Discussion with the New York State Health Foundation 4/17/12

Agenda

Introductions the New York State Health Foundation the Harlem Health Promotion Center the Colin Powell Center for Social Justice the National Black Leadership Council on

AIDS (NBLCA) Racial Disparities in CVD Focus on the Harlem Community Synopsis of the Million Hearts

Campaign Discussion

Magnitude of the problem - nationally

Heart Disease and Strokes are Leading Killers in the U.S.

Cause 1 of every 3 deaths Over 2 million heart attacks and strokes each year

800,000 deaths Leading cause of preventable death in people < 65 $444 B in health care costs, lost productivity

Greatest expression of racial disparities in life expectancy

Age-adjusted death rates for stroke by sex and race/ethnicity, 2007.

Source: NCHS and NHLBI.

©2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010

CVD Leading Cause of Shorter Life Expectancy Among African Americans

Life expectancy loss for blacks, in months

Source: CDC/NCHS, National Vital Statistics System, Mortality, 2007

Every 24 hours… 131 men of color, and 148

women of color will die from cardiovascular disease (heart attacks, strokes, etc.)

American Heart Association, 2008

High Blood Pressure

Plays a significant role in contributing to:

Heart attacks Strokes

CDC. Health, United States, 2008. Hyattsville, MD: National Center for Health Statistics; 2008.

High Blood PressureOne in three adults…Or, about 75 million people, above the age of 20, in the United States have high blood pressure

High Blood Pressure and People of Color

31% of all Americans affected29% of Hispanics

40% of African-AmericansAmong African Americans,

hypertension (HTN) develops earlier in life and tends to be more severe, therefore increasing the risk for HTN-related complications

Age-Adjusted Prevalence Trends for HBP in Adults, ≥20 years of age by race/ethnicity, sex and survey (NHANES:1988-1994, 1999-2004 and 2005-2008).

Source: NCHS and NHLBI. NH indicates non-Hispanic.

©2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010

High Blood Pressure and People of Color In 2004, the mortality

rates from HTN related conditions were disproportionate: 14.9% for white males, compared to 49.7% for black males

14.5% for white females, compared to 40.8% for black females.

(Heart Disease and Stroke Statistics -- 2006 Update).

Community level perspective

High BP in Harlem

Compared to national prevalence rates, Harlem residents had higher rates of elevated BP (41%)

(Rubin M, Chukwu E, Pultre F, Manheimer E, College G. Screening and referral for cardiovascular risk factors in Harlem, New York. Paper presented at the American Public Health Association; 2004.

HARLEM

UPPER EAST SIDE

Hospitalizations due to Hypertensive related diseases

Emotional Costs???

So, what do we do?

Start with the end in mind…

Vickie Powell Harlem resident Worships at

Abyssinian Baptist Church

Told by physician that she had high blood pressure…

What we eat

What we drink

What, how much we smoke

How we exercise

How we deal with stress

Play significant roles in the development of disease.

Management

Lifestyle modification Pre-hypertension, Stage 1 and Stage 2

hypertension Weight loss (5-20 mmHg SBP reduction for every 20

lbs lost) Reduce Sodium (8-14mmHG SBP reduction) Increase Physical activity (4-9 mmHG SBP reduction) Reduce Alcohol consumption (2-4 mmHG SBP

reduction) Reduce Smoking (10-20 mmHG SBP reduction)

Medications Stage 1 and Stage 2 hypertension

An “activated” Vickie…

Changed her diet Began exercising

regularly Embraced yoga

and meditation Lost 20 lbs Normalized her

blood pressure…without medication

Unfortunately…

Vickie is unique

So, how are we doing?

Of those people with high blood pressure, 77.6 percent were aware of their condition.

AHA.org

But… More than one in five (22.4%) people with

high blood pressure don't know that they have it.2

• Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart Disease and Stroke Statistics—2010 Update. A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2010;121:e1-e170.

So, how are we doing?

