public health institute dialogue4health …...rough draft transcript not a verbatim record 1 monday,...

ROUGH DRAFT TRANSCRIPT

NOT A VERBATIM RECORD

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Monday, February 23, 2015

1:00 p.m. – 2:31 p.m. EST

PUBLIC HEALTH INSTITUTE DIALOGUE4HEALTH WEB FORUM

“HYPERTENSION PREVENTION, TREATMENT, AND CONTROL: SUCCESSFUL GLOBAL STRATEGIES”

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Communication Access Realtime Translation (CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings. This transcript is being provided in rough-draft format.

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>> Star Tiffany: Hello and welcome to "Hypertension Prevention, Treatment, and Control: Successful Global Strategies." My name is Star Tiffany and I will be running today's Web Forum along with my colleagues Joanna Hathaway, Valerie Steinmetz, and Holly Calhoun. Closed captioning will be available throughout today's presentation in English and in Spanish. Christine with Home Team Captions will be providing realtime captioning in English. And I'm going to explain those instructions first. The English closed captioning text will be available in the Media Viewer panel. The Media Viewer panel can be accessed by clicking on an icon that looks like a small circle with a film strip running through it. On a PC this can be found in the top right-hand corner of your screen. And on a MAC it should be located in the bottom right-hand corner of your screen. In the Media Viewer window on the bottom right-hand corner you'll see the Show/High Header Text. Click on that and you will be able to see more of that live captioning. During the Web Forum another window may cause the Media Viewer panel to collapse. Don't worry, though, you can always re-open the window by clicking on the icon that looks like a small circle with a film strip running through it. I am going to send the Spanish link out through chat. Art with Home Team Captions will be providing realtime captioning in Spanish. In order to access the Spanish captioning, open a new web browser window and add the link that is on screen and in your chat now. Once you connect to the captioning, you can select text formatting with the options in the top right of the window. You will need to have both the WebEx meeting center and your WebEx browser open. It might be easiest to re-size the panel so you can see both panels at once as shown on screen now. Lynn, please go ahead. >> Dr. Lynn Silver: [Speaking Spanish] >> Star Tiffany: If you experience technical difficulties during the WebEx session, please dial 1-866-229-3239 for assistance. Please take a moment to write that number down in case you need it for future reference. The audio portion of the Web Forum can be heard through your computer speakers or a headset plugged into your computer. If at any time you are having technical difficulties regarding audio, please send a question in the Q&A panel and Joanna or I will provide the teleconference information to you, or Holly. Once the Web Forum ends today a survey evaluation will open in a new window. Please take a moment to complete the evaluation as we need your feedback to improve our web forums. The recording and presentation slides will be posted on our website at www.dialogue4health.org. We would like to invite you to connect to us via Twitter and Facebook. Both of those are @dialogue4health. We are encouraging you to ask questions throughout today's presentation. To do so, click the question mark icon. We will be addressing those questions during the discussion period. We will be using the polling feature to get your feedback. Holly, can you please open the first poll? Thank you. The first poll should be on screen now for you. That's over in the bottom right-hand corner. I am attending this Web Forum individually in a group of two to five people, in a group of six to 10 people, in a group of more than 10 people. Once you've chosen your answer, please click submit. Once you're done taking the poll and you would like to bring the Media



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Viewer panel back up, just go ahead and click on that circle with the film strip running through it and it will bring it back up. It is my pleasure to introduce Dr. Lynn Silver. Lynn silver is a Senior Advisor at the Public Health Institute. She served as Assistant Commissioner of Health in New York City where she led the city's policy efforts to improve the food environment, including banning transfat, reducing salt and sodium consumption, and calorie labeling of fast foods as well as to improve care for diabetes and hypertension. She currently works on prevention and treatment of noncommunicable disease in the US and globally, including collaboration with the Pan American Health Organization under regulation of NCD risk factors and with the CDC on hypertension control. Lynn, please go ahead. >> Dr. Lynn Silver: Thank you. I have the pleasure and the honor of introducing our host for this webinar this morning -- first I'd like to welcome all of our presenters, Dr. Thomas Frieden, Dr. Pragna Patel, Dr. Norm Campbell, and Dr. Marc Jaffe. We'll be doing more detailed bios in a little while. Most importantly, I'd like to welcome our overall host for this webinar, Dr. Thomas Frieden, the distinguished Director of the Centers for Disease Control and Prevention, will be joining us by video link from Atlanta. You will now see on the screen Dr. Frieden's welcome video to us. You can watch this video now through the WebEx interface by pressing play. You may need to allow buffering time as you would with any online video. You can also watch this video on an external browser now or at any time by following the on-screen link. This video will take a little over four minutes. >> Dr. Thomas Frieden: I am delighted to introduce this new webinar series “Global Hypertension” and the steps we can take to combat it. Cardiovascular disease is the number one cause of death in the world today and high blood pressure is the leading risk factor for cardiovascular disease. Hypertension kills an estimated 9.4 million people annually worldwide, about as many as from all infectious diseases combined. About a billion people worldwide have high blood pressure but less than one in seven of them have the condition adequately controlled. Despite the heavy burden of illness, disability, and death from high blood pressure, many countries have been slow to responsibility to this urgent problem. Global progress improving treatment for tuberculosis and HIV shows that rapid improvement in treating and controlling for chronic condition such as hypertension is possible. The question isn't whether we should scale up treatment for high blood pressure but rather how it should be done and how fast we can get it done. To control hypertension we'll need to take steps to reduce the prevalence of the condition, for example, by reducing sodium intake and increasing physical activity. But even if we're successful with these efforts, we need enlarge-scaled treatment program. In fact, treatment of high blood pressure is for most countries the single most effective intervention to save lives that are being lost from preventable causes today. Diagnosis is important but it's only the beginning of a journey. We need to hold ourselves accountable for each and every patient treated. We also need to ensure that we apply the lessons of chronic disease care. First, agree on standard regimens; not just generic but specific to the drugs and dosages to be used. Second, use every member of the healthcare team: primary care workers, community



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volunteers, pharmacists, nurses and others, task sharing is critical to progress. Third, reduce barriers for patients. Eliminate cost barriers with effective low-cost medications, give medicines only once a day, combine medicines when possible, make medical refill and low-burden requirement. And fourth, ensure accountability. Track the progress and control of every single patient diagnosed. We don't expect to get to 100% control but starting, we are sure we can make dramatic improvements. And in doing so we'll prevent heart attacks, strokes, and many other serious health problems. We'll also establish a pathway forward for the treatment of other chronic conditions. CDC in collaboration has launched the Global Standardized Hypertension Treatment Project a framework to manage and control blood pressure. Effective implementation of this framework can help countries meet the global target of reducing raised blood pressure by 25% by 2025. It can prevent 10 million cardiovascular events worldwide over the next 10 years. I hope you'll be inspired to create standard protocols at hypertension registries to ensure the successful use and widespread adoption of hypertension treatment and the use of an information system to monitor patients and outcomes, to improve hypertension control wherever you work. In hypertension control, we need to see the urgency behind the numbers. An elevated blood pressure is a ticking time bomb. It's a risk of a heart attack, a stroke, a death that could be prevented. Thank you for the work you do to bring blood pressure down and improve health in your country. >> Dr. Lynn Silver: Thank you, Dr. Frieden, for the inspiring introduction. I now have the pleasure of introducing our next speaker who is Dr. Pragna Patel, Senior Medical Epidemiologist at the Center for Global Health, of the United States Centers for Disease Control and Prevention. After distinguished years working on HIV she is turning her sights towards noncommunicable disease and Dr. Patel is the engine behind the Global Standardized Hypertension Treatment Project. We're honored to have you with us here today. Dr. Patel? >> Dr. Pragna Patel: Thank you, Lynn. Good morning. It's my pleasure to present to you the Global Standardized Hypertension Treatment Project today. Imagine. Imagine a world where few heart attacks occur, where emergency rooms instead of looking like this, look like this. Imagine a world where few strokes occur and their related disabilities are rare, where grandparents can run with their grandchildren. These are actually realistic and attainable goals. They are not pipedreams. In May 2013 the WHO Global Monitoring Framework identified nine targets for NCD control by 2025. One of these targets was the 25% reduction in blood pressure. The prevalence of hypertension is quite high. A billion people worldwide have it and nine million preventable deaths are attributable to the disease every year. This is not a disease of wealthy countries. It's actually higher in prevalence in low- and middle-income countries and it's the leading remedial risk factor for cardiovascular disease, which is the largest cause of death worldwide. In low- and middle-income countries today eight of 10 deaths are attributable to cardiovascular disease. Hypertension is simply too expensive to ignore. It can cripple our healthcare systems and our families and can lead to loss of productivity in our economy.



