GOOD MORNING.
WELCOME TO DAY TWO OF THE NHLBI
WORKSHOP ON BLOOD PRESSURE
ASSESSMENT ACROSS THE LIFESPAN,
TO IMPROVE CLINICAL RESEARCH AND
CLINICAL PRACTICE.
WE HA HAD A TERRIFIC DAY ONE OFE
WORKSHOP WITH THREE ENGAGING AND
STIMULATING SESSIONS.
TODAY, WE HAVE TWO PRESENTATION
SESSIONS FOLLOWED BY AN
HOUR-LONG CLOSED SESSION 6,
CONVENED IN THREE BREAKOUT
ROOMS.
WE WILL THEN RECONVENE IN THE
MAIN ROOM FOR A REPORT FROM THE
BREAKOUT SESSIONS.
DR. ABDALLA AND DR. JURASCHEK,
DO YOU HAVE ANY OPENING REMARKS
FOR TODAY BEFORE WE TURN IT OVER
TO THE SESSION 4 MODERATORS?
>> REALLY EXCITED FOR THE SECOND
DAY.
WE HAD SUCH A GREAT, RICH
DISCUSSION ON DAY ONE.
AND I THINK WE'LL HAVE PLENTY
MORE THIS AFTERNOON, AND LOOKING
FORWARD TO THE BREAKOUT -- THE
DISCUSSIONS AS WELL TO CONTINUE
TO PROBE SOME OF THE ISSUES
FURTHER.
SO THANK YOU AGAIN TO ALL OF OUR
PARTICIPANTS AND THE DISCUSSANTS
AND NHLBI FOR THIS REMARKABLE
EVENT.
>> THANK YOU.
SO LET US START SESSION 4.
>> OKAY.
GOOD MORNING, EVERYONE.
WELCOME TO SESSION 4.
I THINK FIRST ORDER OF BUSINESS,
WE ARE GOING TO INTRODUCE
OURSELVES.
MY NAME IS DAICHI SHIMBO.
I'M PROFESSOR OF MEDICINE AT
COLUMBIA UNIVERSITY IRVING
MEDICAL CENTER.
I'M A PREVENTIVE CARDIOLOGIST
AND THE DIRECTOR OF OUR
HYPERTENSION CENTER.
>> AND GOOD MORNING, EVERYONE.
I'M HILARY WALL, SENIOR
SCIENTIST IN THE CENTERS FOR
DISEASE CONTROL AND PREVENTION
AND ALSO SERVE AS THE SCIENCE
LEAD FOR THE NATIONAL MILLION
HEARTS INITIATIVE.
SO I THINK WE WILL GET US KICKED
OFF WITH OUR FIRST SPEAKER WHO
IS DR. BEVERLY GREEN.
SHE IS A SENIOR INVESTIGATOR AND
FAMILY PHYSICIAN AT THE KAISER
PERMANENTE WASHINGTON HEALTH
RESEARCH INSTITUTE.
HER RESEARCH FOCUSES ON SYSTEMS
BASED DESIGN AND LEVERAGING
ELECTRONIC HEALTH RECORDS AND
REMOTE COMMUNICATIONS TO DELIVER
MORE EFFECTIVE AND EFFICIENT
EVIDENCE-BASED PREVENTIVE CARE.
SHE'LL BE SPEAKING TO US ON
INTEGRATING PATIENT GENERATED
DATA WITH CLINICAL ASSESSMENTS.
BEV?
>> GOOD MORNING.
AND THANK YOU FOR INVITING ME,
AND THOSE ARE MY CONFLICTS OF
INTEREST TO REPORT.
SO THIS IS MY OUTLINE FOR THE
DISCUSSION TODAY, AND I'M GOING
TO BE DISCUSSING WHY PATIENT
GENERATED BLOOD PRESSURE DATA IS
IMPORTANT.
CURRENT CHALLENGES TO GATHERING
THAT DATA, AND EXAMPLES OF
PROGRAMS THAT HAVE INTEGRATED
SELF-MEASURED BLOOD PRESSURE
INTO CLINICAL CARE, AND GAPS AND
FUTURE OPPORTUNITIES.
SO CURRENTLY, TWO OF THE LEADING
GUIDELINE GROUPS RECOMMEND OUT
OF OFFICE BLOOD PRESSURE
MONITORING FOR EITHER THE
DIAGNOSIS OR FOR TITRATION OF
MEDICATIONS WITH BOTH HAVING A
RECOMMENDATION, WHICH MEANS
THERE'S HIGH QUALITY EVIDENCE.
ALTHOUGH THOSE ARE RECOMMENDED
FOR DIAGNOSIS AND FOR TREATMENT,
IT'S SELDOM DONE.
SO THE EVIDENCE IS QUITE STRONG
FOR SELF BLOOD PRESSURE
MEASUREMENT, AND SELF BLOOD
PRESSURE MEASUREMENT ON ITS OWN
ON SOME META-ANALYSES, NOT THIS
ONE IN PARTICULAR, HAS SHOWN A
SMALL BUT SIGNIFICANT DECREASE
IN SYSTOLIC BLOOD PRESSURE, AND
WHEN YOU ADD MORE COMPONENTS AND
HIGHER INTENSITY INTERVENTIONS,
IT GETS THE EFFECT OF HOME BLOOD
PRESSURE MONITORING PLUS ADDED
SUPPORT GETS EVEN STRONGER, WITH
THE STRONGEST EFFECT BEING FROM
PHARMACISTS OR NURSE-BASED
MEDICATION TITRATION IN ADDITION
TO SELF-MONITORING, AND THAT'S
BEEN DONE A NUMBER OF WAYS,
THROUGH REMOTE MONITORING
PROGRAMS, SECURE -- STUDY AND
TELEPHONE.
AND I PUT UP A LITTLE NOTE THERE
THAT I THINK THAT THERE'S NO ONE
ANSWER FOR HOW TO COMMUNICATE
THE DATA.
IT HAS TO BE TAILORED TO THE
RESOURCES IN THE SYSTEM AND ALSO
PATIENT PREFERENCES.
ALMOST ALL HIGH QUALITY TRIALS
HAVE SHOWN BENEFITS FROM
LOWERING BLOOD PRESSURE USED
OFFICE BASED BLOOD PRESSURE.
IT'S AN ARGUMENT I OFTEN GET
WHEN I SAY WE SHOULD BE DOING
HOME MONITORS.
ALL THE TRIALS USED CLINIC-BASED
MEASUREMENTS.
BUT THE ARGUMENT I GIVE BACK TO
THAT IS A CLINIC BLOOD PRESSURE
MEASUREMENT IS NOT THE SAME AS A
RESEARCH-BASED MEASUREMENT, AS A
RESEARCHER I KNOW THAT AND I
USUALLY DON'T RELY ON EHR BLOOD
PRESSURE MEASUREMENTS UNLESS THE
HEALTH SYSTEM HAS GONE OUT OF
THEIR WAY TO ASSURE GOOD
MEASUREMENT, WHICH IS SELDOM
COMMON.
AND OFTEN CLINIC MONITORS, EVEN
MONITORS WE USE IN CLINIC, ARE
NOT VALIDATED FOR ACCURACY AND
ARE NOT REGULARLY CALIBRATED,
ESPECIALLY ANEROID MONITORS
WHICH ARE STILL USED A LOT
BECAUSE THEY'RE CHEAPER AND IT
HARD TO PUT AUTOMATED MONITORS
IN EVERY ROOM, AND IMPROVE
TECHNIQUE IS COMMON IN CLINICAL
CARE.
WE'VE HAD A LOT OF DISCUSSION
ABOUT THAT, WE ACTUALLY LOOKED
AT THAT, AND WE DID A SECRET
SHOPPER STUDY AND FOUND WITH
ANEROID MEASUREMENTS, THAT ABOUT
90 TO 95% OF THE MEASUREMENTS
HAD ERRORS.
IT WAS A LITTLE BETTER WITH
AUTOMATED, BUT THE MOST COMMON
ERROR WITH AUTOMATED WAS TALKING
TO THE PATIENT.
AND THEN AS WE SAW WITH
DR. JURASCHEK'S PRESENTATION,
NUMBER ROUNDING IS A PROBLEM AND
WHEN YOU GO TO AUTOMATED
MEASUREMENTS, THIS GOES AWAY.
HOWEVER, THERE IS VALUE IN --
WELL, NOT ANEROID BUT I WOULD
SAY MERCURY MEASUREMENT, WHICH
IS MUCH EASIER, BUT WE CAN NO
LONGER USE THAT, THEY'RE
PROHIBITED IN MY STATE, THE
MERCK NIEMANNOMETERS.
ALSO NOT RECHECKING BLOOD
PRESSURE, NOT WAITING FOR TIME,
LACK OF AVERAGING AND RELYING ON
THE LOWEST BLOOD PRESSURE NOT
JUST FOR QUALITY METRICS BUT
ALSO IN CLINICAL CARE, THEY
OFTEN HAVE A PATIENT WAIT, AND
AFTER 5, 10 MINUTES, OFTEN IT'S
LOWER, THERE'S A LOT OF STUDIES
SHOWING THAT AND THEN THEY'RE
HAPPY.
GOOD AVERAGE BLOOD PRESSURE
MIGHT BE QUITE DIFFERENT.
AND THIS SHOWS WE HAVE A LOT OF
DISCUSSION, WHICH I WAS HAPPY TO
HEAR YESTERDAY, ABOUT BLOOD
PRESSURE VARIATION, AND THE
HIGHER YOU ARE, THE MORE YOU
HAVE TO FALL.
I LOVE THAT IN OUR TALK ABOUT
BLOOD PRESSURE CARE IN THE
ELDERLY.
THIS IS A COPY OF THE BLOOD
PRESSURE MEASUREMENTS IN A
24-HOUR REPORT IMOWN, AND IN
THIS PARTICULAR PATIENT, THIS
PERSON WAS 71 YEARS OLD, THERE'S
ABOUT A 50-MILLIMETER DIFFERENCE
THROUGHOUT THE DAY IN SYSTOLIC
BLOOD PRESSURES.
SO I ALWAYS SAY, WELL, THE RIGHT
BLOOD PRESSURE -- WILL THE RIGHT
BLOOD PRESSURE SHOW UP?
BECAUSE YOU'RE GETTING A VERY
SMOOL GLIMPSE IN CLINIC.
-- SMALL
GLIMPSE IN CLINIC.
THEN POWERS FOUND THAT FOR
PEOPLE THAT WERE CLOSE TO THE
THRESHOLD, THAT YOU NEED AT
LEAST 10 READINGS TO HAVE 80%
PROBABILITY OF GETTING THE RIGHT
ANSWER.
AND THAT ONLY WHEN THE BLOOD
PRESSURE IS AT THE MORE EXTREMES
CAN YOU BE CONFIDENT THAT YOU
ARE IN THE RIGHT BALLPARK.
SO THERE'S BEEN A LOT OF
INTEREST IN AUTOMATED OFFICE
BLOOD PRESSURE AND MAYBE WE CAN
DECREASE THE TIME TO TWO OR
THREE MINUTES OF REST, MAKE IT
MORE EFFICIENT WITH HALF A
MINUTE, AND THERE WAS A NICE
STUDY BY RORK THAT SHOWED WHEN
YOU AVERAGE BLOOD PRESSURES,
AOBP IS IDENTICAL TO AMBULATORY.
THAT WAS USING MAINLY STUDIES
FROM CANADA, WHICH ACTUALLY USES
A METHOD WITH NO REST.
WHEN WE LOOK AT THE AOB PROTOCOL
THAT WAS USED IN SPRINT, THAT
WAS PRETTY MUCH RECOMMENDED WITH
THE 5 MINUTES OF REST, YOU
ACTUALLY FIND BLOOD PRESSURES
THAT ARE LOWER THAN AMBULATORY
AND WE'RE NOT THE ONLY ONES THAT
FOUND THIS.
THIS IS A STUDY WE DID.
WE FOUND ALMOST A 4-POINT BIAS
DOWNWARDS.
AND AMBULATORY IS ALREADY
SUPPOSED TO BE LOWER THAN
CLINIC, SO IF YOU USED AOBP, YOU
HAVE TO REMEMBER THAT YOU SHOULD
NOT USE A 140/90 THRESHOLD, SO
THAT IS NOT THE COMPLETE ANSWER
UNLESS PEOPLE USE IT PROPERLY.
THE OTHER THING TO NOTICE IS
BLAND-ALTMAN CURVES.
THIS ISN'T AS BAD AS THE
PEDIATRIC CURVES I SAW
YESTERDAY, BUT THERE IS -- YOU
KNOW, FOR THE AVERAGE, IT MIGHT
BE PRETTY GOOD FOR THE GROUP,
BUT FOR YOU AND ME, NOT SO MUCH.
YOU COULD BE AS MUCH AS
20 MILLIMETERS DIFFERENT THAN
THE AVERAGE, SO YOU MAY BE -- A
VERY GOOD CHANCE YOU COULD BE
MISCLASSIFIED.
SO THE PROBLEM IS BP VARIATION
AND THE SOLUTION IS MORE BLOOD
PRESSURE SO HOW DO WE GET THOSE?
UNFORTUNATELY I PRACTICED BEFORE
THERE WAS HEMOGLOBIN A1C FOR
DIABETES.
WE DON'T HAVE ONE FOR
HYPERTENSION.
WOULDN'T IT BE NICE, IF WE HAD
TO USE ONLY BLOOD SUGARS TO
MANAGE DIABETES AND IT WAS MUCH
HARDER TO KNOW THE OVERALL
PICTURE AND WE HAVE THE SAME
PROBLEM IN HYPERTENSION AND WE
DON'T HAVE A HEMOGLOBIN A1C BUT
WE CAN GET SUMMARY DATA AND JUST
MAKE IT LIKE A1C, AND NICELY
WHEN YOU DO AN AMBULATORY TEST,
YOU DO GET A SUMMARY PAGE THAT
SIMPLIFIES EVERYTHING THAT WAS
RECORDED.
THERE'S QUITE A BIT MORE
INFORMATION, BUT THE SUMMARY
PAGE IS USUALLY CORRECT AND IT
DISTILLS ALL THAT INFORMATION SO
YOU CAN MAKE A JUDGE.
MENT.
SO WE NEED SOMETHING LIKE THAT
FOR SMBP, WHERE WE GET THE
AVERAGE RANGE.
WE TALKED ABOUT THE RANGE BEING
IMPORTANT, PARTICULARLY IN OLDER
PEOPLE AND THE PERCENT OVER
TARGET.
THE BLOOD PRESSURE READINGS.
THAT'S AN IMPORTANT NUMBER TOO
AS WELL TO LOOK AT, SO HOW OFTEN
ARE THOSE BLOOD PRESSURES WHERE
YOU WANT THEM TO BE?
BUT THE NEXT QUESTION IS, HOW DO
WE INTEGRATE SELF-MONITORING
INTO CARE?
SO THERE WAS A POLL DONE IN 2021
AND PUBLISHED IN 2022 IN JAMA
NETWORK THAT LOOKED AT -- THAT
SURVEYED OVER 2,000 PEOPLE AND
ASKED ABOUT HOME BLOOD PRESSURE
MONITORING USE.
AND QUITE ASTOUNDING, OVER 75%
OF PEOPLE IN TOTAL ACTUALLY HAD
A HOME MONITOR, AND OVER HALF
USED IT, AND -- OF THE TOTAL,
AND SOME DIDN'T USE IT.
AND THE REASONS FOR NOT OWNING A
MONITOR WAS, I NEVER THOUGHT
ABOUT IT, IT WAS NOT VERY
DIFFERENT BETWEEN THOSE WITH IT
THAT REPORTED A DIAGNOSIS OF
HYPERTENSION WITHOUT, OR THOSE
WITHOUT A REPORT OF
HYPERTENSION.
TOO EXPENSIVE WAS IMPORTANT.
AND SOME PEOPLE THOUGHT THEY
WEREN'T ACCURATE AND THAT MAY BE
TRUE DEPENDING ON THE MONITOR
THEY HAVE AND THEY WERE NOT SURE
HOW TO USE IT IN A SMALL CASE.
AND THERE WAS ANOTHER SLIDE, I
TRIED TO MAKE THIS SO I WOULD
STICK TO MY 15 MINUTE, BUT IT
SHOWED HOW MUCH WAS USED TO
COMMUNICATE HOME BLOOD PRESSURES
WERE RECOMMENDED, AND THAT
NUMBER WAS ABOUT HALF, YOU SPLIT
THE POPULATION AT ABOUT HALF,
AND HOW MANY ACTUALLY SHARED IT,
THAT WAS ABOUT HALF OF THE HALF.
SO SOME PEOPLE DO SHARE THEIR
BLOOD PRESSURES FROM HOME, BUT
IT'S MUCH SMALLER THAN THE
NUMBER OF PEOPLE WHO ACTUALLY
HAVE HOME MONITORS.
AND I'LL MAKE THE POINT, WE
DON'T KNOW THE QUALITY OF THOSE
HOME MONITORS.
SO WE INTERVIEWED PEOPLE, THIS
IS A PAPER WE'VE WRITTEN AND
IT'S UNDER REVIEW, AND WHO WERE
ASKED TO PROVIDE A HOME BLOOD
PRESSURE READING.
IN MY ORGANIZATION, IT WAS A
QUALITY IMPROVEMENT PROGRAM.
MAYBE NOT ONE I WOULD HAVE
DESIGNED, BUT WE RECEIVED SOME
FUNDING TO EVALUATE IT.
AND WE HEARD FROM PATIENT THAT
THEY WANTED MORE INFORMATION ON
SELECTING A MONITOR, USING IT
AND HOW OFTEN TO MEASURE IT.
SO THE ONES THAT SENT IN BLOOD
PRESSURES FROM HOME, THEY HAD
THE MONITOR BUT THEY DIDN'T HAVE
MUCH OF THE INFORMATION THEY
NEEDED.
AND THEY ALSO, WHEN THEY WERE
ASKED TO SEND IN THE BLOOD
PRESSURES WHEN THEY DID, THEY
OFTEN DIDN'T GET FEEDBACK,
PARTICULARLY IF IT WAS IN A GOOD
RANGE.
SO YOU GUYS SAID IT WAS
IMPORTANT.
IS IT NOT IMPORTANT?
WHAT'S THE DEAL, AND THAT PERSON
ACTUALLY HAD UNCONTROLLED BLOOD
PRESSURE AND GOT NO RESPONSE.
AND I DON'T THINK I HEARD
ANYTHING BACK.
IF IT WAS SPIKING OR SOMETHING,
I WOULD HAVE EXPECTED A
RESPONSE, BUT IT WASN'T.
I REALLY DIDN'T THINK ABOUT IT.
THAT WAS A PERSON WITH
CONTROLLED BLOOD PRESSURE.
AND PATIENTS HA -- AWARENESS OF
HIGH BLOOD PRESSURE BUT ITS
SENSE OF IMPORTANCE, HOW MUCH IT
WOULD HURT YOU AND THE TARGETS,
THEY WERE VERY CONFUSED ABOUT.
AND A PERSON WITH UNCONTROLLED
BLOOD PRESSURE THOUGHT THEY WERE
DOING A FOOD JOB A GOOD JOB, ANR
PERSON, I LOVE THIS QUOTE, SAID
ONE DOCTOR WANTED TO SEE ME
BELOW 130, ANOTHER WAS HAPPY IF
I'M BELOW 140, AND ACTUALLY THIS
PERSON ALSO SAID ANOTHER DOCTOR
WANTED BOTH THOSE NUMBERS TO BE
GOOD, SO EVEN THE DOCTORS
THEMSELVES DON'T KNOW.
SO WE HAVE A LOT TO DO WITH
PATIENTS.
SO THERE'S MULTILEVEL BARRIERS
TO PATIENT GENERATED BLOOD
PRESSURES, AND THAT'S THE
SOCIOECONOMIC MODEL WHICH I
LIKE.
YOU CAN'T REALLY SEE IT, BUT IT
PUTS IN THE CONTEXT OF THE
COMMUNITY, THE ENVIRONMENT,
SOCIAL NEEDS, THE PATIENT, THEIR
FAMILY, AND THE CLINIC AND THE
CLINIC SYSTEM.
AND PATIENTS USUALLY DON'T KNOW
HOW TO SELECT A VALIDATED HOME
MONITOR.
WE'VE BEEN TRYING TO GET THE --
I'M NO LONGER ON THE VALIDATE BP
TEAM, I ENJOYED BEING ON IT BUT
OUR CLINICIANS AND PATIENTS
DON'T UNIVERSALLY -- SOME KNOW
ABOUT IT BUT MOST DON'T.
AND PATIENTS MAY NOT KNOW HOW TO
TAKE THEIR BLOOD PRESSURE
ACCURATELY, BUT THERE WAS A
STUDY THAT SHOWED JUST SHOWING A
VIDEO TO PATIENTS THAT THEY WERE
ABLE TO DEMONSTRATE THAT THEY
COULD TAKE THEIR BLOOD PRESSURE
ACCURATELY, WHICH IS GOOD NEWS,
BECAUSE WE HAVE TO HAVE A LOT OF
WAYS TO REACH PATIENTS.
THEY CAN'T ALWAYS COME IN AND
GET A LESSON.
AND CLINICIANS, PRIMARY CARE
CLINICIANS, MAYBE SPECIALISTS,
REALLY ARE JUST SLAMMED.
AND OFTEN THEY DO TELEVISITS, SO
WE HAVE TO HAVE OTHER WAYS.
AND THEY MAY NOT HAVE ACCESS TO
BE ABLE TO AFFORD BLOOD
PRESSURE, AND FOR MOST, IT'S NOT
A COVERED BENEFIT, AND IN OUR
SYSTEM WHEN IT IS, WE'VE BEEN
TRYING TO GET A VALIDATED BLOOD
PRESSURE MONITOR FOR THE DME
BENEFIT, DURABLE MEDICAL
EQUIPMENT, BUT THE ONE THEY
PROVIDE IS A $25 MONITOR THAT
ISN'T VALIDATED AT ALL.
SO YOU KNOW, THIS IS WHAT WE
FACE AS CLINICIANS IN DEALING
WITH SYSTEMS.
AND CLINICIANS MAY ENDORSE HOME
BLOOD PRESSURE, BUT THEY RARELY
CHECK THE HOME MONITORS FOR
ACCURACY, THEY DON'T KNOW THE
DIFFERENCE BETWEEN CLINIC AND
OUT OF OFFICE, AND AS WE SHOWED
AS AOBP.
AND WE HAVE HEARD FROM
CLINICIANS, DON'T SEND ME ALL
THAT DATA THAT WAS A DISCUSSION
POINT YESTERDAY.
THEY REALLY DON'T WANT TO SEE
IT.
AND THEY DON'T HAVE SUFFICIENT
RESOURCES OR TIME TO IMPLEMENT A
PROGRAM THAT USES ALL THAT DATA.
AND OFTEN IT'S NOT PRESENTED IN
A VERY USABLE WAY AS INDIVIDUAL
MEASUREMENTS AND NOT AVERAGE
RANGE OR THRESHOLD, AND THAT
MAKES IT VERY HARD TO SEE
TRENDS.
YOU CAN LOOK AT THEM, BUT
THERE'S BETTER WAYS.
AND THE SETTING IN MEDICAL
RECORDS IS OFTEN NOT DEFINED.
OURS GET THROWN ALL TOGETHER.
THEY'VE IMPROVED ON THAT, MANY
HEALTH SYSTEMS HAVE AND IN THE
FUTURE, THEY'RE SUPPOSED TO BE
ABLE TO DO THIS, BUT WE HAVEN'T
GOTTEN THERE TO KNOW WHAT THE
SETTING WAS, BECAUSE IT MAKES A
DIFFERENCE.
AND THEN THE HEALTH SYSTEMS
INSURANCE PLANS, MEDICARE DOES
NOT COVER HOME MONITORS UNLESS
IT'S PART OF A REMOTE MONITORING
PROGRAM AND YOU'VE GOT TO HAVE A
WHOLE SETUP FOR THAT.
AND THE FAMILY MEDICINE CODES
ARE NOT USED, AND MEDICAID
COVERAGE VARIES BY STATE.
AND COMMERCIAL INSURANCE MAY OR
MAY NOT COVER HOME MONITORS AS
EQUIPMENT, WE TALKED ABOUT THAT,
AND SUCCESSFUL -- AND THE REASON
MEDICARE ALSO CAN'T GIVE THEM
AWAY, BECAUSE THEY ARE
CONSIDERED AN INDUCEMENT SO THE
INSURANCE PLAN CAN GET IN
TROUBLE.
SO AS I'VE SAID, YOU HAVE TO
HAVE A PROGRAM AND YOU NEED 16
BLOOD PRESSURES A MONTH TO
COLLECT, AND YOU HAVE TO BE FEE
FOR SERVICE BECAUSE MANAGED CARE
CAN'T BILL.
AND NATIONAL POLICIES, HEATUS
DOESN'T HELP US BY TAKING THE
LOWEST BLOOD PRESSURE FROM MORE
THAN ONE READING.
SO HERE'S KEY -- SO THE FUTURE
STATE IS INTEGRATION OF BLOOD
PRESSURE IN THE EHR, A WORK IN
PROGRESS.
I WOULD SAY THAT SOME PLACES ARE
DOING THIS VERY WELL.
THIS IS A SIMPLIFIED VERSION OF
WHAT THE KEY INGREDIENTS ARE.
AND TOOLS FOR ENROLLING, DATA
COLLECTION DASHBOARD, AND MEMBER
DASHBOARD, AND OPERATIONAL
SUPPORT AND CARE PATHWAYS IS THE
HIGH LEVEL PICTURE.
WE HAVE A REMOTE MONITORING
PROGRAM BUT THE REACH IS
EXTREMELY SMALL.
WE DON'T HAVE ENOUGH PHARMACISTS
TO GO AROUND.
IN GEORGIA, THEY'VE BEEN QUITE
SUCCESSFUL, AND THEY ENROLL A
FEW HUNDRED PATIENTS A MONTH BUT
THEY HAVE DEDICATED RESOURCES.
AND MOST COMMUNITY CLINICS DON'T
HAVE A PHARMACIST.
MAYBE FQHCs DO SOMETIMES, BUT
THE VAST MAJORITY OF COMMUNITY
CLINICS DON'T EVEN HAVE A NURSE
RN OFTEN, OR EVEN AN LPN
SOMETIMES.
SO PATIENTS ALSO HAVE TO HAVE A
SMARTPHONE, AND BLUETOOTH IS
PREFERRED.
WE HAVE A PROGRAM CALLED CARE
COMPANION THAT WAS BUILT BY AN
UNNAMED COMMONLY USED EHR
VENDOR.
THESE ARE THE STEPS A CLINICIAN
TAKES TO ENROLL.
OUR HOPE WAS FOR CLINICIANS TO
USE THIS AND ENROLL PATIENTS BUT
I THINK THAT'S A PIPE DREAM.
THEY'RE JUST TOO BUSY AND THE
REACH IS VERY SMALL.
AND HERE'S ANOTHER SET OF THINGS
THEY HAVE TO DO.
THEY CAN CHOOSE ALL THESE
LIFESTYLE MODULES FOR PATIENTS
WHICH SOUNDS GREAT BUT IT'S A
LOT OF STUFF.
AND NEXT, I'M A HEALTH SYSTEMS
RESEARCHER, SO MAKING THINGS
SIMPLE IS MY MOTTO.
THIS IS THE REPRESENTATION
CURRENTLY IN OUR CHART AND
THERE'S A PROBLEM THERE WITH A
HUNDRED OVER 100, I DON'T KNOW
WHAT HAPPENED, BUT IT'S SOMEWHAT
USEFUL.
THERE'S AN AVERAGE IN THE
CORNER, BUT I THINK IT'S TOO
BUSY AND NOT USEFUL ENOUGH.
THIS IS WHAT THE PATIENT SEES.
AND FRANKLY, I WAS INVOLVED WITH
THE PROGRAM, I ACTUALLY HAD
HYPERTENSION, SO THEN WHEN I
LOST MY BLUETOOTH CONNECTION, I
HAD TO GET HELP FROM I.T. TO DO
IT SO IT'S NOT VERY
USER-FRIENDLY.
WE DO HAVE CELLULAR MONITORS
THAT DON'T REQUIRE ANY BLUE
TOOTH, AND THAT'S SOMETHING TO
KEEP LOOKING AT.
I'M GETTING TO THE END.
SO IN SUMMARY, KEY GAPS.
CLINICIANS AND PATIENTS NEED TO
UNDERSTAND HOW TO MEASURE BLOOD
PRESSURE ACCURATELY, AND THEY
REALLY NEED TO UNDERSTAND MORE
ABOUT BLOOD PRESSURE VARIABILITY
AND WHY GETTING MORE BLOOD
PRESSURE IS IMPORTANT WHEN YOU
HAVE TO MAKE CLINICAL DECISIONS.
OBTAINING BLOOD PRESSURES
OUTSIDE OF CLINIC PROVIDES MORE
INFORMATION FOR MANAGEMENT BUT
IS SELDOM USED IN A SYSTEMATIC
WAY.
PATIENTS FREQUENTLY OWN HOME
MONITORS BUT ARE NOT GIVEN THE
TOOLS THEY NEED OR THE RIGHT
CUFF, AND THEY DON'T HAVE EASY
WAYS TO SHARE IT WITH THEIR
CLINICIANS.
REPRESENTATION OF THE DATA IN
THE EHR NEEDS MUCH MORE WORK,
AND EVIDENCE-BASED WORKFLOWS FOR
MANAGING PATIENT GENERATED BLOOD
PRESSURE HAVE BEEN TESTED AND
THEY'RE QUITE EFFECTIVE AND THEY
CAN BE SIMPLE, THEY DON'T HAVE
TO BE AN RMP, WE USE JUST EMAIL
AND WE'RE QUITE SUCCESSFUL WITH
THAT, BUT THEY REMAIN UNDER IT
IS UTILIZED, WE CAN'T GET THE
RESOURCES, THEY NEED
IMPROVEMENTS TO ENSURE THEY'RE
SCALABLE IN REAL WORLD SETTINGS.
FUTURE QUESTIONS FOR RESEARCH.
WHAT IS THE BEST SOLUTION,
CELLULAR, MENTIONED THAT, TEXT,
SECURE EMAIL, GIVING PATIENTS
CHOICE, AND ENGAGEMENT
STRATEGIES, WE HEARD ABOUT THAT,
HOW DO WE GET PATIENTS MORE
ENGAGED, AND WHAT ARE THE
COMPARATIVE EFFECTIVENESS OF
DIFFERENT EHR REPRESENTATIONS OF
CLINICS AND SMBP -- I DIDN'T FIX
THAT -- AND WORKFLOWS ON
DECREASING THERAPEUTIC INERTIA.
AND CAN SELF-MONITORING BLOOD
PRESSURE ALGORITHMS AND AI
ALGORITHMS BE TAILORED SO WE
DON'T DO THIS ON EVERYONE, WE
JUST DO IT ON THE PATIENTS THAT
REALLY NEED THIS INFORMATION.
AND WHAT IS THE COMPARATIVE
EFFECTIVENESS OF SMBP TO
IN-CLINIC MONITOR, WHICH WE KNOW
BUT WE DON'T KNOW IT FOR THE
HARD OUTCOMES, AND WHAT POLICY
SOLUTIONS ARE NEEDED TO ACTUALLY
IGNITE THESE INTERVENTIONS THAT
ARE ALREADY ADDED IN SPACE
SCALABLE.
THANK YOU.
>> OKAY, THANK YOU SO MUCH,
DR. GREEN.
I WOULD LIKE TO INTRODUCE OUR
NEXT SPEAKER, DR. ROBERT BROOK,
WHO'S PROFESSOR OF
CARDIOVASCULAR MEDICINE AT WAYNE
STATE UNIVERSITY.
ALSO THE DIRECTOR OF THE
CARDIOVASCULAR PREVENTION
PROGRAM AND A PHYSICIAN
SCIENTIST AND HAS BEEN A PIONEER
IN THE AREA OF ENVIRONMENTAL
CARDIOLOGY.
TODAY WE'LL SPEAK ON THE
ASSESSING BLOOD PRESSURE BEYOND
THE HOME AND OFFICE, IMPORTANCE
OF ENVIRONMENTAL CONTEXT IN
BLOOD PRESSURE MEASUREMENT.
YOU CAN START WHEN YOU'RE READY.
>> ALL RIGHT, GOOD MORNING,
EVERYONE.
THANK YOU FOR THE INTRODUCTION.
MY TALK I THINK IS A LITTLE
DIFFERENT THAN OTHER TALKS BUT
IT'S IMPORTANT TO ADD TO THE
GLOBAL CONTEXT OF THE COMPLEXITY
OF BLOOD PRESSURE AND IN
PARTICULAR, ITS OVERALL
VARIABILITY.
SO THIS SLIDE IS JUST -- IT'S
BUSY BUT IT'S TO IMPRESS UPON
YOU WHEN THINKING ABOUT
HYPERTENSION OR THINKING ABOUT
SHORT TERM CHANGES IN BLOOD
PRESSURE, OR EVEN DURING THE
MEASUREMENT OF BLOOD PRESSURE
ITSELF, THERE IS A WIDE VARIETY
OF ENVIRONMENTAL EXPOSURES OR
FACTORS THAT PLAY A ROLE IN
IMPACTING BLOOD PRESSURE BOTH
ACUTELY AS WELL AS PROMOTING THE
ONSET OF HYPERTENSION.
THIS WAS A PRIOR PUBLICATION
UPDATED THE SLIDE RECENTLY, AND
CATEGORIZED FACTORS GENERALLY AS
NATURAL FACTORS, AS WELL AS
OTHER NATURAL FACTORS RELATED TO
DISASTERS AS WE'RE SEEING MORE
AND MORE WITH CLIMATE CHANGE,
AND THEN MAN-MADE FACTORS AS
WELL.
AND THEN MORE RECENTLY, OTHER
FACTORS SUCH AS THE IMPACT THAT
CAN OCCUR AFTER LONG TERM
PLAGUES WHICH HAS BEEN KNOWN IN
THE PAST WITH COVID-19.
MANY OF THESE FACTORS ARE KNOWN
SUCH AS THAT I THINK PEOPLE WILL
BE AWARE THAT TEMPERATURE AND
SEASONS AFFECT BLOOD PRESSURE.
SOME OF THEM ARE LESS
WELL-KNOWN, SUCH AS THE PROFOUND
IMPACT OF NORMAL VARIATIONS IN
LIVING OR CHANGING YOUR
ELEVATIONS OR ALTITUDE OR
LATITUDE.
CHANGES IN BLOOD PRESSURE HAVE
BEEN SHOWN AFTER WILDFIRE SMOKE
EXPOSURE, AS WELL AS CLEARLY
AFTER DISASTERS, AFTER HURRICANE
KATRINA, SUPERSTORM SANDY, AFTER
EARTHQUAKES BOTH ACUTELY AND
CHRONICALLY.
MANY MAN-MADE EXPOSURES, SUCH AS
URBAN AND OCCUPATIONAL NOISE,
LIGHT POLLUTION, LIVING NEAR
ROADWAYS, AND THEN MY RESEARCH
WAS PRINCIPALLY IN THE LAST 25
YEARS ON AIR POLLUTANTS HAVE
ACUTE EFFECTS.
I THINK MANY PEOPLE WILL BE
AWARE THAT THE BUILT ENVIRONMENT
PLAYS A ROLE IN MODULATING BLOOD
PRESSURE MORE CHRONICALLY, BUT
BOTH CHRONICALLY AND ACUTELY,
OTHER DIFFERENT TYPES OF
CHEMICALS, PERSISTENT ORGANIC
POLLUTANTS AND DIFFERENT
CHEMICALS WE'RE EXPOSED TO, EVEN
POTENTIALLY DIFFERENT CHEMICALS
IN PLASTICS CAN HAVE AFFEC EFFEN
OUR BLOOD PRESSURE BOTH ACUTELY
AND CHRONICALLY.
SO PERHAPS THE MOST IMPORTANT OR
AT LEAST FROM A PUBLIC HEALTH
STANDPOINT, THE ENVIRONMENTAL
EXPOSURE THAT HAS A EUN VER TALL
IMPACT ON ALL LIVING HUMANS IS
YOUR AMBIENT TEMPERATURE
EXPOSURE.
IT'S BEEN KNOWN FOR QUITE SOME
TIME AND BEEN SHOWN IN DOZENS
AND DOZENS OF STUDIES WITH MORE
AND MORE PRECISE INFORMATION
BEING GAINED THAT IN GENERAL,
THERE'S A LINEAR RELATIONSHIP
BETWEEN LOWER AMBIENT RECENT
TEMPERATURES, WITHIN THE LAST
FEW HOURS TO DAYS, AND YOUR
BLOOD PRESSURE.
BECAUSE WE SPEND MOST OF OUR
TIME, 80, 90% INDOORS, INDOOR
AMBIENT TEMPERATURE CHANGES ARE
ACTUALLY STRONGER PREDICTORS OF
YOUR BLOOD PRESSURE.
YOU CAN SEE SMALL BUT MEANINGFUL
CHANGES, 2 TO 4 MILLIMETERS OF
MERCURY SYSTOLIC IN RELATION TO
THE LAST PRIOR DAYS OUTDOOR OR
INDOOR TEMPERATURE EXPOSURE.