About 80% of those with high blood pressure, were aware, were in treatment

48% had their high blood pressure controlled

But… 52% were not controlled

AHA.org

I have high blood pressure, but no one has every told me what high blood pressure is and how it can affect my life. What are the target numbers?

I already know I have high bloodpressure, it runs in my family. I know it can cause a stroke, but what else? How can I lower it?

There are so many things I don’t knowabout high blood pressure. I don’t knowwhere to turn to. My doctor doesn’t have time to teach me, and none of my friendscan help.

Doctor-Patient Communication

The average visit length was 15 minutes.

The average patient who came with one or more concerns used only 32 seconds to complete their review of concerns.

In 24.6% of visits, the physician did not ask the patient about his/her concerns.

Marvel, MK, Epstein, RM, Flowers, K & Beckman, HB (1999) Soliciting the patient’s agenda: have we improved? JAMA, 281(3):283-287

Lifestyle Modification

Providers have minimal time to provide counseling and education with clients

May not feel comfortable in providing information and support

Lack of resources for other types of clinic-based supports

Need for adjunctive measures

Response

Preventing 1 million heart attacks and strokes in 5 years

Key Components of Million Hearts

Community Prevention Reduce the number of people who

need treatment

Clinical Prevention Optimize care for those who do

Status of the ABCS

Aspirin People at increased risk of cardiovascular disease who are taking aspirin

47%

Blood pressure

People with hypertension who have adequately controlled blood pressure

46%

Cholesterol

People with high cholesterol who have adequately controlled hyperlipidemia

33%

Smoking People trying to quit smoking who get help

23%

Source: MMWR: Million Hearts: Strategies to Reduce the Prevalence of Leading Cardiovascular Disease Risk Factors --- United States, 2011, Early Release, Vol. 60

Million Hearts: Getting to the Goal

Population metric Baseline2017

1

Clinical target2

Aspirin for those at high risk ~50% 65% ~70% Blood pressure control ~50% 65% ~70% Cholesterol control ~33% 65% ~70% Smoking prevalence ~20% 17% ─

Average sodium intake 3.5g/day20%

↓─

Average artificial trans fat intake

1% of calories/day

50% ↓

─

1 Population-wide indicators2 Clinical systems

Multi-system Approach

Community PreventionReducing the Number who Need Treatment Strengthen tobacco control and reduce smoking

Improve nutrition

Clinical Prevention

Uniform, simplified set of ABCS measures Getting the ABCS into federal and state

programs EHR meaningful use criteria

Point of care clinical decision support Systematic assessment of cardiac risk Use of recall reminders and order sets Monitoring of medication adherence

Insurers Measure and incentivise performance on the ABCS;

collect and share data for quality improvement; empower consumers

Medical System Messages

Individuals Know your numbers—and goals Take aspirin, if advised Get aggressive with BP and Cholesterol Cut sodium and trans-fats If you smoke, quit

Getting the messages out

Mobilize the best change agents Pharmacists, health coaches, lay workers, nurses,

community orgs, others

Community Messages

Retailers and Employers Offer blood pressure monitoring and educational

resources; focus on improving ABCS care in retail and worksite clinics

Government Support community and systems transformation to reduce

tobacco use and improve nutrition, including smoke-free policies and food procurement standards; provide data for action; expand coverage for the uninsured

Foundations Support consumer and provider outreach and activation

Advocacy groups Monitor and demand progress toward goal and promote

actions that prevent heart attacks and strokes

Million Hearts Outcomes

10M more people with HBP controlled 20M more people with high cholesterol controlled

4M fewer people will smoke 20% drop in average sodium intake 50% drop in average trans fat intake

Locally

How do we start in Harlem?

I was scared to have my blood pressure taken… But, my friends convinced me to have it taken. Now I have work to do in order to keep it normal.

How do we promote awareness and create opportunities for success?

Community Outreach

Community Outreach

Community Outreach

Community-based Initiatives Involving the faith community Experiences of NYSHF with Diabetes

Program

Community-based Initiatives Involving health ministries, lay health

workers Involving nursing students Involving College students

Faith-based initiative

Next Steps…