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In 2001 hypertension costs $370 billion U.S., that's 10% of annual healthcare expenditures. And if left untreated over the next decade, this number could rise to $3.6 trillion. We're now seeing countries employing three steps to manage hypertension. First is to use strong public health, primary prevention strategies like salt reduction. The second is to improve healthcare and self-management through early detection, timely treatments and empowering patients to engage in their own care. The third is to improve monitoring not only at the patient level but at the population level. Here are some primary prevention strategies that are endorsed by the WHO because they're evidence-based and cost effective. They include reducing salt use, reducing tobacco use, increasing physical activity, and reducing alcohol use. Employing all of these strategies could reduce by 60% cardiovascular disease events in hypertension patients. What we fail to prevent, we must treat. Even with optimum prevention there will always be hypertension. Unfortunately although we know how to diagnose and treat this disease, we're not doing that well. Of the one billion people worldwide that have hypertension, almost half are unaware that they have the disease. And of those that do have the disease, very few are treated. Only one in seven have it under control. And that's the subject of this webinar today. We're going to talk about why this is and what we can do about it. So here I've listed a number of barriers to blood pressure control as a patient, healthcare provider, and health systems level. To give you some examples: patients have limited access to treatment and poor adherence to treatment; healthcare providers are often reluctant to treat hypertension, what we call therapeutic inertia, and sometimes they don't adhere to medication guidelines; third, health issues related to the supply, distribution, and costs of medications. These are all barriers that we can improve upon. So building on lessons learned from the framework, we know that employing the structured approach of high-quality, standardized care and combining that with monitoring targets and indicators to define further action can reduce the burden of disease. With inspiration from our infectious disease model, namely tuberculosis and HIV management worldwide, we developed a Global Standardized Hypertension Treatment Project. And this project complements the U.S. Million Hearts Initiative, a more comprehensive strategy for blood pressure control. We know that effective treatment has potential to significantly improve global population health. And, therefore, we developed a strategy and framework for standardizing the pharmacologic treatment of hypertension that is both feasible and flexible and has worldwide applicability. This approach acknowledges and supports the use of existing evidence-based guidelines. This began as a regional collaboration in the Americas led by the Center for Disease Control and the Pan American Health Organization and supported by numerous key stakeholders and organizations in the region. CDC is also leveraging HIV care delivery systems in countries funded by the President's Emergency Program For AIDS Relief otherwise known as PEPFAR. The framework includes three main components. The first is to identify a core set of medications. The second is to make those medications more widely available. And the third is to improve upon certain key care delivery areas to improve hypertension management in our clinical infrastructure. Here I have a list of the core set of medications that were identified for use in the Latin American and Caribbean Region. As you can see, we identified primary medications as well as alternative backup medications. And we included fixed dose combination pills which



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are known to be valuable in patients who require more than one drug for their hypertension control. The key is to make these drugs more widely available. And the PAHO Strategic Fund does just this. They procure high-quality medications at a low cost. Countries that are member states have the option to use this mechanism for medication purchase. The PAHO Strategic Fund recently reviewed and updated their medicine list and now includes five of our core primary medications and three of our core backup medications. Here is the list of key elements of care delivery that we would like you to focus on in terms of improving hypertension management in your clinics. I'll point out the same four that Dr. Frieden just pointed out. It's important to employ standardized treatment regimens, to use registries for cohort monitoring and accountability, to create team-based care in our clinics, and to empower patients to be involved in their own care. There is something that's even more essential when you embark on this journey and that is to identify strong leaders and champions. These leaders can help create the paradigm shift that is necessary for you to employ these tools within your clinical infrastructure. They are people who are highly regarded and highly respected and have credibility. And we're hoping that there's a pool of leaders out there today listening to this webinar that will help us to effectively treat hypertension worldwide. In addition, CDC developed a clinical toolkit. This toolkit contains resources for healthcare providers and administrators that may be interested in incorporating some of these components into their own clinical infrastructure. It's a dynamic toolkit. We welcome your suggestions for resources that we should include. And it's available at our CDC website. The link is on the slide below. Our vision is for hypertension control globally. And this is a wonderful opportunity for the Latin American and Caribbean Region to lead the way but we're already interested in expansion. And as I mentioned earlier, CDC is leveraging infrastructure in sub-Sahara Africa. We hope the models created by our pilot programs in Barbados will be scalable and replicable and applied to other disease conditions such as diabetes. This is a tremendous task to control hypertension globally. We're suggesting that we move forward together. We need strong partnership between ministries of health, CDC, WHO, other government agencies, and active partnerships with relevant professional associations and NGOs. The interests and commitment that we create will help us use our resources in an efficient way to effectively control blood pressure worldwide. So in sum, we've presented some of the strategies that we know are successful. We have the tools. We have the knowledge and the people. So I encourage you to join us to achieve these goals in hypertension control throughout the world. Now we'll hear about two examples of highly effective hypertension treatment programs in two countries in North America. Thank you. >> Dr. Lynn Silver: Thank you, Dr. Patel, for laying out the vision and the key steps that need to be taken with so much eloquence. I'd like to mention before I introduce the next speaker that we had over 580 people registered for this event from 29 countries in a wide variety of roles and with a whole lot of people saying they were interested in trying to scale up hypertension controls. So we do hope that the people on the call will be some of the leaders and partners that Dr. Patel was referring to.



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I'm going to take a moment to just introduce you to our second poll. We'd like to ask the participants to check off what they perceive to be the biggest obstacle in their settings to ensuring that high-quality hypertension treatment reaches everyone. Please select your top three answers. And you can check in the box on the lower right-hand side of your WebEx screen. With that, I'd like to move on to introducing our next speaker. This is the part of the webinar that's going to talk about two fantastic success stories, two places that have done an amazing job in making progress on hypertension control. Our first example is coming from Dr. Marc Jaffe the Clinical Leader at Kaiser Permanente Northern California Cardiovascular Risk Reduction Program. He's the Chief of Endocrinology at the San Francisco Medical Center. He served as Chief of Endocrinology and the Clinical Leader for the Kaiser national hypertension team. His clinical research is in the area of delivery of population-based cardiovascular care. I would just tell a short story, which is when I was working in Northern California, Dr. Minkoff, one of Kaiser's amazing physicians on the ground, told me that their emergency room had gone for weeks and weeks without seeing a heart attack. And this was the kind of example that moved me as the child of someone who died at age 47 from a heart attack to saying Kaiser is on to something. They're doing something right. This is an example that we need to learn about and spread. With that, I'd like to introduce Dr. Marc Jaffe, our next speaker, to tell us about the Kaiser Permanente experience in hypertension control. >> Dr. Marc Jaffe: Thank you, Dr. Silver. It is an honor to be here today. I'm just so excited to share my passion for hypertension control. I'm from Northern California, not too far from our webinar here. I work for Kaiser Permanente. I have nothing to disclose. We take care of more than 2.3 adult members. We provide comprehensive inpatient and outpatient services and over 2,100 and 45 medical centers. And you have more than 7,000 physicians and thousands of other care providers helping us achieve our mission of caring for our patients. Let's just set a framework here. How do you even get started about controlling hypertension? Well, there's four simple elements. Maybe not so simple but there's four elements. You've got to create your team. You've got to identify your population. You've got to agree on some kind of treatment. And then once you've done all of that, you've got to check in and see how you're doing. So the next 10 or 15 minutes I'm going to go over in detail how we do this in Northern California. Let's talk about the hypertension teams. We use three teams. There's hundreds of teams but I think they can be categorized into three basic levels. At the global level, at the biggest level, for our 2.3 million members, we have a central oversight team. And maybe this would be applicable to you in your care setting. And at this level we have some physician leaders, some very sophisticated analytic reporting structures, and we have some program managers to help us keep on track with our timelines and such. We generate reports on our progress of all the medical centers. We review quality performance. And we check in on who is doing well, who could use some help. We organize a lot of training activities. So we invite people together either in person or on webinars such as we're doing today to share and to meet and to learn. And we develop some very standardized, deliberately targeted support tools such as handouts or treatment care pathways. And then we keep surveying the landscape and we see where the successful strategy as rise so we can identify those and share those.



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Kind of in the middle we have our local hypertension teams. What these teams do, these might have a champion who, very important, generally a primary care doctor as well as a clinic administrator who work over smaller groups of doctors helping those teams get organized in delivered care. They might distribute local reports about performance. They might review in our own personal quality performance. They might attend the regional trainings and the webinars such as this one. And they look to their peers for successful strategies and import them into the local clinics. And then we've got the people who provide the care, the point of service, the face-to-face care who interact with our patients. Those are generally doctors but that's not the only person. Many other important parts of the team, nurses, nurse practitioners, pharmacists, dietitians, medical assistants and many, many others. These individuals decide providing for the day-to-day care of the patient, review their own performance, performance of their clinic, try to garner resources to make their day-to-day practice most effective, and they, again, look to their colleagues and peers and try to import successful strategies. So we've kind of got it set up into three different levels. One thing I wanted to highlight here, take a step sideways, is to talk about a practice we find really successful and that's a medical assistant blood pressure check. We get a lot of questions about this. We do this because meeting every time with the physician is neither cost effective nor convenient for blood pressure medication adjustment and assessment. So by having people come into the doctor's office and meet with a medical assistant it enables a-synchronous communication. That means when I'm here today one of my patients might be back at my office with my medical assistant getting the blood pressure checked. And one of my colleagues might cover for me or I might get an e-mail or a phone message. I think my phone just rang so maybe that was someone checking, telling me about one of my patient's blood pressures or I can view it on the computer tonight. But it's very convenient for the patient. Also, we believe this reduces the white coat effect because it's a convenient way. We believe it increases a consistency because these medical assistants are trained. The setting is appropriate. We don't charge co-pay for this in most cases. And it's more convenient because medical assistants tend to run more on schedule than the doctors run. It enabled repatriation of primary care which means someone seeing a specialty clinic and the blood pressure is high, then we can have the specialty clinic refer the patient back to my medical clinic and have the blood pressure checked by the medical assistants who are really quite fond of this and found it would be very, very useful. Let me talk about something else super important, a registry. A registry is important because once you figure out who it is that's going to help manage hypertension, you get your team assembled, then you have to figure out who you want to target for the delivery of hypertension services. So we use basically everything we can find to generate this list. The master list. We use outpatient codes, data from the pharmacy, records from hospitalizations. And then when we get all of the stuff assembled, we chart review it to make sure we've got appropriate sensitivity and specificity. We tend to use as inclusion in the registry but NCQA uses, HEDIS use, what we -- a blood pressure might be elevated but we actually use the diagnosis of hypertension to establish our registry. The cool thing about the registry, the part about it, is you can make it as big or as little as you like. Once you have this master spreadsheet, you can include, of course, the most