MANY OF YOU ARE PROBABLY AWARE
THAT HYPERTENSION CONTROL RATES
AND BLOOD PRESSURE ARE GENERALLY
HIGHER IN WINTER DUE TO A HOST
OF FACTORS BEYOND JUST THE ACUTE
THERMOREGULATORY
VASOCONSTRICTION AND IMPACTS,
BLOOD PRESSURE SUCH AS WEIGHT
GAIN, ACTIVITY, OTHER BEHAVIORAL
CHANGES, VITAMIN D, BUT CLEARLY
WINTER CAN HAVE AN IMPACT ON
BLOOD PRESSURE.
THIS IS FROM THE ACCOMPLISH TRY
WHICTRIAL, WE HAVE THE DATA, WE
LOOKED AT 10,000 PATIENTS IN
NORTH AMERICA, THE IMPACT OF
SEASON ON BLOOD PRESSURE
CONTROL.
NOW THAT'S BEEN DONE FOR 20
YEARS, BUT WHAT WAS UNIQUE ABOUT
THIS TRIAL, AND THIS ANALYSIS,
WAS THIS WAS DONE IN A VERY,
VERY TIGHTLY CONTROLLED
AGGRESSIVELY TREATED CLINICAL
TRIAL MEASURED ACCURACY BLOOD
PRESSURE TRIAL.
SO PATIENTS WERE ON AVERAGE ON E
MEDICATIONS.
THE BLOOD PRESSURE CONTROL WAS
CLOSE TO 130 SYSTOLIC IN THIS
TRIAL AND DESPITE THE ADDRESS IE
TREATMENT, AGGRESSIVE FOLLOW-UP
AND MANAGEMENT TITRATION OF
MEDICATIONS AND THE GOOD CONTROL
RATE, YOU CAN SEE THE BLOOD
PRESSURE WAS 2 TO 3 MILLIMETERS
OF MERCURY HIGHER IN THE WINTER
IN THE COLDER MONTHS IN NORTH
AMERICA OR IN THE UNITED STATES
IN RELATION TO THE SUMMER MONTHS
AS A REFERENCE AND THE CONTROL
RATE WAS 5 TO 7% LOWER IN THE
COLDER MONTHS.
THIS IS AGAIN ON PEOPLE WHO WERE
VERY AGGRESSIVELY AND WELL
TREATED.
SO THIS IS A IMPACT EVEN IN
MODERN DAY CLINICAL PRACTICE IN
WELL-FREETED PATIENTS.
WELL-TREATED PATIENTS.
PERHAPS MOST IMPORTANTLY FOR
THIS TALK, THERE ARE NOT THAT
MANY BUT THERE ARE A FEW PRETTY
SOLID TRIALS SHOWING THAT DURING
THE PROCESS OF MEASUREMENT OF
BLOOD PRESSURE ITSELF, ACUTE
TEMPERATURE CHANGES, SO NOT JUST
THE PRIOR OR CURRENT DAY OR THE
SEASON, THE TEMPERATURE IN THE
ROOM, EITHER AT HOME OR IN THE
CLINIC WHERE YOU'RE HAVING BLOOD
PRESSURE MEASUREMENT CAN HAVE A
PROFOUND AND RAPID IMPACT ON
YOUR SYSTOLIC AND DIASTOLIC
BLOOD PRESSURE.
SO THE LEFT SIDE PANEL HERE IS A
SLIDE THAT LOOKED AT CLINIC
BLOOD PRESSURE MEASUREMENTS WITH
TEMPERATURE CHANGES BETWEEN
10 DEGREES CELSIUS BEFORE -- FOR
10 TO 15 MINUTES BEFORE
MEASUREMENT AND THEN CROSSED
OVER TO 10 DEGREES CELLS YUM
WARMECELSIUSWARMER AND YOU CAN E
WERE RAPID PROFOUND CHANGES IN
BLOOD PRESSURE WITHIN THE SAME
PERSON WITHIN JUST 10 TO 20
MINUTES OF DIFFERENT TEMPERATURE
CHANGES.
THIS SHOWED ABOUT A 4-MILLIMETER
MERCURY INCREASE IN BLOOD
PRESSURE FOR EVERY 10 DEGREE
CELSIUS LOWER.
A LARGE STUDY FROM YA PAN WHICHT
HAD OVER NEARLY 4,000 PATIENTS
IN MEN AND WOMEN ACROSS
DIFFERENT AGES LOOKED AT HOME
BLOOD PRESSURE AND TEMPERATURE
INSIDE THE HOME DURING
MEASUREMENT IN THE MORNING AS
WELL AS IN THE EVENING AND THIS
WAS JUST REPRESENTATIVE ACROSS
DIFFERENT MEN, WOMEN HAVE THE
SAME IF NOT SLIGHTLY GREATER
IMPACT TO THE SLOPE.
YOU CAN SEE AS YOU AGE, THERE
TENDS TO BE A GREATER IMPACT AS
WELL, WHICH HAS BEEN SHOWN, AND
THAT IS YOUR INDOOR TEMPERATURE
IN YOUR HOUSE DECREASES, YOUR
SYSTOLIC BLOOD PRESSURE DURING
HOME BLOOD PRESSURE MEASUREMENT
INCREASES.
ANOTHER PROFOUND IMPACT IS URBAN
INDUSTRIAL AND MAN-MADE NOISE.
PRESUMABLY ALL NOISES WILL HAVE
THIS IMPACT, BUT MOST OF THE
STUDIES HAVE BEEN BASED UPON
MAN-MADE SOURCES OF NOISE,
OCCUPATIONAL NOISE, AND A LOT OF
NOISE RELATED TO ROADWAYS AND
AIR TRAFFIC.
AND IN GENERAL, 10-DECIBEL
INCREASE OF EXPOSURE TO NOISE IN
YOUR HOME OR EITHER
OCCUPATIONALLY OR NEARBY BEFORE
YOUR BLOOD PRESSURE MEASUREMENT
IS TAKEN, CAN HAVE AN INCREASE
IN HYPERTENSION RATES BY ABOUT
10% ON AVERAGE, LIVING NEAR A
ROADWAY, 50 METERS TO EVEN UP TO
400 METERS CAN INCREASE THE
INSTANCE OF HYPERTENSION BY
ABOUT 13%.
SO THAT'S A LONG-TERM IMPACT.
WHAT ABOUT THE MORE PERTINENT
ACUTE EFFECT OF NOISE WITHIN
REASONABLE CHANGES THAT PEOPLE
ARE EXPOSED TO?
I KNOW WE'RE SUPPOSED TO MEASURE
BLOOD PRESSURE IN A TEMPERATURE
CONTROLLED QUIET SETTING, BUT IN
THIS TRIAL ON THE LEFT, IT WAS A
VERY INTERESTING STUDY WHERE
THEY HAD -- THE PARTICIPANTS
LISTENED TO DIFFERENT TYPES OF
OCCUPATIONAL NOISE SOUNDS
THROUGH HEADPHONES WHICH WERE
MIMICKED, AND THEN MEASURED
BLOOD PRESSURE DURING ACTUALLY
LISTENING TO THE NOISE, SO VERY
ACUTELY, WHAT WAS THE IMPACT?
AND IN THIS STUDY, IT'S SHOWN
ABOUT A MILLIMETER OF MERCURY
INCREASE PER 10-DECIBEL INCREASE
IN OCCUPATIONAL NOISE SOUND
DURING THE PROCESS OF
CLINIC-BASED MEASUREMENT.
THERE'S BEEN A FEW STUDIES THAT
HAVE LOOKED AT WHAT THE IMPACT
OF REALTIME NOISE EXPOSURE IS ON
ABPM MEASUREMENTS, AND NOT
SURPRISINGLY AND QUITE
INTERESTINGLY, YOU SEE SOME OF
THAT VARIABILITY THROUGH THE
COURSE OF THE DAYS, OF COURSE
STRESS AND ACTIVITY AND POSITION
AND FOOD AND SLEEP AND
EVERYTHING WE KNOW ABOUT, BUT IN
FACT, YOUR TEMPERATURE AND
CLEARLY IN THIS STUDY IT LOOKED
AT PATIENTS' INDIVIDUAL NOISE
METER EXPOSURE IMMEDIATELY
PROXIMAL TO THE AMBULATORY BLOOD
PRESSURE MEASUREMENT SHOW 1 TO O
ACUTE IMPACTS OF BOTH
TEMPERATURE AND NOISE.
MY RESEARCH FOR THE LAST 25
YEARS HAS BEEN ON FINE
PARTICULATE MATTER, AIR
POLLUTION AND CARDIOMETABOLIC
HEALTH EFFECTS.
I CAN SAY WITHOUT ANY DOUBT AND
CONCLUSION THAT AIR POLLUTION IS
A RISK FACTOR OF CAUSALLY
RELATED TO CARD VO VASCULAR
DISEASE, RELATED TO THE
INCIDENCE OF CARDIAC DISORDERS
INCLUDING HYPERTENSION AND
DIABETES MELLITUS, AIR POLLUTION
ALSO INCREASES BLOOD PRESSURE,
DOES SO SIMILAR TO MEN
ENVIRONMENTAL FACTORS,
HYPERACUTELY WITHIN HOURS,
ACUTELY WITHIN DAYS AND THEN
CHRONICALLY -- AND THIS WAS ONE
OF SEVERAL MAIN ANALYSES THAT
LOOKED AT THE IMPACT OF THE
INCIDENCE OF LONG TERM FINE
PARTICULATE MATTER, AIR
POLLUTION MATTER, AIR POLLUTION
EXPOSURE BY ABOUT 10MB PER CUBIC
METER.
IN MANY PARTS OF THE COUNTRY, 3,
4 BILLION PEOPLE -- SORRY, OF
THE GLOBE, 3 BILLION PEOPLE ARE
EXPOSED TO MUCH HIGHER LEVELS,
100 TO 200 PER CUBIC METER IN
SOUTH ASIA, INDIA, AND NORTHERN
CHINA, FOR EXAMPLE, ON A ROUTINE
BASIS, SO THIS HAS PROFOUND
GLOBAL IMPACT ON BLOOD PRESSURE.
THIS WAS A SERIES OF STUDIES WE
DID OVER 15 YEARS.
WE DID MANY PANEL STUDIES OF
REAL WORLD EXPOSURES, BUT WE
ALSO WANTED TO SEE WHAT WAS THE
HYPERACUTE IMPACT OF EXPOSURE TO
AIR POLLUTION WHILE YOU'RE BEING
EXPOSED.
AND THIS IS A EXPOSURE CHAMBER
FACILITY THAT WAS A MOBILE UNIT
THAT WE TOOK TO DIFFERENT PLACES
ACROSS THE COUNTRY, MOSTLY IN
MICHIGAN AS WELL AS IN CA CANADA
AND TORONTO, ONTARIO, AND WE
WERE ABLE TO LOOK AT WHAT
CONTROLLED EXPOSURE TO FINE
PARTICULATE MATTER AT AROUND 15R
WHICH IS A COMMON EXPOSURE IN
MUCH OF THE WORLD, 3 BILLION
PEOPLE HAVE BEEN EXPOSED TO
THIS, AND WHAT'S THE IMPACT OF
THIS AS COMPARED TO FILTERED AIR
WITH NO PM2.5 AND NO OTHER GASES
OVER A TWO-HOUR PERIOD.
AND WE ORIGINALLY SHOWED
VASOCONSTRICTION, HEART RATE
VARIABILITY CHANGES, BUT
CONSISTENTLY OVER A DECADE,
DECADE 1/2 OF EXPOSURES, WE SAW
DURING THE FINE PARTICULATE
MATTER EXPOSURE, DISCERNIBLE AND
REPRODUCIBLE COHERENT INCREASES
IN SYSTOLIC BLOOD PRESSURE IN
THE RANGE OF 1 TO 3 MILLIMETERS
OF MERCURY AND QUITE
REPRODUCIBLE DURING THE ACTUAL
INHALATION OF AIR POLLUTION.
SO TAKING ALL THIS INTO ACCOUNT,
AND THIS IS JUST SOME OF THE
IMPACTS, SOME OF THE MOST COMMON
ONES THAT WE ARE EXPOSED TO, WE
ASKED CAN WE ACTUALLY MEASURE
BLOOD PRESSURE OUT IN A
COMMUNITY SETTING OUTSIDE FOR
SCREENING PURPOSES.
WE HAVE PART OF -- WE'RE LUCKY
TO BE PART OF A P50 CENTER AT
WAYNE STATE UNIVERSITY LOOKING
AT MOBILE HEALTH UNITS AS A
MEANS TO ATTACK HEALTH
DISPARITIES AND EQUITY IN
RELATION TO CARDIAC RISK FACTOR
CONTROL IN WAYNE COUNTY AND
PRINCIPALLY I IN THE CITY OF
DETROIT AND COMMUNITIES OF COLOR
ACROSS DETROIT.
ONE OF THE NOVEL ADAPTATIONS TO
THIS WHICH WAS LAUNCHED DURING
2020 FOR COVID WAS THE
MEASUREMENT AND SCREENING OF
CARDIOMETABOLIC RISK FACTORS,
AND THE MOBILE UNITS NOW
SCREENED OVER ABOUT 75,000 TO
80,000 INDIVIDUAL LIVES OVER THE
LAST THREE YEARS HAVE WELL OVER
I THINK NOW 15,000 BLOOD
PRESSURE MEASUREMENTS.
NOW THIS WAS DONE GENERALLY
BECAUSE THE PURPOSE OF THESE
MOBILE UNITS WAS TO SCREEN A
HIGH THROUGHPUT LARGE NUMBER OF
PATIENTS RIGHT IN THEIR OWN
COMMUNITY, 250 DIFFERENT
PARTICIPATING COMMUNITY SITES
ACROSS THE CITY OF DETROIT.
WHAT WOULD BE THE IMPACT OF
MEASURING BLOOD PRESSURE OUTSIDE
ON BLOOD PRESSURE?
AND WHAT WE SHOWED HERE IN THIS
SMALL TRIAL WAS WE TRIED TO
VALIDATE THE IMPACT OF MEASURING
BLOOD PRESSURE WHICH IS OFTEN
DONE WHILE PATIENTS ARE IN THEIR
CAR FOR A HIGH-THROUGHPUT
MECHANISM.
AS COMPARED TO WHAT'S DONE IN
THE CLINIC.
SO BLOOD PRESSURE IS MEASURED IN
THE CLINIC, THEY ARE TRANSPORTED
TO THE CAR, AND THEN MEASURED IN
THE CLINIC AFTERWARDS, AND WE
WANTED TO SEE THE IMPACT OF THE
DIFFERENT ENVIRONMENTAL FACTORS,
TEMPERATURE, NOISE, POLLUTANTS
AND SUCH, AND PERHAPS THE
DIFFERENCE BETWEEN MEASUREMENT
OF BLOOD PRESSURE IN THE CAR.
THESE ALL FOLLOWED VERY
STRINGENTLY USING THE AUTOMATED
BLOOD PRESSURE MEASUREMENT OF
5 MINUTES SEATED BEFOREHAND,
SHOULD LOOK THE A READINGS AND
OF COURSE STRICT ADHERENCE TO
THE GUIDELINES FOR BLOOD
PRESSURE MEASUREMENT.
AND IN THIS STUDY OF 100
PATIENTS, WHAT WE SHOWED WAS
ESSENTIALLY THE DIFFERENCES
BETWEEN -- THERE'S A LARGE
VARIATION IN THE TEMPERATURE
CHANGES AND THE SEASONS.
AND THESE ARE THE MAIN RESULTS,
THAT AS IS COMMON FOR BLOOD
PRESSURE, THE CAR BLOOD PRESSURE
WAS VERY CLOSE TO THE CLINIC
BLOOD PRESSURE AS YOU CAN SEE,
BUT WIDE INTERINDIVIDUAL
VARIABILITY.
SO FOLLOWING AND ADAPTING THE
UNIVERSAL STANDARD FOR
VALIDATION BLOOD PRESSURE
MEASUREMENT DEVICES, WE TRIED TO
VALIDATE THIS METHODOLOGY DUE TO
ALL THE POTENTIAL IMPACTS OF
MEASURING BLOOD PRESSURE OUTSIDE
IN A CAR.
AND WHAT WE SHOWED WAS 85% OR 8H
SYSTOLIC AND DIASTOLIC BLOOD
PRESSURES, BOTH OF THEM LESS
THAN OR EQUAL TO 10 MILLIMETERS
OF MERCURY DIFFERENT BETWEEN THE
AVERAGE OF THE BEFORE AND AFTER
CLINIC READINGS AND THE CAR
BLOOD PRESSURE.
AND OF COURSE THE MEANS WERE
QUITE CLOSE, BUT THERE WAS
ALWAYS VARIATIONS ACROSS
INDIVIDUALS, WHICH IS IMPORTANT
FOR CATEGORIZATION OF DATA.
SO MANY ENVIRONMENTAL FACTORS
CAN INFLUENCE BLOOD PRESSURE
BOTH ACUTELY, CHRONICALLY AND
HYPERACUTELY, AS WELL AS PROMOTE
THE ONSET OF HYPERTENSION.
TEMPERATURE, WE ALL KNOW ABOUT,
HAS AN IMPACT ON ALL LIVING PLA
MALLS.
LIVING
MAMMALS, SEASON HAS A LARGER
IMPACT BECAUSE OF TEMPERATURE
PLUS OTHER FACTORS.
NOISE, EVEN AT A 30 TO
40-DECIBEL RANGE WHICH IS ABOUT
A QUIET CLINIC SETTING, ANYTHING
ABOVE THAT WILL BE RELEVANT TO
IMPACTING BLOOD PRESSURE NOT
JUST CHRONICALLY BUT ALSO WHILE
IT'S MEASURED, SO IN A BUSY COLD
HALLWAY DURING WINTER, YOU CAN
BE ASSURED THAT BLOOD PRESSURE
WILL BE HIGHER.
BLOOD PRESSURE CAN BE ACCURATELY
DETERMINED IN A COMMUNITY
SETTING AS WE SHOWED OUTDOORS.
IF YOU'RE AWARE OF THESE
ENVIRONMENTAL FACTORS, AND YOU
RELIGIOUSLY FOLLOW THE
MEASUREMENT GUIDELINES AND TRY
TO MITIGATE THE ENVIRONMENTAL
FACTORS AS MUCH AS POSSIBLE.
IN THE CARS, WE HAD OF COURSE
AIR CONDITIONING IN THE SUMMER,
HEATING IN THE WINTER AND TRIED
TO HAVE NOISE AND OTHER
ENVIRONMENTAL EXPOSURES
MITIGATED AS MUCH AS POSSIBLE.
OF COURSE IT'S NOT ENTIRELY
POSSIBLE TO ALLEVIATE ALL OF
THEM, BUT YOU CAN SEE, IT IS
PLAUSIBLE TO SAY THAT THIS MASS
SCREENING COULD BE A HIGH
THROUGHPUT SCREENING METHOD OF
BLOOD PRESSURE MEASUREMENT
OUTDOORS IN A CAR.
SO GAPS AND FUTURE KNOWLEDGE.
BASICALLY I THINK IT IS WELL
RECOGNIZED FOR MANY, MANY
DECADES ESSENTIALLY THAT
TEMPERATURE NOISE CAN IMPACT
BLOOD PRESSURE ACUTELY.
I THINK THIS NEEDS TO BE PAID A
LITTLE BIT MORE ATTENTION TO IN
SPECIFIC IN THE GUIDELINES FOR
WHAT TEMPERATURE SHOULD BE, WHAT
NOISE LEVEL SHOULD BE BOTH AT
HOME AS WELL AS IN THE CLINIC,
AS WELL AS THE POTENTIAL FOR
RECENT IMPACTS.
WE'VE SHOWN IN MANY STUDIES THAT
TEMPERATURE THE DAY BEFORE
CLINIC MEASUREMENTS, AIR
POLLUTION THE DAY BEFORE, THE
DAY OF, BLOOD PRESSURE
MEASUREMENTS CAN RAISE BLOOD
PRESSURE 5, 6 MILLIMETERS OF
MERCURY AND MOST CLINICIANS, OF
COURSE, ARE NOT AWARE OF THE
ACUTE IMPACTS OF POLLUTANTS AS
WELL AS TEMPERATURE AND NOISE ON
BLOOD PRESSURE.
NOT JUST WHILE YOU'RE MEASURING
IT BUT ALSO WITHIN THE LAST DAY
OR SO.
WHAT IS THE IMPACT OF THE
ENVIRONMENT AND HOW -- PERHAPS
SOME OF THIS VARIABILITY BETWEEN
DAYS AND EVEN WITHIN DAY IS DUE
TO THE ENVIRONMENT, AS IT SHOWED
WITH NOISE, CLEARLY ALSO BEEN
SHOWN WITH TEMPERATURE AND WE'VE
SHOWN WITHIN THE LAST FEW YEARS
OF AIR POLLUTION, HOW MUCH OF
THIS IMPACTS KNOCK TURNING
DNOCTURNAL DIPPING,OUR COLLEAGUD
A LOT OF DATA ON AIRCRAFT NOISE,
IN FACT IN NOCTURNAL BLOOD
PRESSURE AND HOW MUCH OF THIS
REAL WORLD EXPOSURES THAT WE
ENCOUNTER THROUGHOUT OUR DAY AND
THE ROLE IN THE DIFFERENCE
BETWEEN -- THERE'S SOME
ARTIFICIALALITY BETWEEN THE
CLINIC READING AND PERHAPS
THERE'S A MORE GOOD WINDOW INTO
WHAT WE'RE EXPOSED TO IN OUR
REAL LIFE AND WHY IT MIGHT BE
SLIGHT LEHIGHER.
THIS WILL HAVE PROFOUND IMPACT
ON CUFFLESS BLOOD PRESSURE
MEASUREMENTS OF COURSE AND RAPID
INCREASES AND LASTLY
IMPLICATIONS FOR
HYPERMANAGEMENT.
HOW CAN WE MOVE FORWARD IF WE
WANT TO HAVE A MASS
HIGH-THROUGHPUT TENSION
SCREENING PROGRAMMING IN
COMMUNITIES.
BUILDING A FEW MORE BRICK AND
MORTAR CLINICS IS NOT GOING TO
SOLVE THIS PROBLEM AND OUR MOBIL
HEALTHCARE PROGRAM WITH REMOTE
PATIENT MONITORING LINKAGE IS
ONE OF THE SOLUTIONS TO TRY TO
IMPROVE POPULATION LEVEL BLOOD
PRESSURE.
CAN WE ACCURATELY SCREEN BLOOD
PRESSURE WITH THIS METHOD AND
CHARACTERIZE PEOPLE FOR
APPROPRIATE FOLLOW-UP WITH HOME
BLOOD PRESSURE MONITORING BASED
UPON THOSE READINGS.
AND THEN THERE ARE CLEARLY OTHER
THINGS THAT CLINICIANS NEED TO
BE MORE AWARE OF, WHICH IS
IMPACTS OF SEASON ON BLOOD
PRESSURE, AS WELL AS OTHER
IMPACTS SUCH AS I'VE HAD
PATIENTS TRAVEL TO DENVER AND
HAVE BLOOD PRESSURE BE
20 MILLIMETERS OF MERCURY HIGHER
WITH JUST THAT LEVEL OF
ELEVATION.
I THINK MOST CLINICIANS ARE NOT
AWARE OF WHAT THESE TYPES OF
SEASONAL AND OTHER ENVIRONMENTAL
FACTORS CAN HAVE ACUTELY AS WELL
AS SUBACUTELY ON BLOOD PRESSURE.
AND THAT IS, I THINK, THE LAST
SLIDE.
THANK YOU.
>> GREAT.
THANK YOU SO MUCH, DR. BROOK,
FOR THAT THOUGHT-PROVOKING
PRESENTATION.
WE'RE GOING TO MOVE ON TO OUR
LAST SPEAKER IN OUR SESSION, AND
I JUST WANT TO ENCOURAGE FOLKS
TO PUT YOUR QUESTIONS IN THE Q &
A OR THE CHAT SO THAT WE CAN
HAVE A ROBUST PANEL DISCUSSION
IN A FEW MINUTES.
OUR NEXT SPEAKER IS DR. JESUS
MELGAREJO, WHO IS AN ASSISTANT
PROFESSOR OF NEUROSCIENCE AT THE
INSTITUTE OF NEUROSCIENCE AT THE
UNIVERSITY OF TEXAS, RIO GRANDE
VALLEY.
HE IS A PHYSICIAN SCIENTIST
DEVOTED TO MULTIDISCIPLINARY
CLINICAL AND EPIDEMIOLOGICAL
RESEARCH.
HIS SCIENTIFIC FOCUS AND
RESEARCH INTERESTS ARE TO EE
ELUCIDATE THE CONTRIBUTION OF
24-HOUR BLOOD PRESSURE ON THE
DEVELOPMENT AND PROGRESSION OF
AGE-RELATED CONDITIONS.
TODAY HE'LL BE SPEAKING TO US
ABOUT IDENTIFYING AND USING
NOVEL DEVICE-BASED PHENOTYPES.
>> THANK YOU VERY MUCH,
PROFESSOR WALL, FOR YOUR
INTRODUCTION.
AND GOOD MORNING, EVERYONE.
I THINK IT'S STILL MORNING IN
SOME OTHER AREAS OF THE UNITED
STATES, SO I AM JESUS MELGAREJO
AND I HAVE TO THANK THE
ORGANIZERS FOR PREPARING THIS
IMPORTANT WORKSHOP ON BLOOD
PRESSURE ASSESSMENT ACROSS THE
LIFESPAN.
IT AN HONOR TO MEET HERE TODAY
AND TALK ABOUT IDENTIFYING AND
USING NOVEL DEVICE BASED
PHENOTYPES.
I HAVE NO CONFLICTS OF INTEREST.
SO WHY DO WE MEASURE BLOOD
PRESSURE?
ESSENTIALLY WE DO IT BECAUSE WE
NEED TO TREAT HYPERTENSION.
WE HAVE ALREADY DISCUSSED WE ARE
WELL AWARE ABOUT THIS, THAT
TREATING BLOOD PRESSURE,
DIAGNOSING, TREATING AND
CONTROLLING BLOOD PRESSURE IS
ONE OF THE MAIN MODIFIABLE RISK
FACTORS THAT ARE ASSOCIATED WITH
AN IDEAL LIFECOURSE, AND THAT'S
THE -- WHEN WE LOOK INTO OUR
LIFESPAN AND WE WANT TO ACHIEVE
THIS GREEN LINE, BUT OF COURSE
WE KNOW THERE'S AN AVERAGE
LIFECOURSE IN WHICH INDIVIDUALS,
THEY HAVE A HIGHER RISK OF
DEVELOPING TARGET ORGAN DAMAGE
OR MAJOR CARDIOVASCULAR EVENTS.
THEN WE HAVE THOSE INDIVIDUALS
IN WHICH THEY HAVE POOR VASCULAR
AGING, SO THEY HAVE REALLY
POORLY CONTROLLED BLOOD
PRESSURE, THEY HAVE DIABETES, SO
WHAT WE WANT TO DO WHEN WE
MEASURE BLOOD PRESSURE IS TO --
BUT ALSO IDEAL LIFECOURSE OF
AGING, SO CONDITIONS THAT ARE
CHRONIC, PROGRESSIVE,
DEBILITATING, AND IRREVERSIBLE,
WE DECREASE THE RISK OF
DEVELOPING THOSE CONDITIONS.
AND IT HAS BEEN FUNDAMENTAL, THE
USE OF CLINIC, OFFICE OR
CONVENTIONAL BLOOD PRESSURE TO
ASSESS CARDIOVASCULAR RISK, TO
ASSESS INDIVIDUALS' RISKS AND
THE INTRODUCTION OF OUT OF
OFFICE MEASUREMENTS HAS PROVIDED
NEW CLUES ABOUT THE BEHAVIORS IN
BLOOD PRESSURE AN.
SO WHAT WE MEAN BY THIS, OF
COURSE WE NEED TO FOCUS ON
TREATING THE BLOOD PRESSURE
LEVEL, BUT DEVICES, OUT OF
OFFICE DEVICES ALLOW US TO HAVE
NOVEL PHENOTYPES BACK IN THE END
OF THE 80s, WHICH BECAUSE OF
THE 24-HOUR AMBULATORY BLOOD
PRESSURE MONITORING, WE WERE
ABLE TO CAPTURE DAY TIME AND
NIGHTTIME BLOOD PRESSURE AND,
THEREFORE, WE WERE ABLE TO
DESCRIBE DIP IN CIRCADIAN
RHYTHMS IN BLOOD PRESSURE SUCH
AS NORMAL DIPPING, REVERSE
DIPPING, OR EXTREME DIPPING.
SO WE STARTED TO HAVE SOME CLUES
ABOUT, FOR EXAMPLE, CARDIAC
RHYTHMS AND BLOOD PRESSURE, BUT
ALSO WHEN WE COMPARE THE OUT OF
OFFICE MEASUREMENTS WITH THE
OFFICE ONES, WE ARE ALSO ABLE TO
CLASSIFY AND TO GIVE
CLASSIFICATION OF HYPERTENSION
SUCH AS MASKED HYPERTEANGS,
SUSTAINED HYPERTENSION, OR WHITE
COAT HYPERTENSION, WHICH THIS
HAS BEEN DISCUSSED YESTERDAY AS
WELL.
AND THEN BECAUSE, FOR INSTANCE,
24 HOUR BLOOD PRESSURE
MONITORING, WE'RE ABLE TO
CAPTURE INFORMATION EVERY 15
MINUTES OR 20 MINUTES OR 30
MINUTES DURING THE DAY TIME, AND
30 MINUTES OR EVERY HOUR DURING
THE NIGHTTIME, SO BECAUSE WE
STARTED HAVING REPEATED
MEASUREMENTS, WE WERE ABLE TO
QUANTIFY VARIABILITY.
SO THIS IS AN IMPORTANT CONCEPT
BECAUSE OUR CARDIOVASCULAR
SYSTEM IS DYNAMIC.
SO IF I TAKE A BLOOD PRESSURE
RIGHT NOW AND THEN I TAKE IT
AGAIN, WE KNOW THERE'S GOING TO
BE A VARIATION IN BLOOD
PRESSURE.
THERE'S A NORMAL VARIATION IN
BLOOD PRESSURE BUT THEN WITH --
OF VARIABILITY, THERE WAS A
CUMULATIVE EVIDENCE SHOWING THAT
IN INDIVIDUALS WITH HIGH BLOOD
PRESSURE VARIABILITY, THEY WERE
AT THE HIGHER RISK OF TARGET
ORGAN DAMAGE SUCH AS SMALL
VESSEL DISEASE, HYPERTROPHY AND
ALSO MAJOR ADVERSE COMPLICATIONS
OR HEART ATAKE, HEART FAILURE,
STROKE.
SO THE INTRODUCTION OF OTHER OUT
OF OFFICE MEASUREMENTS, THEY
ALLOW US TO HAVE A BETTER
UNDERSTANDING OF THIS CONCEPT OF
BLOOD PRESSURE RAPIDLY.
AND WHEN DO WE MEASURE BLOOD
PRESSURE, WE CAN TAKE BLOOD
PRESSURE VARIABILITY
WITHIN SECONDS, MINUTES, WITHIN
A DAY, WITHIN DAYS, AND THAT'S
WHAT GIVES US WHETHER WE HAVE
VERY SHORT-TERM VARIABILITY,
LONG-TERM VARIABILITY.
SO I WANTED TO TAKE THE MESSAGE
THAT THE INTRODUCTION -- ALLOWS
US TO HAVE A BETTER
UNDERSTANDING TO IMPROVE THE
RISK STRATIFICATION.
THEN UP TO HERE, YOU MIGHT
ASK -- SO WITH THE CLINIC BLOOD
PRESSURE, IF WE DID OUT OF
OFFICE MEASUREMENTS, WE WERE
ABLE TO IMPROVE THE RISK OF
STRATIFICATION CARDIOVASCULAR
COMPLICATION, NEUROLOGIC
COMPLICATIONS TO CONTROL BLOOD
PRESSURE, WHY DO WE SE SEARCH FR
NOVEL DEVICE BASED PHENOTYPES
AND WHAT DO WE SEARCH IN THAT?
SO ESSENTIALLY, THIS IS JUST ONE
FOCUS OF WHY DO WE SEARCH FOR
NOVEL-BASED DEVICES, THIS IS AN
EXAMPLE OF WHY THE NEED FOR
CUFFLESS DEVICES.
NED THERE WAS AN IMPRESSIVE TALK
ABOUT THE APPLICABILITY OF THESE
DEVICES BUT I JUST WANT TO
EMPHASIZE THAT WITH FOR EXAMPLE
THE 24 -- THERE ARE LIMITATIONS.
SO HERE WE HAVE SOMEBODY
DIAGNOSED WITH HYPERTENSION,
OLDER ADULT.
THE TREATMENT OF HYPERCONTROL
WOULD NOT RELY ON USING JUST ONE
24 HOUR BLOOD PRESSURE AT THE
BASELINE.
THERE'S GOING TO BE CONTINUOUS
ASSESSMENTS EVERY SIX MONTHS OR
EVERY YEAR AND -- THIS IS JUST
TO GIVE AN EXAMPLE OF HOWL
THESE -- THE LIMITATIONS OF THE
CURRENT -- THE CUFFED DEVICES
THAT WE HAVE RIGHT NOW, WHY WE
NEED A TRANSITION OR WE ARE
LOOKING INTO TRANSITION.
THERE'S ALSO TOLERABILITY, TIME
TO ACQUIRE MEASUREMENT, AND
AVAILABILITY OF CUFF SIZE WHICH
WAS ALSO WELL DESCRIBED
YESTERDAY.
SO THE NEED FOR TRANSITION LOOK
INTO CONTINUED MEASUREMENTS
WHICH I'M GOING TO TALK A LITTLE
BIT MORE LATER, IMPROVE COMFORT,
COMFORT AND COMPLIANCE,
INTEGRATION -- LARGER SCALE USE.
IMAGINE THAT WE HAVE 24-HOUR
MONITORING BLOOD PRESSURE THAT
WE WANT TO APPLY AT THE
POPULATION LEVEL TO EVERYONE.
THAT'S NOT GOING TO BE FEASIBLE
OR COMPARED TO, FOR EXAMPLE,
THERE IS A SMART WATCH, A
CUFFLESS DEVICE THAT CAN DO
THIS, COMPARED TO THAT, THE
LARGEST -- IS GOING TO BE --
EARLIER -- WHICH WILL RESULT IN
BETTER -- SO THIS WAS DISCUSSED
YESTERDAY, I'M GOING TO TALK A
LOT ABOUT THIS.
IT JUST TO MENTION THAT ALTHOUGH
THIS IS WHERE WE ARE
TRANSITIONING, WE NOW KNOW THE
OSCILLOMETRIC DEVICES IN CLINIC,
THE ONES THAT ARE VALIDATED FOR
CLINICAL USAGE, MEANING THAT THE
BLOOD PRESSURE INFORMATION WE
GET OUT OF THESE IS THE ONE THAT
WE CAN USE FOR MAKING DECISIONS
BUT AS YOU CAN SEE HERE, THERE
ARE OTHER TYPE OF DEVICES SUCH
AS FINGER CUFF,
PHOTOPLETHYSMGRAPHY, LET'S SEE
WHERE WE'RE GOING TO GO BUT
PROVIDE THAT THESE DEVICES CAN
MAKE SURE OR GET AS ACCURATE AS
POSSIBLE BLOOD PRESSURE
READINGS, WE'RE GOING TO BE ABLE
TO GET NOVEL PHENOTYPES AND
THAT'S IN THE NEXT SLIDE,
PLEASE.
SO WHAT DO WE SEARCH WITH THESE
DEVICES, NOT ONLY DEVICES BUT
THE PHENOTYPES.
SO THE IDENTIFICATION OF NOVEL
BLOOD PRESSURE TRAITS OR
PHENOTYPES, I BELIEVE WE'LL HAVE
THREE ASPECTS.
BLOOD PRESSURE LEVEL, OF COURSE,
VARIABILITY, AND MULTISENSORS.
I'M GOING TO GET THERE TOO.
WHAT I MEAN BY THAT.
SO BLOOD PRESSURE LEVEL OVER
TIME, BECAUSE GUIDELINES OR
CLINICAL DECISIONS ARE STILL
BASED ON THE MEAN BLOOD
PRESSURE, THE AVERAGE BLOOD
PRESSURE OF THE BLOOD PRESSURE
MEASUREMENTS THAT WE CAPTURE.
SO IF WE HAVE AN INCREASED
NUMBER OF READINGS THAT WE ARE
RECORDING, THE ACCURACY OF WHAT
THAT PERSON'S TRUE BLOOD
PRESSURE IS, IS GOING TO BE
HIGHER, SO THE DEVICES ARE GOING
TO BE ABLE TO GIVE US MORE
INFORMATION ABOUT THE
INDIVIDUAL'S BLOOD PRESSURE
LEVEL, WHICH IS THE ONE WE'RE
STILL USING FOR COMMON USE.
I WROTE HERE, NOVEL RISK FACTOR.
IT DOESN'T MEAN IT NO THE A RISK
FACTOR BECAUSE WE KNOW THAT FOR
DECADE, PROBABLY AROUND FIVE
DECADES, BLOOD PRESSURE
VARIABILITY HAS BEEN ASSOCIATED
WITH TARGET ORGAN DAMAGE,
CARDIOVASCULAR EVENTS AND
MORTALITY.
