rajni rao, md intervention: hypertension cardiology clinic
TRANSCRIPT
Intervention: Hypertension The new frontier for “Interventional Cardiology?”
July 11, 2016
Right Care Initiative
Sacramento, CA
Rajni Rao, MD Associate Professor of Medicine
Cardiology Clinic Practice Chief
Division of Cardiology
Department of Medicine
Marilyn Stebbins, PharmD Professor of Clinical Pharmacy
Vice Chair of Clinical Innovation
Department of Clinical
Pharmacy
UCSF School of Pharmacy
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How did we get interested in HTN?
Access
Patient experience
Provider experience
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Don’t always listen to your hospital’s instructions
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MD Engagement 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
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Minutes are myocardium
Seconds are sarcomeres
Door to balloon time
What’s your door to BP control time?
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First, walk the walk
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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%
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Don’t reinvent the wheel
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Train the masses
Empower the patient
Feedback
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What is the role of the patient?
• Quality control
• Feedback
• Knowledge
• Owning their numbers
• Open communication about side effects
• N of 1 trials
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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
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Solutions
• Not another email from a payer or physician’s group or office of population health, please!
• Dashboard fatigue
• A WORKFLOW solution is needed
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Date of download: 7/8/2016 Copyright © The American College of Cardiology. All rights reserved.
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.
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Improve provider efficiency
and have everyone working at
the top of their training level
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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
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But it sure takes a long time to SPRINT
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Personalized medicine?
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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
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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
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• Convenience
• Freeing up clinic for other patients to have access (new pts, sicker pts)
• High touch care from a cardiology team
• Experimentation
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)
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Try something
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Progressive improvement beats delayed perfection.
-- Mark Twain
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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
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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
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Data overload
…the upside of painful knowledge is so much greater than the downside of blissful ignorance.
Sheryl Sandberg
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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
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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
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Questions
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Orchestra
Provider Desktop &
Patient Mobile App
Onboarding Process
UCSF2021
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Case Studies
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Questions