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recent blood pressure, name, date, address, and other things such as what medications the patient happens to be taken, when the last refill was, when the next appointment is, whether there's the presence of indicts beets or cardiovascular disease, renal disease, whether an appropriate lab test has been ordered on and on and on. The number of variables that we have started as very few. Our approach is 200. So you can see the registry gives you the opportunity to customize and ask questions and to sort this, to prioritize. So we find this very, very useful in us organizing ourselves around our treatment programs. And we find that the most effective intervention to improve blood pressure control in the primary care system is to be organized rather than focus primarily on what the doctor and the clinician do together at the point of care. For people -- people ask what the criteria are for our registry. We just imported these from NCQA, HEDIS. You could use any other set of definitions if you wanted to. This seems to work for us. This has been used in larger organizations as well. So we use two outpatient diagnosis of hypertension. We use one outpatient diagnosis or hospitalization with a diagnosis or we use one visit in primary care or -- and a prescription for hypertension medications, or one primary care visit and a stroke-related hospitalization or coronary disease or heart failure or diabetes. You can see there's lots of different ways to get into the registry. Now that we've got our team assembled and we figured out who it is we're going to address, what we'd like to do now is figure out what the heck we're supposed to be doing to help control hypertension. I think getting your team and getting the list of patients isn't sufficient. You have to figure out what it is you're going to do. So we have come up an evidence-based guideline. You can create your own, review the evidence yourselves, take a look to many of the evidence-based guidelines out there. Once you do that, then we encourage our clinicians to follow this algorithm because we develop an algorithm that's based on the most recent evidence. Once we come up with a treatment plan, we share it in every way possible. If I could put more little bubbles on this slide, I would. If you could think of another one, let me know because we give out printed documents, we send out e-mail, use clinician tools have video conferences, we have lectures, we partner with the pharmacy, and we embed the treatment protocols as much as we can into our day-to-day operations in terms of helping the clinicians do what's right for the patient, also to make a little bit easier by having these sorts of treatment suggestions embedded into our electronic medical record. So the health system-wide adoption, evaluation and distribution of evidence-based practice guideline has timely incorporation of new treatment options, introduces the new and emphasizes the existing. Beta blockers. A lot of people have questions about what's the role of beta blockers. I would say for those of you who have been in this hypertension business for a while, I've been doing it for about 20 years now, in the old days beta blockers and diuretics were kind of tie for first-line treatment. At least back in [Indiscernible]. Over the years we're starting to see the role of beta blockers becoming less and less important. I'm not saying unimportant. So this is reflected in our practice guidelines where you can see beta blockers being highly recommended, up front in our treatment algorithms. Over the years they've been relegated to a secondary, tertiary role. This is an example of our treatment care pathway. There's a link on the bottom of the slides where you can go. It's kpcmi.org/how-we-work/hypertension-control. It's a mouthful but



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it is out there on the web. I just point out that we're very deliberate in how we selected this treatment protocol. You can see that we like to start with a fixed-dose combination of ace inhibitor and diuretic. For women who might get pregnant or potentially fertile, of course, we do not recommend an ace inhibitor as a first-line therapy so a diuretic alone. Another subtlety is that we recommend that the dose be a certain dose, not just any dose. And then the pill can be given as a half tablet. If that doesn't work, as a whole tablet. If that doesn't work, two tablets. And that pace, that half, one, two, is also used for our second, amlodipine, at 5 milligrams. We say if the first split dose combination doesn't work then add amlodipine half a tab a day, one, two. There's a certain pace there. And then the fourth drug, third pill, spironolactone which more and more experts are recommending as a very effective drug to use for resistant hypertension. So which treatment protocol is best? Well, that's a loaded question. I refer you to some of the work that Dr. Patel mentioned earlier from the GSTP from March 2013, standardized protocol-driven care facilitated through the use of single hypertension treatment guideline is essential. Within a single country, endorsed by key stakeholders, nationally relevant evidence-based, clear, simple, implementable should be used. And core medications should be integrated into guidelines. So you could say you didn't really answer the question what protocol is best. But I would have to say, you know, any protocol which uses the rational selection of affordable, effective, and available drugs is probably going to be excellent for you. So, does this work? Well, what we can see, in Kaiser Permanente Northern California, the percentage of drugs that were prescribed went up a little bit. But more importantly the number of ace inhibitors prescribed as a single dose combination therapy as an ace inhibitor with a thiazide diuretic increased from 2001 to 2012 representing about 30% of our prescriptions for ace inhibitors written as ace inhibitors with a diuretic.

You can see that in 2001 and 2002 we actually wrote very, very few prescriptions. A little funny side story. When we published our -- this paper in JAMA a few years ago, I got a frantic call from the -- e-mail from the editors a few days before it was published because they wanted to make sure it wasn't a typo because we were prescribing fewer than 100 pills a month in our region back in 2001 and 2002, yet by 2011 and what we published, we were prescribing about 25,000 pills per month of the single-dose combination therapy. I had to say, yes, that's true. It was really hardly ever prescribed 10, 15 years ago and now it's frequently prescribed. So I think that's a key. We find that the single-dose combination theory can be given once daily, two pills -- two drugs in one pill, and it's affordable because it's available as a generic and it's a very effective for most patients. We can look at our control rates and our control rate was about 44% hypertension control in 2001 and now we're about 90% hypertension control rate. You can see in the blue line that Kaiser Permanente Northern California has had a steady upward trend. We used to be below average. And now we're above average compared to our state and our national counterparts. We think the program that we implemented had a lot of influence on our hypertension control rates. Other than hypertension control rates, what about heart disease and stroke? Here's a slide from an abstract we presented not too long ago. We have a 30% reduction. Lastly, we talk about heart attacks and strokes. We can see that heart attacks rates are falling in Northern California even in an era when we're starting to be able to identify heart attacks more readily using sensitive cardiac enzyme markers. So in that era, when you would



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expect heart attacks -- the detection to increase, we witnessed an overall decrease in heart attacks, especially a decrease in ST segment elevation heart attacks, the worst kind. I have some references in summary. There are four very important things we found were really useful for our hypertension control efforts: one is identify your team; two, get ahold of and make a registry a list of patients; three, figure out what you're going to do with the registry which is design an evidence-based clear, simple care path; and, four, monitor and track your progress. Thank you very much. >> Dr. Lynn Silver: Thank you so much, Dr. Jaffe, for a very eloquent laying out of an incredible success story, 90% hypertension control which is really an exceptional level of hypertension control when we look around the world. So I think there's tremendous amount to be learned from that. Just very briefly, let me summarize the results of the poll that many of you participated in. The results were very interesting. The top obstacle that people identified was patient disinterest and non-adherence which I think points clearly to the need for strategies to look at patient engagement in the process of treatment of hypertension which we'll be discussing further in the webinar. Second, a third of penalty identified lack of resources for lifestyle change support as a major obstacle. Third was the general lack of access to healthcare. And fourth was the lack of a team approach and really integrating the team to provide good hypertension care. Before we move on to the next speaker I'd like to just introduce the next poll which is asking you what types of supports or tools you would find most useful to help you scale up improved hypertension treatment in your community. Please select up to your top three answers. And the options are in the box at the right. They include information technology for registries; B, education materials for clinicians; C, education materials for patients; D, training videos on how to measure blood pressure correctly; E, guidelines for treatments and diagnosis; F, low-cost medication procurement systems; G, academic training programs; H, guidance on acceptable blood pressure measurement equipment; I, guidance on program management. So you can click the boxes in the right-hand panel.

Our next speaker is Dr. Normal Campbell, a General Internist and Professor of Medicine at the University of Calgary and the President of the World Hypertension League as well as a Professor of Medicine in Community Health Sciences, Physiology and Pharmacology at the O'Brien Institute for Public Health. He was also really renowned for being the leader of the Canadian Hypertension Education Program which was a nonprofit created in Canada and that coordinated between government, academia, and civil society; and like Kaiser's program in California, had some really extraordinary results for improving hypertension control for the Canadian population. And another story for Dr. Campbell, about eight years ago we were starting our work on salt reduction through the National Salt Reduction Initiative in the United States. And many people told us talk to Dr. Campbell. And he was one of the people who we called and provided really expert input on that. PAHO got wind of this knowledge and pulled him into the taskforce which has had extraordinary results and now as many as 18 countries in the Americas are taking concerted action to reduce sodium in their food supply. Dr. Campbell has been a real leader both on the treatment and the primary prevention side for hypertension. We're delighted to have him here with us today. Thank you.



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Dr. Campbell? >> Dr. Norm Campbell: Thank you very much, Lynn. That's a great honor and pleasure to be here with two very inspiring speakers to talk about how to prevent and control hypertension. It is my distinct pleasure to represent the Canadian Hypertension Education Program. I do not have any financial interests in this topic. Today what I'd like to do is talk about the evolution off the Canadian Hypertension Education Program, some of its key outcomes and some of our future plans. For those of you who are interested, we tried to look at what were the key success factors we published in the current opinion in cardiology. Many of the key success factors are applicable to other countries but the whole program itself has a limited applicability as a package but aspects can be taken to other countries. This slide looks at the key hypertension indicators. In 1985 to 1992 there was a national survey that looked at hypertension in Canada. 21% of adult Canadians had hypertension. It was very depressing that only 13% were treated and controlled, 43% were unaware, and about a fifth were treated if not controlled and another fifth were aware they had hypertension but were not treated. By 2006 we had seen a remarkable improvement, over 60% treatment and control. So the last survey, 2012 to 2013, 68% were treated and controlled, 16% were unaware. We know this was mostly younger people and men much more often than women. A small sliver are aware they have hypertension but are not on drug treatment. 12% are on drug treatment but are not controlled. And we know that this is mostly older people, nearly systolic blood pressure and twice as often women as men. In contrast to the marked success in drug treatment, we have data that there's been little change in lifestyles. This is data from a longitudinal survey looking at the lifestyles of Canadians prior to the diagnosis of hypertension and within two years after the diagnosis. We see that there is very minor changes in smoking, body mass index, physical inactivity, or alcohol consumption in excess. The changes that we see are actually secular trends that are also in the general population. This really emphasizes the need for healthy public policy to create healthy environments that allow people to make lifestyle changes. This next slide talks a little bit about our evolution. In the 1990s when we saw our first health survey we became quite depressed and started some strategic planning. We noted at the time that the United States had twice the treatment and control rate as Canada and had a knowledge translation program. So in 2000, an annually updated recommendations process was developed. Uniquely, this was tied to a very extensive knowledge translation program to try to get the recommendations to the people who were managing hypertension. Finally, in 2003, very much like Kaiser, we wanted to know are our programs actually working or not. So an extensive program was launched to examine the outcomes of Canadians with hypertension. This is the original structure of the program in Canada. I had had a Steering Committee. I think this is quite important. It included primary care organizations, family physicians, nurses and pharmacists as well as the hypertension community, our heart and stroke foundation, and the Canadian government. Under that Steering Committee we had a recommendations taskforce, initially numbering 20 but now it's up over 70 people, who annually systematically review the evidence and create hypertension recommendations. That feeds to an implementation taskforce that tries to translate those evidence-based recommendations into useable tools and resources by people in clinical practice. The people