BUT WHAT I MEANT HERE IS THAT
FOR CERTAIN CONDITIONS SUCH AS
ALZHEIMER'S DISEASE RELATED
DISORDERS, COGNITIVE IMPAIRMENT
OR SMALL VESSEL DISEASE, WHICH
WAS DISCUSSED YESTERDAY, FOR
THESE CONDITIONS, IT SEEMS THAT
VARIABILITY IN BLOOD PRESSURE OR
VARIABILITY IN OUR
CARDIOVASCULAR SYSTEM MIGHT BE
AN IMPORTANT OR MORE IMPORTANT
RISK FACTOR COMPARED TO THE
BLOOD PRESSURE LEVEL FOR THESE
CONDITIONS.
ONE EXAMPLE WHICH WAS DISCUSSED
YESTERDAY FOR SMALL VESSEL
DISEASE AS THE BRAIN -- THESE
AREAS ARE MORE SUSCEPTIBLE TO
DRASTIC CHANGES IN BLOOD
PRESSURE.
SO IN ALSO INDIVIDUALS WITH
ARIZONA DISEASE AND RELATED
DISORDERS, THE PROBABILITY OF
THE BRAIN TO MAINTAIN CONSTANT
BLOOD FLOW IS IMPAIRED, SO IF
THAT INDIVIDUAL FACES BLOOD
PRESSURE, THEN WE MIGHT BE AT
HIGHER RISK OF PROGRESSION OF
THE SPECIFIC DISEASE.
SO FOR CERTAIN CONDITIONS --
NOVEL RISK FACTORS, AND WE KNOW
FOR BLOOD PRESSURE VARIABILITY,
IN ORDER TO CAPTURE ENOUGH
INFORMATION SO VARIABILITY AS A
PHENOTYPE HAS SUFFICIENT
DIAGNOSTIC INFORMATION, WE NEED
TO HAVE AN ADEQUATE NUMBER OF
READINGS.
AND THAT HAPPENS FOR 24 HOUR
BLOOD PRESSURE IF WE HAVE ENOUGH
READINGS, THE VARIABILITY WE CAN
QUANTIFY OUT OF THAT APPROACH IS
NOT GOING TO BE SUFFICIENT TO
REACH A STATISTICAL
SIGNIFICANCE.
SO THIS CONCEPT OF THE NUMBER OF
RINGS THAT WE NEED TO CAPTURE
VARIABILITY WILL BE SIMILAR AS
WHEN WE DO STATUS IN WHICH WE
NEED TO CALCULATE THE SIMPLE --
SO WE NEED TO HAVE A CERTAIN
NUMBER OF READINGS SO WE CAPTURE
ENOUGH INFORMATION FOR US TO
FIND SIGNIFICANT -- BUT I WANT
TO SAY JUST TO CAPTURE ENOUGH OF
THE -- OF THAT INDIVIDUAL.
THERE ARE CONDITIONS AS WELL
HERE IN WHICH 24 HOUR BLOOD
PRESSURE MONITORING HAS BEEN
ASSOCIATED WITH THE
QUANTIFICATION OF VARIABILITY,
AND THEN THE SENSORS.
IT WAS VERY WELL DISCUSSED FOR
EXAMPLE IN THE ENVIRONMENT.
I AM FROM VENEZUELA, MOST OF THE
WORLD, WE KNOW THERE'S WINTER,
THERE'S SUMMERTIME, AND THERE
ARE VARIATIONS IN THE BLOOD
PRESSURE RELATED TO THE SEASONAL
CHANGES AND THE DEVICES THAT ARE
GOING TO BE ABLE TO CAPTURE
AROUND TEMPERATURE, WE JUST DUSH
THAT'S GOING TO PROVIDE
INFORMATION FOR US TO DETERMINE
THAT BLOOD PRESSURE CHANGES
MIGHT BE RELATED NOT TO THE
UNDERLYING DISEASE BUT TO THE
ENVIRONMENTAL FACTORS.
THE OW POTENTIAL ADVANCEMENTS IN
DEVICE-BASED PHENOTYPES.
IT WAS MENTIONED YESTERDAY AS
WELL.
WHAT ARE WE GOING TO DO IF WE
HAVE A DEVICE THAT CONTINUOUSLY
MEASURES BLOOD PRESSURE FOR --
CONTINUOUSLY, EVERY MINUTE, FOR
24 HOURS, FOR 7 DAYS, FOR
365 DAYS, HOW CAN WE ANALYZE
THAT INFORMATION, WHAT WE'RE
GOING TO DO WITH THAT AMOUNT OF
INFORMATION?
I DON'T THINK WE CAN EXPECT
THAT, FOR EXAMPLE, WE CONTINUE
USING THE CONVENTIONAL METRICS
OF AVERAGING OR THE MEAN BLOOD
PRESSURE OR CALCULATING
VARIABILITY AS A STANDARD
DEVIATION OR AVERAGE
VARIABILITY, BECAUSE IT'S A HUGE
AMOUNT OF DATA.
IT'S COMPLEX DATA, THE COMPLEX
DYNAMIC SYSTEM, BUT STILL THE
DEVICES ARE GOING TO BE ABLE TO
CAPTURE THIS INFORMATION AND,
FOR EXAMPLE, HELP US UNDERSTAND
WHETHER THERE ARE BEHAVIORS IN
BLOOD PRESSURE AND ONE WAY TO DO
IT IS TO, FOR EXAMPLE, CLUSTER
ANALYSIS.
SO HERE -- WHEN WE TALK ABOUT
STUDIES ASSESSING BLOOD
PRESSURE, THIS IS A
MULTIDISCIPLINARY EFFORT,
MEANING THAT WE NEED DIFFERENT
APPROACHES FOR DIFFERENT
SCIENCES IN ORDER TO -- WHETHER
WE CAN BRING THESE APPROACHES TO
APPLY TO THIS DATA THAT WE HAVE.
OFFICE BLOOD PRESSURE COMPARED
TO WHAT THE DEVICES CAN MEASURE
THE TYPE OF DATA CONTINUOUSLY
DOES NOT PROVIDE THAT
OPPORTUNITY, BUT IF WE GET
THERE, WE'RE GOING TO BE ABLE --
AND HERE THIS IS SOME WORK WE'VE
BEEN DOING WHICH THE 24-HOUR
BLOOD PRESSURE DATA, WE'RE
ANALYZING THAT INFORMATION AS A
TIME SERIES DATA.
SO BECAUSE WE DO SO, WE'RE ABLE
TO GENERATE SOME CLUSTERS OF
INDIVIDUALS WHO MIGHT HAVE THE
SPECIFIC BEHAVIOR IN THEIR BLOOD
PRESSURE, IN THE GRAPHIC THAT
YOU CAN SEE ON YOUR RIGHT SIDE,
AND MAYBE FOR CERTAIN CONDITIONS
SUCH AS ALZHEIMER'S DISEASE, THE
COMPLEXITY OF THE CARDIOVASCULAR
SYSTEM WILL RESULT IN A
DIFFERENT PATTERN, A DIFFERENT
BEHAVIOR, AND THAT'S ANOTHER
PHENOTYPE.
THE PROBLEM IS GOING TO BE
ANOTHER PHENOTYPE THAT DOES NOT
ONLY INVOLVE VARIABILITY
CAPTURING BY A STANDARD
DEVIATION.
UNFORTUNATELY THE DEVICES WE
HAVE RIGHT NOW, WE CANNOT REALLY
EXPLOIT THAT, BUT I BELIEVE ONCE
NO DEVICES CAN ACCURATELY
MEASURE BLOOD PRESSURE, WE'RE
GOING TO BE ABLE TO GET THERE.
WE'RE GOING TO BE ABLE TO OFTEN
IMPROVE A.I. AND MACHINE
LEARNING MODELS BECAUSE WE KNOW
ESSENTIALLY MACHINE LEARNING
MODELS, ONCE WE INCLUDE HUGE
AMOUNTS OF DATA, IT'S GOING TO
IMPROVE THE RISK STRATIFICATION
OF CONDITIONS.
SO BY INCLUDING CONTINUOUS BLOOD
PRESSURE READINGS AND ALSO
CAPTURING OTHER TYPE OF
INFORMATION, WE'RE GOING TO
PROVE THE -- MACHINE LEARNING
MODELS THAT WILL RESULT IN
BETTER STRATIFICATION OF
INDIVIDUALS' RISK.
AND I'VE BEEN TALKING ABOUT
BLOOD PRESSURE, BUT THESE
DEVICES ARE ALSO ABLE TO CAPTURE
HEART RATE.
SO THERE'S A NOVEL OR IT BEEN
RECENTLY INVESTIGATED HEART RATE
VARIABILITY AS A NOVEL RISK
FACTOR FOR, FOR EXAMPLE,
CARDIOVASCULAR EVENTS, BUT ALSO
I HAVE HERE GRAPHICS FOR SMALL
VESSEL DISEASE.
SO THERE'S A HARD READ AND
THEN -- YOU FOLLOW THE HEARTBEAT
AND IT HAS A EMTEMPO.
TEMPO.
THE DISTANCE BETWEEN THE TWO, IT
HAS A RHYTHM, SO THERE ARE
CERTAIN ASPECTS OF VARIABILITY
IN WHICH THE TEMPO OR THE BEAT
BETWEEN THE TWO IS SHORTER AND
IS IRREGULAR, AS WE CAN SEE IN
THIS FIGURE.
SO REDUCED HEART RATE
VARIABILITY HAS BEEN NECESSARY
WITH THESE CONDITIONS BECAUSE IT
ALLOWS US TO CAPTURE THAT
INFORMATION.
AND HERE I STRIKED THROUGH
ESTIMATES BECAUSE COMPARED TO
WHAT NOVEL DEVICES CAN DO WITH
BLOOD PRESSURE, I PUT HERE
MEASURES HEART RATE, COMPARED TO
BLOOD PRESSURE, IT GIVES US MORE
ACCURATE INFORMATION ABOUT HEART
RATES WHICH WE CAN THEN ANALYZE
HEART RATE VARIABILITY.
AND THIS WILL ALSO GIVE US AN
OPPORTUNITY TO UNDERSTAND THE
DYNAMIC CONFLICTS AND FOSTER
BEHAVIORS WITH HIGH RATE
VARIABILITY OR HEART RATE BASED
ON THIS AMOUNT OF DATA THAT
WE'RE GOING TO BE ABLE TO
COLLECT.
SO SOCIAL DETERMINANTS OF
HEALTH.
I DIDN'T INCLUDE THIS SLIDE
BECAUSE I WANTED TO TALK ABOUT
SOCIAL DETERMINANTS OF HEALTH.
IT BECAUSE WE KNOW SOCIAL
DETERMINANTS OF HEALTH
INFLUENCES DIAGNOSIS, TREATMENT
AND CONTROL OF BLOOD PRESSURE.
AND I BELIEVE THAT THIS HAS FOR
HEALTH EQUITY, THE DEVICES ARE
GOING TO PLAY AN IMPORTANT PART
IN FILLING THAT ALSO, BECAUSE WE
TALKED BEFORE, IT WAS DISCUSSED
IN ENVIRONMENTAL FACTORS, BUT
ALSO THEY ARE GOING TO BE ABLE
TO CAPTURE PSYCHOLOGICAL STRESS
FACTORS.
AND JUST IMAGINE THAT
UNDERSERVED POPULATION FOR
EXAMPLE, HISPANICS, AND WE ARE
THE HIGHER RISK OF ALZHEIMER'S
DISEASE, IN THE PRESENCE OF
ADVERSE OUTCOMES IN LIKE WHICH
WE HAVE HOUSING INSECURITY, WE
HAVE TRANSPORTATION OR -- HOW
CAN YOU EXPECT THESE DEVICES
WILL PERFORM THERE?
BUT ALSO THEY WERE ABLE TO
CAPTURE THAT ENVIRONMENTAL
PSYCHOLOGICAL INFORMATION THAT
PROBABLY IS GOING TO HELP HOW --
IN TERMS OF CONTROL, TREATMENT,
HOW ARE YOU GOING TO MEASURE
THAT INFORMATION SO THEY'RE
GOING TO PLAY A KEY PART HERE,
AND WE ALSO NEED TO CONSIDER
THAT WHEN IT COMES TO
VALIDATION, ACCESS, EDUCATION
AND POLICIES WHEN WE HAVE THESE
DEVICES.
JUST REMINDING THAT THE MORE WE
HAVE THE SMART WATCH THAT
MEASURES BLOOD PRESSURE
CONTINUOUSLY.
THE FASTER WE'RE GOING TO BE
ABLE TO ADDRESS EQUITY THAT
EVERYONE IS GOING TO ACCESS
THESE DEVICES, SO THAT'S
SOMETHING THAT WE ALSO NEED TO
THINK ABOUT.
BUT PROVIDED THAT IT DOES, WE'RE
GOING TO HAVE INFORMATION WE
NEED TO DIFFERENTIATE
VARIABILITY DUE TO UNDERLYING
DISEASE BUT ALSO TO
ENVIRONMENTAL AND PSYCHOLOGICAL
FACTORS.
SO IN CONCLUSION, NOVEL DEVICES
ARE PROVIDING A UNIQUE
OPPORTUNITY TO STUDY NOVEL
PHENOTYPES OF THE VASCULAR
SYSTEM DYSREGULATION SUCH AS
BLOOD PRESSURE VARIABILITY,
HEART RATE, VARIABILITY AND
CIRCADIAN RHYTHMS.
AND THE KEY GAPS -- THE PREVIOUS
ONE, PLEASE?
SO THE KEY GAPS IS THAT
VALIDATION OF CUFFLESS DEVICES
OR DEVICES, WE NEED TO CONSIDER
THAT THERE ARE DIFFERENT
SETTINGS AND GROUPS.
WE CANNOT EXPECT THAT HOW THE
DEVICE WILL PERFORM IN A WELL
CONTROLLED ENVIRONMENT TO AN
ENVIRONMENT WITH STRESS, ALSO
DIFFERENT ADVOCACY GROUPS AS
WELL.
THE METHODS TO UNDERSTAND THE
COLLECTION OF COMPLEX BLOOD
PRESSURE DATA, I THINK IF WE
JUST CONTINUE USING MEAN BLOOD
PRESSURES OR CONVENTIONAL
METRICS, WE'RE GOING TO BE
LOSING A LOT OF INFORMATION, AND
CHANGES NEEDED TO ADDRESS THESE
TECHNOLOGIES.
THE FUTURE OPPORTUNITIES INCLUDE
IMPROVE DIAGNOSIS, TREATMENT AND
CONTROL OF HYPERTENSION, ADDRESS
HEALTH EQUITY, IN THE RIGHT WAY
I THINK IT'S GOING TO HELP US TO
GET OUT INFORMATION WE NEED TO.
AND THE NOVEL PHENOTYPES WILL
EVALUATE ENVIRONMENTAL AND
PSYCHOLOGICAL FAK FORS WHICH I
JUST MENTIONED TO UNDERSTAND THE
REALLY COMPLEX DYNAMIC
BIOLOGICAL SYSTEM SO WE REALLY
NEED TO DIFFERENTIATE IS IT
BECAUSE OF UNDERLYING DISEASE OR
BECAUSE OF THE ENVIRONMENT.
SO THAT'S ALL I HAVE TO SHARE,
AND THANK YOU VERY MUCH.
>> GREAT, THANK YOU SO MUCH.
IF WE COULD HAVE ALL OF OUR
SPEAKERS GET THEIR CAMERAS ON?
GOOD, WE'RE ALL THERE.
SO DAICHI, DO YOU WANT TO KICK
US OFF WITH SOME QUESTIONS?
>> YEAH, THANK YOU SO MUCH.
OKAY.
I'VE BEEN WRITING A LOT OF NOTES
BUT WE DON'T HAVE MUCH TIME.
SO I HAVE A QUESTION FOR ROB.
THIS IS WHAT I'M TRYING TO
GRAPPLE WITH.
CLINIC BLOOD PRESSURE, WHETHER
IT'S MEASURED WELL OR NOT, IS
NOT IN THE REAL WORLD.
IT'S IN AN ARTIFICIAL
ENVIRONMENT.
AND I JUST SAW LOTS OF
COMPELLING DATA THAT BLOOD
PRESSURE OUTSIDE OF THE OFFICE
IS BETTER PREDICTIVE OF OUTCOMES
AND SO FORTH.
AND IT'S INTERESTING THAT YOU'RE
STUDYING CAR BLOOD PRESSURE AND
YOU'RE ALSO STUDYING BLOOD
PRESSURE IN MOBILE VANS.
BUT THAT DOESN'T FIT NEATLY
WITHIN AMBULATORY MONITORING OR
HOME MONITORING.
SELF MEASUREMENT OF BLOOD
PRESSURE AT HOME.
WHAT'S YOUR CONCEPTUALIZATION OF
THAT KIND OF BLOOD PRESSURE?
BECAUSE TO ME, THAT'S REAL BLOOD
PRESSURE.
IT'S THE BLOOD PRESSURE THAT
YOU'RE MEASURING IN THE REAL
WOMPLETD I JUST WANTED TO KNOW,
ROB, IF YOU THOUGHT ABOUT THAT.
>> WELL, THANK YOU FOR OF COURSE
THAT COMPELLING INTRIGUING
QUESTION AND THERE'S NO ANSWER
TO THAT.
OF COURSE, YES, WE THOUGHT ABOUT
IT, WE'VE ALL THOUGHT ABOUT IT
AND I THINK IT COMES DOWN TO A
PHILOSOPHICAL QUESTION OF WHAT
IS BLOOD PRESSURE, RIGHT, THAT
JESUS AND OTHER SPEAKERS HAVE
MENTIONED THAT IT CHANGES SECOND
TO SECOND AND IT'S VARIABLE
WITHIN DIFFERENT ORGAN SYSTEMS
AND DIFFERENT VASCULAR BEDS, AND
WE JUST BY CONVENTION MEASURE IT
THIS WAY AND WE KNOW IF YOU
MEASURE IT THIS WAY IN A CERTAIN
SETTING, IT SEEMS TO HAVE A
CRYSTAL BALL FOR YOUR FUTURE.
AND IT'S BEEN SAID IN THE PAST
THAT OBVIOUSLY THE REAL BLOOD
PRESSURE IS THE ONE THAT BEST IS
MOST ASSOCIATED WITH YOUR
CARDIOVASCULAR RISK AND
OUTCOMES, BUT THAT MAY ALSO BE
VARIABLE FOR DIFFERENT PEOPLE.
EVERYTHING WE DO IS AT A
POPULATION LEVEL, THEN WE
ATTRIBUTE TO INDIVIDUALS, AN
THERE'S NO SUCH THING AS
INDIVIDUAL LEVEL RISK.
WE USE A FREQUENTISM APPROACH TO
POPULATE PROBABILITY.
SO I DON'T KNOW, DAICHI.
I JUST KNOW THAT WHAT WE CAN DO
AT THE TIME BEING IS TO TRY TO
MIMIC AND PROVIDE READINGS THAT
CATEGORIZE REASONABLY WELL WITH
THE READINGS THAT WE KNOW ARE
PROGNOSTIC, AND THEN
SCIENTIFICALLY MOVE ON
AFTERWARDS SUCH AS ALL THE
INFORMATION THAT JESUS IS GOING
TO SAY, DO WE GET INCREMENTAL
INFORMATION AFTERWARDS?
MY SUPPOSITION IS LIKELY VERY
SMALL.
ONCE WE PARSE OUT THREE, FOUR,
FIVE, SIX WELL-DONE BLOOD
PRESSURES, THE OLD SMIRK, BASAL
BLOOD PRESSURE FROM THE 1940s,
ONCE WE GET THAT READING DONE,
THERE WILL BE A SMALL WAVEFORM
OF ADDITIONAL INFORMATION THAT
WILL GIVE US PROGNOSTIC
INFORMATION, BUT DAICHI, I'M NOT
SURE WHAT WE'RE GOING DO WITH
IT.
I'M NOT GOING TO TITRATE --
>> ABSOLUTELY.
>> -- CONTINUES WITH US
MEASUREMENTS OF NITROGEN -- SO
THANK YOU FOR THE TALK.
I DON'T KNOW.
AND I'LL STOP WITH THAT.
>> I JUST WANTED TO FOLLOW UP,
YOU ANSWERED MY QUESTION
BEAUTIFULLY AND THE REASON WHY
I'M PRESSING ON YOU, I KNOW YOUR
STUDIES, OKAY?
THE REASON WHY I'M PRESSING ON
YOU IS YOU SHOWED THE DATA
COMPARING CAR DATA TO OFFICE
BLOOD PRESSURE, OF COURSE CAR
BLOOD PRESSURE CAN BE DONE WHEN
IT REALLY HOT OR COLD OUTSIDE
BUT THAT'S THEIR BLOOD PRESSURE.
SO ON THE ONE HAND YOU MAY ARGUE
WHY ARE YOU COMPARING TO A BLOOD
PRESSURE THAT'S NOT OUTSIDE?
BECAUSE YOU'RE GOING TO SEE
WITHIN PERSON DIFFERENCES,
THAT'S JUST THE NATURE OF IT.
BUT AT THE SAME TIME, YOU'RE
SAYING THAT, YES, A LOT OF THE
PROGNOSTIC DATA IS BASED ON
CLINIC BLOOD PRESSURE.
SO I'M JUST WRAPPING MYSELF
AROUND THAT.
>> I'VE GOT A SIMPLE ANSWER TO
THAT.
>> GO FOR IT.
GO AHEAD.
>> LOWER IS BETTER.
WHAT ABOUT THESE THRESHOLDS
ABOUT PERFECTION, YOU KNOW?
JUST LOOK AT YOUR TRENDS, AND
KEEP IT IN THE LOW LEVEL.
>> SO IT MAY BE THAT WE'RE
DUMBING DOWN THE INFORMATION TO
ACTUALLY TAKE A STEP BACK TO
LOOK AT THE PROGNOSTIC VALUE OF
THIS TRADITIONAL PAROCHIAL WAY
THAT WE MEASURE, BUT THAT'S WHAT
WE HAVE IN THE TIME BEING, AND
IT MAY TURN OUT AS WE KNOW THAT
ABPM WHICH IS IMPACT BID ALL
THESE FACTORS IS -- THIS TENDS
TO FOLLOW THAT WHEN IT'S
DISCORDANT FROM CLINIC READINGS,
SO IT'S SOMETHING ABOUT THE REAL
WORLD ENVIROME THAT PROVIDES
ADDITIONAL INFORMATION FROM THE
CLINIC READING WHICH IS JUST A
SURROGATE OF ABPM.
BUT THANK YOU FOR THE QUESTION.
IT'S REALLY INTERESTING.
>> ABSOLUTELY.
THANK YOU SO MUCH.
>> GREAT.
I THINK BEV, I'M GOING TO THROW
BACK AT YOU ONE OF THE GAPS THAT
YOU HIGHLIGHTED.
WHAT POLICY SOLUTIONS DO YOU
THINK ARE NEEDED TO INCREASE
EVIDENCE-BASED SMBP PROGRAMS?
>> WELL, I WOULD LIKE -- I MEAN,
HOME BLOOD PRESSURE MONITORS ARE
INEXPENSIVE, EVEN THE CELLULAR
ONES ARE NOT VERY EXPENSIVE
COMPARED TO MEDICATIONS, AND
THEY LAST FOUR YEARS ONCE
THEY'RE OUT OF THE SHOP AND
THEY'RE ACCURATE.
SO WHY DON'T WE JUST GIVE THEM
OUT TO THE PEOPLE THAT NEED IT.
SO WE NEED A POLICY THAT
MEDICARE AND MEDICAID JUST
ACROSS THE BOARD COVERS THIS.
AND THEN WE HAVE TO CONSIDER I
THINK -- I THINK THAT HEDUS WAS
STARTING TO THINK ABOUT LOWER
BLOOD PRESSURES BUT BACKED AWAY,
AND THEY'RE PROBABLY NOT GOING
TO BRING UP THE TOPIC AGAIN FOR
A COUPLE YEARS.
SO I THINK WE NEED TO FIGURE
OUT, SCIENTISTS, WE'RE NOT
POLICY CHANGERS.
WE HAVE TO FIND THE GROUPS THAT
ARE.
AND HELP THEM UNDERSTAND THAT WE
NEED BETTER MEASURES OF BLOOD
PRESSURE BECAUSE IT REALLY
INFLUENCES WHAT ORGANIZATIONS
FOCUS ON.
THOSE ARE TWO EASY ONES.
>> THANK YOU.
>> AND THEN EHR RISING TO THE
STANDARDS, RIGHT?
I WROTE DOWN THE WEBSITE THAT
YOU PRESENTED, BUT I ASKED MY --
WEBSITE THAT YOU PRESENTED,
GETTING THAT BLOOD PRESSURE DATA
IN A VERY EASY TO USE WAY FOR
CLINICIANS AND PATIENTS.
>> WE'RE WORKING ON IT.
>> CAN I FOLLOW UP ON THAT
QUESTION TO YOUR EXCELLENT
QUESTION?
AND THIS IS FOR EVERYONE.
I THINK EVERYONE KNOWS I'M A
BIG, HUGE FAN OF SELF MEASURED
BLOOD PRESSURE SO I DON'T WANT
MY NEXT COMMENT TO SOUND LIKE
IT'S A CRITICISM.
BUT ONE THING THAT I STRUGGLE
WITH IS WE DO OUR BEST TO TRAIN
THE PATIENTS TO DO HOME
MONITORING BUT WE ACTUALLY DON'T
KNOW IF THEY'RE DOING IT RIGHT.
AND THAT ALWAYS CONCERNS ME.
BECAUSE OBVIOUSLY, THEY COULD
COME BACK TO YOU AND HAND YOU
ALL THE READINGS, THAT'S GREAT,
THEY DID ALL 12 OR ALL 48.
BUT YOU DON'T KNOW IF THEY DID
IT WELL.
DOES IT MATTER?
BECAUSE THE DATA SHOWS IT'S A
BETTER PREDICTOR OF OUTCOMES
THAN IN OFFICE.
I JUST WANTED TO ASK YOU.
>> IF I MIGHT COMMENT, THE LAST
PART WAS ESSENTIAL.
AND ANYTHING ELSE THAT COMES
WITH -- WE GET NOCTURNAL
RATINGS, PATIENTS WAKE UP AND
THE SAME BLOOD PRESSURE -- YOU
ARE NOT SURE WHETHER BLOOD
PRESSURE WAS TAKEN THE RIGHT
WAY, BUT THEN WHEN WE DO, WE
CONDUCT -- THAT INFORMATION
ASSOCIATED WITH CARDIOVASCULAR
OUTCOMES, THAT'S THE PART THAT
INTREETION ME BECAUSE THEN
EVIDENCE BASE USES THIS
INFORMATION TO THEN MAKE
DECISION TO DIAGNOSE PROVIDE
THRESHOLDS FOR EXAMPLE BASED ON
THAT INFORMATION.
I BELIEVE WE NEED TO MAKE SURE
THEY'RE MEASURING IT WELL BUT UP
TO RIGHT NOW, WHATEVER
INFORMATION THEY'RE CAPTURING,
WHEN WE ANALYZE THAT IN RELATION
TO EVENTS, WE'RE BEING ABLE TO
FIND THERE'S A SIGNIFICANT --
AND THEREFORE DECISIONS ARE MADE
BASED ON THAT INFORMATION, SO I
BELIEVE WE SHOULD CONTINUE USING
THAT INFORMATION.
WHETHER THEY DID IT THE WRONG
WAY OR RIGHT WAY, BUT IT'S
INFORMATION THAT WE --
>> AND THEY CAN TAKE THEIR
AMBULATORY MONITOR OFF AND
RE-WRAP IT THE WRONG WAY, RIGHT?
SO -- I THINK THAT GOES ACROSS
THE BOARD AND WE ALREADY SAW --
I MEAN, I'VE BEEN ASTOUNDED,
WHAT I SEE IN CLINIC.
I KNOW YOU CAN TAKE FOREARM
BLOOD PRESSURES, BUT WHEN I WAS
GOING ON A DIFFERENT TOPIC
BECAUSE I WORK ON OTHER AREAS
BESIDES BLOOD PRESSURE, AND I
ASKED AN M.A. TO DEMONSTRATE HOW
SHE TOOK A BLOOD PRESSURE AND
SHE TOLD ME ON THE FOREARM.
LIKE, THIS IS A MEDICAL
ASSISTANT.
SO YOU KNOW, IT'S INDEMIC OR
EPIDEMIC PROBLEM, AND I DON'T --
I THINK WE ALL NEED TO
BE -- YOU KNOW, I THINK PUTTING
THESE POSTERS IN -- MAKING --
ENABLING AND ENGAGING THE
PATIENTS TO BE AS SMART AS WE
ARE, AND I THINK MOST CAN DO
THAT.
OBVIOUSLY SOME PEOPLE CAN'T.
BUT I THINK MOST PATIENTS CAN.
AND THEY WANT TO BE ABLE TO DO
IT RIGHT.
>> ABSOLUTELY.
AS YOU SAID, BEV, THERE'S
DEFINITELY TOOLS OUT THERE TO
HELP WITH THAT AND MAYBE MORE
NEED TO BE DEVELOPED.
SO GREAT COMMENTS, EVERYONE.
ROBERT, WE'VE GOT A QUESTION
FROM STEPHEN JURASCHEK.
YOUR CAR STUDY IS FASCINATING
WITH REALLY IMPORTANT
IMPLICATIONS.
DID YOU LOOK AT SEASON IN YOUR
STUDY, AND DID YOU HAVE ANY
CASES WITH THE CAR ENG IP OFF?
ENGINE OFF?
YOU ADDRESSED TEMPERATURE AND
HOW YOU CONTROL THAT, BUT HE
SAYS OSCILLOMETRIC DEVICES HAVE
UNKNOWN PERFORMANCE IN MOVING
VEHICLES.
PERHAPS THE CAR VIBRATION IS NOT
SO BAD WHEN IDLING.
>> SIMPLE ANSWERS FOR THIS.
WE ARE EVALUATING SECONDARY
ANALYSES, ALL THE IMPACT OF THE
EXPOSURES ON THE VARIATIONS OR
DIFFERENCES, WHILE THE ACTUAL
READINGS OF THE CAR -- AND THE
DIFFERENCES COMPARED TO CLINIC
READINGS, THOSE ARE THINGS WE'RE
ANALYZING AT THIS POINT IN TIME.
WE DID TRY TO ROLL ACROSS
DIFFERENT SEASONS FOR THAT
PARTICULAR POINT TO SEE IF IT
WAS MAYBE MORE OR LESS ACCURATE
DURING HOT OR COLD SEASONS.
I DON'T HAVE THOSE DATA YET.
OF COURSE IT WILL BE
UNDERPOWERED TO ACTUALLY SHOW
ANY SIGNIFICANCE, BUT WE CAN
LOOK TO SEE -- WE SPECULATE IT
WILL BE PERHAPS LESS ACCURATE
DURING THE COLD SEASONS.
I WAS A LITTLE RUSHED FOR TIME
TO DESCRIBE FULLY THE PROTOCOL.
IT'S A HIGH-THROUGHPUT PROTOCOL
TO TRY TO SCREEN LITERALLY
THOUSANDS IF NOT TENS OF
THOUSANDS OF PATIENTS IN A
DRIVE-UP MOBILE UNIT.
AND EVERYONE, THE CAR HAS BEEN
STOPPED FOR FIVE MINUTES, SO
IT'S NOT IDLING.
AND THERE'S A LINE OF CARS.
THIS WAS ORIGINALLY DESIGNED
AFTER COVID-19 FOR SCREENINGS OF
TENS OF THOUSANDS OF PATIENTS
WITH COVID-19, AND WE ADAPTED
THAT SO, HEY, WE CAN MEASURE
BLOOD GLUCOSE AND A1C AND LIPIDS
AND MAYBE WE CAN GET BLOOD
PRESSURES.
WHAT IS THE BLOOD PRESSURE IN A
CAR?
SO YOU CAN SURPRISINGLY GET A
PRETTY GOOD POSITION IN A CAR,
RIGHT, WITH AN ARMREST AND THE
SEATED POSITION, AS LONG AS YOU
USE A REASONABLE METHODOLOGY.
SO IT'S OF COURSE ATTENDED
BECAUSE SOMEONE IS RATE THERE,
BUT WE'RE NOT TALKING TO THEM.
AND WE CAN HAVE ALL THE OTHER
POSITION AND FACTORS, AVERAGE
READINGS DONE ACCORDING TO
GUIDELINES.
BUT TO ANSWER THAT, THE CARS ARE
ALWAYS OFF, AND WE ATTEMPT TO
HAVE TEMPERATURE WITHIN A
REASONABLE RANGE OF CLOSE TO 70,
BUT THERE'S STILL VARIATION IN
THAT, WHICH IS ALSO INTERESTING
TO EXPLORE.
SO OS IT SHOULD NOT BE IMPACTEDY
THE CAR BEING OFF BUT MAYBE
WE'LL FIND THAT IT IS.
>> THANK YOU.
>> YOU KNOW, I LIKE THAT,
STEPHEN SHOWED KOEPKE'S SLIDE
WHERE THEY DID SHOW IN THOSE
2,000 BLOOD PRESSURE
MEASUREMENTS JUST A STRONG
ASSOCIATION OF SEASON, AND YOU
COULD SEE IT GO UP AND DOWN.
I THINK THE SEASONALITY IS --
BUT YOU KNOW, THE TEMPERATURE
CHANGES IN A CAR.
BUT SOME PEOPLE, THEIR JOB IS IN
A CAR TOO.
>> ALL RIGHT.
SOME MORE QUESTIONS IN THE CUE
FOR FOLKS.
JESUS, HAVE YOU IDENTIFIED ANY
NOVEL PHENOTYPES THAT SEEM
PARTICULARLY PROMISING FROM
ABPM, AND ANY YOU THINK MIGHT BE
IMPORTANT TO EXPLORE?
>> I WANT TO SAY YES, BUT THIS
IS JUST TO -- RESEARCH WE'VE
BEEN DOING, IT STILL NEEDS
REPLICATION, BUT WE'VE BEEN ABLE
TO IDENTIFY SPECIFICALLY, FOR
EXAMPLE, FOR GLAUCOMA OR FOR
HIPPOCAMPAL VOLUME THAT WHEN YOU
LOOK INTO VARIABILITY, 24 HOUR
BLOOD PRESSURE VARIABILITY, IF
WE QUANTIFY JUST STANDARD
DEVIATION OR ANY OF THESE
METRICS, BUT WE ACTUALLY LOOK
INTO VARIABILITY, WHEN IT DROPS,
THE QUANTIFICATION OF THOSE
DRASTIC REPETITIVE AND EXTREME
DROPS IN BLOOD PRESSURE OVER 24
HOURS HAS BEEN ASSOCIATED WITH
GLAUCOMA OR WITH THINNER
HIPPOCAMPAL VOLUME OR LOWER --
WE'VE BEEN PUBLISHING ON
GLAUCOMA, WE HAVE A PUBLICATION
COMING UP WITH HIPPOCAMPAL
VOLUME OVER AD REGIONS OF
INTEREST AND WE'VE BEEN
COMPARING THOSE DRASTIC DROPS
VERSUS ALSO THE PEAKS IN BLOOD
PRESSURE.
AS IT WAS MENTIONED YESTERDAY
THE LOWER IS GONNA FALL.
SO FOR THESE CONDITIONS, THERE'S
ONLY VERY LITTLE BIT DRASTIC --
IN BLOOD PRESSURE -- I DON'T
WANT TO SAY --
>> WAS THAT WORSE AT NIGHT?
>> NO, NO, THAT'S THE TRICKY
PART.
SO EVEN IF WE QUANTIFY, LET'S
SAY, THE FIVE LARGEST DROPS,
THEY MUST OCCUR DURING THE DAY
TIME, BECAUSE DURING THE DAY
TIME, WE HAVE MORE -- THERE'S
MORE ACTIVITY, SO PEOPLE ARE
MORE SUSCEPTIBLE TO DRASTIC
CHANGES IN BLOOD PRESSURES,
ACTUALLY MOST OF THE DRASTIC
CHANGES THROUGH DROPS IN BLOOD
PRESSURE OCCURRED DURING THE DAY
TIME.
AND THIS ISN'T JUST GLAUCOMA
OR -- MOST OF THEM, THEY ARE
ACTUALLY HYPERTENSIVE SO THEY
ARE MORE PRONE TO DROPS IN BLOOD
PRESSURE.
>> ALSO IF WE COULD ADDRESS
WHICH MEDICATIONS DECREASE
VARIATION THE MOST AS AN
IMPORTANT TOPIC.
>> I HAVE A QUESTION UNLESS,
HILARY, YOU HAVE A FOLLOW-UP?
I DIDN'T WANT TO INTERRUPT YOU.
SO I'M GETTING ABOUT TWO EMAILS
A WEEK ASKING ME ABOUT THIS GAP,
AND I'M INTERESTED IN WHAT YOU
THINK.
I OBVIOUSLY WANT IMPLEMENTATION
OF HOME MONITORING, PARTICULARLY
HOME TELEMONITORRING, TO BE
SUCCESSFUL.
BUT WHAT I FOUND IS THAT THE
NEXUS BETWEEN DEVICE, CLOUD AND
EHR, IS HANDLED BY DIFFERENT
COMPANIES.
AND THAT'S ALSO DIFFERENT --
THAT'S ALSO DIFFERENT THAN THE
HOSPITAL SYSTEM.
THIS OFTEN HAS PROBLEMS WITH
PRIVACY.
DO YOU HAVE KIND OF AN OUT OF
THE BOX SOLUTION THAT FIXES
THIS?
IF YOU UNDERSTAND WHAT I'M
SAYING?
BECAUSE I DON'T THINK THERE'S A
UNIVERSAL SOLUTION.
>> I DON'T KNOW IF I KNOW ALL
THAT BECAUSE I'VE GOTTEN SOME
STRANGE QUESTIONS ABOUT THAT
RECENTLY MYSELF.
