Division of Cardiology Department of Medicine Rajni Rao, MD Associate Professor of Medicine Cardiology Clinic Practice Chief Department of Clinical Pharmacy UCSF School of Pharmacy Marilyn Stebbins, PharmD Professor of Clinical Pharmacy Vice Chair of Clinical Innovation Intervention: Hypertension The new frontier for Interventional Cardiology? July 11, 2016 Right Care Initiative Sacramento, CA
How did we get interested in HTN? Access Patient experience Provider experience School of Medicine 2
Don t always listen to your hospital s instructions School of Medicine 3
MD Engagement School of Medicine 55% of our pts have HTN 70% have HTN or a comorbid condition with BP guidelines (eg DM, CHF, etc.) 10% of pts have a primary dx of HTN HTN mgmt takes time away from other aspects of care Barriers: Unclear chain of command (PCP vs. cardiologist vs. nephrologist) No time Affects access Not another dashboard please Not that fun 4
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Minutes are myocardium Seconds are sarcomeres Door to balloon time What s your door to BP control time? School of Medicine 7
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First, walk the walk Rest period from arrival to BP: 2% of patients Measurement of arm circumference: 0% Second confirmatory BP: 5% Active conversation during measurement: 40% Measurement taken on a clothed arm: 41%, Cuff and arm not positioned at heart level: 75% Feet not flat on floor: 35% Legs crossed: 20% 10
Don t reinvent the wheel School of Medicine 11
Train the masses Empower the patient Feedback 12
What is the role of the patient? Quality control Feedback Knowledge Owning their numbers Open communication about side effects N of 1 trials School of Medicine 13
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Barriers for patients Asymptomatic condition Easily forgotten Meds rarely make you feel better, often worse No home measurements Drs don t care so why should I? Low priority Hard to come to appointments, expensive No surrogate measures of efficacy Don t see results School of Medicine 15
Solutions Not another email from a payer or physician s group or office of population health, please! Dashboard fatigue A WORKFLOW solution is needed School of Medicine 16
From: The Role of the Clinical Pharmacist in the Care of Patients With Cardiovascular Disease J Am Coll Cardiol. 2015;66(19):2129-2139. doi:10.1016/j.jacc.2015.09.025 Clinical Pharmacists: Their Role in Cardiovascular Disease The various roles clinical pharmacists perform in both inpatient and outpatient settings are depicted. A clinical pharmacist or team of clinical pharmacists may perform a variety of patient-specific functions related to medications. Clinical pharmacists often lead facility-level initiatives and even global initiatives toward improving and optimizing systems of medication use. Date of download: 7/8/2016 Copyright The American College of Cardiology. All rights reserved.
Improve provider efficiency and have everyone working at the top of their training level School of Medicine 18
9,361 non-diabetic patients with increased CV risk Intensive tx (SBP <120) vs Standard (<140) 27% lower hazard of composite endpoint (MI, ACS, stroke, HF, or death) with intensive treatment 25% lower hazard of death with intensive treatment School of Medicine 19
But it sure takes a long time to SPRINT School of Medicine 20
Personalized medicine? UCSF HIPSTER Hypertension: Innovating Personalized Strategies for Excellent Results Set timelines Set guideline directed goals vs. individualized goals High touch care from a cardiology TEAM Intense patient engagement Staff engagement School of Medicine 21
mhealth for HTN Advantages mhealth for closer monitoring Faster time to control Rapid intervention with Ses Pt self-awareness of triggers Diurnal variation, masked HTN Convenience Freeing up clinic for other patients to have access (new pts, sicker pts) High touch care from a cardiology team Experimentation School of Medicine We are embarking on a time when each individual will have all their own medical data and the computing power to process it in the context of their own world. This will set up a tectonic (or "tech-tonic") power shift, putting the individual at center stage. What have been dubbed the six most powerful words in the English language "The doctor will see you now" will no longer be true. -- Eric Topol in The Patient Will See You Now: The Future of Medicine is in Your Hands (2015) 22
Try something School of Medicine Progressive improvement beats delayed perfection. -- Mark Twain 23
School of Medicine 120 patient pilot Home blood pressure monitoring using mobile Orchestra app and team-based care Goal setting and enrollment by cardiologist in-person Medication management and virtual communication via the pharmacist In-app patient engagement tools, surveys In-app communication platform 24
Outcomes measured: JNC 8 and cardiologist goal attainment at 30-day intervals from 30-180 days Self-reported adherence Patient engagement and satisfaction with therapy and process Team-based productivity School of Medicine 25
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Data overload the upside of painful knowledge is so much greater than the downside of blissful ignorance. Sheryl Sandberg School of Medicine 27
Where are we headed Pharmacist hired in Cardiology HTN is the focus Create Hypertension Innovation Lab In-person visits App-based solutions Text/SMS lower-tech interventions Virtual visits Phone / My Chart management Collaborative Practice Agreements Care team development School of Medicine 28
Huge challenges Data, meta-data, microdata, macrodata Run? Or embrace and use it White Coat HTN, Masked HTN, Minute to minute variation in HTN what to do with this information N of 1 trials Achieving goals how realistic is SPRINT Surrogate markers of end organ damage, or impending end organ damage vs just treating the bp itself Avoiding orthostasis Combo pills and branded meds vs. generic-only? How is it sustainable for practices Revenue model for HTN mgmt Making the mgmt of HTN enjoyable EMR integration Disparities reaching out to underserved populations School of Medicine 29
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