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in the implementation taskforce would be largely primary care and mostly educators. The third component is really the outcomes research taskforce that at one time numbered up to 50 people creating surveillance mechanisms and monitoring and evaluating the process. In 2006, a funded leadership position was created to try to drive the process forward. The Steering Committee is now in something we call a Hypertension Advisory Committee which is 12 of the leading healthcare scientific organizations in Canada. They try to oversee our national strategy and in particular at the current time are interested in helping public policy that might prevent hypertension from actually occurring. So this next slide really reviews our recommendations taskforce. We see about 70 people there. They're structured in about 15 subgroups, do the systematic reviews of the literature. If they believe the literature reflects needs to change recommendations or develop new recommendations, they provide feedback with the evidence to what we call a Central Review Committee. There are scientific methodologists on the committee without conflict of interest to try to ensure that any new or changed recommendations are closely reflected by the evidence. This process is largely designed to convince Canadians and especially our Canadian primary healthcare professionals that the recommendations are the right ones for Canada. And Canada has a strong culture in primary care of being highly focused on evidence. Now, that process creates about 130 recommendations which are far too many to try to implement. So that's distilled down to the five key things that we want healthcare professionals to do. One is to measure the blood pressure in all adults at every appropriate visit. And that can be translated to know the blood pressure of your patients. We try to promote self-efficacy of people with hypertension. And that's largely manifested by trying to promote self-measurement of blood pressure. We like people to have their vascular risk assessed when the diagnosis of hypertension is established and that these other vascular risk factors such as smoke are also managed. We try to promote lifestyle changes in all our hypertensive patients. We've seen that that aspect of our program has not been highly successful. And lastly, we like to promote the treatment to target, recognizing that that requires lifestyle change as well as in general more than one anti-hypertensive drug. So those five things are really the essential steps that a healthcare professional can take to manage blood pressure. This is a very recent diagnostic algorithm. I don't want to go through it in detail but this is just from this year. It promotes two substantial changes. One is to strongly encourage people to move away from oscillation of blood pressure to use of automated techniques that are more accurate. And the second is to incorporate out-of-office blood pressure self-measurement and ambulatory measurement to make a more rapid diagnosis of hypertension. Now, it doesn't really matter what recommendations you have. If you have published them and walk away from them, absolutely nothing will happen. So the most critical step is the implementation process. And this is just an article on the slide that indicates some of the implementation steps that we have taken. One of the most important things is a strong partnership with the healthcare professionals that are actually managing blood pressure. In Canada this is family physicians, nurses, and pharmacists. So they've been heavily engaged in our process. This next slide indicates some of the steps. It's not just the organizations but actually



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individual healthcare professionals need to be engaged. We develop different tools and resources usually numbering around 15 to 20 for healthcare providers to help them manage blood pressure. We develop similar tools and resources for people with hypertension so that Canadians with hypertension will know what their healthcare professional should be or how they should be managed by their healthcare professional. So very parallel recommendations to the public as well as patients. The tools are designed to engage people, change their behaviors. As noted earlier, the Public Health Agency of Canada, Statistics Canada, and provincial governments have been involved in our management program representing really our healthcare system. The different resources, we have up to 40 publications a year in Canada on how to manage hypertension. We try to make it interesting by developing a new theme each year. The theme is usually chosen from management gaps that we see. We've worked with other national organizations to make sure there's no competition, giving mixed messages. And importantly, we have tried to determine who it is that's educating people around hypertension -- are they teaching nurses, pharmacists, family physicians, medical school -- and put them on an essentially electronic list where we can send them our tools and resources to, again, create some uniformity in education. This is the current website where all of our tools and resources can be accessed both for healthcare professionals and for patients. The World Hypertension League that I also represent is developing increased tools and resources as well. We work with healthcare organizations. And we've developed templates for developing strategic plans. We have developed fact sheets and instructions on how to develop a national fact sheet for advocacy purposes. And we also have a really nice, short video on how to properly measure blood pressure with an automated device, whleague.org. I'd like to also encourage everyone to celebrate World Hypertension Day with the League which is May 17, every year, by submitting blood pressure surveys or screenings that you've done. In Canada, we have noticed very marked improvements in awareness of hypertension, a marked increase in treatment. We have seen that if we recommend people not do something, that those practices tend to reduce. We've seen a marked increase in intensity by Kaiser in the use of combination medications, improve blood pressure control and improvements in outcome. This next slide looks at national rates of dying of stroke, heart failure or acute myocardial infarction in Canada. The blue bars in the middle of the slides represent when our program started. What you can see is very marked increases in the rate of decrease of dying of stroke, which is over 50% related to hypertension, dying of heart failure, which is at least 50% related to hypertension, and again an improvement -- or in reduced risk of dying of acute myocardial infarction which is about 25% related to hypertension. This was really parallel by marked increases in prescriptions of anti-hypertensive drugs. We're looking at the rate of anti-hypertensive drugs prescribing when the program started, population of 35 million. We have 80 million prescriptions for anti-hypertensive drugs in Canada. On the other panel we see continued decreases in the rate of dying of cardiovascular disease in Canada. The Canadian Hypertension Education Program was designed as a model that could



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be expanded to other cardiovascular risks or chronic disease. Aspects have been used in other parts of the world; in particular Yaroslavl; Russia, adopted implementation aspects; Iran adopted many of the recommendations aspects off our program. There are lots of new things with new technology: Internet-based education programs so people can learn from a distance, mobile device apps; we have programs where pharmacists are the ones who are screening and managing hypertension which are expanding in different provinces where regulations allow; automated cardiovascular risk assessments, when lipid tests are done, and core curriculum videos so that people can find out what the latest recommendations are from the comfort of their home. I'd like to thank you very much for the ability to outline our program. >> Dr. Lynn Silver: Thank you so much, Dr. Campbell. This was really a wonderful presentation about a program that wasn't in the clinic, wasn't in the hospital; it was in an entire nation of Canada. And that really changed the epidemiology of hypertension and heart disease across a large country. It's so important in that way. I thought the comments about how you build the credibility of a program can bring the buy-in of the health professionals of an entire country, particularly an important lesson. I'd like to briefly summarize the results of the last poll before we move on to the next phase of our webinar. Interestingly, the first choice was educational materials for patients. So I would encourage people watching this webinar go to the sites Dr. Campbell just cited, hypertension, where they have an excellent collection of materials developed for parents through the Canadian Hypertension Education Program. The second one is a little harder to solve but information technology for registries for monitoring hypertension. There are examples in technology out there although often getting that working in your country can be challenging. The third was low-cost medication procurement system. It's something that really needs to be worked out in every country. Fourth was treatment algorithms. Fifth was medication guidelines. And lastly, assistance for guidance in program management. With that, we're going to move on to the next phase of the webinar which is a roundtable with our three speakers. As you know, we have a Q&A feature that was explained earlier. So please feel free to submit questions for the Q&A and we'll be starting with questions that have already been submitted. Again, the members of our roundtable are Dr. Pragna Patel, Dr. Norm Campbell and Dr. Marc Jaffe. I'd like to start with the first question which came from Dr. George Mansur at Mount St. John Medical Centre in Antigua. Hypertension treatment is a modern paradox. We know how to treat it. We have the drugs and they are relatively cheap and we have good healthcare facilities yet hypertension-related morbidity and mortality continue to increase. How can we reverse this? I'd add: What are the essential steps for scaling up highly effective hypertension controls? Dr. Jaffe, would you like to start? >> Dr. Marc Jaffe: Absolutely. That's the same question that we asked ourselves about 15 years ago. It was almost like someone was bitten by a snake and you had the anti-venom and you had to figure out how could I get the antidote into the patient? So at that time we felt -- I don't know if powerless was the word but we felt like we could do a lot more, let's put it that way. The steps I outlined, it may sound boring and repetitive but that's what I think we



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really found most effective. Number one was to get organized, at least with some form of team work to make sure you have the proper people there; not just physicians but administrators, leaders, pharmacists, everybody you can think of who might be important to help develop a structure. Two would be get a registry. Put your arms around who exactly you would need to treat. Even a registry to get started, that's what we did initially. We started ours before we had an electronic medical record. We were able to cobble together a registry on basically paper and pencil. Thirdly, figure out the best evidence that you can use and whether you do it yourself like they do in Canada or whether you borrow a treatment algorithm or evidence from one of the many excellent guidelines that are available. I think it's important to get something to be your guide. And then fourth, probably the way to go from adequate to excellent is to continuously monitor your progress so you can see how you're doing. Look at yourself in the mirror, modify things as needed. And share both your successes and places where you need to improve, share those with one another so you can learn from yourselves. I think those four components are what we found useful and I think are likely to be useful or possibly useful in other care environments. >> Dr. Lynn Silver: Thank you. Dr. Campbell? >> Dr. Norm Campbell: The only thing that I would add to that is that -- each location -- is that you need to assess what your local barriers are and then also what you can do feasibly in your locale. Other than that, I think that was a perfect answer. >> Dr. Lynn Silver: I'd like to move on to the next question which came from Dr. Darwin Labarthe at Northeastern University. He asks: What is the experience to date in implementing the Global Standardized Hypertension Treatment Project in Latin America and the Caribbean or other regions if any? Dr. Patel? >> Dr. Pragna Patel: I think -- [Inaudible] providing technical assistance to a handful of countries. We've helped stand up a pilot program in Barbados. We're currently discussing implementation with St. Lucia and Columbia. And in addition, we've stood up a hypertension screening and treatment program in Malawi. But I'd like to point out that we're trying to create synergy with some of our partners. So the Healthy Caribbean Coalition which is led by [Indiscernible], working with local NGOs in four Caribbean countries to implement some of the Global Standardized Hypertension Treatment Projects and components. And in addition Pedro with PAHO, is actively discussing implementation in many Latin Americans -- [Inaudible] these include Ecuador, Chile, Mexico, Costa Rica, Brazil just to name a few. So we're hoping for a very wide reach. >> Dr. Lynn Silver: Thank you, Dr. Patel. Our next question is: What would you consider to be the most important characteristics of a hypertension treatment algorithm? Dr. Jaffe? >> Dr. Marc Jaffe: Thank you. I think the most important aspect of a hypertension algorithm is to have an algorithm. I mean, when you go from chaos to order or choice to direction, I think you really -- a lot of good things happen. A lot of downstream consequences can occur. If the first step on your algorithm is pick one of these 11 drugs, it's really going to be quite difficult to



