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

School of Medicine

How did we get interested in HTN?

Access

Patient experience

Provider experience

2

School of Medicine

Don’t always listen to your hospital’s instructions

3

School of Medicine

4

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

School of Medicine

5

School of Medicine

6

School of Medicine

7

Minutes are myocardium

Seconds are sarcomeres

Door to balloon time

What’s your door to BP control time?

School of Medicine

8

9

First, walk the walk

10

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%

School of Medicine

Don’t reinvent the wheel

11

Train the masses

Empower the patient

Feedback

12

School of Medicine

What is the role of the patient?

• Quality control

• Feedback

• Knowledge

• Owning their numbers

• Open communication about side effects

• N of 1 trials

13

14

School of Medicine

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

15

School of Medicine

Solutions

• Not another email from a payer or physician’s group or office of population health, please!

• Dashboard fatigue

• A WORKFLOW solution is needed

16

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.

School of Medicine

18

Improve provider efficiency

and have everyone working at

the top of their training level

School of Medicine

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

19

School of Medicine

But it sure takes a long time to SPRINT

20

School of Medicine

Personalized medicine?

21

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

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

22

• 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)

School of Medicine

Try something

23

Progressive improvement beats delayed perfection.

-- Mark Twain

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

School of Medicine

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

25

26

School of Medicine

Data overload

…the upside of painful knowledge is so much greater than the downside of blissful ignorance.

Sheryl Sandberg

27

School of Medicine

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

28

School of Medicine

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

29

Questions

School of Medicine

Orchestra

Provider Desktop &

Patient Mobile App

Onboarding Process

UCSF2021

School of Medicine

Case Studies

School of Medicine

Questions