BUT I THINK WHAT KAISER DOES,
THEY ORIGINALLY USED A VENDOR
AND THEN THEY JUST BROUGHT IT
IN-HOUSE, BUT THEY HAVE THE
RESOURCES TO DO THAT AND
INCREASINGLY, THEY DON'T WANT TO
GO TO A VENDOR.
THERE'S OTHER PROBLEMS WITH
VENDORS, YOU MIGHT SEND A
CONTRACT -- NOT USE IT AS MUCH
AS YOU THOUGHT.
SO I THINK HILARY MIGHT HAVE AN
ANSWER TOO FOR THIS WITH ONE OF
THE VENDORS SHE'S BEEN USING.
WHO HAS MORE OF AN OPEN ACCESS
POLICY.
NOT TOWARDS THE DATA, BUT IT'S
NOT AS FINANCIALLY MOTIVATED.
HILARY, CAN YOU COMMENT ON THAT?
>> YES, I DON'T NECESSARILY WANT
TO CALL OUT A VENDOR, BUT I
THINK -- COME ON, FEDERAL
EMPLOYEE, I CAN'T DO THAT.
>> YES, UNDERSTOOD.
>> WE HAVE BEEN -- YES, THIS IS
A HUGE PROBLEM, AND THE CLINICAL
SETTINGS THAT HAVE BEEN
SUCCESSFUL HAVE SORT OF HACKED
OUT THEIR SOLUTION AND MADE IT
SPECIFIC TO THEIR CONTEXT.
SO WHAT ARE THOSE BROADER
SOLUTIONS?
THERE IS ONE VENDOR THAT I CAN
THINK OF THAT HELPS IN THIS
SPACE, AND HOPEFULLY WE'RE GOING
TO SEE A HANDFUL MORE OF THOSE
THAT ARE COMING, BUT IT REALLY
IS A HARD ISSUE, AND SO SOME OF
THE STANDARDS THAT I DIDN'T
QUITE GET A CHANCE TO TALK ABOUT
YESTERDAY, FIRE STANDARDS, I DO
THINK THAT THIS IS GOING TO
HELP, BECAUSE IF ALL OF OUR
DEVICES AND OUR RECEIVING
EHRs, IF WE'RE ALL SPEAKING
THE SAME LANGUAGE, THAT'S GOING
TO HELP STREAMLINE THAT MESSAGE
TRANSMISSION.
SO IT A SLOW AND PAINFUL
PROCESS, BUT THERE ARE
DEFINITELY SORT OF BABY STEPS
THAT ARE HAPPENING THAT ARE
MOVING THAT FIELD FORWARD.
>> THANK YOU.
>> HOW ARE WE ON TIME?
DO WE HAVE TIME FOR --
>> WE HAVE TWO MINUTES LEFT.
WE CAN DO ONE MORE I THINK.
>> LET'S SEE.
I HAVE A COUPLE QUESTIONS, BUT
IN MY HEAD, ONE OF THE THINGS
I'M THINKING OF IS, LIKE, COULD
WE LOOK AT CLIMATE CHANGE OVER
TIME AND SEE HOW THAT'S -- THE
IMPACT IT'S HAD ON SEASONALITY.
ANYWAY, ROBERT, THERE'S A STUDY
FOR YOU TO DO.
BUT --
>> OH, NO, THAT'S ALREADY DONE.
>> HAS IT BEEN?
>> BY OTHER PEOPLE, RIGHT, YOU
KNOW, TODAY'S SCIENTIFIC
LITERATURE, BY THE TIME YOU
THINK OF IT, SOMEBODY HAS LIKE
THREE PAPERS IN PRESS OUT
SOMEPLACE ELSE, SO THERE'S A LOT
OF LITERATURE ON CLIMATE CHANGE
AND BLOOD PRESSURE, OF COURSE,
BUT GO AHEAD.
SORRY.
>> WELL, SO I'LL ASK YOU THIS,
THOUGH, SO AS I HEAR YOU, YOU
KNOW, TALK ABOUT TEMPERATURE AND
SEASON AND NOISE, OBVIOUSLY
SEASON, WE CAN'T CONTROL, BUT
TEMPERATURE --
>> YOU CAN MOVE: I TELL PEOPLE
TO MOVE TO A LOW ALTITUDE PLACE
ON A BEACH THAT'S QUIET IN
HAWAII.
>> THERE YOU GO.
>> AND IT SOLVES ALL YOUR
PROBLEM.
>> THERE'S THE UNIVERSAL
SOLUTION.
I LOVE IT.
WELL, I WORK AT CDC SO I'M
TRYING TO THINK ABOUT EQUITY,
AND YOU KNOW, WE'VE GOT SORT OF
OUR DISPARATE POPULATIONS LIVING
NEAR HIGHWAY, PROBABLY IN URBAN
AREAS, LIKE, IS THERE A WAY FOR
US TO SORT OF ATTEND TO THE
ENVIRONMENT, THE ENVIRONMENTAL
CONDITIONS AS WE THINK ABOUT
SOCIAL DRIVERS OF HEALTH OR -- I
DON'T KNOW, DO YOU HAVE ANY SORT
OF BIG PICTURE THOUGHTS ON THAT
AND THE EQUITY ISSUES?
>> RIGHT, IT'S A FANTASTIC
QUESTION, BECAUSE THESE THINGS
TEND TO CLUSTER, RIGHT?
AND CLEARLY CONTRIBUTE MASSIVELY
TO HEALTH DISPARITIES.
I THINK IT'S A LARGER SOCIETAL
ISSUE.
SO SOME OF THE QUESTIONS HAVE
BEEN -- OR SOME OF THE SOLUTIONS
HAVE BEEN SUCH AS MOVING TO
THINGS LIKE 15-MINUTE CITIES,
WHICH YOU MAY HAVE HEARD OF,
DIFFERENT TYPES OF URBAN DESIGN.
NO ONE WOULD HAVE DESIGNED OUR
CITIES OR OUR HEALTHCARE SYSTEM
THE WAY IT'S TURNED OUT TO BE AT
THIS POINT IN TIME, IT'S GUM AND
TOOTHPICKS AND SUCH.
SO IF YOU CHANGE THINGS SUCH AS
A 15-MINUTE CITY WITH
SUPERBLOCKS WHERE WE'RE NOT ALL
WITHIN -- THESE ARE DIFFERENT
URBAN DESIGNS THAT REDUCE NOISE
EXPOSURE, INCREASE GREENNESS,
INCREASE WALKABILITY, DECREASE
PARTICLE AIR POLLUTION EXPOSURE,
YOU CAN DECREASE HEAT WITH MORE
GREEN SPACES.
LOTS OF DECREASED -- TARMAC FOR
DECREASED INTENSIVE HEAT, WHICH
HAS IMPACTS ON HEALTH AS WELL.
THERE ARE THINGS THAT WE CAN DO
AT A SOCIETAL LEVEL,
PARTICULARLY FOR URBAN SETTINGS.
OVEN TOFTEN THE WILL IS JUST NOT
THERE, THE MONEY IS NOT THERE,
AND THEN NOT TO GET TOO
POLITICAL ABOUT IT, BUT, LIKE,
PEOPLE WILL SAY THAT, WELL, THIS
IS IMPACTING ON FREEDOMS AND
CHOICE AND UNFORTUNATELY, SO
MUCH OF EVERYTHING ALWAYS TURNS
INTO POLITICAL, AND DON'T
CONTROL HOW MY LIFE IS AND MY
CITY IS, AND SO THEY OFTEN DON'T
GO VERY FAR.
BUT I WOULD SAY ONE OF THE MAIN
THINGS FOR HEALTH EQUITY IS
BETTER URBAN DESIGN AND
DECREASING POINT SOURCES OF
EXPOSURE, WHICH WE DISCLOSED
INCINERATOR IN DETROIT WHICH WAS
CONVENIENTLY RIGHT NEXT TO A
WHOLE BUNCH OF LOWER
SOCIOECONOMIC HOUSING.
IT LIKE NOT A GREAT PLACE FOR
THIS.
OBVIOUSLY HIGHWAYS GO RIGHT
THROUGH LOW SOCIOECONOMIC
SETTINGS.
SO THERE'S A LOT OF FACTORS, AND
IT'S A SOCIETAL ISSUE.
THE LAST POINT I WANTED TO MAKE
WAS WE'VE ADDRESSED -- WE'VE
TRIED TO ADDRESS A LOT OF THE
PROBLEMS OF EQUITY WITH CHANGING
THE WAY THE WHOLE MODEL OF
PAYMENT IS DONE.
SO IF IT'S ALL CONTINGENT --
WHICH EVERYONE HERE KNOWS, ALL
CONTINGENT ON THE STANDARD
SYSTEM, IT'S VERY HARD TO MOVE
THE NEEDLE.
I DON'T NEED 16 RPM MEASUREMENTS
TO ALL OF A SUDDEN GET A BILL
HERE.
SO WE'VE DONE CAPITATED PAYMENT
MODELS WITH INSURANCE CONTRACTS
WITH MEDICARE INSURANCES THAT WE
TAKE CARE OF LIVES, THE QUALITY
AND HAVE HYPERTENSION TREATED
WITH A CAPITATED MODEL WITH OUR
TREATMENT PARTNERS, PART OF THAT
IS YOU GET A HOME BLOOD
PRESSURE, YOU GET ARPM, YOU GET
A PHARMACIST THAT TAKES CARE OF
YOUR SYSTEM, I DON'T CARE WHAT
IT COSTS OVERALL AND OVERALL FOR
YOUR INDIVIDUAL LIFE AND OVERALL
THE COSTS OF COURSE ARE LOWER,
YOU'RE INCENTIVIZED NOT TO ORDER
TONS OF TESTS OR INCENTIVIZED
NOT TO COME IN TO GET CLINIC
MEASUREMENTS OR TO GET -- IT'S
ACTUALLY A SANE WAY TO DO IT AND
MOST OF THE INSURERS AND PAYORS
ARE HAPPY TO APPROACH AND TAKE
PREVENTION OUT OF THAT MODEL OF
REGULAR HEALTHCARE, WHEN HALF
THE ADULT POPULATION IS
HYPERTENSION, TREATING IT AS A
REGULAR RARE DISEASE LIKE YOU
HAVE TO GO SEE A DOCTOR AND GET
PAID FOR THIS DISEASE IS JUST
ABSOLUTELY SILLY.
AND I THINK PAYMENT STRUCTURE
FOR THESE VERY, VERY PREVALENT
POPULATION HEALTH PROBLEMS NEEDS
TO CHANGE, AND WE CAN DO A
BETTER JOB OF HANDING OUT BLOOD
PRESSURE CUFFS, IT JUST HOW YOU
DO THIS IN SOCIETY, I THINK BEV
MENTIONED THAT EARLIER.
THAT'S JUST WHAT WE DO IN OUR
CLINICAL PRACTICE NOW.
>> HEAR, HEAR.
WELL, THANK YOU TO OUR
PANELISTS.
I THINK WE ARE UP FOR A BREAK.
MAYBE WE CAN PASS IT BACK TO
PAULA?
>> WELL, YES, WE ARE AT THE
BREAK, AND LET US RECONVENE IN
LIKE 6 MINUTES.
IN TERMS OF PREVENTION AMONG
BLACK MEN THROUGHOUT NEW YORK
CITY AND BEYOND, THIS ENGAGED A
LOT OF COMMUNITY RESEARCH
NETWORKS, OVER 200 OF THEM
INCLUDING CHURCHES, BARBER
SHOPS, AND ULTIMATELY MORE THAN
20,000 NEW WORKERS ARE PART OF
THIS RESEARCH, TO WELCOME,
DR. RAVENELL.
TAKE IT AWAY.
>> THANK YOU FOR THE INVITATION
TO JOIN YOU TODAY.
TODAY I'M GOING TO BE TALKING
ABOUT COMMUNITY CENTERED
APPROACHES TO BP ASSESSMENT AND
HYPERTENSION MANAGEMENT.
I ONLY HAVE A SINGLE DISCLOSURE,
I'M FUNDED BY THE AMERICAN HEART
ASSOCIATION CURRENTLY TO DO A
HYPERTENSION PREVENTION STUDY.
SO IN MY 13 MINUTES, I'D LIKE TO
COVER THE FOLLOWING OBJECTIVES:
DISCUSS HIGH QUALITY
BROMOPROPANE ASSESSMENT IN THE
COMMUNITY CONTEXT, BRIEFLY
REVIEW THE HISTORY OF
COMMUNITY-BASED BLOOD PRESSURE
ASSESSMENT AND HYPERTENSION
MANAGEMENT, DISCUSS SOME
SUCCESSFUL EXAMPLES OF COMMUNITY
CENTERED BLOOD PRESSURE
ASSESSMENT AND MANAGEMENT
PROGRAMS, AND THEN SUMMARIZE
SOME OF THE RESEARCH GAPS AND
FUTURE OPPORTUNITIES.
SO THIS QUOTATION COMES FROM DRD
COLLEAGUES FROM THEIR SCIENTIFIC
STATEMENT ON BLOOD PRESSURE
MEASUREMENT IN HUMANS FROM 2005
THAT WAS RECENTLY UPDATED BY DRT
SAYS BLOOD PRESSURE
DETERMINATION CONTINUES TO BE
ONE OF THE MOST IMPORTANT
MEASUREMENTS IN ALL OF CLINICAL
MEDICINE AND IS STILL ONE OF THE
MOST INACCURATELY PERFORMED.
ACCURATE MEASUREMENT OF BLOOD
PRESSURE IS ESSENTIAL TO
CLASSIFY INDIVIDUALS, TO
ASCERTAIN BLOOD PRESSURE RELATED
RISK AND TO GUIDE MANAGEMENT,
AND THAT'S REALLY WHY WHAT WE'RE
TALKING ABOUT IS SO IMPORTANT
BECAUSE IT REALLY DOES GUIDE
WHAT WE DO NEXT.
SO THIS IS A TABLE THAT IS IN
THE MOST RECENT STATEMENT BY DRT
BLOOD PRESSURE MEASUREMENT IN
HUMANS AND I WON'T GO THROUGH
THE WHOLE THING BUT BASICALLY
WHAT THIS DESCRIBES IS, IT'S AN
OVERVIEW OF THE STEPS TO MEASURE
BLOOD PRESSURE PROPERLY, AND IT
INCLUDES PREPARING THE PATIENT,
IT INCLUDES THE DOS AND DON'TS
OF WHAT PATIENTS SHOULD DO IN
PREPARATION FOR GETTING THEIR
BLOOD PRESSURE TAKEN PROPERLY,
POSITIONING, CUFF SELECTION,
MEASUREMENT TECHNIQUE, AND
DOCUMENTING AND COMMUNICATING
WITH THE PATIENT.
THESE STEPS ARE A WAY TO
OPERATIONALIZE BASICALLY THE
CORRECT WAY TO MEASURE ACCURATE
BLOOD PRESSURE.
AND THERE'S BASICALLY ONE
CORRECT WAY, WHETHER YOU'RE IN
AN OFFICE OR WHETHER YOU'RE IN A
COMMUNITY CONTEXT, AND AS WE'VE
HEARD FROM MANY PRESENTERS
THROUGHOUT THE LAST TWO DAYS,
THE DEVIL REALLY IS IN THE
DETAILS.
AND SO THIS QUOTATION THAT YOU
SEE AS THE TITLE OF THE SLIDE,
THE STANDARD IS THE STANDARD.
THIS COMES FROM -- THOSE OF YOU
WHO MIGHT LIVE IN PIT B PITTSBUR
MIGHT BE FANS OF THE PITTSBURGH
STEELERS KNOW THAT THIS IS
BASICALLY SOMETHING THAT THEIR
HEAD COACH SAYS, WHICH BASICALLY
SAYS IT DOESN'T MATTER WHAT THE
CONTEXT IS, THERE'S BASICALLY
ONE STANDARD, AND I THINK THAT
APPLIES TO BLOOD PRESSURE
MEASUREMENT, WHETHER WE'RE IN AN
OFFICE OR WHETHER WE'RE IN A
BARBERSHOP, THERE ARE STILL
IMPORTANCE TENETS TO MEASURE THE
BLOOD PRESSURE PROPERLY.
AND THE KEY TO MAKING SURE THAT
THAT HAPPENS IS ADEQUATE
TRAINING AND RETRAINING.
ONE OF THE IMPORTANT PARTS OF
THE STATEMENT ON MEASUREMENT OF
BLOOD PRESSURE IN HUMANS
INCLUDES THE IMPORTANCE OF
TRAINING.
THE REPORT SAYS THE TRAINING
GIVEN TO LAY OBSERVERS SHOULD BE
AS COMPREHENSIVE AND SIMILAR TO
THAT RECOMMENDED FOR HEALTHCARE
PROFESSIONALS IN AMBULATORY AND
COMMUNITY SETTINGS.
AND WE BELIEVE THAT WITH CAREFUL
TRAINING, EVEN VOLUNTEERS IN
LARGE POPULATIONS CAN MEASURE
BLOOD PRESSURE ACCURATELY, AND
SO THE TRAINING INCLUDES MAKING
SURE THAT FOLKS ARE USING A
VALIDATED DEVICE, MAKING SURE
THAT THE PATIENT IS PROPERLY
POSITIONED, SELECTING THE
APPROPRIATE ARM CUFF, OBTAINING
A VALID AND RELIABLE
MEASUREMENT, RECORDING THE
MEASUREMENT ACCURATELY, AND
REPORTING ABNORMAL VALUES
PROPERLY.
SO THERE ARE SOME SCREEN SHOTS
HERE OF PART OF VARIOUS TRAINING
MANUALS THAT WE HAVE DONE OVER
THE YEARS THAT MAKE SURE THAT
OUR OPERATORS, WHETHER THEY BE
RESEARCH ASSISTANTS OR COMMUNITY
VOLUNTEERS, THAT THEY ARE
FAMILIAR WITH HOW TO USE A
VALIDATED MONITOR THAT THEY ARE
FAMILIAR WITH HOW TO SELECT THE
APPROPRIATE SIZE CUFF, AND HOW
TO PROPERLY PLACE THE CUFF SO
THAT IT FITS APPROPRIATELY SO
THAT WE CAN GET A GOOD
MEASUREMENT.
SO THIS SLIDE JUST SUMMARIZES
SOME OF THE SEMINAL EVENTS IN
COMMUNITY-BASED BROMOPROPANE
COMMUNITY-BASED BLOOD PRESSURE
ASSESSMENTS.
THE FIRST PANEL IS BASICALLY
SOMETHING I FOUND IN PREPARATION
FOR THIS TALK, WHICH IS A
SCREENSHOT OF THE PUBLIC USE
DATA TAPE DOCUMENTATION FOR THE
FIRST NATIONAL HEALTH
EXAMINATION SURVEY, WHICH
STARTED BACK IN 1960 TO NE 1962.
THIS WAS SUCH AN IMPORTANT
DEVELOPMENT BECAUSE IT REALLY
WAS AN IMPORTANT, RIGOROUS
EPIDEMIOLOGIC ASSESSMENT OF THE
PREVALENCE OF MANY CONDITIONS IN
THIS COUNTRY, HYPERTENSION BEING
ONE OF THE MOST IMPORTANT.
SO AMONG OVER 6,000 INDIVIDUALS
WHO UNDERWENT THESE DETAILED
HEALTH INFORMATION SURVEYS, THEY
FOUND OVER 1900 CASES OF
HYPERTENSION.
AS YOU KNOW IN THE 1960s, IT
REALLY WAS A TIME WHEN WE WERE
LEARNING A LOT ABOUT
HYPERTENSION, INCLUDING ABOUT
THE BENEFITS OF TREATING
HYPERTENSION STUDIES SUCH AS THE
VA COOPERATIVE STUDIES AND
OTHERS REALLY GAVE RISE TO MUCH
OF THE KNOWLEDGE THAT WE HAVE
NOW, BUT ALSO GAVE RISE TO MANY
COMMUNITY-BASED EFFORTS
INCLUDING IN THE SECOND PANEL
WHO WE SEE FEATURED IS THE LATE
GREAT DR. ELI SAUNDERS, WHO
REALLY STARTED EARLY ON TO DO
COMMUNITY-ENGAGED WORK IN
RESPONSE TO OUR KNOWLEDGE THAT
HYPERTENSION DISPROPORTIONATELY
IMPACTS BLACK COMMUNITIES, AND
THAT THE ONLY WAY THAT WE WERE
GOING TO GET ON TOP OF THIS
PREDICAMENT IS TO MOVE OUTSIDE
OF CLINICAL SETTINGS AND INTO
COMMUNITY SETTINGS.
A BIG PART OF MOVING THAT
FORWARD WAS ALSO THE NATIONAL
HIGH BLOOD PRESSURE EDUCATION
PROGRAM, WHICH STARTED BACK IN
1972.
DR. ED ROCCELLA WAS REALLY AT
THE FOREFRONT OF THAT WORK, BUT
AS PART OF THAT, THERE WAS A
HUGE EMPHASIS ON COMMUNITY-BASED
PROGRAMS IN VARIOUS WAYS OF
MAKING COMMUNITIES MORE AWAIRL
OMORE AWARE OFTHE PROBLEM OF HYD
REALLY MOVE FORWARD OUT OF
OFFICE BLOOD PRESSURE
MEASUREMENT.
AND THEN THE LAST PANEL ON HERE
FEATURES DR. KEITH FERDINAND'S
WORK, LESSONS LEARNED FROM THE
HEALTHY HEART COMMUNITY
PREVENTION PROJECT IN REACHING
THE AFRICAN AMERICAN POPULATION.
THIS REALLY BUILT ON SOME OF THE
GREAT WORK OF DR. ELI SAUNDERS
AND DR. WAYNE KONG IN BALTIMORE,
BUT DR. FERDINAND'S WORK REALLY
WAS ONE OF THE FIRST DOCUMENTED
EFFORTS OF UTILIZING BARBERSHOPS
TO INCREASE HYPERTENSION
AWARENESS AND IMPROVE
HYPERTENSION MANAGEMENT
UTILIZING BLACK -- UTILIZING
BLACK BARBER SHOPS.
DR. FE FERDINAND'S PROJECT IN
BARBER SHOPS WAS CALLED "CUT
YOUR PRESSURE," WHERE THEY
TAUGHT BEAUTICIANS AND TAUGHT
BARBERS HOW TO MEASURE BLOOD
PRESSURE IN A STANDARDIZED WAY,
AND ALSO HOW TO CONVEY THAT
INFORMATION TO THEIR CUSTOMERS
SO THAT THEY COULD RECEIVE
APPROPRIATE MANAGEMENT.
AND THE GREAT WORK OF
DR. FERDINAND GAVE RISE TO "CUT
YOUR PRESSURE 2," WHICH I WAS
PRIVILEGED TO BE A PART OF WITH
DR. RON VICTOR, WHO PASSED AWAY
SEVERAL YEARS AGO, BUT THAT WORK
IN DALLAS REALLY BUILT ON THE
WORK OF DR. SAUNDERS AND
DR. FERDINAND, AND IT WAS BASED
ON A PROTOCOL TOAS I MENTIONED
WITH CUT YOUR PRESSURE ONE IN
NEW ORLEANS, WHERE BARBERS WERE
TAUGHT HOW TO MEASURE BLOOD
PRESSURE, BUT ALSO HOW TO REFER
THEIR CUSTOMERS TO THE DOCTOR IF
THEIR BLOOD PRESSURE WAS HIGH,
WITH THE IDEA BEING THE
FREQUENCY WITH WHICH BLACK MEN
GO TO BARBERS, WHICH IN OUR
FORMATIVE WORK WE FOUND TO BE
ROUGHLY EVERY TWO WEEKS, THAT
THAT WAS A GREAT FREQUENCY FOR
US TO MONITOR THE IMPACT OF ANY
THERAPY THAT WAS STARTED AS A
RESULT OF OUR REFERRAL TO
THE DOCTOR UPON IDENTIFYING
ABNORMAL BLOOD PRESSURES.
AND SO THIS IS DR. VICTOR
PICTURED HERE, AND THIS REMINDS
ME OF WHEN HE WAS RECRUITING ME
TO DALLAS, TEXAS AND WAS TELLING
ME ABOUT SOME OF THE GREAT WORK
THAT HE HAD STARTED WITH
DR. FERDINAND, AND HE SAID,
WE'RE GOING TO GET THIS WORK
PUBLISHED IN THE NEW ENGLAND
JOURNAL, SO IT WAS WONDERFUL TO
SEE THAT COME TO FRUITION IN
2018, A CLUSTER RANDOMIZED TRIAL
OF BLOOD PRESSURE REDUCTION IN
BLACK BARBERSHOPS, WHERE HE WAS
ABLE TO PUBLISH THAT BY ADDING
PHARMACISTS INTO THIS MODEL,
THAT IT COULD HAVE A DRAMATIC
IMPACT ON BLOOD PRESSURE
REDUCTION AND HYPERTENSION
CONTROL.
AND SO WORKING WITH 52 BARBER
SHOPS, THEY WERE ABLE TO SHOW IN
THE BOTTOM LINE HERE THAT WE
COULD ACHIEVE A 27-POINT DROP IN
SYSTOLIC BLOOD PRESSURE BY
MEASURING BLOOD PRESSURE IN THE
BARBERSHOP, BY GETTING THEM
CONNECTED TO A PHARMACIST TO
START THERAPY WHEN APPROPRIATE
RIGHT AWAY, BUT ALSO TO MAKE
SURE THEY WERE CONNECT TODAY
PRIMARY CARE FOR ONGOING
MANAGEMENT.
AND THEY WERE ABLE TO ACHIEVE AN
INTERVENTION EFFECT OF NEARLY 22
POINTS OF SYSTOLIC DROP IN THE
SIX MONTHS FOLLOWING ENROLLMENT
INTO THE STUDY.
THERE HAVE BEEN OTHER RANDOMIZED
TRIALS TO SHOW THAT THERE CAN BE
SUCCESSFUL COMMUNITY-BASED
EFFORTS.
DR. GBENGA OGEDEGBE SHOWED IN A
RANDOMIZED TRIAL OF 32 CLCHS,
TH32 CHURCHESTHAT WE COULD TRAIS
TO BE ESSENTIALLY FUNCTION AS
COMMUNITY HEALTH WORKERS AND TO
NOT ONLY FOCUS ON BLOOD PRESSURE
MEASUREMENT BUT ALSO LIFESTYLE
COUNSELING AND IN THAT STUDY THE
INTERVENTION GROUPS SAW A
SIGNIFICANT DECREASE IN BLOOD
PRESSURE AND INCREASE IN BLOOD
PRESSURE CONTROL AT SIX MONTHS
COMPARED TO CHURCHES THAT ONLY
HAD A HEALTH EDUCATION CONTROL.
AND SO CURRENTLY, WHAT WE ARE
WORKING ON THREUM A G THROUGH AT
FUNDED BY THE AMERICAN HEART
ASSOCIATION IS CAN SOME OF THESE
MODELS WORK NOT JUST TO IMPROVE
HYPERTENSION CONTROL BUT ALSO
FOR HYPERTENSION PREVENTION.
SO THE RESTORE NETWORK IS A
HEALTH EQUITY RESEARCH NETWORK
THAT AIMS TO ADDRESS SOCIAL
DETERMINANTS TO PREVENT
HYPERTENSION, AND THIS STUDY
AIMS TO PARTNER WITH BLACK
COMMUNITIES TO MITIGATE THE
IMPACT OF SOCIAL DETERMINANTS OF
HEALTH ON BLOOD PRESSURE TO
DEVELOP AND EVALUATE STRATEGIES
TO IMPLEMENT EVIDENCE-BASED
LIFESTYLE INTERVENTIONS TO LOWER
BLOOD PRESSURE TO DISSEMINATE --
TO POLICYMAKERS AND STAKEHOLDERS
AND TO ENSURE SUSTAINABILITY AND
TO TRAIN THE NEXT GENERATION OF
EARLY CAREER SCIENTISTS.
SO THERE ARE FIVE DIFFERENT
PROJECTS THAT ARE HAPPENING IN
FIVE DIFFERENT CITIES USING FIVE
DIFFERENT APPROACHES TO
MEASURING BLOOD PRESSURE AS A
WAY TO IDENTIFY ELEVATED BLOOD
PRESSURE, AND TO HOPEFULLY
PREVENT THE DEVELOPMENT OF
HYPERTENSION.
THESE STUDIES ARE ONGOING, AND
WE HOPE IN THE NEXT YEAR OR SO
TO HAVE INFORMATION ABOUT
MEASURING BLOOD PRESSURE IN
THESE DIVERSE SETTINGS,
INCLUDING BARBER SHOPS,
CHURCHES, MOBILE VANS, FEDER
FEDERALLY -- HEALTH CENTERS AND
AN INTERVENTION BY DR. STEVE
JURASCHEK, BY UTILIZING AMAZON
GO FRESH AS A WAY TO PREVENT
HYPERTENSION.
SO THERE ARE SEVERAL KEY
KNOWLEDGE GAPS THAT WE CAN
CERTAINLY WORK ON TO IMPROVE OUR
KNOWLEDGE OF HOW TO BEST UTILIZE
STRATEGIES FOR COMMUNITY-BASED
BLOOD PRESSURE ASSESSMENT, SO
FIRST WHAT IS THE ROLE OF
COMMUNITY-BASED BLOOD PRESSURE
ASSESSMENT GOING FORWARD?
TWO, HOW DO WE SUSTAIN AND SCALE
COMMUNITY-BASED APPROACHES?
THREE, HOW CAN WE LEVERAGE
EVOLVING TECHNOLOGIES, INCLUDING
BLOOD PRESSURE TELL MONITORING,
TELEMONITOR, ANDHOW DO WE OPTIMY
CLINICAL LINKAGES AFTER BLOOD
PRESSURE ASSESSMENT REALIZING
ASSESSING BLOOD PRESSURE IN THE
COMMUNITY IS ONLY THE FIRST
STEP, REALLY GETTING FOLKS
CONNECTED TO SUSTAINED CARE IS
REALLY THE ULTIMATE GOAL FOR
IMPROVING BLOOD PRESSURE CONTROL
AND ADVANCING HEALTH EQUITY.
SO THANK YOU SO MUCH FOR YOUR
TIME AND ATTENTION AND I LOOK
FORWARD TO THE PANEL AT THE END.
>> SO THANKS, PROFESSOR
RAVENELL, THAT WAS GREAT.
APPRECIATE THAT.
I KNEW RON VICTOR AS WELL, GOOD
GUY.
I WANT TO INTRODUCE FROM YVONNE
COMMODORE-MENSAH ALSO AN
ASSOCIATE PROFESSOR AT HOPKINS,
ALSO FROM THE RESTORE STUDY, HER
RESEARCH FOCUSES ON REDUCING
CARDIOVASCULAR DISEASE RISK
AFRICAN POPULATIONS IN THE U.S.
AND AFRICA THROUGH
COMMUNITY-ENGAGED RESEARCH AND
IMPLEMENTATION SCIENCE.
>> THANK YOU SO MUCH FOR THAT
INTRODUCTION, AND THANK YOU TO
THE ORGANIZERS FOR THE
OPPORTUNITY TO BE HERE TODAY.
AND WE'LL GET STARTED TALKING
ABOUT IMPLEMENTATION CHALLENGES
AND SUCCESSES IN REMOTE BP
MONITORING.
THE ONLY DISCLOSURE I HAVE IS
THAT MY WORK IS ALSO FUNDED BY
THE NIH, SPECIFICALLY THE NIMHD.
I'LL BE TALKING ABOUT THE
LINKED-HEARTS PROGRAM, WHICH
STANDS FOR CARDIOMETABOLIC
HEALTH PROGRAM LINKED WITH
COMMUNITY HEALTH WORKERS AND
MOBILE HEALTH TELEMONITORRING TO
REDUCE HEALTH DISPARITIES.
SO BEFORE GOING ANY FURTHER, I'D
LIKE TO ACKNOWLEDGE THE TEAM
THAT MAKES THIS WORK POSSIBLE.
ONE OF THE THINGS WE'RE REALLY
PROUD OF IS THE DIVERSITY OF OUR
TEAM NOT JUST IN TERMS OF THE
BACKGROUND BUT ALSO IN TERMS OF
HAVING PREDOCTORAL, POSTDOCTORAL
TRAINEES AND ENDOCRINOLOGISTS,
NEPHROLOGISTS, PRIMARY CARE
CLINICIANS AND PUBLIC HEALTH
RESEARCHERS AS WELL.
SO LINKED-HEARTS SEEKS TO
COMPARE THE EFFECT OF THE LINKED
HEARTS PROGRAM VERSUS HOME BLOOD
PRESSURE MONITORING ALONE, AND
IMPROVING BLOOD PRESSURE
CONTROL.
AND WE'RE LOOKING AT OUTCOMES AT
6 AND 12 MONTHS AMONG
INDIVIDUALS WITH UNCONTROLLED
HYPERTENSION PLUS DIABETES OR
CHRONIC KIDNEY DISEASE.
SO THAT'S OUR PRIMARY AIM.
FOR OUR SECONDARY AIM, WE'RE
EVALUATING THE REACH ADOPTION
MAINTENANCE OF THE INTERVENTION
AT 12 AND 24 MONTHS, AND WE'RE
DOING THIS AMONG ADULTS, LIKE I
SAID, WITH UNCONTROLLED
HYPERTENSION, AND DIABETES OR
CKD, AND THE SETTING IS
COMMUNITY HEALTH CENTERS OR
PRIMARY CARE CLINICS, AN IN THE
MARYLAND D.C. AREA, WE'RE USING
A HYBRID TYPE I EFFECTIVENESS
IMPLEMENTATION DESIGN AND IN
TERMS OF THE EFFECTIVENESS AIM,
LIKE I SAID WE'RE COMPARING THE
SUPERIORITY OF THE INTERVENTION,
THE LINKED-HEARTS PROGRAM TO
ENHANCED USUAL CARE, WHICH IS
HOME BLOOD PRESSURE MONITORING
ALONE.
SO WE ARE RANDOMIZING ACTUALLY
18 SITES, IN THE ENHANCED USUAL
CARE ARM, NINE IN THE
INTERVENTION ARM, AND WE'RE
RECRUITING BLACK, WHITE OR
HISPANIC ADULTS.
CONDUCTING THESE ASSESSMENTS AND
THE FOLLOW-UP TIMES ARE 6, 12
AND 18 MONTHS AND YOU CAN SEE
THE EXCLUSION CRITERIA LISTED ON
THE SCREEN AND THE PRIMARY
OUTCOME IS BLOOD PRESSURE
CONTROL DEFINED AS LESS THAN
140/90.
SO IN TERMS OF THE ACTUAL LINKED
HEARTS INTERVENTION, I WANTED TO
SPEND A LITTLE MORE TIME TALKING
ABOUT EACH OF THE COMPONENTS OF
THIS MULTILEVEL INTERVENTION.
SO LINKED HEARTS INCLUDES HOME
BLOOD PRESSURE MONITORING.
IT ALSO INCLUDES THE USE OF A
MOBILE HEALTH APPLICATION CALLED
SPHMIGMO AND I'LL TALK MORE
ABOUT IT IN THE SUBSEQUENT
SLIDES AND WE ALSO ENGAGED
PHARMACISTS SO WE KNOW THE
EVIDENCE SUGGESTS THAT
PHARMACIES-LED INTERVENTIONS
IMPROVE BLOOD PRESSURE CONTROL,
SO WE HAVE A KOSM COMBO OF COMY
HEALTH WORKER PLUS PHARMACIST
WORKING TOGETHER TO PROVIDE
ADDITIONAL SUPPORT, IN ADDITION
TO HOME BLOOD PRESSURE
MONITORING, TO IMPROVE BLOOD
PRESSURE CONTROL.
AND ONE THING I WANT TO
HIGHLIGHT IS THAT WHEN IT COMES
TO COMMUNITY HEALTH WORKER,
WE'VE ALREADY TALKED ABOUT THE
IMPORTANCE OF PROVIDING TRAINING
TO PATIENTS IN TERMS OF ACCURATE
BLOOD PRESSURE MEASUREMENT, SO
WHAT WE'RE DOING IN THE LINKED
HEARTS TRIAL IS WHEN
PARTICIPANTS ARE ENROLLED, FOR
YOUR BASELINE VISIT, THE
COMMUNITY HEALTH WORKER MEETS
THEM AT THE CLINIC OR AT A
PUBLIC PLACE, PROVIDES THE HOME
BLOOD PRESSURE DEVICE, TEACHES
THEM HOW TO CORRECTLY MEASURE
THE BLOOD PRESSURE, TALKS ABOUT
THE IMPORTANCE OF ACCURATE
MEASUREMENT, ALSO HELPS THEM TO
DOWNLOAD THE SPHY DPGMO APP, SIT
DOWN WITH THEM, ASK THEM TO PULL
OUT THEIR PHONE, TEACH THEM HOW
TO DOWNLOAD THE APP BUT TO SIT
WITH THEM, TEACH THEM -- SO THE
FIRST INTERVENTION VISIT IS
REALLY HAPPENING IN PERSON BUT
THE SUBSEQUENT VISITS ARE
HAPPENING REMOTE LELY VIA TELL
HEATELEHEALTH VISITS.
WE'VE ALL TALKED ABOUT AND AWARE
OF THE IMPORTANCE OF USING
VALIDATED BLOOD PRESSURE
DEVICES, WE'RE USING THE ARMAND
SERIES -- THIS IS THE SPHYGMO
APP.