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develop a care protocol to be able to be aligned, to be able to measure anything, frankly. So I think the key is to simplify an algorithm. I think that's way more important than whether or not you're going to put this drug ahead of that drug or that drug ahead of this drug or you can't get this drug here or that drug there. I think actually having an algorithm which is simple, which can be applied to 80% of your patients, that is logical and that, of course, uses drugs that are affordable, effective, well tolerated and available. I just point out as an aside that in a wealthy care environment like Kaiser Permanente, we use almost exclusively. And the vast majority of our medications are generically available, well-proven medication that have been around for a long time. So I really don't think it's necessary to use the latest and greatest. I think the evidence supports using lots of medications which are available and are quite affordable for our members. It allows us an opportunity to spend those healthcare resources on other important exercises which will improve the health of our members. >> Dr. Lynn Silver: Dr. Campbell? >> Dr. Norm Campbell: I think it's important to note when we scam randomized control trials they have an algorithm or protocol-driven care. Some more recent, they look at algorithm-based with a nurse or pharmacist versus usual care. In every circumstance that I'm aware of the algorithm care is superior to the usual care. I think it's important to note that the way physicians are trained, we're trained to treat everyone individually and not use algorithms yet nurses and pharmacists, their training is often based in an algorithm-based care environment. So I think one of the most important things is task sharing, things like hypertension, best managed buy-in algorithm usually with a nurse or pharmacist. And if patients don't fit the algorithm, then they would go to the physician for that individualized care. I think that would result in a lot of superior outcomes. >> Dr. Lynn Silver: Thank you, Dr. Campbell. Are the algorithms a straitjacket for clinicians or do they have flexibility? How hard do you push these in your clinical setting? Dr. Jaffe? >> Dr. Marc Jaffe: First of all, I agree with Dr. Campbell. An algorithm followed by the appropriate care providers that's licensed in your state, country, or province is terrific. Actually, I see no reason why legislation -- if permitted that it couldn't be done by the patient him or herself. I think it's no mystery that a step-wise approach using a standard set of medications in a logical fashion is superior than anything else you come up. So I'm not surprised with Dr. Campbell's experience. In terms of whether you force people to do it or not, what we have chosen to do in my care setting is make what we believe the right thing to do, make that the easiest thing to do. So what we've done is -- every clinician of course can decide what's appropriate for that patient and the context of the care environment. And, of course, that's expected. But the vast majority of patients can be treated in a similar fashion. So we have our teaching materials, our patient education materials, our handouts, the rest of our programs are really geared around our core set of medications in a certain sequence. And our decision support tools, such that we have, our electronic medical record geared towards the medication that we suggest. So although we don't actively discourage using off-protocol medications, we make it very, very easy and probably the easiest thing to do is to use the medications which we believe are appropriate for the vast majority of the patients with hypertension. >> Dr. Lynn Silver: Thank you.



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We have a question from Dr. Alberto [Indiscernible]. He asks: Should we use global cardiovascular risks in the decision whether or not to initiate anti-hypertensive treatment in grade one hypertension? Dr. Campbell? >> Dr. Norm Campbell: I think that's a difficult question to answer right now given the evidence. However, if you're in a highly resource-constrained environment, those resources should be allocated to those who are at highest risk, who have the greatest advantage from that therapy. I think that's without question -- world hypertension does support a risk-based approach. But there's very few global experiences in how to successfully apply that. So a lot of different protocols are really driven more by the numbers. And that has been demonstrated to have success certainly in Kaiser Permanente in Canada and in some other environments. >> Dr. Lynn Silver: Thank you. The doctor also asked if we should keep beta blockers as first-line drugs in uncomplicated blood pressure which I think Dr. Jaffe spoke briefly to. And I would add: How did we get to core medications for the GSHTP program and could you describe that process briefly? Dr. Patel? >> Dr. Pragna Patel: There were criteria created to help [Inaudible] for the core medication list. Those criteria include efficacy, safety, tolerability, inclusion on the WHO [Inaudible] clinically proven to be [inaudible]. >> Dr. Lynn Silver: Thank you Would you want to add anything on beta blocker, Dr. Campbell? >> Dr. Norm Campbell: I think there are clear indications for beta blockers in people with hypertension, the presence of heart failure, ischemic heart disease and other scenarios. They appear to have similar efficacy but in the older people, they have less efficacy. So they certainly could be avoided in the run-of-the-mill management of hypertension. [No audio] >> Star Tiffany: Dr. Silver? [No audible response.] I am not sure what is going on right now but it sounds like we don’t have the audio in the room where the presenters are. I wonder if the phone is muted. >> Dr. Lynn Silver: Hello? How about now? >> Star Tiffany: We can hear you. >> Dr. Lynn Silver: Can you hear? >> Star Tiffany: It is a little quiet. >> Dr. Lynn Silver: Ok. Thank you. Dr. Jaffe? Is the sound ok? If people are not hearing, please let us know. >> Star Tiffany: Yes. Yes. We can hear you. >> Dr. Lynn Silver: Ok. The next question is Dr. Kenneth Connell at the University of the West Indies in Barbados. Dr. Connell asks: What is the role of industry in making available cheap core drugs as part of the GSHTP model? And I would add: What are the best strategies for assuring people do, indeed, have access to the needed pharmaceutical? Dr. Campbell? >> Dr. Norm Campbell: Sure. Rather than an industry responsibility I view this as mostly a



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governmental responsibility. I think the first step was really the PAHO Strategic Fund agreeing to incorporate these antihypertensive drugs which reduces their costs. Other regions of the world that are on the call could strongly encourage their regional WHO offices to do similar things. Governments can purchase these generic drugs in bulk to make them very affordable. This scenario, one might imagine that a bulk purchase drug might be substantially lower than the cost of nonbulk purchase drugs so that someone might prefer a calcium channel blocker at a quarter of the price or a tenth of the price of one that was not bulk purchased. >> Dr. Lynn Silver: Thank you, Dr. Campbell. I’d like to move on to a question. As a healthcare service, how do you track who you are reaching and controlling or not? As the leader of the Healthy Carribean Coalition puts it: How do you look in the mirror to see how you are doing, to evaluate the effectiveness of your programs, and to provide feedback to providers and facilities? Marc? >> Dr. Marc Jaffe: Of course, there’s no way to know how well you’re doing unless you are performing an ongoing assessment. And I have to confess that we thought we were doing great until we actually got the information. I think Dr. Campbell shared similar experience. I think it’s human nature to take pride in the activities that you are doing and to think that you are doing a good job. After all, we are all trying pretty hard. I don’t think it’s that we weren’t trying hard. It just I don’t think we were organized enough. I can’t emphasize enough the value of developing a metric. And I would also point out that it can even be a lousy metric because having a lousy metric which isn’t perfect is way better than having a perfect metric. And you know what? We’re still working on the perfect metric. If you wait for the perfect metric, you will never get there. So I encourage organizations to, as soon as they can, get some form of metric; whether it’s the blood pressure, systolic and diastolic or just systolic, or the rates of certain blood pressure medicines even if you can only get it for a certain subset. Get something which you can track and monitor. And it’s really amazing the traction you could get when you start to really look at how well you are doing. It allows you to make changes to in your course and to assess If you are making meaningful difference. So I think that’s extremely important. >> Dr. Lynn Silver: We just received a question from Dr. Janice Ballard to you Dr. Jaffe. She asks: During a recent discussion of our goals for control rates in our registry we’ve noted that a 90% control rate was unrealistic and reflective of over medicating and that 80% is more reasonable. How did your team establish goals for control rates? >> Dr. Marc Jaffe: So, I think no-one really knows the answer about what is an adequate control rate. And certainly I won’t pretend to know it. What we try to do is we – we don’t pick an arbitrary number out of the sky. We assess our performance. We take a look at the subset of patients, usually through chart review, the subset of patients whose blood pressure appears not to be controlled. We keep an eye on spared events and adverse events. And I’m not really sure anyone knows the answer. I do think 100% would be too much and I think the 44% where we were 15 years ago was too low. And, you know, whether the range is 80% or 90% or somewhere in the middle, I think it depends on a lot of things like the ages -- the age cut off and certainly in advanced age that may not be as appropriate or even safe. I think that's something that is worthy of keeping in mind. But I can tell you that rates, where we were 15 years ago, were far too low.



