CLINICAL INNOVATORS
per smoker who quit, less than $400 per year of
life saved, and less than $3,000 per life saved, far
less than commonly accepted cost-effectiveness
thresholds. The money spent on this campaign
is equal to the amount of money the tobacco
industry spends on advertising and promotion in
about three days, so we must continue to invest
in hard-hitting media campaigns.
You have spoken about the fact th at better
blood pressure control could save more lives
than any other clinical intervention we have to
offer, though just over half of adults with hypertension have it under control. How have some
communities, such as Minneapolis-St. Paul,
improved control rates to 70%-80%?
About one in three U.S. adults—an estimated
68 million—have high blood pressure, which
increases the risk for heart disease and stroke,
the leading causes of death in the U.S. However,
only about half of all Americans with high blood
pressure have it controlled. But we know there
are communities, health care systems, and health
care providers who are making a difference. They
are showing that control rates of 70% to 80% are
possible.
Minnesota and some of the Kaiser Permanente
systems are great examples of successful strategies to control blood pressure. The rate of blood
pressure control in Minneapolis-St. Paul and
nationally was around 30% in the mid-late 1990s.
However, Minneapolis-St. Paul has since made
much more rapid progress than we have nationally
to improve blood pressure control—the control
rate there is up around 70%. They got there by
addressing multiple drop offs in the blood pressure cascade. They got more people with high
blood pressure onto treatment and improved
control among those treated. If the U.S. had the
same control rates as Minnesota, about 14 million
more Americans would have their blood pressure
controlled, preventing millions of heart attacks
and strokes. Minnesota has done many things that
have contributed to the increase in blood pressure
control—including establishing agreed upon treatment protocols and quality measures, providing
feedback on performance to providers, and reporting performance publicly through Minnesota Community Measurement.
Kaiser Permanente is another health system
that has succeeded in improved blood pressure
control rates. Did they do it the same way?
Kaiser Permanente Northern California made a
number of changes to improve blood pressure
among patients. This included the creation of a
disease registry to identify and track patients with
uncontrolled hypertension and the use of teambased care around the patients. Over the course of
a decade, the organization was able to increase its
hypertension control rate to more than 85% and
was recognized as a 2013 Million Hearts Hypertension Control Champion. Kaiser Permanente
36 CardioSource WorldNews
Southern California improved the hypertension
control rate of all patients while also reducing the
blood pressure control rate gap between African
Americans and whites from 6% to 3.8%. They accomplished this through several methods, including the development of a hypertension registry
with treatment and testing reminders, as well as
tapping medical assistants to take walk-in, 10-minute blood pressure checks.
Implementing
systems that are
patient-centered
and reduce
barriers to care
and medication
adherence, and
using team-based
care and innovation
through programs
that extend care
beyond the doctor’s
office can improve
care across patient
populations.
We have learned from these and other top performers that there are common elements of successful programs. These include standardization of
care, patient-centeredness, team-based approaches
to care, rigorous monitoring of outcomes, and
continuous innovation.
Accountability for outcomes has been a topic
of debate. While holding providers accountable will likely lead to improved care, there is
a concern that providers will be incentivized
to take on panels of healthier patients who are
compliant with treatment as opposed to those
who may be less compliant and need the most
care. How can we hold providers accountable
while taking into account the heterogeneity of
patient populations?
Accountability for outcomes is key to improving
patient outcomes. Implementing systems that are
patient-centered and reduce barriers to care and
medication adherence, and using team-based care
and innovation through programs that extend care
beyond the doctor’s office can improve care across
patient populations.
With tuberculosis, we are accountable for
knowing how many patients we have cured. With
HIV, we know that treating to viral load suppression both improves the health of the patient and
dramatically reduces the risk of HIV transmission
to others. With blood pressure control, we need
to see real, rapid improvements in rates of blood
pressure control across the U.S. The rate of blood
pressure control has been increasing gradually
over time, but reaching our Million Hearts goal
of 70% blood pressure control will require much
more rapid progress. Reaching this goal will mean
that at least 10 million more Americans’ blood
pressure will be under control—and we’ll see
fewer heart attacks and strokes.
What advances in public health do you hope to
see in the next decade?
Antibiotic resistance is probably the biggest public
health threat we face today. Without immediate,
decisive action, we risk entering a post-antibiotic
era. The way we practice medicine and treat
patients is at risk. Treatment of cancer, chemotherapy, organ transplant, dialysis—each depends
on our ability to successfully treat infections. We
are looking at the very real possibility that we may
not be able to treat many of our patients. With
some patients and organisms, we are already there.
We can make some immediate advances by
having programs in every community to address this problem. Every hospital needs to have
a stewardship program. Each outbreak needs to
be tracked. It can be done. By implementing core
infections control programs, hospitals in Illinois
were able to cut CRE by half. The best way for
us to win this battle is to work together. It can’t
be done alone. Hospitals, nursing homes, and the
community— each has a role to play.
If fully funded by congress, we would be
able to have programs in all 50 states to address
anti-microbial resistance. This would support
centers of excellence, expand testing, and detect
outbreaks. We think we can prevent half a million
infections, thousands of deaths, and millions of
dollars in medical care s pending. ■
Katlyn Nemani, MD, is a physician
at New York University.
January 2016