WHAT YOU CAN SEE IS THE PROVIDER
INTERFACE WHERE YOU CAN SEE 3,
7, 30-DAY AVERAGES AS WELL.
SO IN TERMS OF THE ORIGINAL
PLAN, OUR GOAL WAS TO HAVE THESE
BLOOD PRESSURE READINGS DIRECTLY
INNOVATED INTO THE EMR SO THAT
WAS THE PLAN, BUT IN TERMS OF
THE REALITY, THAT DID NOT
HAPPEN.
AND IT DIDN'T HAPPEN FOR A LOT
OF REASONS.
SO HALF OF THE SITE THAT WERE
ENGAGED WITH OUR COMMUNITY
HEALTH TERES CENTERS AND THEY T
CLEAR THEY DIDN'T HAVE
INFRASTRUCTURE OR ALSO COULDN'T
AFFORD THE COST OF THIS DIRECT
INTEGRATION, AND THIS IS
SOMETHING THAT WOULD HAVE HAD TO
BE COVERED BY THE GRANT, AND WE
DIDN'T HAVE THE RIGHT RESOURCES
TO BE ABLE TO AFFORD THE COST OF
INTEGRATION INTO THE EMR, SO THE
REALITY OF WHAT WE DID WAS THEN
THE COMMUNITY HEALTH WORKERS
ENTERED THE -- OR ENTERING THE
AVERAGES INTO THE EMR AND
THEY'RE ALSO PROVIDED ACCESS TO
THE EMR, SO THE IDEAL VERSION IS
TO BE ABLE TO DIRECTLY INTEGRATE
THAT BUT COST WAS A MAJOR
BARRIER.
STO WHSO WHAT ARE SOME IMPLEMENN
SUCCESSES?
WE LEARNED A LOT.
ONE IS THAT WE FOUND THAT
BECAUSE THE PHARMACIST HAS
ACCESS TO THE HOME BLOON
READBLOODPRESSURE READINGS, THEE
TO ADDRESS TREATMENT INERTIA, SO
BLOOD PRESSURE IS UNCONTROLLED,
THE PHARMACIST IS REACHING OUT
TO THE PRIMARY CARE CLINICIAN TO
SAY IS THERE SOMETHING WE CAN
DO, CAN WE MODIFY THE DOSAGE OF
THE MEDICATION, THE SIDE EFFECTS
THAT ARE BEING -- THIS IS
ADDRESSING SOME OF THE
MEDICATION-RELATED ISSUES.
WE ALSO ARE PROVIDING TECHNICAL
SUPPORT.
WE HAVE A DEDICATED RESEARCH
ASSISTANT WHO IS READY WHEN
PARTICIPANTS HAVE ANY
APP-RELATED OR BLOOD PRESSURE
DEVICE-RELATED CHALLENGES.
AND WE NO THAT PEOPLE DO GET
FRUSTRATED WHEN TECHNOLOGY
DOESN'T WORK AS IT SHOULD, AND
SO WE HAVE A DEDICATED PERSON
FOR THAT.
AND ALSO TEAM WORK.
SO HAVING THIS PHARMACIST
COMMUNITY HEALTH WORKER TEAM
THAT IS WORKING COLLABORATIVELY
TO IMPROVE BLOOD PRESSURE
CONTROL HAS BEEN TREMENDOUSLY
HELPFUL.
AND THE COMMUNITY HEALTH WORKERS
AND THE PHARMACISTS BOTH HAVE
ACCESS TO THE SAME INFORMATION
AND CAN ACT APPROPRIATELY.
AND ALSO THE ABILITY TO SHARE
INFORMATION WITH THE PROVIDER,
SO AGAIN IF THE COMMUNITY HEALTH
WORKER OR THE PHARMACIST NOTICES
THAT, AGAIN, BLOOD PRESSURE
CONTROL IS NOT ACHIEVED OR BLOOD
PRESSURE IS ELEVATED, THIS
COMMUNICATION THAT HAPPENS
BETWEEN OUR COMMUNITY HEALTH
WORKERS, THE PHARMACIST AND THE
PRIMARY CARE CLINICIANS.
AND WE'RE ALSO USING THE APP
AMONG PEOPLE WHO SPEAK ENGLISH
AND SPANISH.
I DIDN'T MENTION THE APP IS
AVAILABLE IN ENGLISH, SPANISH,
MANDARIN, CHINESE, AS WELL AS
FRENCH.
SO THE LANGUAGE IS NOT ONLY
AVAILABLE FOR ENGLISH SPEAKERS
BUT ALSO PEOPLE WHO SPEAK
SPANISH AS WELL.
SO WHAT ARE SOME CHALLENGES?
TECHNOLOGY.
TECHNOLOGY IS GREAT WHEN IT
WORKS, NOT GREAT WHEN IT DOESN'T
WORK AS IT SHOULD.
SO THERE HAVE BEEN INSTANCES
WHERE THE APP HAS DISCONNECTED
AND IT'S NOT SYNCED
APPROPRIATELY, SO THEY'VE HAD TO
DISCONNECT AND RECONNECT SO
THAT'S BEEN FRUSTRATING BUT LIKE
I SAID, WE HAVE A TEAM MEMBER
DEDICATED TO ADDRESSING THESE
BARRIERS.
ALSO THE RIGHT CUFF SIZE, WE
HAVE MEDIUM TO LARGE AND EXTRA
LARGE, BUT THERE HAVE BEEN
INSTANCES WHERE MAYBE
PARTICIPANTS HAVE LOST WEIGHT
AND SO WHAT WE'RE DOING NOW IS
WHEN PEOPLE ARE BETWEEN THE
LARGE AND EXTRA LARGE, WE'RE
PROVIDING BOTH CUFFS SO THAT IF
THERE ARE ANY CHANGES, THEY CAN
USE THE RIGHT CUFF SIZE.
BUT ALSO COORDINATING DELIVERY
OF BLOOD PRESSURE DEVICES TO
PARTICIPANTS, THERE HAVE BEEN
INSTANCES WHERE WE'VE MAILED THE
DEVICES AND SOMETIMES
PARTICIPANTS MAY SAY THEY DIDN'T
RECEIVE IT, THE IDEAL WOULD BE
TO MEET WITH THEM IN THE CLINIC,
BUT SOMETIMES WE JUST CAN'T GET
AHOLD OF PEOPLE, SO THERE HAVE
BEEN CHALLENGES WITH THAT.
BUT ALSO STABLE INTERNET,
BECAUSE WE'RE USING A MOBILE
HEALTH AM KAI THERE ARE PEOPLE
WHO'VE REPORTED CHALLENGES WITH
INTERNET ACCESS AND THERE ARE
PEOPLE WHO RESIST USING THE APP
BECAUSE OF PRIVACY CONCERNS, AND
ALSO THE FEAR OR CONCERN OF
BEING TRACKED.
AND THIS IS SOMETHING THAT WE'VE
NOTICED WHEN WORKING WITH
PARTICIPANTS ON THE EASTERN
SHORE, AND IN MORE RURAL
POPULATIONS.
BUT ALSO OLDER ADULTS IN TERMS
OF TECHNOLOGY, SOME OF THE OLDER
PARTICIPANTS HAVE NOT BEEN AS
OPEN TO USING THE APP AND HAVE
SAID THEY PREFER TO ACTUALLY
WRITE DOWN THEIR READINGS, SO
WORKING WITH THEM TO TAKE PHOTOS
AND SEND US THE PHOTOS.
SO WE DON'T WANT TO FORCE PEOPLE
TO USE TECHNOLOGY IF THEY'RE
AVERSE TO IT, SO FINDING WAYS TO
WORK AROUND THAT.
SO JUST WRAPPING UP IN TERMS OF
KNOWLEDGE GAPS AND FUTURE
OPPORTUNITIES, FIRST LIKE I
ALLUDED TO EARLIER, AS
INTEGRATION INTO THE EMR, THAT
IS THE IDEAL SCENARIO, BUT IT
ALSO COMES WITH SOME CHALLENGES
IN TERMS OF TECHNICAL SUPPORT
AND ALSO THE COST IMPLICATIONS
AS WELL.
SO BEYOND ENGLISH, SPANISH, CLIE
NIECE AND FRENCH, THERE ARE
PATIENTS WHO SPEAK OTHER
LANGUAGES, SO FOR THOSE
PATIENTS, WHAT OTHER OPTIONS
EXIST THAT ALLOW THEM TO USE THE
APP IN THEIR PREFERRED LANGUAGE.
ALSO CUFF SIZES.
THERE ARE PEOPLE WHO ARE USING
THE EXTRA LARGE CUFF BUT BECAUSE
OF THE CONICAL SHAPE, ARE HAVING
ISSUES IN TERMS OF GETTING
PROPER READINGS, SO THAT'S
SOMETHING THAT NEEDS TO BE
ADDRESSED IN THE FUTURE.
BUT THEN THERE ARE ALSO
OPPORTUNITIES, SO ONE OF THE
THINGS WE'VE BEEN TALKING ABOUT
IS, WHAT ARE SOME INCENTIVES,
HOW DO WE INCENTIVIZE MEASURING
BLOOD PRESSURE AT HOME?
THERE ARE POINTS THAT COULD BE
AWARDED TO PATIENTS TO ENCOURAGE
THEM, WHAT ARE SOME REWARDS THAT
COULD BE INTEGRATED INTO SOME OF
THESE MOBILE HEALTH APPLICATIONS
THAT WILL ENCOURAGE THEM TO
MONITOR THE BLOOD PRESSURE
OFTEN, BUT ALSO WHAT ARE
OPPORTUNITIES IN TERMS OF THE
USE OF ARTIFICIAL INTELLIGENCE
IN TERMS OF FOLLOW-UP MESSAGING,
AND ALSO LIKE I SAID EARLIER,
WHAT OTHER LANGUAGES COULD BE
INTEGRATED IN A LOT OF THESE
MOBILE HEALTH APPLICATIONS.
AND THEN THE LAST PIECE IS
INTEGRATION OF BLOOD PRESSURE
CLINICAL GUIDELINES.
SO LIKE I SAID AS THE PATIENT
FACING PIECE OF THE SPHYGMO AP
BUT ALSO THE PROVIDER PORTAL,
WHAT ARE SOME OPPORTUNITIES TO
INTEGRATE CURRENT GUIDELINES,
AND ALTHOUGH THE 2017 GUIDELINES
ARE STILL BEING DEBATED, HOW DO
WE INTEGRATE THE GUIDELINES SO
THAT THE CLINICIANS HAVE THIS
INFORMATION READILY AVAILABLE
AND THAT COULD ALSO INFORM HOW
BLOOD PRESSURE CONTROL IS
ACHIEVED AND HOW THEY TAKE
ACTION TO REDUCE BLOOD PRESSURE.
I BELIEVE THAT'S IT.
THANK YOU SO MUCH FOR YOUR TIME
AND ATTENTION.
>> SO THANK YOU, I'M GOING TO
HAND THE REINS OVER TO MY FRIEND
KEITH FERDINAND TO INTRODUCE THE
NEXT TWO SPEAKERS.
>> THANK YOU, RAY.
SO THE NEXT SPEAKER IS GOING TO
BE ON AVOIDING BIAS IN RECORDED
BLOOD PRESSURE BY KATHRYN FOTI.
DR. FOTI IS AT UAB IN
BIRMINGHAM.
SHE ALSO WORKS WITH THE RESTORE
NETWORK AND HER RESEARCH IS
FOCUSED ON MONITORING AND
IMPROFFERRING THE PRIMPROVING TD
CONTROL OF HYPERTENSION NOT ONLY
IN THE UNITED STATES BUT
GLOANLLY AND HAS DONE EXTENSIVE
WORK WITH THE CDC.
>> THANK YOU FOR HAVING ME.
IT'S REALLY A PLEASURE TO BE
PART OF THIS WORKSHOP.
CAN WE ADVANCE THE SLIDES,
PLEASE?
I THINK WE CAN KEEP GOING, ONE
MORE.
I HAVE NO DISCLOSURES BUT LISTED
MY SOURCES OF FUNDING HERE.
IN BORROWING FROM YVONNE, I'D
LIKE TO START BY ACKNOWLEDGING
MY COLLABORATORS ON THE WORK
THAT YOU'LL SEE TODAY.
AS WELL AS OUR FUNDING SUPPORT
FROM RESOLVED TO SAVE LIVES.
WHAT I'M SHOWING YOU TODAY
REALLY CAME ABOUT AS A RESULT OF
SEFESEVERAL OF OWRP COLLABORATOR
WORKING IN HYPERTENSION CONTROL
PROGRAM, NOTICING PATTERNS IN
THEIR RECORDED BLOOD PRESSURE
DATA THAT WERE SUGGESTIVE OF
REPORTING BIASES AND THEY ASKED
FOR TOOLS TO BETTER DETECT AND
ULTIMATELY PREVENT BIAS FROM
OCCURRING.
SO THIS PRESENTATION IS NOT
MEANT TO NAME OR SHAME ANYONE,
RATHER TO RAISE AWARENESS OF
RECORDING BIASES AND AS OUR
PARTNERS DID, ENCOURAGE RIGOROUS
REVIEW OF BLOOD PRESSURE
MEASUREMENTS AND DATA
TRANSPARENCY.
SO IN THIS TALK, I'LL FIRST
PROVIDE SOME BACKGROUND ON
CERTAIN TYPES OF REPORTING
BIASES, TERMINAL DIGIT
PREFERENCE AND THRESHOLD BIAS IN
PARTICULAR.
I'LL FOCUS THE MAJORITY OF THE
PRESENTATION ON THRESHOLD BIAS
INCLUDING KE SCRIBING A METHOD
WE DEVELOPED FOR DETECTING
THRESHOLD BIAS AND THEN SHOW HOW
WE'VE APPLIED IT IN CLINICAL
PRACTICE AND CLINICAL TRIAL
DATASETS AND THEN DISCUSS
POTENTIAL SOLUTIONS AND
CONCLUSIONS.
SO I THINK WE'RE ALL AT THIS
WORKSHOP BECAUSE WE RECOGNIZE
THAT ACCURATE BLOOD PRESSURE
MEASUREMENTS ARE ESSENTIAL FOR
THE DIAGNOSIS AND TREATMENT OF
HYPERTENSION.
AND AS WE'VE HEARD OVER THE LAST
TWO DAYS, BLOOD PRESSURE
MEASUREMENT ERROR CAN BE
INTRODUCED IN ANY NUMBER OF
WAYS, REALLY IN ANY STEP OF THE
BLOOD PRESSURE MEASUREMENT
PROCEDURE INCLUDING RECORDING.
SO EVEN IF YOU HAVE YOUR
VALIDATED DEVICE AND ARE DOING
EVERYTHING CORRECTLY THE BLOOD
PRESSURE COULD STILL BE
MISRECORDED.
ERRORS CAN OCCUR EVEN WHEN
AUTOMATED DEVICES ARE USED.
I THINK WE'VE SEEN SOME EXAMPLES
OF STUDIES WHERE THE
INTRODUCTION OF AUTOMATED
DEVICES HAS REDUCED TERMINAL
DIGIT PREFERENCE, BUT I THINK
RESEARCH STUDIES DONE IN THE
CONTEXT OF QUALITY IMPROVEMENT
PROGRAMS MAY NOT REPRESENT
TYPICAL CLINICAL PRACTICE, AND
ALSO KEEPING IN MIND THAT EVEN
WITH AB AUTOMATED DEVICE,
SOMEONE STILL HAS TO TRANSCRIBE
THE READING FROM THE DEVICE INTO
THE MEDICAL RECORD IN MOST
SITUATIONS.
SO ONE TYPE OF BIAS THAT I THINK
THIS AUDIENCE IS FAMILIAR WITH
AND WE TALKED ABOUT DURING THIS
WORKSHOP ALREADY IS TERMINAL
DIGIT PREFERENCE.
THIS REFERS TO A TENDENCY BY THE
OBSERVER TO RECORD MEASUREMENTS
USING CERTAIN END DIGITS MORE
FREQUENTLY THAN OTHERS SO AS
SHOWN ON THE RIGHT, THIS USUALLY
PRENPRESENTS AS AN EXCESS OF END
DIGIT ZEROS.
AND IN THIS EXAMPLE, 38% OF ALL
THE SYSTOLIC BLOOD PRESSURE
MEASUREMENTS SHOWN END IN ZERO.
THIS IS AS COMPARED TO AN
EXPECTED 10% OF MEASUREMENTS
WITH AN AUTOMATED DEVICE OR 20%
IF TAKEN WITH A MANUAL DEVICE
AND ONLY EVEN DIGITS ARE
RECORDED.
ANOTHER TYPE OF RECORDING BIAS
IS THRESHOLD BIAS, AND THIS
REFERS TO A TENDENCY BY THE
OBSERVER TO RECORD MEASUREMENTS
AT VALUES JUST BELOW SPECIFIC
THRESHOLDS OF INTEREST.
FOR EXAMPLE, FOR HYPERTENSION
DIAGNOSIS OR BLOOD PRESSURE
CONTROL.
THE HISTOGRAM ON THE RIGHT ARE
CLINICAL DATA FROM A
HYPERTENSION CONTROL PROGRAM.
THERE'S A BLOOD PRESSURE GOAL OF
LESS THAN 140/90.
AND WHAT YOU SEE IN THIS SLIDE
IS A CLUSTER OF MEASUREMENTS
JUST BELOW A SYSTOLIC OF 140.
RIGHT AT 140, WE HAVE THIS
DROPOFF OR DISCONTINUITY IN THE
DISTRIBUTION.
WE REFER TO THIS SORT OF
CASUALLY AMONG OUR RESEARCH TEAM
AS THE CLIFF AND THEN A MUCH
LOWER FREAK SIG FREQUENCY OF MES
ABOVE 140.
UNLIKE WITH TERMINAL DIGIT
PREFERENCE, WE REALLY DON'T HAVE
ESTABLISHED METHODS FOR
DETECTING THRESHOLD BIAS OTHER
THAN VISUALLY LOOKING AT A
HISTOGRAM.
THIS IS A RELATIVELY CLEAR-CUT
EXAMPLE, I THINK, BUT IT'S NOT
ALWAYS QUITE SO STRAIGHTFORWARD
SO WE'LL COME BACK TO METHODS
FOR DETECTING THRESHOLD BIAS
SHORTLY.
AND THESE ERRORS IN BLOOD
PRESSURE RECORDING ARE NOT
BENIGN.
THEY HAVE IMPLICATIONS FOR THE
CORRECT DIAGNOSIS AND TREATMENT
OF HYPERTENSION.
PREVIOUS RESEARCH HAS SHOWN THAT
PATIENTS AT PRACTICES WITH
HIGHER LEVELS OF TERMINAL DIGIT
PREFERENCE MAY BE LESS LIKELY TO
HAVE AN ANTIHYPERTENSIVE
PRESCRIPTION AND MORE LIKELY TO
HAVE A CARDIOVASCULAR EVENT.
THERE ARE MANY FEWER STUDIES OF
THRESHOLD BIAS IN THE
LITERATURE, HOWEVER IN ONE PAPER
BY WINGFIELD AT ALL WHAT THEY
FOUND WAS THAT WOMEN WHOSE
DIASTOLIC BLOOD PRESSURE WAS
RECORDED AT 88 OR 89 ACTUALLY
HAD HIGHER CARDIOVASCULAR
DISEASE AND TOTAL MORTALITY THAN
THOSE WITH LOWER OR HIGHER
DIASTOLIC BLOOD PRESSURES
RECORDED SUGGESTING THAT THOSE
WOMEN WHOSE DBP WAS RECORDED AS
88 OR 89 WERE UNDERTREATED.
AGAIN GIVEN THAT THRESHOLD BIAS
IS RELATIVELY UNDERSTUDIED, I'LL
SPEND SOME TIME ON THIS
PARTICULAR ISSUE, THIS CONCEPT
HAS BEEN DESCRIBED AT LEAST AS
EARLY AS THE 1960s, HOWEVER,
THE EXTENT OF THRESHOLD BIAS IN
CLINICAL PRACTICE AND CLINICAL
RESEARCH IS UNKNOWN, AND AS
MENTIONED BEFORE, WE DON'T HAVE
ESTABLISHED METHODS FOR
DETECTING IT.
AND WHILE THE ROOT CAUSES HAVE
NOT BEEN SYSTEMATICALLY STUDIED,
BASED ON THE PAPERS THAT ARE IN
THE LITERATURE AND IN TALKING
WITH PARTNERS WORKING IN THE
FIELD, THIS MAY ARISE DUE TO
INCENTIVES TO IMPROVE BLOOD
PRESSURE CONTROL.
THERE'S ONE PUBLISHED PAPER
AFTER THE INTRODUCTION OF THE
QUALITY IN OUTCOMES FRAMEWORK IN
THE U.S. K. THAT DOCUMENTED SORT
OF THE INTRODUCTION OF THRESHOLD
BIAS SO IT MAY BE AN UNINTENDED
CONSEQUENCE OF QUALITY PROGRAMS.
IT ALSO MAY ARISE BASED ON A
DESIRE TO AVOID MEDICATION
TITRATION OR PERHAPS CLINICIAN
ASSUMPTIONS ABOUT A PATIENT'S
BLOOD PRESSURE, SO IF A YOUNGER
PATIENT HAS A SYSTOLIC OF
142 MAYBE IT GETS RECORDED OF
138 BECAUSE THEY'RE THOUGHT TO
BE YOUNG AND HEALTHY.
SO NEXT I'D LIKE TO SHARE SOME
WORK WE'VE BEEN DOING IN OUR
GROUP TO DEVELOP A METHOD FOR
DETECTING THRESHOLD BIAS.
SIMILAR TO TERMINAL DIGIT
PREFERENCE WHERE WE HAVE A
REFERENCE DISTRIBUTION OR SOME
EXPECTED PERCENT OF MEASUREMENTS
TO COMPARE TO, WE NEED SOME
EXPECTED BLOOD PRESSURE
DISTRIBUTION AGAINST WHICH TO
EVALUATE THE POTENTIAL FOR
THRESHOLD BIAS.
WHAT WE'VE DONE IS TO USE
POPULATION-BASED SURVEILLANCE
DATA FOR THIS.
AND THE REASON WE'RE USING
SURVEILLANCE DATA IS BECAUSE IN
A SURVEILLANCE STUDY, THERE'S NO
BLOOD PRESSURE GOAL, AND THERE'S
NO INCENTIVE FOR MISRECORDING SO
WE CAN LOOK AT THE DISTRIBUTION
OF BLOOD PRESSURE IN ADULTS WITH
TREATED HYPERTENSION AND GET A
SENSE OF WHAT THAT SHOULD LOOK
LIKE IN THE ABSENCE OF BIAS.
AND IN THE ABSENCE OF BIAS, WE
EXPECT THAT BLOOD PRESSURE
DISTRIBUTION IS GOING TO BE A
NICE SMOOTH CURVE, IT WON'T HAVE
THAT CLIFF THAT I SHOWED YOU
EARLIER, THERE WILL BE APR
APPROXIMATELY NORMAL OR LOG MORE
MNORMAL IN SHAPE.
THEN WHAT WE'VE DONE NEXT IS
DEVELOP A METRIC THAT WE CALL
THE THRESHOLD RATIO AND
ESSENTIALLY TAKING THE NUMBER OF
MEASUREMENTS JUST BELOW VERSUS
JUST ABOVE.
IF WE HAVE A BLOOD PRESSURE GOAL
OF LESS THAN 140 OVER 90, FOR
EXAMPLE, WE WOULD DEFINE THE
SYSTOLIC THRESHOLD RATIO AS THE
NUMBER OF MEASUREMENTS DIVIDED
BY THE NUMBER OF MEASUREMENTS
140 TO 149.
NOW OBVIOUSLY IF WE HAVE A
DIASTOLIC BLOOD PRESSURE GOAL OF
LESS THAN 9 90 -- DIVIDED BY THE
NUMBER OF MEASUREMENTS 90 TO 94.
JUST TO UNDERSCORE WHY WE'RE
INTERESTED IN THIS METRIC OF THE
THRESHOLD RATIO, IN THE
HISTOGRAM ON THE LEFT, THESE WHY
JUST SIMULATED DATA BUT MIGHT BE
WHAT A SURVEILLANCE DATASET
WOULD LOOK LIKE.
IF WE WERE TO CALCULATE THE
THRESHOLD RATIO, SO AGAIN,
NUMBER OF MEASUREMENTS, 130-139
DIVIDED BY 140-149, THAT
MEASUREMENTS IS GOING TO BE
1 BUT IT WILL BE CLOSE TO IT.
IN CONTRAST ON THE RIGHT IN THE
SETTING OF THRESHOLD BIAS, WE
HAVE A LARGE NUMBER OF
MEASUREMENTS BETWEEN 130 AND ONE
39 AND A MUCH SMALLER NUMBER OF
MEASUREMENTS BETWEEN 140 AND 149
SO WE'LL HAVE A MUCH HIGHER
THRESHOLD RATIO WHICH WE CAN
THEN COMPARE.
SO COMING BACK TO OUR METHOD
ITSELF, THE NEXT THING WE DID
WAS TRY TO UNDERSTAND THE
PROBABILITY OF OBSERVING HIGHER
RATIOS THAT MIGHT INDICATE
THRESHOLD BIAS IN A CLINICAL
DATASET BASED ON WHAT WE SEE IN
THE SURVEILLANCE DATA, AND WE
USED A BOOTSTRAPPING APPROACH
FOR THIS.
THEN FINALLY WE CALCULATE THE
OBSERVED THRESHOLD RATIO IN THE
CLINICAL DATASETS AND AGAIN
COMPARE THAT TO THE PROBABILITY
BASED ON THE SURVEILLANCE DATA.
AND I'LL WALK THROUGH A COUPLE
OF EXAMPLES NEXT OF HOW WE'VE
APPLIED THIS METHOD AND SORT OF
DESCRIBE EACH OF THESE STEPS IN
DETAIL AS WE GO SO YOU CAN
VISUALIZE THEM.
SO THE FIRST EXAMPLE I'LL SHOW
YOU IS OF A CLINICAL PRACTICE
DATASET THAT WE EVALUATED.
THESE CLINICAL DATA CAME TO US
FROM ONE OF OUR PARTNERS WORKING
IN ANOTHER COUNTRY, SO THE
SURVEILLANCE DATA THAT WE USED
AS THE REFERENCE IN THIS CASE
CAME FROM THEIR WHO STEP SURVEY,
THE BLOOD PRESSURES HERE ALL
TAKEN WITH AN OSCILLOMETRIC
DEVICE.
I'LL FOCUS ON THE STOILINGS
BLOOD PRESSURES JUST FOR THE
SAKE OF TIME.
SYSTOLIC.
SO IF WE CALCULATE THE THRESHOLD
RATIO IN THIS SURVEILLANCE DATA,
SO AGAIN TAKING THE NUMBER OF
MEASUREMENTS 130 TO 139 SHOWN IN
THE PINK BARS DIVIDED BY THE
NUMBER OF MEASUREMENTS 140 TO
149 SHOWN IN THE BLUE BARS, THIS
RATIO HERE IS 1.10.
THEN WHAT WE DID WAS TO SORT OF
DRAW FROM THESE SURVEILLANCE
DATA, SO WE USED BOOTSTRAPPING
WITH THEN THOUSAND RANDOM DRAWS,
WE LOOKED AT SEVERAL
DIFFERENT -- TRYING TO
UNDERSTAND THE PROBABILITY OF
OBSERVING HIGHER RATIOS THAT
MIGHT INDICATE THRESHOLD BIAS IN
OUR SURVEY LABS SURVEILLANCE D.
YOU MAY BE MORE CONSERVATIVE IN
TERMS OF PLAGUING RATIOS -- THE
TAKEAWAY HERE IS IF WE SEE A
RATIO OF 2.5 TO 3, IT'S VERY YOU
UNLIKELY TO BE OBSERVED IN THE
SURVEILLANCE DATA THAT MAY
INDICATE THAT BIAS IS OCCURRING.
LOOKING AT THE CLINICAL PRACTICE
DATASET, THESE ARE DATA FROM
JUST ONE HEALTHCARE FACILITY
THAT HAS OVER 10,000
OBSERVATIONS.
THE THRESHOLD RATIO WE
CALCULATED HERE IS 3.56.
AND IF WE COME BACK TO THE TABLE
OF PROBABILITIES BASED ON THE
SURVEILLANCE DATA, WE SEE THE
THRESHOLD RATIO OF 3.56, THIS
LIKELY INDICATE THERE'S SOME
BIAS OCCURRING.
I THINK WE CAN ALSO SEE THAT
PRETTY WELL VISUALLY IN THIS
PARTICULAR EXAMPLE.
SO AFTER LOOKING AT A NUMBER OF
CLINICAL PRACTICE DATASETS, OUR
RESEARCH TEAM WAS INTERESTED IN
LOOKING AT OTHER TYPES OF DATA,
IN PARTICULAR, CLINICAL TRIALS
WHICH ALSO HAVE A BLOOD PRESSURE
CONTROL GOAL.
AND THE CLINICAL TRIAL EXAMPLE
THAT I'LL SHOW YOU COMES FROM
THE U.S., SO THESE SURVEILLANCE
DATA THAT ARE USED AS THE
REFERENCE HERE IN THE NATIONAL
HEALTH AND NUTRITIONAL
EXAMINATION SURVEY, THESE ARE
THE MEASUREMENTS FROM 2017 TO
2020.
THE THRESHOLD RATIO WE
CALCULATED HERE IS 1.39.
AND AGAIN USING OUR
BOOTSTRAPPING APPROACH, WE FOUND
THAT RATIOS OF 2.5 OR 3 OR EVEN
HIGHER ARE UNLIKELY TO BE FOUND
IN SURVEILLANCE DATA.
RATIOS OF 1.8 OR 2 MAY BE MORE
INTERMEDIATE MAY WARRANT SOME
ADDITIONAL REVIEW, WHEREAS A
RATIO OF 1.5 IS COMPATIBLE WITH
THE SURV SURVEILLANCE DATA.
THIS SHOWS DATA FROM A
HYPERTENSION TREATMENT TRIAL.
THE DATA ARE FROM THE STANDARD
TREATMENT ARM OF THE TRIAL,
WHICH HAS SYSTOLIC BLOOD
PRESSURE GOAL OF LESS THAN 140.
WE TOOK THE DATA FROM THE STUDY
VISIT CLOSEST TO THE MEAN
OVERALL FOLLOW-UP TIME AND HERE
THE THRESHOLD RATIO IS 2.26.
COME BACK TO OUR TABLE OF
PROBABILITIES OUTLINED IN THE
BLACK BOX WHERE THIS RATIO WOULD
FALL, I THINK THIS MIGHT WARRANT
REVIEW OF BLOOD PRESSURE
REPORTING PROCEDURES, OR IT'S
POSSIBLE THAT THERE'S SOME BIAS
OCCURRING.
I KNOW SOMEONE MAY COMMENT WHILE
TRIAL POPULATIONS ARE DIFFERENT
FROM SURVEILLANCE POPULATIONS OR
THAT THIS MIGHT REPRESENT
OPTIMAL BLOOD PRESSURE CONTROL,
I THINK I WOULD ASK THE
CLINICIANS, HOW PRECISELY IS
BLOOD PRESSURE TYPICALLY
CONTROLLED?
AND AGAIN, THIS METHOD IS ALSO
NOT MEANT TO PROVE THAT THERE'S
BIAS OCCURRING, RATHER TO PROMPT
FOR REVIEW OF PROCEDURES AND
ENCOURAGE QUALITY CONTROL
THROUGHOUT A STUDY.
SO IN TERMS OF POTENTIAL
SOLUTIONS, ONE WAY TO AVOID
THRESHOLD BIAS AND OTHER TYPES
OF RECORDING BIAS AS WELL IS TO
USE DEVICES THAT HAVE THE
CAPABILITY TO AUTOMATICALLY
UPLOAD DATA.
THERE WAS JUST A NICE PAPER BY
WU ET AL. FROM CHINA THAT I
THINK PROVIDES A FLIES EXAMPLE
OF THIS.
NICE EXAMPLE OF
THIS HOWEVER THESE ARE NOT
WIDELY AVAILABLE AND ACCESSIBLE,
SO IN THE INTERIM, ROUTINE
REVIEW OF HISTOGRAMS OF
MEASUREMENTS IN BOTH CLINICAL
PRACTICE AND CLINIC BASED
RESEARCH MAY BE ONE POTENTIAL
SOLUTION.
SO IN CONCLUSION BOTH VISUAL
INSPECTION AND STATISTICAL
METHODS MAY BE USEFUL FOR
DETECTING THRESHOLD BIAS AS WELL
AS OTHER TYPES OF BIASES.
WE IDENTIFIED SEVERAL DATASETS
WITH THE POTENTIAL FOR THRESHOLD
BIAS, AGAIN I'M UNDERSCORING
POTENTIAL HERE.
OUR METHODS SHOULD BE TESTED IN
OTHER SETTINGS AND FURTHER
REFINED.
THIS IS A WORK IN PROGRESS,
WE'RE WORKING ON A PAPER RIGHT
NOW.
I THINK THE META CONCLUSIONS
HERE IS THERE'S A NEED FOR
RENEWED EMPHASIS ON HIGH QUALITY
BLOOD PRESSURE MEASUREMENTS
INCLUDING ACCURATE REPORTING.
THIS IS MY LAST SLIDE ON THE KEY
KNOWLEDGE GAPS AND FUTURE
OPPORTUNITIES.
KEY GAPS CURRENTLY INCLUDE A LOW
AWARENESS OF THRESHOLD BIAS, AS
WELL AS A MISPERCEPTION THAT
RECORDING BIASES ARE ELIMINATED
WITH AUTOMATED DEVICES.
AND A NEED FOR QUALITY
IMPROVEMENT PROGRAMS THAT
ADDRESS THAT REPORTING PIECE.
FUTURE OPPORTUNITIES INCLUDE
TESTING THE METHOD FOR DETECTING
THRESHOLD BIAS IN OTHER SETTINGS
AS I MENTIONED AND CONTINUING TO
REFINE IT.
AS WELL AS EXAMINING ROOT CAUSES
OF THRESHOLD BIAS AND FINALLY
DEVELOPING STRATEGIES TO PREVENT
IT, OF QUALITY ASSURANCE AND
QUALITY CONTROL PROCEDURES IN
BOTH CLINICAL PRACTICE AND
CLINIC-BASED RESEARCH.
AS MENTIONED THIS MAY INCLUDE
ROUTINE DATA MONITORING AND
MAYBE EVEN TAKING IT A STEP
FURTHER TO PUBLISH HISTOGRAMS OF
BLOOD PRESSURE MEASUREMENTS WHEN
REPORTING DATA.
THANK YOU VERY MUCH, HAPPY TO
TAKE QUESTIONS AT THE END.
>> THANK YOU VERY MUCH.
OUR NEXT PRESENTATION IS GOING
TO BE BY C. BARRETT BOWLING, IF
WE CAN HAVE -- THERE YOU GO,
ASSOCIATE PROFESSOR OF MEDICINE
AND ASSOCIATE PROFESSOR OF
PUBLIC HEALTH AND SCIENCES AT
DUKE.
HE HAS WORKED FOR YEARS IN THE
DIAGNOSIS, TREATMENT AND
FUNCTIONAL HEALTH STATUS, UNIQUE
AMONG OLDER ADULTS.
HE'S GOING TO ADDRESS
AGE-RELATED CHALLENGES IN BLOOD
PRESSURE ASSESSMENT.
DR. BOWLING?
>> THANK YOU SO MUCH.
THANK YOU FOR THE INTRODUCTION
AND THANK YOU FOR THE INVITATION
TO PARTICIPATE IN THIS
OUTSTANDING WORKSHOP.
I'VE ALREADY LEARNED A LOT.
I'M GOING TO FOCUS ON OLDER
ADULT FOR THIS SESSION.
WE CAN GO ON TO THE NEXT SLIDE,
PLEASE.
AND REALLY I'M GOING TO THINK
ABOUT KIND OF THE TWO MAJOR
CHALLENGES THAT WE FACE IN
GERIATRIC MEDICINE.
SO WHEN I TAKE CARE OF PATIENTS
IN THE CLINIC, WHEN I SEE OLDER
ADULTS, I OFTEN FIND MYSELF
ASKING MYSELF, WHAT IS IT ABOUT
GETTING OLDER THAT MAKES
DIAGNOSIS AND MANAGEMENT OF
CHRONIC CONDITIONS DIFFICULT OR
IN OTHER WORDS, WHAT'S GOING TO
GET IN THE WAY HERE OF TRYING TO
APPLY AND FOLLOW GUIDELINES.
THIS IS AN IMPLEMENTATION
CHALLENGE.
IT'S A CHALLENGE THAT WE MIGHT
THINK ABOUT AT THE INDIVIDUAL
OLDER ADULT LEVEL, WE MIGHT
THINK ABOUT IT FOR OUR ENTIRE
CLINIC POPULATION OR WE MIGHT
THINK ABOUT IT ACROSS OUR HEALTH
SYSTEM, BUT IT'S AN
IMPLEMENTATION CHALLENGE.
ANOTHER QUESTION THAT I FIND
MYSELF ASKING IS, DO THE
FINDINGS FROM CLINICAL ROW
SEARESEARC
STUDIES APPLY TO MY PATIENTS?
ARE THESE GENERALIZABLE TO THE
PEOPLE I'M SEEING AND TAKING
CARE OF?
AND THIS IS AN EVIDENCE
GENERATION CHALLENGE AND IT'S A
CHALLENGE THAT OFTENTIMES DUE TO
THE UNDERREPRESENTATION OF OLDER
ADULTS IN RESEARCH.