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>> Dr. Lynn Silver: Thank you. I think the 90% was what you managed to reach safely if I'm not mistaken. We have a whole bunch of questions in relation to the team of care. Maria asks: What other health professionals should participate in hypertension programs? Another person asks: What can we do with users who live in rural areas with low education and inadequate number of health professionals? And with pharmacists available in every neighborhood we can need to utilize these professionals to achieve control of blood pressure and many considered as primary care providers. I would ask the members of the panel what do you think about the use of team care and not just physicians for helping to control hypertension. Dr. Campbell? >> Dr. Norm Campbell: Absolutely. In the city where I live, there's a million people. Every fire hall is open to the public. The firefighters are all trained to measure blood pressure and often the healthcare providers send people there for ongoing monitoring of their blood pressure. In other communities, it's barber shops or churches where blood pressure screening is occurring. Because hypertension is so prevalent, it's very important to use and develop community resources for the screening. And in some cases diagnostic algorithms can be built in there. In the province where I work, pharmacists are allowed to prescribe and we're working diligently to have hypertension managed in pharmacies. The pharmacists require special training but regulations allow that. And the regulations ensure that there's communication of information between the pharmacists and the physicians. In remote Canada, hypertension control is challenging. A lot of those communities are served by nurse practitioners who follow algorithms and it would not surprise me if many of those communities have better treatment and control rates than the rest of Canada because of the systematic approach that they use. Dr. Patel? >> Dr. Pragna Patel: I come from the world of HIV, so I can't help but talk about [Indiscernible]. This program has been highly successful in standing of HIV treatments in very low-resource countries. Where there are also -- was an issue with a number of adequate professionals to treat HIV, it's a very complex disease and they employed standardized treatment algorithms and trained nurses and clinicians who are not necessarily MDs to treat HIV. They've been very effective in doing this. So if we borrow from lessons and apply them to hypertension, I think it's very possible to use standardized treatment algorithms and re-- in resource-poor countries in other parts of the world. In addition, I think we need to think creatively and use some of the technology that we have at our fingertips. A lot of these countries patients have mobile phones. So we can think about how we could use mobile phones to increase care and treatment in rural areas. Telemedicine is now becoming very popular in Africa. And I don't see why we couldn't use that model in other regions in the country, in the world. >> Dr. Marc Jaffe: I agree. I think the answer is all of the above as you both have mentioned. And I think -- of course, different places are going to have different rules and regulations about licensure and what's allowed. I can tell you if we stripped all of that, if we were talking in a world where we were creating something from scratch, I don't think any of the three of you would say have hypertension control done only under the pen of the prescribing physician. I agree that that would not likely be how you would be designing a system. I think hypertension control is



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basically quite straight forward and as has been pointed out, and then providing a very easy access to the -- to a reliable blood pressure medicine. And somehow closing that loop, getting information back to the decision-make process is the key. I'm sure someone will have an excellent model out there. We'll develop something. I bet it won't involve -- it will be all members of the care team as alluded to and not just those at the very top. >> Dr. Lynn Silver: Thank you. We have another group of questions about the spreading of this type of approach internationally. Dr. Catrell asks: What is the transferability of the techniques discussed to help manage hypertension to low and middle income countries? And another question: Do you believe the strategies will be universal or are there differences that demand regionally specific strategies? And lastly, from the CDC: What are the opportunities to expand this to other countries? And she gives the example of Turkey. Dr. Patel? >> Dr. Pragna Patel: I'll start with -- [Inaudible] the package which outlines what the steps would be to employ a lot of these components and tools in countries to improve blood pressure control. We're hoping that this packet can be disseminated to many countries. We're happy to provide technical assistance to countries that are interested in implementing GSHTP but we're really wanting to create a tool that is very easy to use and very comprehensive so that ministries of health can decide what would be the best -- what would be the best components for them to employ. Whenever CDC works with a country, we ask them to do a baseline assessment of where they are. And this assessment should include things like what drugs are available, where do we need to interface in the supply chain and distribution to improve the affordability and availability of these drugs, to look at what their current hypertensions control rates are [Inaudible], and to identify where they could use their limited resources -- >> I'm having a hard time hearing Dr. Patel. >> Dr. Pragna Patel: Just wanted to refer to the slide. I would implore everybody to visit the CDC website that's at the bottom of this slide where we have compiled a number of resources in the form of a clinical toolkit. And this webinar will be included in on slide once we have finalized it to use for your implementation in your country. >> Dr. Lynn Silver: Thank you. My last question to the panelists will be: If you wanted to launch the Global Standardized Hypertension Treatment Program, or your national equivalent where you work, in your clinic, city, or country, what would be your advice on what to do first, second, third? What are the key steps to getting this off the ground successfully? Dr. Campbell? >> Dr. Norm Campbell: Sure. I think it's really a reiteration of what we were talking about before: clearly identified leader; establishing the effective partnerships; identifying what the barriers are; what's feasible; and keeping it very simple in terms of screening and diagnosis of hypertension; assessing vascular risk and managing that risk; advising lifestyle changes and starting treatment typically knowing that this is going to require more than one drug for effective control. >> Dr. Lynn Silver: Dr. Patel? >> Dr. Pragna Patel: I would add to that, again, to do a baseline assessment to encourage non-physicians to be involved in the care of patients, to involve the community and create



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awareness of hypertension. It's a silent disease. Many people don't treat it because they feel fine. Marc? >> Dr. Marc Jaffe: I would do four things. I would get my administrative team, my lead team, together. I would then develop a registry, figure out who it was I was going to look after and try to treat, either adopt or create an evidence-based guideline. Number four, I would do create performance metrics with constant feedback. And then five and six as a bonus, I would be thinking about practice efficiencies. And I mean using every member of the team up to the highest level of their scope and skill. We've talked about that a little bit here today. And also I'm a big proponent of efficiently managing medications using single-dose combination therapy. That's what I would do as a start. >> Dr. Lynn Silver: Thank you. I'd like to -- we're going to have to wrap up this roundtable discussion now which has been incredibly rich. We hope that this will be one of the first of a series of webinars that the Centers for Disease Control and Prevention will be carrying out on this issue of improving hypertension prevention and treatment globally. I'd like to thank our presenters, Dr. Pragna Patel, Dr. Norm Campbell, Dr. Marc Jaffe for their wonderful contributions not only here on this webinar but to hypertension control globally. And where you work, you guys are incredible examples and inspirations to all of us. We hope that the hundreds of people on the webinar today will be the next generation if they're not already there. Some of them are already. Those who aren't will be the next generation of leaders for hypertension control globally. So I'd like to thank all of our participants. I apologize if we didn't get to your questions because of limited time but we thank you for your input. Today's presentations have demonstrated that hypertension is clearly perhaps the most important thing that a healthcare service can do to keep people healthy and help them age healthy and able to live with their families and take care of their children and their grandchildren. We hope that you seek to increase your effectiveness in that role. And the Center for Disease Control and our partners here today are here to work with you to try to build that collaboration. Let's do it. Thank you. [The webinar ended at 2:31 p.m.]



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Spanish Transcript

Monday, February 23, 2015

1:00 p.m. – 2:31 p.m. EST

PUBLIC HEALTH INSTITUTE DIALOGUE4HEALTH WEB FORUM

“HYPERTENSION PREVENTION, TREATMENT, AND CONTROL: SUCCESSFUL GLOBAL STRATEGIES”

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[email protected]



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Estén atentos esperamos, empezar en un breve momento. >> Bienvenido a Hypertension Prevention, Treatment, and Control: Successful Global Strategies. Yo soy estrella y voy a creccer la Web forum, con Valerie y Holly. Subtítulos los tenemos en inglés y español. Christine lo hace en inglés. Primero, están disbonible en su panel. Pueden tocar como una circulo, está arriba de su pantalla. En la zona de su ventana abajo en la derecha, tome un momento. Y puede ver más de los subtítulos en vivo. Durante la Web forum, no se apruebe, puede abrir la ventana. Voy a mandar para que lo miren en español en CHAT. Arturo va a realizar los subtítulos en español. Para mirar los subtítulos, abren una nueva ventana y ponnan el CHAT ahora. Una vez que se conecte puede usar el formate. Puede ser mejor, trabajar el penal para ver los dos a la misma vez como está en la pantalla ahora. Lynn? >> Arturo va a dar en tiempo real para los subtítulos, abre cualquiera navegador que esta en la pantalla en la caja CHAT, cuando se conecta, puede selecciónar el formato con la opción en la part superior, tendrá que tenner el centro de Web y su navegador Web abiertos, puede hacer más fácil de cambiar el tamaño para pueda ver los ambos en el mismo tiempo como está en pantalla ahora. >> Si tiene problemas, marce 1 866 229 3239. Si en cualquiera tiene problemas sobre audio, mande un mensaje y Joanna o yo les vamos a dar la información que necesita. O también Holly, tome tiempo para completar el paquete necesitamos su palabra para mejorar el forum. Vamos a tenner la información en el sitio de Web, queremos invitarlos que se conecten con nosotros en Twitter y Facebook. Esperamos que pregunte ahora sus preguntas, use y pregunte, vamos a realizar las preguntas con ustedes. Vamos a usar para tomar su respuestas. Holly, abre la primera por favor, gracias. La primera está ahora para usted y está en la esquina baja. Yo estoy en el forum Web individual. O más de 10 personas, cuando escoga su respuesta, mandela. Cuando cabe y quiere regresar, quiero presentarle a Lynn Silver, ella es como asistente comisión de salud en Nueva York donde, ella ayudó la soddia y calorías de las comidas rapidas y también, ayuda de diabetes y Hipertension.



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Trabaja en tratamiento en el Estados Unidos y global, como con el Pan American situación y también con el C D C con el control. Lynn, adelante por favor? >> Gracias. Yo tengo el honor de presentar el Dr. primero, bienvenido a todos presentadores, el Dr. Frieden, y también Dr. Thomas Frieden el director, él va an estar con nosotros de video de Atlanta, van a ver en la pantalla, el vídeo del Dr. Frieden y lo puede ver empujando juggar. Dale tiempo y también puede ver el vídeo ahora en la conexión en pantalla, el vídeo va a tomar 4 minutos. >> Gracias. Dr. Frieden por la presentación. Ahora vamos a presentar el próximo presentador, Dr. Patel. Después de años trabajando en el SIDA, ella está buscando con enfermedades y es presentadora del proyecto, gracias. Dr. Patel? >> Gracias Lynn. Buenos días es mi placer presentarle el Hypertension Prevention, Treatment, and Control: Successful Global Strategies. Imagenes, un mundo donde pocos taques de corazón passan donde hospital se mirran así. Donde, bajos accidente cerebrovascular passan, donde abuelos pueden juggar con sus niños? En mayo 2013, global trabajo identificó nueve maneras de control por 2025. Uno era un 25% en presión. Es alta y billones la tienen, no es una enfermedad de ricas paises pero es más alta en mediana paises y es la razón por ataques, la más grande manera de muerte en todo el mundo. En paises de bajo nivel, ocho de 10 muertes son conectados nos puede afectar la familia y bajjar de producción en la economía. En el 2001, casó 370 billones de dólares, 10% de costo por el año y si no esta tratado, puede subir a 3.7 primero necesitamos usar estrategias como bajo en sal y también ayudar de tratamientos y consejando a los pacientes que trabajen en ellos mismos. Aquí, tenemos estrategias presensación son, bajando sal, usó de tobaco y también, no usando alcohol, usando esto, pueden bajjar 14, sabemos como trattar la enfermidad lo estamos haciendo bien. Media gente sabe que tienen la enfermedad y lo que sí lo tiene, no lo trattan. Aquí tenemos un número de manera de controlar la presión, como trabajador de salud, pacientes tienen acese bajo para el tratamiento. Y a veces no realizan las guias de medicación TSHGS tercero, tiene problemas de costo de medicación y son problemas que podemos mejorar. Trabajando en lección, sabemos con una manera de cuid estándar puede ayudar la enfermidad. Con un inspiración con el modelo, y H I V en todo el mundo, tenemos el global tratamiento para el control de presión alt ade sangre.



