.0
90.0
30.0
75.0
75.0
25.0
0.047
0.54
0.047
50.0
0
10.0
20.0
75.0
75.0
0.056
0.04
0
Lowest 25th
(n=4)
70.0
75.0
0.02
Middle
Highest 25th
50th
(n=4)
(n=10)
11.6 (21) 23.9 (95)
0.001
Program engagement*, mean % (n)
14.1 (39)
10.4 (15)
Engagement mechanism
Hypertension management classes, %
33.3
25.0
20.0
75.0
0.15
Communication encourage uploads
Face-to-face contact, %
50.0
25.0
40.0
75.0
0.08
Email, %
77.8
100.0
90.0
25.0
0.02
Engagement tracking
Paper logs
38.9
0
40.0
75.0
0.11
* Performing groups were defined separately for each outcome. Sites may be in different groups
•
Check. Change. Control.™ is a novel community-based initiative
for each outcome.
Conclusions
that demonstrated significant reduction in BP among 18 United
States communities.
Several programmatic factors were associated with improved
program implementation and success that may guide future
implementation of programs in other communities.
Funding statement: This research was supported in part by the American Heart Association and
•
Novartis, as well as the Duke Clinical Research Institute. The views expressed in this abstract
represent those of the author(s), and do not necessarily represent the official views of the AHA or
its associated professional societies identified at www.heart.org.
Conflict of interest disclosures: Author disclosures can be found at www.dcri.org.
The Guideline Advantage
•
•
•
•
•
•
•
•
•
•
•
•
•
•
The Guideline Advantage interactive platform gives you a powerful new data advantage. Now, you can not only
meet
your reporting requirements but also
transition your practice into advanced
population health management—an
important new technology that offers you
exciting potential to improve your patients’
health. Couple this powerful solution with
the robust resources of the American
Cancer Society, American Diabetes
Association, and the American Heart
Association to support quality improvement
efforts, your new data advantage provides
www.guidelineadvantage.org
everything your practice needs to move
forward— with The Guideline Advantage.
High Blood Pressure Control
Big Systems Approach
Community-Clinical Linkages Model
Information
link
Clinical
Setting
Community
Setting