WITH THESE TWO CHALLENGES IN
MIND, WHAT I HOPE TO DO IS THAT
BY THE END, YOU'LL BE ABLE TO
DESCRIBE SOME CHALLENGES AND
POTENTIAL SOLUTIONS TO OPTIMIZE
OUT OF CLINIC BLOOD PRESSURE
ASSESSMENT IN OLDER ADULTS, AND
ALSO TO BE ABLE TO IDENTIFY SOME
BARRIERS AND POTENTIAL SOLUTIONS
TO THE UNDERREPRESENTATION OF
OLDER ADULTS IN BLOOD PRESSURE
ASSESSMENT STUDIES.
ALONG THE WAY, WE'RE GOING TO
THINK ABOUT A LOT OF GAPS AS
WELL THAT MAYBE NEED TO BE
ADDRESSED.
SO WE'LL START WITH WHAT WE DO
KNOW.
AND WE DO KNOW THAT A LOT OF
OLDER ADULTS ARE CHECKING THEIR
BLOOD PRESSURE AT HOME.
AS THESE DATA COME FROM THE
BEHAVIORAL RISK FACTOR
SURVEILLANCE SYSTEM, THERE WAS A
SPECIAL MODULE ON SELF-MEASURED
BLOOD PRESSURE THAT INCLUDED
OVER 66,000 OLDER ADULTS OR
ADULTS WITH HYPERTENSION, AND
WHAT THEY SHOWED IS THAT OLDER
ADULTS ARE MORE LIKELY TO CHECK
THEIR BLOOD PRESSURE BUT THEY'RE
LESS LIKELY TO COMMUNICATE IT
BACK TO THEIR PROVIDERS USING
TECHNOLOGY.
THAT'S SHOWN IN THAT FIGURE
HERE, WHERE YOU SEE THAT THERE'S
A PROGRESSIVE INCREASE IN THE
PERCENTAGE OF PARTICIPANTS WHO
REPORTED CHECKING THEIR BLOOD
PRESSURE AT OLDER AGES.
THAT GOES UP WITH OLDER AGES BUT
THE NUMBER WHO SHARE IT VIA
EMAIL OR INTERNET GOES DOWN.
OVERALL, ALL PARTICIPANTS WERE
MOST LIKELY TO SHARE THEIR
RESULTS IN PERSON.
SO I THINK THE TAKE-HOME HERE IS
THAT REALLY OLDER ADULTS ARE
CHECKING THEIR BLOOD PRESSURE AT
HOME.
HOW THEY PREFER TO COMMUNICATE
THAT TO PEOPLE MAY DIFFER ACROSS
AGE GROUPS.
A GAP I HAVE TO KIND OF POINT
OUT IS NOT NECESSARILY SPECIFIC
TO THIS STUDY BUT FOR MANY
STUDIES THAT THINK ABOUT AGE, IS
THAT HERE AGE IS DEFINED AS
65 YEARS AND OLDER AND WHAT WE
KNOW IN GERIATRICS IS THAT
THERE'S A WIDE RANGE OF
FUNCTIONAL ABILITIES, COGNITIVE
ABILITIES, HEALTH STATUS AND
HEALTH PREFERENCES IN OLDER AGE,
SO BY LUMPING PEOPLE WHO ARE
OLDER ALL INTO 65, OFTENTIMES
YOU MAY MISS SOME OF THAT
HETEROGENEITY.
AND SO I THINK THERE IS MAYBE AN
OPPORTUNITY TO LOOK MORE INTO
OLDEST OLD AND TO TRY AND
UNDERSTAND THE USE OF HOME BLOOD
PRESSURE MONITORING.
SO WHILE THEY ARE CHECKING THEIR
BLOOD PRESSURE, THEY MAY NOT BE
DOING IT NECESSARILY IN A WAY
THAT IS ACTUALLY HELPFUL FOR
CLINICAL DECISION-MAKING.
THEY MAY NOT MEASURE IT OFTEN
ENOUGH.
THESE RESULTS COME FROM THE
NATIONAL HEALTHY POLL ON AGING,
INCLUDE OVER 2,000 PEOPLE 50 TO
80 YEARS OLD.
I THINK WE SAW SOME OF THESE
RESULTS EARLIER.
HERE I'M GOING TO SHOW IT IN A
DIFFERENT WAY, THINKING ABOUT,
WELL, ABOUT HALF OF PEOPLE
REGULARLY MONITOR THEIR BLOOD
PRESSURE, BUT OF THOSE, ABOUT
50% ONLY DO IT ONCE A WEEK.
AND SO HERE REALLY THINKING
ABOUT IS IT ENOUGH OR IS IT DONE
AT A TIME AT WHICH IT WOULD BE
HELPFUL FOR CLINICAL
DECISION-MAKING.
AND SO I THINK THERE IS A
KNOWLEDGE GAP ON HOW TO BOTH
OBTAIN, WHAT IS THE APPROPRIATE
TIMING, AND HOW TO OBTAIN THOSE,
SO THAT THERE ARE RELATIVE TO A
CLINIC VISIT OR RELATIVE TO
CHANGES THROUGHOUT THE DAY AS
WE'VE HEARD IN OTHER TALKS THAT
MIGHT REALLY IMPACT
DECISION-MAKING AROUND BLOOD
PRESSURE TREATMENT.
SO IN ADDITION TO KNOWING OLDER
ADULTS ARE DOING THIS, WE ALSO
KIND OF -- THERE'S SOME
INFORMATION ABOUT WHAT PROVIDERS
AND SPECIFICALLY PRIMARY CARE
PROVIDERS THINK ABOUT HOME BLOOD
PRESSURE READINGS, AND A LOT OF
THIS COMES FROM QUALITATIVE
ANALYSES THAT HAVE USED SEMI
STRUCTURED DATA.
THIS IS JUST ONE EXAMPLE THAT
SURVEYED AND INTERVIEWED PRIMARY
CARE PHYSICIANS.
I REALLY FOUND THESE BARRIERS TO
USING HOME BLOOD PRESSURE GO ON
TO IMPACT THE FACT THAT OLDER --
THAT THESE AREN'T BEING USED IN
CLINICAL DECISION-MAKING.
SO I THINK THE TWO QUOTES THAT
ARE SHOWN HERE, NOT BEING ABLE
TO ALWAYS TRUST THE HOME VALUES,
WHETHER IT'S I'M NOT SURE ABOUT
THE DEVICE OR I'M NOT SURE ABOUT
HOW THE PATIENT IS DOING IT ARE
BIG BARRIERS.
AND I THINK WE HEARD THAT TYPE
OF SENTIMENT ECHOED BOTH
YESTERDAY AND TODAY.
AND THE SECOND QUOTE, THERE'S
TALK ABOUT ENCOURAGING PATIENTS
TO USE MYCHART FOR UPLOADING
BLOOD PRESSURES.
IF THE MEDIAN AGE IS 82, THEY'RE
GOING TO HAVE MORE CHALLENGES
THAN A YOUNGER POPULATION AT
EVEN GETTING ACCESS.
SO THIS REMINDED ME OF ONE OF
THE SPEAKERS YESTERDAY TALKED
ABOUT ADVOCATING FOR A YOUNGER
FAMILY MEMBER IN THEIR LIFE
THROUGH MYCHART, AND CONNECTING
WITH THEIR PROVIDERS.
HERE THIS MIGHT BE AN EVEN MAJOR
CHALLENGE FOR THE INDIVIDUAL
OLDER ADULT OR THE PEOPLE THAT
ARE PROVIDING THEIR CARE.
I DO THINK AN AREA OF KNOWLEDGE
GAPS AROUND THIS IS THERE'S LESS
DATA ON PATIENT AND CAREGIVER
PERCEIVED BARRIERS.
DR. GREEN SHOWED SOME RESULTS
TODAY FROM THE PATIENT
PERSPECTIVE, AND THERE WERE SOME
OLDER ADULTS IN THE QUOTES THAT
SHE SHOWED, SO I'M EXCITED TO
SEE THAT FULL REPORT.
I'LL ALSO BE INTERESTED TO KNOW
WHAT CARE PARTNERS OR CAREGIVERS
QUESTION ABOUT THE POTENTIAL
BARRIERS OF THIS TYPE OF WORK.
SO I THINK SOME MORE WORK TO BE
DONE.
REALLY TO KIND OF -- FROM THE
OLDER PATIENTS' PERSPECTIVE
ABOUT BARRIERS TO HOME BLOOD
PRESSURE.
SO WITH ALL OF THIS IN MIND, AND
WITH REVIEWING THE EXTENSIVE
LITERATURE ON BARRIERS TO
CHRONIC DISEASE MANAGEMENT MORE
GENERALLY OR MORE BROADLY, WE'VE
PUT TOGETHER A KIND OF
PRELIMINARY MODEL TO HELP THINK
THROUGH WHAT MIGHT BE SOME OF
THE AGE-RO-RELATED BARRIERS TO T
OF OFFICE BLOOD PRESSURE
MONITORING.
A LOT OF THIS EVIDENCE COMES
FROM OTHER CHRONIC DISEASE
MODELS WHERE I THINK IT HAS BEEN
STUDIED MORE EXTENSIVELY.
AND SO THOSE ARE SHOWN HERE IN
THIS FIGURE.
THEY INCLUDE COGNITIVE
IMPAIRMENT, HEALTH LITERACY,
FUNCTIONAL IMPAIRMENT, FINANCIAL
BARRIERS, TECHNOLOGY ANXIETY,
UNDERREPRESENT TAITION INATION,S
WITH VISUAL, OTHER SENSORY
IMPAIRMENT, AND ISSUED AROUND
INTERNET ACCESS.
SO YOU MIGHT BE LOOKING AT ALL
OF THESE POTENTIAL BARRIERS AND
KAY WELL THESE COULD OCCUR AT
ANY AGE BUT I THINK THE ONE
POINT I REALLY WANT TO MAKE HERE
IS THAT OLDER ADULTS BECAUSE OF
THESE THINGS ARE COMONL AND MAY
BECOME MORE COMMON AT OLDER AGE,
SO THE COMBINATION OF THEM
BECOMES MORE COMMON AND SO
HAVING VISUAL IMPAIRMENT, SOME
FUNCTIONAL IMPAIRMENT AND ISSUED
AROUND HEALTH LITERACY REALLY
ARE COMPOUNDED OR MAGNIFIED AND
OFTENTIMES A GERIATRIC PRINCIPLE
THAT WE HAVE CHALLENGES OR
PROBLEMS IN OLDER AGE OR
OFTENTIMES MULTIFACTORIAL.
REALLY WHAT THE GOAL IS, IS
ABOUT TRYING TO MAKE SURE THAT
WHAT IS DONE OR WHAT IS
ACCURATE, IN A TIMELY WAY, THAT
THE TIMES THAT IT'S ACHIEVED ARE
THE MOST LIKELY TO BE USED IN
CLINICAL DECISION-MAKING AND
THAT WAY IT'S ACTIONABLE.
THERE'S REALLY LIMITED EMPIRICAL
EVIDENCE AROUND HYPERTENSION IN
GENERAL OR SELF-MEASURED BLOOD
PRESSURE OR HOME OR OUT OF
OFFICE BLOOD PRESSURE MEASURES
ABOUT THESE SPECIFIC BARRIERS.
BUT I THINK THERE IS SOME FACE
VALIDITY TO THESE.
IF YOU BELIEVE THAT, WHICH I
THINK WE DO, THAT THERE ALSO
THEN ARE POTENTIAL STRATEGIES
THAT REALLY DRAW FROM A
GERIATRIC APPROACH TO CARE OR
WHAT'S KIND OF NOW BEING CALLED
AN AGE-FRIENDLY APPROACH TO CARE
TO HELP ADDRESS THEM, AND THOSE
ARE SHOWN IN THIS TABLE.
SO WE MAY THINK ABOUT SOME OF
THE AGE-RELATED CHALLENGES AND
THEN POTENTIAL SOLUTIONS, SO AN
EXAMPLE AROUND FUNCTIONAL
LIMITATIONS OR PROBLEMS WITH
MOBILITY, DEXTERITY, FINE MOTOR
SKILLS, SOME POTENTIAL SOLUTION
IS TO INVOLVE FAMILY AND CARE
PARTNER, OR TO REFER PATIENTS TO
OCCUPATIONAL THERAPY, WHERE
THERE'S A LOT OF GREAT SELF
MANAGEMENT WORK DONE BY OUR
OCCUPATIONAL THERAPY COLLEAGUES.
COGNITIVE IMPAIRMENT, OFTENTIMES
COGNITION IS NOT EVEN ASSESSED,
SO WE DON'T KNOW THE EXTENT TO
WHICH IT MIGHT IMPACT THAT GREAT
TEACHING THAT MAYBE WE'RE DOING
ONE-ON-ONE WITH A PATIENT.
AND THEN THERE ARE
OPPORTUNITIES, SIMPLIFY
SCHEDULES, INVOLVE FAMILY CARE
PARTNERS.
OTHER EXAMPLES HERE SHOWN FOR
VISUAL IMPAIRMENT, NOT HOW I DID
ON THAT PRIOR SLIDE BUT THIS
IDEA OF MULTI-MORBIDITY OR JUST
GENERAL COMPLEXITY I THINK IS
ONE THAT ALSO HAS TO BE
EMPHASIZED.
THESE PROGRAMS THAT FOCUS ON
BLOOD PRESSURE ARE GREAT, BUT
BLOOD PRESSURE IS ONLY GOING TO
BE ONE PROBLEM THAT AN OLDER
ADULT HAS AND HOW DOES IT FIT
INTO ALL OF THE MEDICAL PROBLEMS
THEY HAVE, AND CAN YOU TIE IT
BACK TO WHAT REALLY MATTERS MOST
TO THEM?
AND THEN ALSO SOME SOLUTIONS
POTENTIALLY AROUND DIGITAL
HEALTH, HEALTH LITERACY, HOW
COMFORTABLE THEY ARE WITH USING
TECHNOLOGY.
I GUESS ACROSS ALL OF THESE, A
COUPLE OF THEMES THAT COME FROM
GERIATRIC CARE ARE THAT THIS
TYPE OF WORK HAS TO INVOLVE TEAM
INTERDISCIPLINARY TEAMS, AND
THAT OFTENTIMES THIS WORK --
THIS REALLY HAS TO BE
INDIVIDUALIZED AT A PATIENT
LEVEL.
SO WHILE I THINK THAT THERE'S
SOME FACE VALIDITY AND THERE'S
CLEARLY EVIDENCE THAT THESE
STRATEGIES WORK IN GENERAL FOR
CARE OF OLDER ADULTS, WE DON'T
HAVE PRAGMATIC TRIALS OR
IMPLEMENTATION STUDIES SPECIFIC
TO OLDER ADULTS AROUND BLOOD
PRESSURE ASSESSMENT.
SO I'M GOING TO SWITCH GEARS A
LITTLE BIT AND TALK ABOUT THE
INCLUSION OF OLDER ADULTS OR
REPRESENTATION OF OLDER ADULTS
AS ONE OF THE FACTORS THAT MAY
BE CONTRIBUTING TO CHALLENGES OF
UNDERSTANDING SELF MEASURED
BLOOD PRESSURE.
WE KNOW THE PREVALENCE OF
HYPERTENSION AND CARDIOVASCULAR
DISEASE INCREASES IN OLDER AGE
BECAUSE OLDER ADULTS MAY NOT BE
INCLUDED IN RESEARCH STUDIES,
THIS RESEARCH MIGHT NOT BE
GENERALIZABLE TO THOSE WHO NEED
IT THE MOST.
YOU'RE PROBABLY FAMILIAR WITH
THE INCLUSION ACROSS THE
LIFESPAN POLICY AT THE NIH WHICH
REALLY SAYS YOU CAN'T HAVE AGE
CUTOFFS FOR RESEARCH STUDIES.
YOU MAY NOT BE AWARE THAT
ANOTHER PART OF THAT POLICY IS
THAT YOU HAVE TO SUBMIT DATA ON
AGE AT ENROLLMENT ON AN ANNUAL
BASIS IF YOU'RE ENROLLING
PARTICIPANTS IN AN NIH FUNDED
STUDY.
THESE DATA COME FROM FY 22 AND
WHAT WE'RE LOOKING AT IS THE
PERCENTAGE OF PEOPLE IN ALL
CLINICAL RESEARCH STUDIES WHO
WERE 65 YEARS AND OLDER OR ALL
WHO ARE 80 YEARS AND OLDER.
AND BOTH -- ALL RESEARCH STUDYS
THAT ENROLLED DURING '22.
THEN SPECIFICALLY IN CLINICAL
TRIALS AND WHAT YOU KIND OF SEE
IN BOTH OF THESE SITUATIONS IS A
PRETTY BIG DROPOFF AT AGE 80.
TAKING A LOOK AT TIERP TENSION N
STUDIES, THE INCLUSION OF PEOPLE
65 AND OLDER WAS ACTUALLY A
LITTLE BIT HIGHER THAN OVERALL
CLINICAL RESEARCH OR CLINICAL
TRIAL WHICH MIGHT BE GIVEN THE
PREVALENCE OF HYPERTENSION AT
OLDER AGES BUT THIS DOESN'T
REALLY TELL THE FULL STORY
BECAUSE THIS IS KIND OF LIKE A
SNAPSHOT OF ALL STUDIES BEING
DONE.
SO IF YOU TOOK LOOK AT ALL
PEOPLE ENROLLED IN RESEARCH
STUDIES, THAT'S HOW YOU GET THIS
NUMBER.
ANOTHER WAY TO THINK ABOUT IT
WOULD BE TO LINE UP ALL THE
RESEARCH STUDIES FROM THOSE THAT
HAD THE FEWEST PERCENTAGE OF
OLDER ADULTS TO THOSE THAT HAD
THE MOST AND FIND THE MIDDLE
POINT OR THE MEDIAN.
WHAT YOU CAN SEE FOR CLINICAL
RESEARCH IN GENERAL AND CLINICAL
TRIALS, AND THE ENROLLMENT, WHAT
AN AVERAGE STUDY ROLLS IS LESS
THAN 1% OF OLDER ADULTS.
FOR HYPERTENSION, MUCH BETTER
BUT STILL EVEN LOWER THAN WHAT
YOU SEE WHEN YOU'RE KIND OF
LOOKING AT THIS OVERALL NUMBER.
SO AVERAGE STUDY ENROLLS FEWER
THAN 12% OR FEWER OLDER ADULTS
AND THAT'S A PROBLEM BECAUSE
MOST RESEARCH STUDIES ARE
ADDRESSING DIFFERENT RESEARCH
QUESTIONS.
SO MANY ARE GOING TO BE LEFT OUT
OF RESEARCH STUDIES ABOUT THAT
ARE ADDRESSING SPECIFIC
QUESTIONS.
SOME HAVE ARGUED THERE MAY BE
EVEN A BETTER WAY TO MEASURE
REPRESENTATION AT THE
PARTICIPATION TO PREVALENCE
RATIO WITH OUR RATIO OF
PARTICIPATION IN A STUDIES TO
PREVALENCE IN THE POPULATION.
IF YOUR PREVALENCE IS BETWEEN .E
REPRESENTATION.
IF YOU TRY TO APPLY THAT TO
OLDER POPULATIONS AND
HYPERTENSION STUDIES, THE PPR
RANGES SOMEWHERE FROM .2 TO .7.
SO I THINK THERE'S NOT A LOT OF
DATA THAT HELP GUIDE US ON THIS.
A FEW STUDIES SPECIFIC TO
SELF-MONITORING BLOOD PRESSURE.
IN A STUDY -- WELL, WE ALREADY
SAW SOME RESULTS OF THIS STUDY
EARLIER TODAY WITH DR. GREEN,
BUT THIS IS LOOKING AT THE
NUMBER OF OLDER ADULTS.
21% OF PEOPLE THAT WERE PART OF
THESE META ANALYSIS WERE GREATER
THAN 80.
AND SO ALSO SOME STUDIES HAD AGE
CUTOFFS GREATER THAN 80.
REALLY THERE'S A LOT LESS THAT
WE KNOW ABOUT EMERGING
TECHNOLOGY, AND IF WE TRY TO
PULL SOME FROM THE ENROLLMENT
STATISTICS, WE REALLY KIND OF
SEE THAT THE MEDIAN INCLUSION IN
STUDIES AROUND ASSISTIVE
TECHNOLOGY, BIOTECHNOLOGY AND
TELEHEALTH HAVE A LOW MEDIAN
INCLUSION OF OLDER ADULTS.
WE TRY TO DO SOME WORK TO HELP
DEVELOP A FRAMEWORK TO IMPROVE
THE INCLUSION OF OLDER ADULTS IN
RESEARCH.
WE REALLY DID THIS IN AN
ENGAGEMENT STRATEGY WHERE WE
TALKED TO OLDER ADULTS, TO
RESEARCHERS AND STAFF AND TRIED
TO UNDERSTAND WHAT WERE THE
CHALLENGES, AND THEN COME UP
WITH A WAY TO COMMUNICATE THE
BEST PRACTICES THAT ARE USED BY
MANY RESEARCHERS TO ENROLL OLDER
ADULTS IN RESEARCH.
AND THAT'S SHOWN ON THE NEXT
SLIDE.
MORE INFORMATION ABOUT THE 5Ts
FRAMEWORK CAN BE FOUND AT
5T.FRAMEWORK -- AS A TARGET
POPULATION, THE TEAM, TIME --
TIPS TO ACCOMMODATE AND TOOLS.
AND HERE'S JUST SOME EXAMPLES OF
THOSE.
AGAIN, THESE ARE AVAILABLE ON
OUR WEBSITE.
SO A LOT OF OLDER ADULTS MEASURE
THEIR BLOOD PRESSURE OUTSIDE OF
CLINIC SETTINGS, BUT THOSE
MEASUREMENTS DON'T ALWAYS END UP
IMPACTING CLINICAL
DECISION-MAKING.
WE EVEN HEARD ABOUT SOME
FRUSTRATIONS AROUND THAT EARLIER
TODAY.
WE COULD POTENTIALLY IMPROVE
IMPLEMENTATION BY ADDRESSING
AGE-RELATED BARRIERS, AS WELL AS
ADDRESSING THE BARRIERS TO
PARTICIPATION IN RESEARCH.
HERE ARE SOME GAPS THAT REALLY
KIND OF FOLLOW THAT.
OLDER ADULTS, CARE PARTNERS
BARRIERS TO OUT OF OFFICE BLOOD
PRESSURE ASSESSMENTS ARE NOT
WELL CHARACTERIZED.
EVIDENEVIDENCE-BASED IMPLEMENTAN
STRATEGIES TO IMPROVE BLOOD
PRESSURE USE SPECIFICALLY FOR
OLDER ADULTS ARE LACKING.
WE CAN CONDUCT PRAGMATIC TRIALS
TO INCORPORATE AGE-FRIENDLY
STRATEGIES, TEST IMPLEMENTA
IMPLEMENTATION -- AND WE CAN
ALSO ENSURE THAT EMERGING BLOOD
PRESSURE TECHNOLOGIES ADDRESS
THE NEEDS OF OLDER ADULTS RATHER
THAN CREATING NEW BARRIERS.
THATHANK YOU.
>> THANK YOU.
CAN ALL THE PARTICIPANTS GET ON
THE -- I WOULD FIRST LIKE TO ASK
A QUESTION TO DR. RAVENELL AND
LEAD WITH A COMMENT.
JOE, THANK YOU SO MUCH FOR GOING
THROUGH A BRIEF HISTORY, THOSE
WARRIORS, THE LATE GREAT
DR. SAUNDERS, THE LATE GREAT DR,
YOU MENTIONED ME BUT MY WIFE
WHO'S A PH.D. IN NURSING
DR. DAPHNE FERDINAND DID MUCH OF
THE WORK.
HOW DO YOU KEEP THOSE BARBERS
ENGAGED?
I KNOW IN A CLINICAL TRIAL, YOU
HAVE THE TIME, MONEY AND EFFORTS
BUT IN A REAL CLINICAL SET,
BARBERS HAVE TO MAKE MONEY, THEY
HAVE TO WORK AND CUT.
HOW DO YOU KEEP THEM ENGAGED AND
HOW DO YOU CHECK ON THE QUALITY
OF THE BLOOD PRESSURES THEY'RE
DOING?
>> THANK YOU FOR THE QUESTION,
DR. FERDINAND.
AND SO A COUPLE THINGS.
MONEY IS REALLY IMPORTANT.
ALL OF US NEED TO BE PAID FOR
OUR TIME AND FOR OUR WORK.
AND BARBERS ARE NO DIFFERENT.
WHAT WE SAW IN ALL THESE STUDIES
IS THAT IF WE CAN INCENTIVIZE
BARBERS APPROPRIATELY, THEY WILL
DO IT.
WE ALSO KNOW ONCE WE STOP PAYING
THE BARBERS, THEY WILL NOT DO
IT.
AND SO I THINK IT BECOMES A --
LARGELY A POLICY QUESTION AND I
DO THINK THAT WE HAVE TO GET OUR
PAYORS INVOLVED.
WE HAVE TO GET OUR HEALTH
SYSTEMS ENVOFLED TO HELP FOOT
THE BILL, IN THE SAME WAY THAT
WE WOULDN'T EXPECT OUR NURSES OR
COMMUNITY HEALTH WORKERS TO GO
OUT THERE AND TO DO THIS ON A
VOLUNTEER BASIS, WE HAVE TO LOOK
AT OUR BARBERS IN THE SAME VEIN.
WE LARGELY TRAIN THEM TO BE
COMMUNITY HEALTH WORKERS AND
SORT OF COMMUNITY BLOOD PRESSURE
SPECIALISTS, MODELED AFTER YOUR
WORK IN NEW ORLEANS.
SO WE HAVE TO FIGURE OUT A WAY
TO FUND THE BARBERS IF WE'RE
GOING TO KEEP THIS GOING.
>> GREAT ANSWER.
RAY, YOU HAVE SOME THINGS YOU
WANT TO FOLLOW UP WITH?
>> WE'LL STAY WITH YOU, JOE, IF
THAT'S OKAY.
THERE'S A QUESTION FROM STEVE
JURASCHEK HERE THAT HAS TO DO
WITH ASKING YOU ABOUT HOW DO WE
BALANCE THE NEED FOR TIMELY
ACCESSIBLE SCREENING WITH
CONCERNS OVER MAYBE MISSING THE
DIAGNOSIS, EITHER OVERDIAGNOSING
HIHIGH BLOOD PRESSURE OR TELLING
SOMEONE YOU'RE FINE, MEANWHILE,
THEY'RE NOT.
HE SUGGESTS IS FOLLOW-UP LINKAGE
THE KEY, EDUCATION VALUABLE?
>> I THINK LINK IS ABSOLUTELY
KEY.
WE KNOW THAT SCREENING PROGRAMS
WRIT LARGE WITHOUT FOLLOW-UP
REALLY JUST DON'T DO A WHOLE
HECK OF A LOT.
SO WE HAVE TO MAKE SURE THAT
WHEN THEY'RE SCREENING, THAT
THERE'S ALSO APPROPRIATE LINKAGE
TO CARE.
AT THE ENOF THE DAY, THE REASON
THAT WE ARE GOING OUT THERE TO
IDENTIFY FOLKS WITH ELEVATED OR
WITH HIGH BLOOD PRESSURE IS TO
GET THEM INTO CARE SO THAT WE
CAN PREVENT THOSE AWFUL
CONSEQUENCES THAT I LEARNED FROM
DR. ELI SAUNDERS THAT BACK IN
THE 1960s, WE WERE JUST
STARTING WITH THE NATIONAL
HEALTH EXAMINATION SURVEY, AND
V.A. COOPERATIVE TRIALS THAT THE
STROKE RATE AMONG BLACK MEN WAS
900 TIMES HIGHER THAN AMONG
WHITE MEN, LARGELY DUE TO
UNCONTROLLED HYPERTENSION.
SO THE WHOLE REASON FOR US DOING
THIS IS TO GET PEOPLE INTO CARE,
AND SO WE CAN SCREEN PEOPLE IN
THE COMMUNITY, WE CAN EVEN
SCREEN PEOPLE IN HOSPITAL
SETTINGS BUT WE HAVE TO HAVE
SOME FOLLOW-UP LINKAGE TO LONG
TERM HOPEFULLY PRIME RAO CARE
BECAUSE WE KNOW AS HAS BEEN
MENTIONED BEFORE, HYPERTENSION
CLUSTERS WITH A WHOLE BUNCH OF
OTHER THINGS THAT CAN ALSO
BENEFIT FROM ATTENTION FROM
PRIMARY CARE PROVIDERS.
>> THANKS SO MUCH.
LET ME TURN TO YOU, YVONNE, AND
ASK YOU A QUESTION.
ONE OF THE THINGS I LEARNED FROM
MY COLLEAGUE, BRENT EGAN, IS
THAT THERE'S NOTHING LIKE
GETTING NEAR THE END OF THE
STUDY TO TELL YOU ALL THE THINGS
THAT YOU WOULD DO OVER
DIFFERENTLY IF YOU HAD THE
OPPORTUNITY TO DO IT AGAIN.
IT LOOKS TO ME LIKE FLEXIBILITY
IS THE SOUL OF THE ENTERPRISE OF
LINKED HEARTS.
IF THERE WAS ONE THING IN LINK
HEARTS FOR EXAMPLE TO DO
DIFFERENTLY, WHAT WOULD YOU DO
DIFFERENTLY AS ONE OF THOSE
TECHNICAL ISSUES YOU WOULD
ADDRESS FOREMOST ON YOUR LIST?
>> THANK YOU FOR THAT QUESTION.
I THINK I ALLUDED TO THIS
EARLIER WHEN I TALKED ABOUT
ISSUES WITH USING THE BLOOD
PRESSURE DEVICES AS WELL AS THE
APP.
SO THIS IS SOMETHING THAT WE
DISCOVERED LATER ON.
OUR EXPECTATION IS THAT THE
COMMUNITY HEALTH WORKERS WOULD
MEET WITH THE PARTICIPANTS,
TEACH THEM HOW TO USE THE APP,
THE APP SHOULD WORK AS IT
SHOULD, THINGS WILL BE CONNECTED
AND THROUGHOUT THE TRIAL, AND
LATER ON WE LEARNED THERE WERE
SOME DISCONNECTIONS THAT WERE
HAING.
WERE
HAPPENING.
THAT TIME THE COMMUNITY HEALTH
WORKERS SPENT TROUBLESHOOTING
THE APP-RELATED ISSUES REALLY
WASTED A LOT OF TIME THAT
COMMUNITY HEALTH WORKERS COULD
HAVE USED ON WHAT THEY WERE
SUPPOSED TO BE DOING IN TERMS OF
EDUCATING PARTICIPANTS ABOUT,
YOU KNOW, TAKING THEIR
MEDICATIONS AS DESCRIBED AND
ADHERING TO LIFESTYLE
RECOMMENDATIONS.
SO I WISH FROM THE GET-GO, WE
HAD DATED RESEARCH ASSISTANCE
WHOSE SOLE JOB WAS TO HELP WITH
TECHNOLOGY OF RELATED ISSUES IN
TERMS OF HOW THIS EXTENDS TO
HEALTH SYSTEMS OR CLINICAL CARE,
THAT THERE'S SOMEONE, IF AN SMBP
PROGRAM IS DEVELOPED, THAT
THERE'S A DEDICATED PERSON WHOSE
JOB IT IS TO ADDRESS SOME OF
THESE TECHNOLOGY-RELATED
CHALLENGES, AND NOT HAD IT FALL
ON THE COMMUNITY HEALTH WORKERS,
YES, DIGITAL NAVIGATORS, I LOVE
THAT TERM, THANK YOU, HILARY.
THIS IS SOMETHING AFTER TALKING
WITH THE COMMUNITY HEALTH
WORKERS ABOUT THEIR WORKLOAD,
WHAT'S TAKING UP ALL OF THEIR
TIME, TECHNOLOGY, THE APP, IT
KEPT COMING UP, THAT THEY FELT
LIKE THEY WERE SPENDING SO MUCH
TIME TRYING TO FIGURE OUT WHAT'S
GOING ON WITH THE APP AND NOT
SPENDING TIME WITH THE
PARTICIPANTS.
SO THAT'S WHAT I WOULD SAY.
>> YOU KNOW, WE WERE DOING A
STUDY WITH HOME BLOOD MONITORS
USING -- WE FOUND IOS AND IPHONE
IS DIFFERENT THAN AN ANDROID OR
GALAXY, SO THAT JUST CREATED ALL
SORTS OF HAVOC IN THE FIRST
COUPLE MONTHS OF GETTING GOING.
SO KEITH, TURNING BACK TO YOU, I
HAVE A COUPLE OTHER QUESTIONS
BUT I DON'T WANT TO --
>> I HAVE A PRETTY
STRAIGHTFORWARD QUESTION.
I DON'T UNDERSTAND BIAS IN THE
MACHINE.
IT SEEMS TO ME MACHINES SHOULD
BE SOMEONE WHO DOES NOT KNOW A
PERSON, A THING THAT DOES NOT
KNOW A PERSON.
YOU SAID 10%, ZERO, THAT SOUNDS
NORMAL TO ME, BUT ZERO TO 9, 10%
IS WHAT YOU WOULD EXPECT BY THE
ROLL OF THE DICE.
NOW THE 1/100, THE 0/0, THAT IS
SOMETHING I'D LIKE TO KNOW.
WHAT'S THE CHANCE OF GETTING THE
ZERO TO ZERO?
>> OH, I WOULD HAVE TO DO THE
MATH.
THERE'S A LOT MORE COMBINATIONS
ON BOTH THE SYSTOLIC AND THE
DIASTOLIC ENDING IN ZERO.
>> RIGHT.
>> YEAH.
>> HOW IS IT BIAS IF IT'S 10%
ZERO?
I THINK THE DATA WOULD REFLECT
THAT IF THE MACHINE WAS
MEASURING NUMBERS, I DON'T SEE
WHERE THAT'S BIAS.
>> WE WOULD EXPECT IN THE
ABSENCE OF ANY BIAS THE MACHINE
JUST DOING ITS THING, THAT 10%
OF ALL MEASUREMENTS ARE GOING TO
END, OR AT LEAST ONE OF THE --
ARE GOING TO END IN ZERO, YES.
>> I THOUGHT YOU INCLUDED THAT
AS A BIAS IN YOUR REPORTING.
>> THAT WAS NOT MY -- MORE OF
THE HUMAN SIDE OF THE
TRANSCRIBING THE NUMBERS.
I DIDN'T NEED TO INTEND THE
MACHINE ITSELF IS BIASED,
ALTHOUGH THERE IS ONE PAPER
SOMEONE SHARED WITH ME LOOKING
AT SOME OF THE ALGORITHMS, WHAT
THE DEVICE IS DOING, SOMETIMES
THEY DON'T RECORD CERTAIN
NUMBERS AS OFTEN, BUT IN
GENERAL, NO, I THINK WE EXPECT
THE MACHINES IN THE ABSENCE OF
BIAS ARE GOING TO GIVE YOU ABOUT
10% OF MEASUREMENTS ENDING IN
EACH END DIGIT.
>> GOT IT.
DR. BOWLING, ONE QUICK
FOLLOW-UP.
I LOVE YOUR WORK WITH OLDER
PERSONS.
I THINK IF YOU LOOK AT THE
TECHNOLOGY, IT'S REALLY
DIFFICULT FOR OLDER PERSONS TO
NAVIGATE THE TECHNOLOGY.
SO HOW DO YOU KEEP THEM ENGAGED
IF YOU DON'T HAVE SOME AUTOMATIC
WAY OF EITHER BLUETOOTHING OR
SENDING THROUGH THE WIRELESS OR
THROUGH THE WEB TO GET THOSE
NUMBERS, HOW DO YOU KEEP THE
PATIENTS ENGAGED?
>> IT'S A GREAT QUESTION.
AND I THINK WHAT WE SOMETIMES
SEE IS THAT RESEARCH TEAMS
EXCLUDE OLDER ADULTS FOR THAT
PURPOSE AND I THINK THAT IS THE
WRONG ANSWER.
WHAT WE HEAR FROM OLDER ADULTS
IS THEY WANT FLEX IBILITY IN HOW
THEY ENGAGE WITH TECHNOLOGY, AND
SO IT'S NOT ALL OR NONE.
AND IT HAS TO BE KIND OF
INDIVIDUALIZED FOR WHAT THEIR
LEVEL OF KNOWLEDGE AND WHAT
THEIR LEVEL -- HOW COMFORTABLE
THEY ARE WITH IT.
WE ALSO HEARD THAT THAT KIND
OF -- THAT OPPORTUNITY TO
CUSTOMIZE AND TO ENGAGE WITH
RESEARCH TEAMS IS REALLY ONE OF
THE THINGS THAT THEY LIKE ABOUT
PARTICIPATING IN RESEARCH.
SO IT'S ALSO A MOTIVATOR TO
BEING IN A RESEARCH STUDY.
AND SO IF YOU COME TO AN OLDER
ADULT AND SAY HERE'S WHAT WE'RE
GOING TO DO, THERE'S NO WAY --
NO OTHER ALTERNATIVES, THEY'RE
MUCH LESS LIKELY TO PARTICIPATE
IN THAT RESEARCH.
SO I THINK THAT BY BUILDING IN
SOME FLEXIBILITY, YOU ALSO HAVE
THE CHANCE OF INCREASING
PARTICIPATION.
BUT THESE ARE DEFINITELY
CHALLENGES.