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Esto puede ayudar y tenemos una manera para ayudar tratamiento Hipertension. Tenemos las guias. Empiezo como un trabajo en América, por el centro de enfermedades control y pan América an control. También, tienen ayuda de SIDA. El trabajo incluye tres temas. La primera es identificar medicación, y que estén disponible y que lleguen a los que la necesitan, tenemos una lista de la medicación que eran indentificación de usso en la región Caribe, miramos medicación y incluimos tres pastillas combinación que son importante cuando un pacientese necesita más que una manera de medicación. La clave que estén disponible. Ellos tiene medicación disponible en un costo bajo. El fondo revisó la lista de medicación y ahora hay cinco medicación y tres. Aquí están la lista de elementos de cuidado para mejorar Hipertension en su clínica. Es importante que tengan estándarizado tratamiento para trabajar y crear equipos de base en nuestras clínicas. Y para, impodder pacienteses para que participen en su cuidado. Pero hay algo más que es importante cuando llegamos an este camino, identificar grandes líderres y campeones, es pueden ayudar crear lo que es necesario para que usted use estás herramientas, esperamos que hay líderres escuchando y nos pueden trattar el Hipertension en todo el mundo. Han hecho un heramiento clave y tiene recursos para todos que pueden estar interesados para realizar esto en su clínica y extractura, sus preguntas son bienvenidos y esta disponible. Nuest visión es para que Hipertension global, es una oportunidad para Latinoamérica y región Caribe para que ellos vayan adelante, tenemos ex pensión y C D C tiene extractura aquí y Africa esperamos que los modelos que tenemos de nuest programa piloto, pueden ser trabajados y también aplicados por otras enfermedades condiciones como diabetes. Es algo grande, y esperamos que nosotros vamos adelante juntos, necesitamos trabajo y compañeros y otros agencias con tú profesional ayuda, el interés que creamos va an ayudar que usemos nuestros recursos y controlar la presión alta en todo el mundo. Tenemos maneras que sabemos que son exitoso, tenemos la herramienta, y la gente. Esperamos que ustedes participen para ayudar en todo el mundo. Ahora vamos an escuchar dos ejercicio de tratamiento en América del norte. Gracias. >> Gracias Dr. Patel por los pasos que se necesitan tomar. Bueno, quiero menciónar ante que presentamos el próximo, tenemos 529 participantes y con con la gente dicen que San interesados para mejorar este control, esperamos que la gente ellos sean líder que habló Dr. Patel, vamos a tomar un momento y presentarle al próximo, queremos pedir que seppan que este tratamiento llegue a todos, escoga su primeras tres propuestas. Con esto, quiero ir adelante y presentar el próximo. Es parte de la junta que va a hablar de dos historias de exitoso de Hipertension. El Dr. Marc Jafee. Él es el jefe en el central en San Francisco y el líder del Kaiser Permanente. Quiero decir una corta historia, cuando yo estaba trabajando en el norte de California, él me



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dijjo que su cuatro de mejor, miró pocos. Porque, Kaiser Permanente está haciendo algo correcto, quiero presentar al Dr. Marc Jafee, adelante por favor. >> Gracias Dr. Silver. Es un honer estar aquí con ustedes, gracias Dr. Frieden, Dr. Patel y Dr. Campbell. Déjame decirle de donde estoy, yo soy del norte de California. Yo trabajo por Kaiser Permanente en el norte de California. Tenemos servicios en casa o afuera de casa y tenemos más de siete mil ayudándose. Vamos a ver. Cómo uno empieza de controlar la Hipertension? Hay cuatro elementos, bueno no son simple pero hay cautio, crear su equipo. Identificar su pobulación, llegar an un acuerdo de un tratamiento y después, necesita ver como están haciendo, vamos a ver en detalle como lo hacemos en el norte de California. Vamos hablar de la equipo de Hipertension. Nosotros tenemos tres equipos, hay cien equipos pero hay tres niveles. En el global nivel, el más grande, para el 2.3 millones de miembroros tenemos un equipo de verificar. Tenemos líderres, unos extracturas y tan manejador de programa. Generamos reportes en nuest progreso en el centro de médico, revisamos y miramos quién está bien, quién necesita ayuda, tenemos entrenamiento y esperamos que se junten como ahora para aprender y saber y realizar unos herramientas de apoyo como, paquetes de información y miramos donde están y llegga el éxito. Los equipos pueden tenner un director y pueden atender el entrenamiento como éste, y es mirran para su gente para maneras y importarlos en la clínica local. Después, tenemos la gente que nos da el cuidado. El punto de servicio, que trabajan con los pacientes, y ellos son doctores, enfermeras y más. Estos individuales ellos deciden el cuidado del paciente, pero también mira como ellos trabajan, buscar recursos para que su práctica sea mejor y también mirran su compañeros para ayuda. Son tres niveles. Una cosa que quiere decir, es hablar de la práctica de exito. Juntando con un doctor no es efectivo de precio para la alta presión de sangre. Cuando uno se junta con el asist sente, quiere decir que cuando yo soy aquí un paciente mío puede estar con mi asistentie tomando pruebas y una colega puede ayudarme o puedo recibir un e mail y me pueden dar toda la información o lo puedo mirar en la computadora. Pero esto ayuda el paciente, aumenta consistencia, y no cobramos c o paggo. Y también, si alguien mir aun especialista y su sangre está aumenta, podemos tenner el especialista pueda realizar la prueba, nosotros estamos contentos y ayuda bastante. Vamos hablar de algo más. Una vez que uno sabe que va an ayudar la Hipertension, uno necesita saber quién va a buscar para el servicio. Nosotros usamos todo lo que modemos encontrar para generar la lista, la lista general. Después, usamos en la registadora lo que es, Hipertension no tomamos la sangre puede estar elevado pero nosotros usamos para registar. La cosa buena, lo puede hac her tan grande o pequeña que usted quiera, puede ponner si hay



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diabetes, si hay pruebas ordenados, números que tenemos es 200, uno puede ver con más información aquí, uno tiene la oportunidad para hacer y preguntar, nosotros miramos que nos ayuda. La mejor manera del control es estar organizado. Y no enforcarnos en que el doctor hacen juntos en el punto de cuidado. La gente pregunta qué necesitamos? Bueno, nosotros trabajamos esto de nuestras ideas y esto trabaja para nosotros. Esto ha estado usado en organizaciones más grandes. Y usamos una visita de cuidado y medicación. O una, visita y accidente cerebrovascular o diabetes, pero puede ver que hay varias maneras para entrar en la registación. Ahora que tenemos el equipo, y sabemos con quién vamos, lo queremos que hacer es cómo vamos a controlar la Hipertension. Solamente realizando su equipo no es bastante, necesitamos una guía de evidencia, usted puede crear el suyo, pero mira la evidencia que están disponible pero cuando lo hace, esperamos que ustedes ussen este ritmo. Está basado en el más reciente evidencia. Una vez que tenemos tratamiento, lo ponemos para que usted lo vea, mandamos e mail, tenemos vídeos y literaturas, y trabajamos el tratamiento más que podemos en nuestra operación darria para ayudar la clínica hacer lo que es correcto para el paciente y tenner este tipo de tratamiento en nuestro récord electrónico. El sistema de salud adoptación de evidencia guía, tiene tiempo, tratamiento opciones, con el nuevo y lo que existe, déjame hablar de data, con la gente tiene preguntas qué es data blocadores. Uno que ha estado en este negocio, yo lo ha estado aquí por unos 20 años. En los años, miramos el blocador de data es menos y menos importante. Está reflecciónado en nuestra guía donde están recomendado y tratamiento y en los pasado años han llegado al segundo. Uno puede entrar aquí, y está en el Web, quiero decir, nosotros lo hacemos, queremos empezar con la combinación de, los dos para mujeres que pueden estar embarazada. Y, otra cosa es que recomendación, en la doses no cualquiera se puede dar en una pastilla mediana si no trabaja, dos. Pero este sistema es usado y si el primero combinación no trabaja, ponga una media tabla por día. Y después, la tercera pastilla es una que, más Hipertension expertos recomiendan para esta enfermedad. Cuál tratamiento es mejor? Bueno, es una pregunta grande. Vamos hablar del trabajo que dijjo Dr. Patel, el protocolo y guía que es importante. Y nacional base debe hacer usado. Dice, Marc no contestó la pregunta pero cualquiera manera que ussan, es posiblemente excelente para usted, trabaja? Bueno, lo que miramos en Kaiser Permanente del norte de California, el porcentaje de drogas, subio pero el número como una solamente doses aumento de 2001 a 2012. Casi 30% son escritos en el 2001 y 2002, escribimos pocas. Yo recibí una llamada y quería estar escurros que no era un error.