AND I THINK THE OTHER THING TO
JUST THINK ABOUT OLDER ADULTS,
AND AS WE TALK ABOUT OLDER
ADULTS LIKE THEY'RE ONE GROUP,
ALL OLDER ADULTS ARE LIKE THIS,
BUT REALLY, THERE'S THIS WIDE
RANGE OF EXPERIENCES, LIFE
EXPERIENCES AND HOW THEY GOT TO
WHERE THEY ARE RIGHT NOW SO WE
HAVE TO KIND OF KEEP THAT IN
MIND.
>> DR. TOWNSEND IS GOING TO
FINISH OUT THE QUESTION AND I'M
GOING TO MAKE TWO COMMENTS.
ONE OF THEM IS SOMEWHAT
FACETIOUS, BUT YOU HAVE TO
RECOGNIZE A LOT OF OLDER PEOPLE
DIDN'T GROW UP WITH THIS
TECHNOLOGY SO YOU SAY THINGS
LIKE CLICK HERE, INTO HERE, GO
TO THIS WEBSITE, AND IT SOUNDS
EASY TO A YOUNGER PERSON BUT
THEY DON'T KNOW WHAT YOU'RE
TALKING ABOUT.
THEY DON'T KNOW WHAT YOU'RE
TALKING ABOUT.
ALL RIGHT.
HERE'S THE SERIOUS STATEMENT.
WHAT DR. RAVENELL IS DOING AND
DR. MENSAH, SAUNDERS, DOCTORS
WOULD SIT IN EMERGENCY ROOMS AND
CLINICS TO WAIT FOR PEOPLE TO
COME IN WHEN THEY'RE SICK.
THAT'S WHAT THE DOCTOR DID.
FOR A DOCTOR TO GO OUT TO A
BARBERSHOP OR CHURCH AND
INTERVENE IN THOSE SETTINGS,
PEOPLE THOUGHT WE WERE CRAZY.
SO I'M GLAD TO SEE THIS WORK IS
BRINGING FRUITION.
YOU NEED TO CONTINUE THIS WORK
AND RECOGNIZE THAT THERE ARE
PEOPLE WHO STILL THINK IT'S A
WASTE OF TIME.
RAY, I'LL LET YOU END WITH THE
LAST COUPLE QUESTIONS.
>> BUILDING ON WHAT KEITH JUST
SAID, THERE'S A QUESTION FROM
HILARY WALL ABOUT EXPANDING THE
BARBERSHOP EXPERIENCE INTO THE
REAL WORLD -- REAL WORLD --
EXPANDING -- LET ME LEAVE IT AT
THAT, NOT JUST THAT IT'S NOT --
>> BARBERSHOPS ARE REAL.
>> BACK UP HERE, TOWNSEND.
SO YOU PROBABLY SAW THE QUESTION
IN THE Q & A, BUT IT HAD TO DO
WITH THE HUB, AND THE
METHODOLOGY TO IMPLEMENT AND HOW
TO FIND YOUR WAY INTO THESE
COMMUNITIES, AND HOW TO ENGAGE
AT THAT LEVEL.
SO DO YOU HAVE ANY ADVICE FOR,
LIKE, SOMEBODY IN PHILADELPHIA,
LIKE ME, TRYING TO DO THIS SORT
OF THING, MAYBE NOT AS MUCH IN A
BARBERSHOP, MAYBE -- A
DELICATESSEN, SOME OTHER
PHILADELPHIA ARCHITECTURAL
GATHERING POINT?
>> YES, SO I DEFINITELY
APPRECIATE THE QUESTION
BASICALLY ABOUT A COMMUNITY HUB
AS THE SORT OF CENTRAL POINT FOR
MUCH OF THIS WORK TO BE ABLE TO
TRAIN BARBERS, FOR INSTANCE, OR
OTHER COMMUNITY LEADERS TO
CORRECTLY ASSESS BLOOD PRESSURE.
AND SO THERE'S NO EASY ANSWER TO
THAT QUESTION.
BUT WHAT I WILL SAY IS, IN ALL
OF OUR EXPERIENCES, WE HAVE MADE
THE HUB WHEREVER PEOPLE ARE.
AND SO WHAT I MEAN BY THAT IS,
IF WE WANTED BARBERS TO BE
PROPERLY TRAINED ON
HYPERTENSION, ON BLOOD PRESSURE
MEASUREMENT, WE WENT TO THOSE
BARBERSHOPS AND WE WENT TO THEM,
WE DIDN'T EXPECT THEM TO COME TO
US.
HOW WE SCALE THAT IS A WHOLE
OTHER QUESTION, BUT I DO THINK
WE HAVE THE MOST IMPACT WHEN WE
GO TO WHERE PEOPLE ARE.
>> LET ME ASK ANYONE WHO'S
WILLING TO POTENTIALLY TAKE THIS
ON, SINCE WE'RE LOOKING AT
TRYING TO DO MORE COMMUNITY
BASE, GET OUT THERE, MEASURE AND
HOPEFULLY MANAGE ELEVATED BLOOD
PRESSURES IN THE COMMUNITY.
AT PENN, WE HAVE A LOT OF
PROGRAMS THAT OUR MEDICAL
STUDENTS DO.
SO WHAT DO YOU SEE AS LIKE THE
ROLE FOR MEDICAL STUDENTS OR
PHARM D STUDENTS, OR NURSING
STUDENTS, ET CETERA, BECAUSE ONE
OF THE PROBLEMS OBVIOUSLY IS BY
THE TIME YOU GET THEM TRAINED TO
BE ABLE TO DO RESEARCH, THEY'RE
IN A COURSE WHERE THEY CAN'T
SPEND THE TIME OR THEY GRADUATE
AND GO ON TO SOMETHING ELSE, SO
I'M JUST CURIOUS, WHAT YOU SEE,
HOW FAR DOWN IN OUR FOOD CHAIN
IN MEDICINE WE SHOULD BE GOING
TO ENGAGE THE NEXT GENERATION OF
DOCTORS, NURSES, PHARMACISTS, ET
CETERA, IN DOING THESE KIND OF
THINGS THAT ARE SO
COMMUNITY-MINDED AND SO
IMPORTANT?
>> I CAN JUST SUPER QUICKLY JUMP
IN.
WE HAVE DEFINITELY ENGAGED WITH
MEDICAL STUDENTS IN GOING OUT TO
BARBER SHOPS AND CHURCHES TO
MEASURE BLOOD PRESSURE.
THEY ARE ACTUALLY TERRIFIC AT
IT.
THEY LOVE DOING IT.
OF COURSE THE ISSUE OF
CONTINUITY IS ONE THAT'S
PROBABLY THE BIGGEST CHALLENGE.
BUT I THINK WITH APPROPRIATE
INFRASTRUCTURE AND FUNDING, WE
CAN FIND WAYS TO MAKE THE
CONTINUITY WORK BUT WE TO WANT
TO MAKE SURE THAT WHEN WE'RE
GOING OUT THERE TO MEASURE BLOOD
PRESSURE THAT WE'RE, AGAIN, NOT
JUST SCREENING BUT ALSO MAKING
LINKAGES POSSIBLE SO THAT WE
DON'T DO MORE HARM THAN GOOD.
>> LET ME ASK KATHRYN.
>> I WAS JUST GOING TO SHARE AN
EXPERIENCE AT HOPKINS.
WE RECEIVED AN AMA GRANT TO
ACTUALLY TRAIN MEDICAL STUDENTS,
NURSING STUDENTS IN ACCURATE
BLOOD PRESSURE MEASUREMENT AS AN
ONLINE COMPONENT THAT THEY ALSO
HAD TO DO SOME IN-PERSON
TRAINING, BUT BEYOND THAT, WE
HAD THE OPPORTUNITY TO ENGAGE
THAT IN OUR COMMUNITY-BASED
PROJECTS.
IN BALTIMORE WHERE THEY HAD THE
OPPORTUNITY TO ACTUALLY
PRACTICE, WHERE WE'RE TALKING
ABOUT HOW TO ACTUALLY TAKE
ACTION.
WHAT IF SOMEONE'S BLOOD PRESSURE
IS HIGH, WHAT ARE THE NEXT
STEPS.
WE ACTUALLY HAD AN INCIDENT
WHERE SOMEONE'S BLOOD PRESSURE
WAS ELEVATED AND THE STUDENTS
ACTUALLY WALKED THE PERSON TO
THE EMERGENCY ROOM BECAUSE IT
WAS SO HIGH, AND SO THAT'S WORK
THAT WE'RE ALSO DOING HERE AT
HOPKINS.
THANK YOU.
>> LET ME MAKE ONE COMMENT.
MEDICINE, I THINK, IS GOING
BACKWARDS.
THE CLINICIANS, THE DOCTORS, THE
NURSE PRACTITIONERS ARE NOW
PRACTICING IN 15-MINUTE VISITS
FOR 99214, OUTPUTS MONITORED BY
BUSINESS PEOPLE TO MAKE SURE
THEY'RE SEEING ENOUGH PEOPLE
QUICKLY.
WE'RE NOT GOING TO CONTROL 50,
60% OF THE POPULATION WHO'S OVER
50 YEARS OF AGE AND HYPERTENSION
ESPECIALLY IN THE BLACK
COMMUNITY, BY WAITING FOR
DOCTORS IN 15-MINUTE VISITS TWO
TO THREE TIMES A YEAR TO DO
ANYTHING.
>> OKAY.
SO BACK TO YOU, KATHRYN.
I SERVE ON A COUPLE OF DIFFERENT
JOURNALS AS, YOU KNOW, HELPING
WITH EDITOR-TYPE STUFF, AND ONE
OF THE THINGS THAT I VALUE BY
OUR STATISTICIANS EXTREMELY FOR
IS BEING ABLE TO LOOK AT A LARGE
POPULATION SURVEY, FOR EXAMPLE,
FOR SOMETHING LIKE BLOOD
PRESSURE AND CHRONIC KIDNEY
DISEASE OR SOMETHING LIKE THAT.
AND ARE THERE -- IS THERE A TIP
OR TWO YOU CAN GIVE ME AS A
REVIEWER POTENTIALLY FOR WHEN I
SEE THESE KIND OF ARTICLES THAT
MIGHT HELP ME TO FOCUS IN ON,
HEY, LISTEN, THIS IS A LARGE
ENOUGH STUDY THAT MAYBE THERE'S
SOME UNDERLYING BIAS HERE THAT
MIGHT SCREW THE RESULTS.
IS THERE SOMETHING THAT YOU LOOK
AT WHEN YOU GET ONE OF THESE
ARTICLES THAT YOU CAN SAY YOU
KNOW WHAT, THIS MIGHT HAVE A
PROBLEM.
>> THAT'S A GREAT QUESTION.
AND I THINK IT'S EASIER TO SEE
THE ISSUE WHEN YOU CAN SEE THE
DATA.
SO I THINK IF THERE WERE
STANDARDS IN TERMS OF REPORTING
CLINICAL TRIALS OR EVEN RESEARCH
STUDIES WHERE YOU ASK FOR THE
HISTOGRAM OF THE BLOOD PRESSURE
MEASUREMENTS AT DIFFERENT STUDY
VISITS OVER TIME, YOU KNOW,
MAYBE THOSE WERE INCLUDED AS A
SUPPLEMENT OR THEY'RE PART OF
YOUR SORT OF REPORTING
CHECKLIST, I THINK THAT COULD BE
REALLY VALUABLE IN JUST
PROMOTING TRANSPARENCY IN THE
FIELD AT LARGE.
I THINK WHEN YOU'RE LOOKING AT
PROPORTIONS, I THINK JUST
QUESTIONING THE RESULTS AND
THINKING ABOUT THE POTENTIAL
SOURCES OF PI BIASES, I THINK TE
ARE THINGS WE MAY NOT EVEN
RILIZE ARE HAPPENING, SO
UNDERSTANDING WHICH MECHANISMS
BY WHICH BIASES MAY BE
OCCURRING, IF YOU CAN SEE ALL
THE DATA AND LOOK AT A HISTOGRAM
THAT MAY BE QUICKEST WAY TO TELL
IF THERE MAY BE AN ISSUE.
>> I HAVE A QUESTION FOR
DR. BOWLING.
A LOT OF THE OLDER CLIENTS ARE
NOW GOING ON THE INTERNET AND
YOU CAN CLICK SOMETHING OR YOUR
DAUGHTER CAN GET ONE OF THESE
FDA-APPROVED WRIST DEVICES OR
WATCHES, ET CETERA.
HOW DO YOU EDUCATE YOUR PATIENTS
OR HOW DO YOU THINK WE CAN ALL
EDUCATE OUR PATIENTS THAT JUST
BECAUSE SOMETHING WAS FDA -- AND
IT'S NOT REALLY FDA-APPROVED,
BUT THESE DEVICES ARE OUT THERE,
WHAT DO YOU DO WITH THEM, HOW DO
YOU HANDLE THAT INFORMATION?
>> YEAH, IT'S A GOOD QUESTION.
AND I THINK WHERE IT OFTEN COMES
FROM IS FAMILY ENGAGED AND
CARING FAMILY MEMBERS WHO WANT
THE KIND OF BEST FOR THEIR LOVED
ONE.
I THINK IT OFTENTIMES IN
GERIATRIC CARE IN GENERAL, IS TO
STEP BACK AND SAY LET'S NOT TALK
ABOUT THIS ONE DEVICE OR THIS
ONE PILL THAT WE'RE TAKING, BUT
KIND OF TRY TO STEP BACK AND SAY
WHAT'S MOST IMPORTANT HERE.
THINK ABOUT WHAT MATTERS FOR
THIS PATIENT.
AND THEN KIND OF COME UP WITH A
PLAN THAT ADDRESSES THE BEST IT
CAN.
AND SOMETIMES THAT MIGHT BE
USING TECHNOLOGY DEVICES.
I'M WORRIED ABOUT THE DEVICES
JUST FROM WHAT WE'VE HEARD ABOUT
CUFFLESS AT THE V DEVICES JUST T
WE HEARD YESTERDAY BUT IF WE PUT
IT IN THAT FRAMEWORK, JUST
SOLVING ONE QUESTION AT A TIME
THAT AN OLDER PATIENT AND THEIR
FAMILY HAS, WE SHOULD REALLY PUT
IT IN A CONTEXT FOR THEM.
I THINK THAT OFTENTIMES HELPS US
TO GET TO THE RIGHT ANSWER FOR
THEM.
AND YOU'RE RIGHT, THAT REALLY
DOESN'T -- IS THAT GOING TO MAKE
ME -- KEEP ME OUT OF THE
HOSPITAL, KEEP ME OUT OF THE
NURSING HOME, YOU KNOW, FOR WHAT
MATTERS MOST TO YOU, HOW LIKELY
IS THIS APPROACH GOING TO HELP
YOU ADDRESS THAT.
AND OFTENTIMES I THINK WHEN WE
TALK WITH OLDER ADULTS AND THEIR
FAMILY MEMBERS, THEY'RE
REALLY -- THE FAMILY MEMBERS ARE
WORRIED ABOUT SAFETY.
AND ARE THEY GOING TO FALL, ARE
THEY GOING TO -- YOU KNOW, IS
SOMETHING BAD GOING TO HAPPEN.
AND IF WE CAN'T KIND OF LINK
THESE KIND OF NEW APPROACHES TO
AVOIDING THAT, IT'S HARD FOR US
TO KIND OF SAY THIS FITS WITH
WHAT'S MOST IMPORTANT TO YOU.
>> RAY, THERE'S BEEN A LOT OF
QUESTIONS AND COMMENTS ABOUT
GETTING THESE NUMBERS FROM THE
COMMUNITY-BASED MEASUREMENTS
INTO THE ELECTRONIC HEALTH
RECORDS.
THAT IS A CONCERN.
THERE'S A CONCERN THAT THE
NUMBERS ARE JUST KIND OF
FLOATING OUT THERE AND NO ONE IS
REALLY LOOKING AT THEM.
IN NEW ORLEANS, WE DID USE
BLUETOOTH, SOME OF THE SAME
DEVICES THAT DR. COMMODORE
MENSAH IS USING AND WITH
BLUETOOTH, IT WILL COME BACK
WITH US EVEN WITHOUT THE PATIENT
DOING ANYTHING, THEY CAN BE
AUTOMATED WHERE YOU COULD SEE
THOSE RESULTS.
AND IN THAT PARTICULAR CASE, IT
OFTEN IMPROVES BLOOD PRESSURE
CONTROL EVEN WITHOUT THE
INTERVENING WITH CHANGE IN
PHARMACOTHERAPY.
IT'S ALMOST LIKE A HAWTHORNE
EFFECT, JUST HAVING THOSE
NUMBERS COME BACK TO US AND KNOW
WE'RE KIND OF LOOKING AT THEM,
THEY DO BETTER.
DO YOU HAVE ANY OTHER QUESTIONS,
RAY, BEFORE WE CLOSE?
>> NO, JUST ONE QUICK ONE FROM M
MARWAH ABDALLA, ONE OF THE
CO-CHAIRS OF THIS ENTIRE
SESSION.
BACK TO YOU, JOE, WHEN THE
FUNDING DOES END, DO YOU HAVE
ANY EXPERIENCE WITH WHAT HAPPENS
WITH THE PATIENTS?
DOES IT BREAK TRUST AND THINGS
LIKE THAT, IF SUDDENLY THEIR
BARBERSHOP GUY OR GAL IS SAYING,
I'M HERE TO CUT YOUR HAIR, WE
GAVE THE BLOOD PRESSURE MACHINE
BACK, YOU'RE GOING TO HAVE TO
GET YOUR HEALTHCARE AT YOUR --
WHEREVER?
>> YES, IT'S VERY CHALLENGING
WHEN THESE PROGRAMS END BECAUSE
WE OFTEN DON'T HAVE THE
PERSONNEL TO CONTINUE TO DO
THEIR WORK.
AND BARBERS HAVE VOTEED WITH
THEIR FEET THAT WHEN THEY'RE NOT
GETTING PAID, THEY'RE NOT GOING
TO MEASURE BLOOD PRESSURE AND
RIGHTLY SO.
THEY GO TO WORK EVERY DAY TO BE
ABLE TO MAKE A LIVING.
SO WE HAVE TO FIND A WAY TO MAKE
SURE THAT FUNDING DOES NOT END.
>> CAN I MAKE A COMMENT?
I THINK ONE OF THE THINGS YOU
MIGHT BE DOING, AND
COMMODORE-MENSAH, YOU'RE DOING
THE SAME, EMPOWERING THE
PATIENTS SO WHEN THEY GO BACK TO
THEIR CLINICIAN AND THEY SAY
YOUR BLOOD PRESSURE IS A LITTLE
HIGH AND THEY SAY WELL WHAT IS
MY NUMBER?
SOMETIMES THE DOCTOR IS GOING TO
GET FRUSTRATED BECAUSE THEY
DON'T WANT THE PATIENT TO BE AN
INFORMED AND EDUCATED PERSON,
BUT IF YOU CAN JUST STAY OUT
THERE AND EDUCATE PATIENTS, EVEN
IF YOUR PROGRAM IS NOT OP GOING,
I THINK YOU NOW HAVE A CADRE OF
INDIVIDUALS WHO CAN CHALLENGE
THEIR SO-CALLED PRIMARY CARE
PROVIDER TO DO THE RIGHT THING.
AND WE KNOW THERE'S REAL BIAS IN
THE SYSTEM WHERE DOCTORS DO TELL
PEOPLE A THING LIKE WELL, YOUR
PRESSURE IS A LITTLE HIGH TODAY.
>> YES, ABSOLUTELY,
DR. FERDINAND.
THANK YOU FOR THAT.
AND YOU KNOW, ONE OF THE
CHALLENGES THAT WE SAW BACK WHEN
WE WERE DOING THIS WORK WAS THE
NOTION OF A DIFFERENT OUT OF
OFFICE THRESHOLD COMPARED TO
OFFICE THRESHOLD WAS VERY
COMMON, YOU KNOW, TO THOSE OF US
WHO WERE IN THE HYPERTENSION
BUSINESS, BUT WAS NOT WELL-KNOWN
TO OUR PRIMARY CARE DOCTORS.
SO OUR BARBERS WOULD BE TELLING
OUR -- WOULD BE TELLING
CUSTOMERS THAT THEIR BLOOD
PRESSURE IS HIGH, THEY WOULD GO
TO THEIR DOCTOR WHO WOULD SAY,
YOUR BLOOD PRESSURE IS JUST FINE
BECAUSE IT'S LESS THAN 140/90.
AND SO WE'RE SORT OF LIVING
THROUGH THAT CURRENTLY, WHERE
MANY DOCTORS HAVE NOT YET
ADOPTED THE 2017 AMERICAN HEART
ASSOCIATION, AMERICAN CARDIOLOGY
THRESHOLDS, AND WE'RE PREACHING
130/80 BUT MANY PRACTITIONERS
ARE STILL ALLOWING 140/90 TO GO
UNTREATED.
SO THANK YOU.
>> WELL, I THINK IT'S KNOCKING
AT 2:00 EASTERN TIME HERE.
SO THAT'S OUR TIME FOR A BREAK
AND MAYBE THOSE OF YOU THAT ARE
A LITTLE HYPOGLYCEMIC BY NOW
MIGHT WANT TO ATTEND TO THAT.
SO I WANT TO THANK OUR FOUR
PRESENTERS FOR I THINK IT WAS A
GREAT SESSION, CERTAINLY HAD
ENOUGH Q & A.
WE DIDN'T GET TO ONE OR TWO OF
THE QUESTIONS, SO THANKS,
EVERYONE, FOR PARTICIPATING.
SO LOOKING FORWARD
TO HEARING OUR REPORT OUTS FROM
EACH OF THE MODERATORS AND EACH
OF THE SESSIONS.
IT'S A PLEASURE TO INTRODUCE
TAMMY AND RAMA WITH A
STIMULATING CONVERSATION ABOUT
THE PRACTICAL OR IMPRACTICAL USE
OF EMERGING DEVICES.
SO I'LL LET RAMA AND TAMMY, AND
JOSH, IF YOU WOULDN'T MIND
SHARING FOR THEM THE DOCUMENT
THAT THEY JUST SENT YOU.
OR I THINK IT'S ANTOINE.
CAN YOU CONFIRM YOU RECEIVED THE
DOCUMENT?
>> YES, THE DOCUMENT HAS BEEN
RECEIVED.
JUST WAITING FOR AV TO SHARE.
>> OKAY, THANK YOU.
OWOKAY, RAMA AND TAMMY.
>> RAMA, DO YOU WANT TO GO
FIRST?
I THINK THAT WOULD PROBABLY BE
BEST.
>> IF YOU COULD JUST LOOK AT THE
GREEN, WE HAVE A LOT OF STUFF
THAT, YOU KNOW, WE'LL NEED TO
RECONSIDER LATER, BUT WE WERE
AIALITTLE BIT UNDER DURESS DOWNE
STRETCH.
ANYWAY, I THINK THAT AT LEAST AS
OF -- YOU KNOW, IN THE TIME
PERIOD WE HAD, THESE WERE THE
THREE -- THE INSTRUCTIONS SAID
TO COME UP WITH AT LEAST THREE
KEY QUESTIONS.
AND THESE WERE THE THREE
QUESTIONS THE GROUP CAME UP
WITH.
QUESTION ONE, HOW TO VALIDATE
THESE DEVICES FOR ACCURACY.
LIKE THAT'S -- I THINK IT'S A
CRUCIAL QUESTION.
HOW TO USE THE DEVICES ONCE
THEY'RE VALIDATED IN CLINICAL
PRACTICE.
AND WHAT ARE THE USE CASES FROM
THE PROVIDER PERSPECTIVE.
AND THIRDLY, WHAT ARE THE
SPECIAL POPULATIONS.
SO THOSE WERE, I THINK, THE
THREE QUESTIONS THAT EMERGED,
CAME TO THE SURFACE.
AND UNDERNEATH, IF YOU COULD
SCROLL DOWN, PLEASE, SO HOW TO
VALIDATE THESE DEVICES FOR
ACCURACY.
THESE WERE SOME OF THE BARRIERS.
I THINK THERE'S MANY.
THERE'S EVEN MORE THAN WHAT WE
HAVE.
COULD YOU SCROLL UP A LITTLE
BIT, PLEASE, TO CAPTURE THE
ONE -- HERE IT IS.
SO HERE ARE SOME OF THE BARRIERS
WE IDENTIFIED.
THERE'S A MULTITUDE OF DEVICES
AND THEY ALL HAVE DIFFERENT
FUNCTIONS, DIFFERENT
CALIBRATIONS, AND SO
UNDERSTANDING HOW THEY WORK IS A
HUGE BARRIER.
AND MAKING THE VALIDATION
PRACTICAL TO MANUFACTURES YET
MEANINGFUL TO THE USERS, RIGHT,
AND HAVING REGULATORY AND
GUIDELINES COINCIDE, WHAT
YARDSTICK IS USED FOR ACCURACY.
SO IF REGULATORY WANTS A CLEAR A
DEVICE, IT WOULD BE IDEAL IF THE
CLINICIANS WERE ON BOARD AND
VICE VERSA.
AND DEFINING THESE ARE
FUNDAMENTALLY BP CHANGE
MEASUREMENT DEVICES SO DEFINING
THE TYPES OF BLOOD PRESSURE
CHANGES THAT ARE NEEDED FOR THE
VALIDATION.
IT'S A SUPER HARD PROBLEM.
THAT CONNECTS TO TRACTABILITY
AND MEANINGFULNESS, THAT
TRADEOFF.
DETERMINING WHAT REFERENCE TO
USE WHEN THERE IS NO REFERENCE.
THAT WILL INVARIABLY COME UP AT
LEAST IN THESE CURRENT DEVICES.
AND ADDRESSING ALL THE DIFFERENT
CATEGORIES AND TECHNOLOGIES THAT
ARE E EMERGING, THAT CONNECTS BK
TO UNDERSTANDING HOW ALL THE
DEVICES WORK AND ADDRESSING EACH
ONE OF THEM.
AS ONE EXAMPLE, THESE OPTICAL OR
PPG DEVICES, HOW DO WE EVALUATE
THEM FOR SKIN COLOR, IF YOU'RE
LOOKING AT THE BACK OF THEIR
WRIST, FOR EXAMPLE, DEVICE, YOU
KNOW, IT'S NOT THE PALMAR SIDE
OF THE HAND OR ANYTHING AND
THERE'S A LOT OF MELANIN THERE,
SO THAT WILL BE A CONCERN AND
HOW DO WE HANDLE THAT.
THAT'S NOT IN ANY OF THE
PREVIOUS IEE STANDARD OR EVEN
THE ESH RECOMMENDATIONS, UP TO
NOW IT'S BEEN IGNORED, I
BELIEVE.
COULD YOU SCROLL DOWN?
SO HOW TO USE THE DEVICES, THAT
WAS THE -- NO, THESE ARE --
YEAH, RIGHT HERE.
SO HOW TO USE THE DEVICES.
SO I THINK A BARRIER IS TO
SOMEHOW LEVERAGE THE POTENTIALLY
NUMEROUS SERIAL MEASUREMENTS OF
BLOOD PRESSURE VARIATIONS THAT
COULD COME OUT OF THESE DEVICES
AND TO TRY TO COUPLE THEM TO THE
CONTEXTUAL INFORMATION, THAT WAS
TALKED ABOUT IN SOME OF THE
SESSIONS.
YOU KNOW, LIKE WHEN BLOOD
PRESSURE CHANGES, KNOWING THAT
IT OCCURRED AFTER A MEAL, FOR
EXAMPLE, OR IT WAS FOLLOWED BY A
FALL.
AND ALSO IN TERMS OF USE, WE
SHOULD DETERMINE THE BENEFITS
AND RISKS FOR THE PROVIDER AND
USER.
YOU KNOW, FOR THE PROVIDER,
GETTING INFORMATION OVERLOAD,
FOR THE USER, OVERREACTING TO A
MEASUREMENT.
LIKE FOR EXAMPLE, IF THEY SEE
THEIR BLOOD PRESSURE IS LOW,
I'LL JUST SKIP MY MEDS, YOU
KNOW, THINGS LIKE THAT.
AND DETERMINING HOW TO ENSURE
THAT PEOPLE USE THE DEVICE
CORRECTLY.
MUCH OF THIS WORKSHOP IS GETTING
PEOPLE TO USE THE CUFF DEVICE
CORRECTLY, AND THAT COULD VERY
WELL APPLY HERE WITH CUFFLESS
DEVICES.
IN TERMS OF OUR THIRD KEY
QUESTION ABOUT WHAT ARE THE
SPECIAL -- HANDLING SPECIAL
POPULATIONS, WE DON'T KNOW WHAT
THEY ARE.
IN CUFFLESS DEVICES, THEY'RE
MACHINE LEARNING BASED, THEY'RE
DATA-DRIVEN, WE DON'T KNOW WHAT
THE TRAINING DATA ARE.
MAYBE THE TRAINING DATA HAS VERY
FEW CHILDREN IN IT, FOR EXAMPLE.
OR MAYBE IT HAS VERY FEW PEOPLE
WITH DARK SKIN OR SOMETHING.
SO WE DON'T KNOW WHAT THE
SPECIAL POPULATIONS ARE.
IN A LOT OF WAYS IT'S DETERMINED
BY THE DATA THAT WAS USED TO
BUILD THE DEVICE.
YOU KNOW, IN THAT LIGHT, GETTING
TRANSPARENCY FROM THE
MANUFACTURERS AND PERHAPS EVEN A
DESCRIPTION OF THE DATA, THAT
WOULD HELP A LOT IN EFFICIENT
DETERMINATION OF SPECIAL
POPULATIONS, BUT CERTAINLY IT'S
A BARRIER.
THEY DON'T WANT TO SHARE
ANYTHING IN GENERAL.
SO I THINK THAT THOSE ARE THE
THREE QUESTIONS AND SOME OF THE
BARRIERS.
IF WE HAVE -- YOU KNOW, WE CAN
SPEND MORE TIME THINKING ABOUT
THOSE BARRIERS, AND THESE WERE
SOME OF THE FUTURE DIRECTIONS ON
ALL OF THEM, ALL THE QUESTIONS
AND BARRIERS.
I THINK THE MOST IMPORTANT ONES
ARE FOCUSING ON GETTING ALL
STAKEHOLDERS, MANUFACTURERS,
PROVIDERS, USERS, TOGETHER, AND
ESPECIALLY COLLABORATING WITH
THE MANUFACTURER, SO INSTEAD OF
LOOKING AT THEM AS ADVERSARIES,
LOOKING AT THEM AS OUR PARTNERS
TO TRY TO GET THEIR DEVICES INTO
PRACTICE.
AND YOU KNOW, I THINK A SECOND
AND RELATED VERY IMPORTANT THING
IS GETTING MORE CLINICIANS
INVOLVED IN TERMS OF THE NEEDS,
WE DO, NOT I, I DO, BUT SO DOES
TAMMY AND EVERYONE ELSE, RAISING
CONCERNS, ENSURING WHICH TYPES
OF CLINICAL TESTING IS NEEDED
AND WHICH TYPES ARE NOT, SO I
THINK THE MAIN FUTURE DIRECTION
AND STRATEGY WE HAVE IS GETTING
THE STAKEHOLDERS IN APPROPRIATE
PROPORTIONS TOGETHER TO TRY TO
GET THESE DEVICES INTO PATIENTS'
HANDS AND IMPROVING
HYPERTENSION, AWARENESS AND
CONTROL RATES.
SOME OF THE OTHER THINGS WE HAD
TALKED ABOUT IN TERMS OF LIKE
USE AND STUFF IS FOCUSING ON
HYPERTENSION BRANDING, NOT FROM
THE EXPERTS BUT LIKE FROM
PUBLIC, AND EDUCATION WITH THE
DEVICES TO BRING TO SOCIETY.
WHEN WE DESIGN TRIALS, THAT IT
TAKES A HUMAN CENTERED APPROACH
WHERE THE PARTICIPANT HAS TO USE
THE DEVICE THEMSELVES.
SO -- AND ALSO TO CONSIDER
IMPLEMENTATION OF NEW DEVICES IN
THE IMPLEMENTATION OF OLD
DEVICE, LIKE ABPM, IF WE ARE
LUCKY ENOUGH TO GET TO THAT
POINT.
TO SUMMARIZE, I THINK OUR MAIN
FUTURE DIRECTION IS GETTING THE
RIGHT PEOPLE TOGETHER TO ADDRESS
THESE THREE KEY QUESTIONS IN THD
THE NUMEROUS BARRIERS RELATED TO
EACH.
TAMMY, DO YOU HAVE ANYTHING TO
CORRECT OR ADD?
>> NO, THAT WAS GREAT.
THAT WAS GREAT.
>> THANK YOU, TAMMY AND RAMA,
REALLY APPRECIATE IT.
THE NEXT BREAKOUT IS GOING TO BE
LED BY -- AND JOE, ENSURING
ACCESS AND EQUITY IN BLOOD
PRESSURE ASSESSMENT AND
MONITORING.
>> GREAT, THANK YOU.
TERRIFIC JOB, BREAKOUT NUMBER
ONE.
SO I EMAILED OUR SLIDES TO
YOU -- OH, THANK YOU, JOSHUA.
APPRECIATE THAT.
ALL RIGHT.
SO I WAS HAPPY TO BE YVONNE'S
WINGMAN FOR BREAKOUT GROUP 2.
WE HAD A TERRIFIC GROUP WHERE
OUR CHARGE WAS TO TALK ABOUT
ENSURING ACCESS AND EQUITY IN
BLOOD PRESSURE ASSESSMENT AND
MONITORING.
WE CAME UP WITH A NUMBER OF GAPS
THAT ARE ALL LISTED HERE, BUT
BASICALLY WE DISTILLED IT INTO
THESE FOUR KEY RESEARCH
QUESTIONS, WHICH INCLUDE
ANALYZING COST-EFFECTIVENESS OF
SCREENING AND LINKAGE TO CARE
APPROACHES, REALIZING THAT
ULTIMATELY WHAT WE NEED TO SCALE
AND SUSTAIN MANY OF THESE
PROGRAMS IS BUY-IN AND FUNDING
FROM PARTNERS SUCH AS PAYORS, AS
WELL AS GOVERNMENT ENTITIES AND
SO HAVING AN UNDERSTANDING OF
COST IS GOING TO BE KEY IN THAT.
ALSO THINKING ABOUT MESSAGING
FOR HOW WE CAN MAKE PATIENTS
MORE LIKELY TO ENGAGE AND STAY
ENGAGED IN SELF-MONITORING.
ANOTHER KEY QUESTION WAS AROUND
IMPLEMENTATION SCIENCE TO
SUPPORT PROGRAMS TO ENHANCE
ACCESS, REALLY THINKING ABOUT
ACCESSIBILITY POPULATIONS WHO WE
KNOW ARE INCREDIBLY UNDERSTUD
DIEDSTUDIEDIN THE HYPERTENSION E
BUT FOR EXAMPLE, AS WE THINK
ABOUT OUR VALIDATED MONITORS,
YOU KNOW, ARE THEY USABLE BY
PEOPLE WHO ARE BLIND AND/OR LOW
VISION AND WHAT ABOUT FOLKS WHO
HAVE OTHER TYPES OF NEEDS,
THAT'S AN AREA WHERE WE CAN
DEFINITELY STAND SO HAVE MORE
SCIENCE.
THEN WE TALKED A LOT ABOUT
TRANSDISCIPLINARY APPROACHES TO
INNOVATE AND IMPROVE ACCESS AND
ADVANCE EQUITY.
IN OUR ROOM WE TALKED ABOUT THIS
TRANSDISCIPLINARY APPROACH
REALLY WHERE WE'RE THINKING
ABOUT HEALTH W EQUITY FROM THE
VERY START, INVOLVING KEY
PARTNERS SUCH AS THE COMMUNITY,
NOT JUST AT THE POINT OF
MARKETING A NEW DRUG, BUT REALLY
FROM THE POINT OF EVEN BEGINNING
TO UNDERTAKE A RESEARCH QUESTION
OR AN INVESTIGATION AND MAKING
SURE THAT WHAT WE'RE DOING IS
BOTH PRIORITIZED AND RESONATES
WITH THE END COMMUNITY OR THE
END USER.
SO WE IDENTIFIED SEVERAL
BARRIERS.
WE IDENTIFIED SEVERAL BARRIERS
FOR TRYING TO ADDRESS SOME OF
THOSE KEY QUESTIONS.
AND THOSE BARRIERS INCLUDE
MISALIGNMENT OF INCENTIVES TO
SUPPORT ADHERENCE TO BEST
PRACTICES AND GUIDELINES,
VARIABILITY IN -- HERE WE GO,
THANK YOU.
SO MISALIGNMENT OF INCENTIVES TO
SUPPORT ADHERENCE AND
INCONSISTENT ADHERENCE WITH
REGARD TO SPECIAL POPULATIONS,
SPECIFICALLY WE TALKED ABOUT
PREGNANT PERSONS AND LACK OF
ROBUST TRIAL DATA, AS WELL AS
LACK OF VO VALIDATED DEVICES FOR
SPECIAL POPULATIONS SUCH AS
PREGNANT PEOPLE, PERSONS WITH
CKD AND OTHERS.
OTHER BARRIERS, AGAIN IF WE
COULD -- FOR SOME REASON MY
SCREEN IS NOT UPDATING TO THE
BARRIERS.
BUT WE ALSO TALKED ABOUT AS
BARRIERS, LACK OF ACCESS TO
COACHING ON MEASURING AND
MANAGING BLOOD PRESSURE,
INSUFFICIENT COVERAGE OF BLOOD
PRESSURE DEVICES, AND SPECIAL
BARRIER-FREE COVERAGE FOR
SPECIAL POPULATIONS SUCH AS
POSTPARTUM PERSONS, LACK OF
PRIORITIZATION OF HYPERTENSION
AND ACCURATE BLOOD PRESSURE
MEASUREMENT IN PEDIATRIC
SETTINGS.
LACK OF POLICIES TO SUPPORT
DIVERSE POPULATIONS WHO ARE
NON-ENGLISH-SPEAKING WHEN IT
COMES TO BLOOD PRESSURE
MEASUREMENT.
AND THEN ALSO THINKING ABOUT
MARKET FORCES SUCH AS AMAZON, OR
OTHERS, WHERE THERE'S VERY
LITTLE REGULATION OF THE BLOOD
PRESSURE MONITORS THAT ARE SOLD,
WHICH MAKES IT VERY, VERY
DIFFICULT FOR US WHO VALUE
ACCURATE BLOOD PRESSURE
MEASUREMENT, OUR PATIENTS
UNFORTUNATELY HAVE MORE ACCESS
TO UNREGULATED DEVICES THAN THEY
OFTEN DO TO OUR REGULATED
DEVICES, AND SO THINKING ABOUT
HOW WE ADDRESS THOSE.
POSSIBLY POLICY CHALLENGES IS
SOMETHING FOR US TO THINK ABOUT
FOR THE FUTURE.
AND THEN ALSO THINKING ABOUT
LACK OF INTEGRATED CARE MODELS
AND OUR CURRENT FEE FOR SERVICE
MODEL ALSO MAKES IT VERY
DIFFICULT FOR US TO MAKE CHANGE
IN THIS AREA.
SO MOVING ON TO STRATEGIES AND
FUTURE DIRECTIONS, SO SOME OF
THE STRATEGIES THAT WE TALKED
ABOUT ARE APPLICATION OF
IMPLEMENTATION SCIENCE TO
SUPPORT A LIFESPAN APPROACH TO
SCREENING AND LINKAGE TO CARE.
AND SO FUNDING OF LONGITUDINAL
STUDIES WHERE WE CAN ADDRESS
SOME OF THESE LIFECOURSE
QUESTIONS OVER A LONGER
FOLLOW-UP PERIOD, PARTICULARLY
AS WE THINK ABOUT SPECIAL
POPULATIONS SUCH AS PREGNANT
PERSONS AND THEN OF COURSE THE
SORT OF NEXT STOP ON THE
SPECTRUM IS THE PEDIATRIC
POPULATION, BEING ABLE TO STUDY
THOSE TRANSITIONS WILL MAKE A
BIG DIFFERENCE, WE THINK, AND SO
FUNDING OF THOSE TYPES OF
MULTILEVEL AND LONGITUDINAL
STUDIES WILL BE IMPORTANT.
LEVERAGING AI TO DO MANY THINGS
THAT A.I. CAN DO MUCH MORE
EASILY THAN WE COULD IN THE PAST
SUCH AS IDENTIFYING WHO'S AT
HIGHEST RISK, IDENTIFYING
THRESHOLD BIAS OR ZERO DIGIT
PREFERENCE, HARKENING TO THE
PRESENTATION BY DR. FOTI ON
MEASUREMENT BIAS, THINKING ABOUT
CHATBOTS TO SUPPORT PATIENTS AND
TO FEED INFORMATION TO
CLINICIANS FROM OUR AUTOMATED OR
HOME DEVICES.
ANALYZING AND TRIAGING INCOMING
DATA FROM OUR OUT OF OFFICE
DEVICES TO CLINICAL
DECISION-MAKERS, AND THINKING
ABOUT WAYS TO DECREASE CLINICAL
BURDEN.
INCREASING TIMELINESS OF
TREATMENT IN ACUTE SITUATIONS IS
PARTICULARLY IMPORTANT IN THE
POSTPARTUM SETTING, AND
INCORPORATING MULTIMODAL DATA
SOURCES, REUSING ALL OF THE DATA
THAT WE HAVE AT OUR DISPOSAL,
INCLUDING ENVIRONMENTAL DATA,
NOISE, TEMPERATURE, AND OTHER
THINGS THAT WE DON'T TYPICALLY
THINK ABOUT IN THE CLINICAL
SETTING.
AND THEN THINGS LIKE A FIDELITY
CHECKLIST TO IMPROVE OUR
CONFIDENCE IN HOME BLOOD
PRESSURE MEASUREMENT READINGS,
GIVEN THAT MANY CLINICIANS DON'T
BELIEVE THE VALIDITY OR ACCURACY
OF HOME BLOOD PRESSURE MONITORS,
SO HOW CAN WE INCREASE SORT OF
QUALITY CONTROL FOR THAT.
INCREASING CLINICIAN RECOGNITION
OF BIASES IN MEASUREMENT, AND
THEN FINALLY DEVELOPING QUALITY
MEASURES TO ADDRESS EQUITY IN
HOME BLOOD PRESSURE MONITORING.
AND THINKING ABOUT QUALITY
MEASURES TO ADDRESS EQUITY
AROUND HYPERTENSION MANAGEMENT
GENERALLY IS ANOTHER PLACE WHERE
WE CAN -- WHERE WE HOPEFULLY
WILL SEE SOME ADVANCEMENTS IN
THE NEAR FUTURE.
SO VERY GRATEFUL TO BREAKOUT
ROOM 2.
YVONNE, DID I MISS ANYTHING?
PLEASE FEEL FREE TO CORRECT OR
ADDEND.
>> YOU GOT IT.
THANK YOU SO MUCH.
, DR. RAVENELL.
>> THANK YOU BOTH VERY MUCH.
AND SO I'LL JUST INTRODUCE THE
LAST TWO MODERATORS, I WAS
PRIVILEGED TO BE IN THE SESSION
ON BREAKOUT 3 ABOUT RELIABLE
BLOOD PRESSURE MEASUREMENTS,
GUIDING PROVIDERS, RESEARCHERS
AND PATIENTS AND TRUSTING TRUSTG
CURRENT AND URGENT BLOOD
PRESSURE DEVICES.
SO REALLY EXCITED TO HEAR FROM
OUR LAST TWO MODERATORS.
>> GO AHEAD, JORDY.
THANK YOU.
>> GREAT, THANK YOU.
I THINK WE'RE JUST WAITING FOR
OUR SLIDES AND I'LL GET STARTED.
I'LL START BY SAYING, SO WE WERE
TASKED WITH TALKING ABOUT
GUIDING PROVIDERS, RESEARCHERS
AND PATIENTS AND TRUSTING
CURRENT EMERGENT BLOOD PRESSURE
DEVICES AS STEPHEN MENTIONED.
WE TOOK A LITTLE DIFFERENT
APPROACH TO PRESENTING SORT OF
THE DISCUSSION.
WE DIVIDED INTO ABOUT FOUR MAIN
QUESTIONS AND I'LL TALK ABOUT
THE KEY BARRIERS THAT WERE
DISCUSSED AS WELL AS SOME OF THE
FUTURE DIRECTIONS THAT WE
DISCUSSED.
ARE MY SLIDE STILL -- THEY'RE
NOT SHOWING RIGHT.
I CAN JUST TALK THROUGH IF WE
DON'T HAVE THEM UP YET.
SO I'LL JUST START TALKING JUST
TO -- FOR THE SAKE OF TIME.
THE FIRST QUESTION THAT WE
IDENTIFIED AS BEING SORT OF THE
HIGHEST PRIORITY ONE WAS WHAT
ADDITIONAL RESEARCH IS NEEDED TO
IMPROVE THE INTEGRATION OF AND
STANDARDIZATION OF BLOOD
PRESSURE FROM EMERGING
TECHNOLOGIES WITH CURRENT
CLINICAL PRACTICE.
AND WE'VE IDENTIFIED A FEW KEY
BARRIERS TO TRYING TO DO THIS.
FIRST OF ALL THE NEED TO BE ABLE
TO TRANSMIT HOME BLOOD PRESSURES
DIRECTLY INTO THE ELECTRONIC
HEALTH RECORD BY MULTIPLE MEANS
IS SOMETHING THAT IS A BIG
CHALLENGE THAT WAS BROUGHT UP
MULTIPLE TIMES IN THE
DISCUSSIONS.
ALSO SOMETHING THAT'S REALLY
CHALLENGING THAT WAS IDENTIFIED
WAS THE IDEA OF STANDARDIZATION
IS SOMEWHAT LIMITED BY THE FACT
THAT THERE IS THIS NATURAL
VARIATION IN BLOOD PRESSURE AND
WE STILL DON'T FULLY UNDERSTAND
EXACTLY WHICH PARAMETERS WE
SHOULD BE USING.
SHOULD WE BE USING AN AVERAGE?
PROBABLY NOT.
PROBABLY SOMETHING MORE LIKE THE
PROPORTION OF TIME AND TARGET
RANGE PLUS UNDERSTANDING THE
PROPORTION OF OUTLIERS IN EACH
DIRECTION AND HOW MUCH OF A
BURDEN THOSE ARE AND WHETHER
THEY'RE SYMPTOMATIC.
SO THERE'S A LOT MORE TO TO
UNPACK THAN JUST UNDERSTANDING
AVERAGING BLOOD PRESSURES IN
TERMS OF DELIVERING THE
INFORMATION.
ALSO WHAT WAS BROUGHT UP AS
ANOTHER IMPORTANT BARRIER IS
PRIVACY CONCERNS FROM THIRD
PARTY APPLICATIONS, AND THAT'S
SOMETHING THAT'S GOT TO VERY
IMPORTANTLY BE ADDRESSED AND
THAT COULD PREVENT SOME OF THESE
FROM BEING INTEGRATED IN ALL
HEALTH SYSTEMS, SINCE DIFFERENT
HEALTH SYSTEMS HAVE DIFFERENT
LEVELS OF PRIVACY REQUIREMENTS
THAT EVEN IF SOMETHING IS
DEVELOPED, IT MAY NOT BE ABLE TO
BE IMPLEMENTED ON A BROAD SCALE.
SO FOR FUTURE DIRECTIONS, WE
TALKED ABOUT HOW WE REALLY NEED
HIGH QUALITY STUDIES TO ADDRESS
A FEW OF THESE ISSUES.
ONE IS A BETTER UNDERSTANDING
HOW DRUGS IMPACT THE VARIABILITY
I MENTIONED AND BRINGING BLOOD
PRESSURES OUTSIDE OF THOSE
OUTLIER RANGES MORE INTO A
NARROWER RANGE, WHETHER THERE
ARE SPECIFIC DRUGS THAT ARE
BETTER AT DOING THAT OR JUST THE
ACT OF INITIATING DRUGS CAN HELP
TO IMPROVE THAT.
ALSO DEVELOPING A USER INTERFACE
FOR HYPERTENSION THAT CAN BE
USED ACROSS THE TEAM FROM
PROVIDERS TO PHARMACISTS, FROM
ANYBODY WHO WOULD HAVE ACCESS TO
IT AND THAT CAN BE IDEALLY
MODIFIED BY THE INDIVIDUAL TO
SERVE THEIR NEEDS, TO GIVE THEM
THAT INFORMATION WE TALKED
ABOUT, EITHER THE FULL BREADTH
OF BLOOD PRESSURE OR SUMMARY
INFORMATION SUCH AS BOTH THE
TIME AND TARGET RANGE AND THOSE
OUTLIERS SO PEOPLE WOULDN'T
NECESSARILY HAVE TO GO ACROSS
SEVERAL DIFFERENT SYSTEMS TO BE
ABLE TO ACCESS THIS CRITICAL
INFORMATION.
THERE ALSO REALLY NEED TO BE
BETTER WAYS TO INPUT MULTIPLE
SOURCES OF BLOOD PRESSURE INTO A
MORE UNIFORM AREA, NOT JUST
USING BLUETOOTH.
SO WE WERE THINKING FUTURE
DIRECTIONS FOR RESEARCH WOULD BE
TO EXPLORE WHETHER THERE'S A WAY
TO INTEGRATE DELIVERY OF BLOOD
PRESSURES USING VERBAL
INFORMATION, USING PHOTOGRAPHS
OF BLOOD PRESSURES, OTHER WAYS
TO MEET PATIENT WHERE THEY ARE.
THERE WAS GREAT DISCUSSION ABOUT
BRINGING PATIENTS INTO CLINIC TO
HELP THEM USE THE BLUETOOTH
DEVICES AND TO HELP UPLOAD THEIR
BLOOD PRESSURES DIRECTLY, BUT
NOT EVERYBODY HAS ACCESS TO THAT
SORT OF ENGAGEMENT WITH THE
HEALTHCARE SYSTEM, AND ALSO TO
THAT TECHNOLOGY TO BEGIN WITH.
SO I THINK WE NEED TO BE HONEST
WITH OURSELVES ABOUT THAT AND
MAKE IT MORE ACCESSIBLE.
AND ALSO MAKING SURE THAT BLOOD
PRESSURE MONITORS CAN SEND
INFORMATION IN A HARMONIZED WAY.
RIGHT NOW THERE ARE MANY
APPLICATIONS ACROSS MANY
DIFFERENT TYPES OF DEVICES, SOME
OF WHICH CAN UPLOAD DIRECTLY TO
THE EHR, SOME OF WHICH CAN'T.
ELECTRONIC HEALTH RECORD
COMPANIES HAVE EXPRESSED
INTEREST IN BEING ABLE TO DO
THIS BUT AREN'T ABLE TO DO THIS
ACROSS MANY, MANY, MANY
DIFFERENT SOURCES.
THERE NEEDS TO BE AN INTEGRATED
A SINGLE SOURCE, SUCH AS SPHYGMO
WAS ONE EXAMPLE.
I THINK THIS IS GOING TO BE MORE
OF AN INDUSTRY-WIDE ISSUE BUT
CLEARLY SOMETHING THAT'S AN
IMPORTANT BARRIER THAT I THINK
THE ANSWER IS HARMONIZATION AND
CONSISTENCY.
ACROSS DEVICES AND
HEALTH SYSTEMS.
SO REALLY -- OH, I THINK BACK
ONE, PLEASE.
SORROWLY THE SUMMARY IS THAT WE
NEED TO REMOVE BARRIERS AND
BROADEN TOOLS TO BE ABLE TO
ALLOW PEOPLE WHO ARE LESS
TECHNOLOGICALLY SAVVY AND ACROSS
DIFFERENT SYSTEMS ACCESS TO THE
SAME INFORMATION.
SOME PEOPLE BROUGHT UP EXAMPLES
OF HOW THIS HAS BEEN DONE SUCH
AS WITH HEART MO MONITORING APPS
AND REALLY THIS IS FEASIBLE AND
JUST NOT BEING DONE IN BLOOD
PRESSURE, PERHAPS THERE'S JUST
TOO MANY PLAYERS IN THE FIELD.
THE NEXT KEY GAP THAT WE
IDENTIFIED WAS TRY AND
UNDERSTAND WHAT FACTORS ARE
RELATED TO DISCORDANCE BETWEEN
OFFICE AND OUT OF OFFICE BLOOD
PRESSURE MEASUREMENT AND WHETHER
WE NEED TRIALS TO IDENTIFY AN
OPTIMAL GOAL IN AND OUT OF
OFFICE BLOOD PRESSURE
MEASUREMENT AND WHETHER WE CAN
JUST USE HOME BLOOD PRESSURE
DATA AS IT IS TO GUIDE TREATMENT
AND WHETHER THE DISCORDANCE
MATTERS ENOUGH THAT WE REALLY
SHOULD BE THINKING ABOUT THEM
DIFFERENTLY OR THINKING ABOUT
THEM THE SAME, AND DO WE HAVE
ANY CONCERNS WITH USING OFFICE
BLOOD PRESSURE AS OUR GUIDE, IS
THERE POTENTIALLY HARM THAT
COULD BE INVOLVED IN TREATING
BLOOD PRESSURE OR ARE WE CAUSING
HARM BY EXPECTING THERE TO BE
HARM AND SHOULD WE JUST BE USING
ALL THE DATA WE HAVE?
SO SOME IMPORTANT BARRIERS THAT
WE TALKED ABOUT IN THIS REGARD
WERE BASICALLY THAT FIRST OF ALL
THERE ARE FEWER NO VALIDATED
HOME BLOOD PRESSURE DEVICES IN
SEVERAL POPULATIONS WHICH MAKES
THIS NOT EVEN ACCESSIBLE, FOR
EXAMPLE TO CHILDREN AND MANY
PREGNANT WOMEN.
THERE ARE A LOT OF ISSUES WITH
THE QUALITY OF BLOOD PRESSURES
WE GET IN AND OUT OF THE OFFICE
INCLUDING SEVERAL BIASES WITH
HOW THEY'RE PERFORMED DUE TO HOW
PEOPLE ARE TRAINED TO CHECK
BLOOD PRESSURE AND WE'LL TALK
MORE ABOUT OTHER ISSUES WITH
REGARD TO MEASUREMENT LATER, AND
AS HAS ALREADY BEEN TALKED
ABOUT, THESE DEVICES ARE
DIFFICULT TO CALIBRATE, AND
REALLY ALSO WE THINK THAT IT'S
REALLY IMPORTANT FOR US TO NOT
JUST THINK ABOUT EITHER OF THESE
EXCLUSIVELY, OF COURSE, SIMILAR
TO OTHER PREVIOUS SLIDES, WE
THINK THAT HAVING ACCESS TO
TRENDS, THE RANGE, AVERAGE,
VARIATION OF BLOOD PRESSURE IS
REALLY GOING TO BE IMPORTANT,
HOW WE'RE USING ALL THIS DATA.
OF COURSE THERE ARE SAFETY
CONCERNS IN TERMS OF ALLOWING
BLOOD PRESSURE TO GO TOO LOW AND
WHETHER THERE IS A TOO LOW, AND
JUST IN TERMS OF HOW HIGH
QUALITY DATA IS EVEN FEASIBLE TO
PERFORM IN THESE SETTINGS.
AND THE NEED AGAIN AS MENTIONED
PREVIOUSLY TO INTEGRATE THIS ALL
WITHIN THE ELECTRONIC HEALTH
RECORD IN A WAY WHERE WE CAN
INTEGRATE IT BUT ALSO UNDERSTAND
WHICH DATA IS FROM WHICH SOURCE
IF WE'RE THINKING THAT THEY ARE
DISTINCTIVE.
SO FOR FUTURE DIRECTS, WE THINK
THAT IDEALLY THERE SHOULD BE --
THERE NEEDS TO BE SOME SORT OF
LINKAGE, WHETHER IT'S A TRIAL OR
STUDY LOOKING AT THE
RELATIONSHIP OF OUT OF OFFICE
BLOOD PRESSURES WITH MAJOR
EVENTS, THERE HAS BEEN WORK IN
THIS REGARD, THERE IS ONGOING
WORK IN THIS REGARD, BUT WE
STILL DON'T REALLY UNDERSTAND
OPTIMAL THRESHOLDS FOR OUT OF
OFFICE BLOOD PRESSURE AND
THRESHOLDS ARE BASED OFF
INADEQUATE SOURCES OF DATA, SO
THIS IS AN AREA THAT REALLY IS
RIPE FOR BETTER UNDERSTANDING OF
WHAT HE WE SHOUL WE SHOULD BE S,
AND ALSO AGAIN AS MENTIONED
DEVELOPING WAYS TO BE ABLE TO
LOOK AT TRENDS AND NOT JUST
SINGLE VALUES IN A SYSTEMATIC
WAY THAT CAN BE OPERATIONALIZED
ACROSS CLINICAL SPACES, NOT JUST
RESEARCH SPACES.
WE THINK A LOT OF THIS IS BEST
DONE USING PRAGMATIC TRIALS AND
WAYS TO REALLY INTEGRATE PEOPLE
ON A LARGE SCALE, ESPECIALLY
BECAUSE IF WE WANT TO DO ANY
KIND OF OUTCOME STUDIES, IT MAY
RETIREE NORMS AMOUNTS OF PEOPLE
AND OBSERVATIONAL DATA MAY BE
THE BEST WAY TO ATTAIN SOME OF
THESE ANSWERS BECAUSE OF
FEASIBILITY AND SCALE OF
CONCERNS BUT IDEALLY RANDOMIZED
TRIALS WOULD BE THE BEST.
I THINK THAT THE DECISION WAS
THAT THERE WILL NOT BE A
RANDOMIZED CONTROL TRIAL
RANDOMIZING PEOPLE TO HOME
VERSUS OUT OF OFFICE AS THEIR
WAY OF MANAGING BLOOD PRESSURE.
REALLY WHAT CAME OF ALL OF THIS
AND THE SUMMARY OF IT, I THINK
THE CONCLUSION WAS WE NEED TO
DEVELOP A HYBRID APPROACH TO
USING BOTH OFFICE AND OUT OF
OFFICE BLOOD PRESSURES TO GUIDE
THERAPY, AND THAT BETTER TRIALS
REALLY SHOULD BE DONE TO BE ABLE
TO DO THAT IN A WAY THAT'S
ADOPTABLE AND NOT JUST IN A
PERFECT TRIAL SETTING.
THE NEXT GAP THAT WE TALKED
ABOUT OF OUR FOUR WAS CLINIC
BLOOD PRESSURE NEEDS TO BE
STREAMLINED.
IT TECHNICALLY CHALLENGING.
AND WE'RE ASKING IF THERE'S A
WAY TO STREAMLINE TO PERFORM IT
BETTER.
AND A LOT OF THE BARRIERS THAT
HAVE BEEN IDENTIFIED AS CLINICAL
WORK FLOWS, ARCHITECTURE, TIME
CONSTRAINTS AND CLINIC
RESTRAINTS REALLY HAVE DEVELOPED
BLOOD PRESSURE MEASUREMENT TO
OCCUR IN A WAY THAT'S NOT
OPTIMAL AND THAT REALLY RESULTS
IN A LOT OF INACCURACIES.
THE AMA HAS DEVELOPED AMAZING
TOOLS THAT WERE TO GO INTO
CLINICS AND IDENTIFY WHERE BLOOD
PRESSURES ARE IN THEIR OWN
PLACES, HOW TO HELP PLAQ PRACTIS
IMPROVE THEIR BLOOD PRESSURE
MEASUREMENTS.
A LOT OF THE SENSE -- BEING DONE
IS QI WORK, THE PROBLEM IS
GETTING PEOPLE TO UPTAKE THIS
AND IT HASN'T BEEN REALLY
ACHIEVING DISSEMINATION.
SO I'LL TALK MORE ON OUR NEXT
FEW SLIDES ABOUT EDUCATION
FACTORS RELATED TO THAT AND
OTHER BARRIERS, BUT REALLY THE
KEY TO THIS WAS RADICALLY
CHANGING THE ROOMING PROCESS,
BRINGING IN AUTOMATED OFFICE
BLOOD PRESSURE ON A LARGER
SCALE, AND REALLY THEN ONCE YOU
DO THAT, THE BIGGER PROBLEM
BECOMES INERTIA RATHER THAN JUST
THE MEASUREMENT ERRORS, BUT THIS
IS THE REALLY SORT OF FIRST LOW
HANGING FRUIT THAT'S STILL NOT
ADEQUATE IN MOST PLACES.
SO WE DISCUSSED WE THINK THE
FUTURE DIRECTIONS IN THIS REGARD
ARE LIKELY AGAIN REALLY
PRAGMATIC RCTs AND EVEN MAYBE
IMPLEMENTATION STUDIES AND
DISSEMINATION WORK INTO HOW TO
GET PEOPLE TO ADOPT ABPM AND IT
SEEMS SOMETHING WHERE AMA HAS
REALLY OPTIMIZED THIS AND
DEVELOPS MORE AMAZING TOOLS TO
DO THIS, THEY'RE GOING TO BE
MAKING THEM MORE PUBLIC AND MANY
MORE SINL TO WHOEVER NEEDS THEM
BUT THE ISSUE IS HOW COULD DO WT
PEOPLE AWARE OF THIS AND HOW DO
WE GET PEOPLE TO ACTUALLY DO
THIS?
AND I THINK THAT IS THE BIGGER
QEP, THERE'S DEFINITELY A HUGE
GAP AND A NEED FOR THIS.
LAST OBVIOUSLY SOME BIG ASPECT
OF THIS IS LACK OF EDUCATION.
WE TALK A LOT ABOUT BARRIERS TO
EDUCATION, BOTH PATIENTS AND
CLINICIANS WITH REGARD TO
TRUSTING AND INTERPRETING BLOOD
PRESSURE MEASUREMENT USING NEWER
TECHNOLOGY AND WHAT RESOURCES
COULD USE TECHNOLOGY TO HELP
WITH THAT AS WELL.
AND SO A LOT OF THIS IS RELATED
TO WHAT RESOURCES ARE
SPECIFICALLY NEEDED AND HOW BEST
TO ENGAGE PATIENTS AND
CLINICIANS AND A BIG ISSUE THAT
WAS BROUGHT UP WAS THAT THERE
WAS A LOT OF CULTURAL
DIFFERENCES, PARTICULARLY IN
PATIENTS AND HOW THEY THINK
ABOUT BLOOD PRESSURE, WHAT IT
MEANS TO THEM, WHETHER
SPECIFICALLY IT'S SOMETHING THEY
SEE AS JUST BEING A
REPRESENTATION OF STRESS AND
THAT ONLY MATTERS WHEN IT'S
SYMPTOMATIC AND THESE OTHER
ISSUES ARE SORT OF INDOCTRINATED
THAT REQUIRE A LOT OF BEHAVIORAL
TYPE RESEARCH AND A LOT OF
REALLY UNDERSTANDING CULTURALLY
SPECIFIC INFORMATION TO GET AT.
AND ALSO ADDRESSING STIGMA WHILE
DOING THAT.
THIS IS REALLY PROBLEMATIC AND
CHALLENGING AND REQUIRES A
DIFFERENT TYPE OF RESEARCH THAN
I THINK MOST PEOPLE IN THIS ROOM
TEND TO TYPICALLY ENGAGE IN AND
I THINK REQUIRES PARTNERING WITH
OTHER AREAS OR OTHER PEOPLE OF
EXPERTISE THAT WOULD BE ABLE TO
BETTER GET AT THIS.
AND TESTING STRATEGIES IN
DIFFERENT PATIENT POPULATIONS.
WE HAVE REALLY GOOD EXAMPLES OF
WHERE THIS HAS WORKED LIKE THE
BARBERSHOP STUDY AND LIKE THE
FAITH STUDY THAT HAVE EMBARKED
ON DOING THIS AND MEETING PEOPLE
WHERE THEY ARE, BUT I THINK THAT
THIS BECOMES STILL A BROADER
ISSUE IN AREAS WHERE IT'S
DIFFERENT WITHIN EACH CULTURE
AND THIS NEEDS TO BE BROUGHT IN
TO OTHER SUBGROUPS OF PEOPLE
THAT HAVEN'T BEEN REACHED AND
MADE FEASIBLE IN THE REAL WORLD,
WHICH IS THE BIGGER CHALLENGE.
AND SO FOR FUTURE DIRECTIONS FOR
THIS, WE TALKED ABOUT PERHAPS
CONSIDERING PROPOSING A.I.
ASSISTIVE TECHNOLOGIES,
PARTICULARLY WHERE WE CAN USE
THEM IN WAYS THAT DON'T
NECESSARILY ADDRESS THOSE
CULTURAL ISSUES BUT THAT ADDRESS
HELPING PEOPLE WALK THROUGH
TESTING AND COACHING WITH
MANAGING THEIR BLOOD PRESSURE,
HELPING PEOPLE IN TERMS OF HOW
TO PERFORM BLOOD PRESSURE
CORRECTLY AND THAT YOU CAN USE
ADDITIONAL TECHNOLOGICAL TOOLS
TO ASSESS WHERE THEY ARE, TIME
AND SPACE, ECOLOGICAL ASSESSMENT
TO HELP UNDERSTAND BLOOD
PRESSURE VARIABILITY AND TO HELP
UNDERSTAND THAT THEY ARE
ACTUALLY CHECKING THEIR BLOOD
PRESSURES CORRECTLY.
THAT SEEMS LIKE A FUEL TOUR
FEAFUTUREFEASIBLE DIRECTION BUTE
TALKED ABOUT HOW IT WILL BE
REALLY, REALLY CRITICAL TO
UNDERSTAND HOW PEOPLE WANT TO
COMMUNICATE AND HELP PEOPLE SORT
OF IN THAT PRECONTEMPLATIVE
STAGE REALLY EVEN UNDERSTAND HOW
DO WE START TO COMMUNICATE WITH
PEOPLE AND GET AT BETTER
MANAGING BLOOD PRESSURE WHO
STRUGGLED WITH EVEN THINKING
IT'S SOMETHING WORTH MANAGING.
SO THAT'S A BIGGER CHALLENGE
THAT WE THOUGHT WOULD BE A BIT
MORE CHALLENGING TO ADDRESS IN
THE FIRST PLACE.
SO WE WERE THINKING THERE WERE A
FEW POTENTIAL WAYS, INFLUENCING
THE INFLUENCERS AS MENTIONED,
THINGS LIKE BARBERSHOPS AND
OTHER OU OUTREACH, USING MOBILE
VANS LIKE WHAT WAS USED IN
COVID, ADDRESSING THOSE FOR THE
TYPE OF SITUATION.
THINKING ABOUT STANDARDIZED
PROCESS OF COMPETENCIES FOR
STAFF AND TRAINING, THE AMERICAN
MEDICAL ASSOCIATION IS COMING
OUT WITH A FREE TRAINING PROGRAM
FOR CLINICIANS, THINGS LIKE THIS
NEED TO BE DISSEMINATED WIDELY,
THOUGH, FOR PEOPLE TO EVEN BE
AWARE THIS IS NEEDED.
I THINK THERE ARE A LOT OF
BARRIERS TO MAKING HEALTH
SYSTEMS AWARE OF HOW IMPORTANT
THIS IS.
TESTING, AND OF COURSE EXAMINING
WORKFLOWS AND IDENTIFYING THE
BEST WAYS TO IMPLEMENT THESE ALL
WOULD BE USEFUL WITH
IMPLEMENTATION RESEARCH AND
PRAGMATIC TRIALS WHICH SEEMS TO
BE THE FUTURE OF THIS AREA, AND
THEN AS MENTIONED PROBABLY ALSO
SOME BEHAVIORAL INTERVENTIONS TO
TEST SOME OF THE OTHER
STRATEGIES WE'VE TALKED ABOUT,
PARTICULARLY WITH BOTH
CLINICIANS AND PATIENTS OF HOW
BEST TO GET PEOPLE TO EVEN THINK
THAT THIS ALL MATTERS.
SO I THINK THAT WAS EVERYTHING.
>> FAN FANTASTIC SUMMARY, JORD.
THANK YOU FOR ALL THE HARD WORK
AND ACTUALLY TO ALL THE BREAKOUT
SESSIONS FOR THIS REPORT.
I THINK WE'RE NOW A OUT OF TIME,
BUT JUST SOME CLOSING THOUGHTS.
WE WANTED TO, A, THANK ALL THE
PARTICIPANTS OBVIOUSLY AND
SPEAKERS AND MODERATORS TO
CONTRIBUTED TO THIS REALLY
IMPORTANT WORKSHOP, AND THANK
YOU TO -- I SEE DR. PAULA
EINHORN AND TO ALL THE OTHER
NIH, NHLBI FOR CONVENING THIS
WORKSHOP I THINK AT A VERY
CRITICAL TIME, AND OVER THE PAST
TWO DAYS, WE'VE EXPLORED THE
CURRENT STATE OF BLOOD PRESSURE
ASSESSMENT ACROSS CLINICAL
PRACTICE AND RESEARCH, WE
ATTEMPTED TO IDENTIFY CRITICAL
KNOWLEDGE GAPS AND DISCUSS
OBVIOUSLY INNOVATIVE SOLUTIONS
TO ADVANCE THE FIELD.
I THINK IT WAS AMAZING TO LISTEN
TO A DIVERSITY OF TOPICS FROM
PEDIATRICS, PREGNANCY RELATED
BLOOD PRESSURE MONITORING,
INTEGRATIONS OF EMERGING
TECHNOLOGIES AND OBVIOUSLY
ADDRESSING EQUITY IS OUR RUNNING
THEME WHICH OBVIOUSLY
UNDERSCORES THE COMPLEXITY AND
IMPORTANCE OF IMPROVING BLOOD
PRESSURE ASSESSMENT.
SO FOR US, OUR KEY TAKEAWAYS
HAVE INCLUDED THE NEED TO
VALIDATE OBVIOUSLY THESE
EMERGING CONTINUOUS AND CUFFLESS
BLOOD PRESSURE MONITORING
TECHNIQUES FOR DIVERSE
POPULATIONS ACROSS THE LIFESPAN,
ADDRESSING ANY CHALLENGES IN
SPECIFIC POPULATIONS AND
CLINICAL CONDITIONS, OBVIOUSLY A
CALL TO ACTION TO ENSURE
EQUITABLE ACCESS THROUGH A
RELIABLE BLOOD PRESSURE
ASSESSMENT TOOLS AND MITIGATE
POTENTIAL BIAS AND EMERGING
TECHNOLOGIES, AND NECESSITY OF
INTEGRATING PATIENT GENERATED
DATA INTO WORKFLOWS WHILE
LERCHGING LARGE DATASETS FOR
MEANINGFUL CLINICAL
DECISION-MAKING SO OUR NEXT
STEPS WILL BE TO CONVENE A
WRITING GROUP TO TRANSLATE THE
FINDINGS FROM THIS WORKSHOP INTO
A MEANING FULL ROAD MAP FOR A
BROAD RANGE OF KNOWLEDGE HOLDERS
INCLUDING CLINICIANS PATIENTS,
RESEARCHERS AND FUNDERS BUT I
THINK ALSO POLICYMAKERS IN ORDER
TO INSPIRE SYSTEM CHANGE
ULTIMATELY FOCUSING ON HOW WE
CAN IMPACT CLINICAL GUIDELINES,
HEALTHCARE DELIVERY AND PUBLIC
HEALTH POLICY TO IMPROVE BLOOD
PRESSURE CONTROL EQUITABLY.
I'LL HAND IT OVER TO STEPHEN FOR
NEXT STEPS.
>> THANK YOU TO YOU, MARWAH, FOR
ALL YOUR LEADERSHIP AND
SHOULDERING OF BULK OF ALL THE
LOAD, BUT IT BEEN SUCH A
PLEASURE, AND I AGAIN JUST WANT
TO ECHO MY THANKS TO NHLBI AND
ALL OF YOU FOR CONTRIBUTING SO
MUCH TO THIS CRITICAL DISCUSSION
AROUND SUCH AN IMPORTANT RISK
FACTOR FOR CARDIOVASCULAR
DISEASE.
SO AS MARWAH WAS SAYING, OUR
HOPE IS TO CONVENE THE WORKING
GROUP AND TO WORK EFFICIENTLY,
WHILE IDEAS ARE FRESH.
OUR UNDERSTANDING IS THERE WILL
BE AN EXECUTIVE SYNOPSIS FOR
POSTING BY NHLBI, WHICH WILL BE
REALLY IMPORTANT FOR
HIGHLIGHTING THE KEY OVERARCHING
CONCLUSIONS FROM THE DISCUSSION.
BUT IN ADDITION, IN THE KIND OF
TRADITION OF THE LAST WORKSHOP,
I THINK A MAJOR OBJECTIVE WOULD
BE TO HAVE A SIMILAR WHITE PAPER
THAT WAS PUBLISHED BY THE FORMER
WORKING GROUP, I BELIEVE THAT
ONE WENT TO JACK IN 2019, AND I
THINK IT WAS A REALLY HELPFUL
DOCUMENT FOR FOLLOWING UP ON
SOME OF THE RESEARCH
RECOMMENDATIONS OR NEXT STEPS
FUTURE DIRECTIONS THAT WERE
IDENTIFIED BY THAT WORKING
GROUP, AND THAT CERTAINLY IS
SOMETHING THAT WE BELIEVE COULD
BE REALLY VALUABLE WAY TO
SUMMARIZE WHAT WAS DISCUSSED
TODAY AND CAPTURE IT FOR OTHERS
TOO, TO KIND OF CARRY OUT AND
WORK ON A NUMBER OF THE ITEMS.
AND SO OUR HOPE IS TO CONVENE
THE WORKING GROUP TO VERY
QUICKLY PUT TOGETHER A DRAFT, AN
OUTLINE WITH SOME ASSIGNMENTS
THAT WE CAN CIRCULATE TO THE
GROUP AND THEN ESTABLISH A
TIMELINE FOR ACCOMPLISHING THIS
WHITE PAPER DRAFT, AND OBVIOUSLY
IN COORDINATION WITH NHLBI, OUR
THINKING MIGHT BE THAT IT WOULD
BE GREAT IF THIS COULD GET
PUBLISHED IN THREE TO SIX MONTHS
POTENTIALLY.
THAT'S OVERLY AMBITIOUS, BUT
THERE WILL BE ADDITIONAL
CORRESPONDENCE AROUND JUST HOW
TO IMPLEMENT THE NEXT STEPS.
SO STAY TUNED, WE'RE REALLY
EXCITED TO BE WORKING WITH SUCH
A GROUP, AND IT WILL BE A BIG
TASK TO CAPTURE ALL THE IDEAS
AND THOUGHTS BUT CERTAINLY, I
THINK, THAT BACK AND FORTH IN
DISCUSSION WILL REALLY MAKE IT A
REALLY USEFUL DOCUMENT FOR
OTHERS.
SO THANK YOU SO MUCH.