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En el año 2011, pretenamos 25 mil pastillas por mes y les dije sí es verdad. No era prescribida y ahora, lo hacen bastante. Es la clave, la combinación que puede estar una vez por el día, son dos drogas en una pastilla, y es efectiva. Miramos el grad e de control. Tuvimos 44% de control y ahora estamos en unos 90%. Miramos en la línea azul, Kaiser Permanente norte California está arriba. Estamos arriba del normal, comparado en el nacional. El programa que tenemos tiene con la influencia en el Hipertension. Y también, enfermidad de corazón y accidente cerebrovascular? Tenemos 42% redución en accidente cerebrovascular. Hablamos de accidente cerebrovascular, miramos que taques de corazón están bajando en el norte de California cuando identificamos taques de corazón usando cardíaco marcadores. Nosotros miramos bajos en ataques de corazón, especialmente el más mal tipo de taque. Quiero decir, hay cuatro cosas que nosotros encontramos para nuestro control y esfuerzo, uno identificar su equipo. Dos, tome y hagga una registación de pacientes y tres, qué van hacer con él, y monitar su proceso. Gracias. >> Gracias Dr. Jafee por la información y su historia de exitos, 90% es increíble. Ha con lo que podemos aprender de eso. Déjame hablar de los resultados que ustedes participaron. Es bien interesante. Lo que la gente identificó es paciente que no están interesados. Y también, la gente que identifica que en hay bastante recursos de cambio de vida. Tercero, no hay acceso para el cuidado médico y cuatro, no hay equipo para ayudar con el Hipertension cuidamiento. Antes de ir adelante, quiero pero sentar el próximo, qué tipos de apoyos o herramienta les puede ayudar en su comunidad. Las opciones están en la derecha de la pantalla. Guias para tratamiento. Entrenamiento, guias de equipo. Guias de manejador de programa. El próximo vocero es el Dr. Norm Campbell y también es el Presidente de la liga Hipertension. Él era muy importante del líder de la Hipertension programa en Canadá y coordinó entre el gobierno y la sociedad. Y como el programa de Kaiser Permanente, tenía unos resultados de éxito. Una más historia, hace unos ocho años empezamos el trabajo de sal reducción y la gente nos dijjo que él era uno que hablamos y él nos ayudo con su opinión experto. Ha tenido buena resultados y ahora unos 18 paises tomman acción para reducir sal en su comida. Él ha siddo un líder en el lado de prevención, estamos contentos de tennerle aquí, adelante Dr. Campbell.



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>> Gracias, es un honer para estar con ustedes, con dos voceros inesperadores y como controlar Hipertension. Es mi honer de resentar este programa. Yo no tengo un interés financiamento en el topico. Lo que quiero hablar es de la educación de Hipertension. El clave y resultado y los planes del futuro. Los que están interesados, nosotros miramos que eran con las claves varias claves son aplicable an otras paises, pero todo el programa tiene limitado aplicable como paquete pero pueden tomarlos an otros paises. Aquí miramos la clave indicador. En el año 1985. Solamente 13% eran tratados y controlaron. En otro sabía que lo tenía pero no eran tratados. En el año, 2006 miramos que se mejoró, más de 60% de tratamiento y control. En el 2012 2013, 68% tratados y controlados, y miramos que eran jóvenes, hombres más que mujeres y pocoitos sabben que lo tienen, 12% están en tratamiento de medicamiento pero no controlado. Ahora, contra de la éxito, hay poco cambios en el estilo de vida. Tenemos la información de el estilo de la gente de Canadá. Miramos que hay poco cambios en fummar, aumento de cuerpo, actividad y alcohol. Los cambios son también en la gente. Esto realmente quiere decir la necesidade para realizar actividad para que la gente hagga los cambios. Ahora, hablamos de como ha cambiado en los 90 cuando miramos la primera, estuvemos depresiónado. La notamos que Estados Unidos tenía doble el tratamiento que Canadá y tenía un programa, en el año de 2000 una recomendación proceso era realizado. Y era conectado con una tranlación y programa para que salgan alas recomendación que controla la Hipertension, en el año 2003, si nuestros programas están trabajando, por eso realizamos un programa para mirar el resultado. Aquí tenemos la tractura del programa en Canadá. Tenía comité y tenía organizaciones, doctores, enfermeras y el gobierno de Canadá. Baj e de ese comité tuvimos una recomendación unos 20, y ahora tenemos 70 y revisamos la evidencia y creamos recomendación de Hipertension. Después, queremos ver y passar estos recursos en la gente que están en la práctica de clínica. Varios eran educadores. La tercera es, que era ante #50 persona. En el año, 2006 una fundación de líder era creado para ir adelante. El comité ahora está en una Hipertension comité que son 12 de los científicos y organizaciones en Canadá. Ellos quieren sobre ver la, miramos unos 70 personas ahí, hay unos 15 subgrupos. Si ellos creen los escritos y la recomendación de cambiar y nueveras recomendación, tenemos la evidencia para el centro comite de revissar. Ellos están en el comité sin conflictos de interés. Ahora, este proceso es desejado para convencer a la gente de crea unos 130



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recomendación, son muchos pero tenemos los cinco claves que queremos que los médicos ussan. Manifestación realizar la presión, queremos que la gente este lista cuando salga y que el factor de riesgo como fummar es formado. Queremos controlar eso y miramos que esto de nuest programa no es un éxito y último queremos promottar realizar que necesitan cambiar el estilo de vida. Y también más que una medicación Hipertension. Esto pueden usar para controlar la presión alta de sangre. No quiero passar en detalle pero, tenemos dos cambios importantes, uno es para que la gente salga y use maneras que son más mejores y la segunda es usar afuera de maneras para que haggan una mejor decisión Hipertension. Si uno las haces y se va, nada va a passar. Lo has importante passo es el proceso. Aquí tenemos los pasos que nosotros hemos tomado, uno es el? La gente que esta usando este sistema. Como enfermidades, doctores ellos han estado en nuest proceso. Ahora, miramos los pasos no solamente el organización pero individual profesionales, tenemos herramientas en los 15 20 para ayudar manejar la regresalta de sangre. Y la gente ellos sabben qué su profesional debe estar manejado, es una recomendaciónra el público y pacientes, la herramienta para cambiar su pensamiento. La agencia de Canadá, han estado participando en este programa representando nuestro sistema. Recursos, tenemos unos 40 publicación de como manejar el Hipertension en Canadá. Esperamos tenner un título cada año, es escogido por los manejadores, trabajamos con varios más organización para no ver competencia. Y más importante, quién está educación a la gente y a quién educan y ponnerles en una lista eléctrica donde les podemos mandar nuestros herramientas para la educación. Éste es el sitio de Web donde todo los recursos que tenemos y pueden usar. El mundo de Hipertension también tiene sus recursos y herramientas. Tenemos en página de como desarrollar y tenemos un vídeo pequeño de como mirar la presión alta de sangre. Quiero también preguntar que necesitan celebrar el día de hipir tensión que es el 17 de mayo, cada año. En Canadá miramos que hay más interés en la Hipertension y cuidado. Hemos visto si recomendación que si la gente no hac algo, se reduce. Hemos visto intensidad en medicación y mejor control de sangre, y más importante, mejorar en el resultado. Miramos el nivel nacional de muerte y accidente cerebrovascular. El azul índicca cuando el programa empiezo, miramos el alto en la gente que se mueve por accidente cerebrovascular, más de #50%. Muriendo de fallo de corazón. Por Hipertension. Y mejorando en bajo riesgo unos 25% relacionados de Hipertension. Éste era como empiezo el programa, gente de 25 mil, tuvimos en el otro miramos bajos en la manera de morir por la enfermedad. La educación de Hipertension era como un model o y se han usado como varios otros paises



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como Rusia, Irán también. Hay más cosas nuevas con la tecnología, una gente puede aprender por distancia. Pruebas y también vídeos para que la gente sepa las más recientes recomendación. Gracias. >> Gracias Dr. Campbell. Era una bella presentación de un programa que no estaba en la clínica o hospital. Es importante. Pensé que como uno tiene ola credibilidad de un programa puede ayudar un país. Es una lección importante. Vamos a revissar los datos, la primera era material de educación. Esperamos que vaya al sitio donde nos dijjo el Dr. Doctor que nos puede ayudar y la educación. La segunda es poquito más dura. Hay ejemplos. La tercera era costo bajo y sistema. Que es algo que necesita estar trabajado en cada país. Las guias de medicación y último asistencias y GI agencia, ahora vamos a la próxima fase de la mesa redonda. Pueden realizar preguntas. Los miembroros son, Dr. Petal, Dr. Campbell y el Dr. Jafee. Quiero preguntar con la primera preguntar que llegó de Dr. George. Pregunta, hipir tensión tratamiento, sabemos como tratarlo y ten asalto las drogas pero Hipertension muertes aumentan como podemos mejorar esto? Y qué son los pasos? Dr. Jafee, quiere empezar? >> Bueno, es la misma pregunta que nosotros nos preguntamos hace unos 15 años. Como si alguien era afectado y como puede mejorar. Nosotros, que podemos hacer más. Los pasos, pueden sonar aboridos pero eran lo más afectivos. Organizarse con un equipo para que tengan la gente proppia disponible. Líderres, todos que uno puede pensar que puede a ser importante para ayudar. Y también registador, y que necesita a trattar. Y esto lo hicimos. Nosotros empezamos antes que tuvimos el electrónico. Tercero, mirar la mejor manera y evidencia que uno puede usar si usted lo hace como en Canadá o usar un tratamiento de los excelente guias que están disponible. Y también, continuar vigilar su proceso, para que usted se puede ver en el espejo y trabajar y modificar y también, hablar de los éxitos. Esto nos ayuda y esperamos que pueden hacer usados en otro lados. >> Dr. Campbell? >> Lo que quiero decir, cada local es que necesita ver lo que puede trabajar.



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>> La siguiente pregunta. Pregunta, cuál es la experiencia a dato sobre Hipertension en Latinoamérica? >> Sí. Ahora tenemos asistencia para varios paises, hemos ayudado un programa piloto donde ahora, tenemos maneras con Colombia y también, tenemos tratamiento de Hipertension pero también quiero decir, queremos crear Copperación con nuestros compañeros. Si trabajando con los locales para el tratamiento proyecto y también [Inaudible] Ecuador, Chile, México, Brasil. Esperamos que sea éxito. >> Gracias. La próxima, qué considera que es lo pas importante de un tratamiento de Hipertension. >> Cuando si la primera, es, escoga uno de los 11 medicamiento va a hacer con difícil para realizar un cuidado y estar alinado. La clave es, hacerlo simplemente. Es más importante que sí o no uno va a ponner uno arriba del otro. Esperamos que, pueda hacer aplicada an 80% de los pacienteses. Que, es lógico y ussa drogas que son efectivos y disponible. En Kaiser Permanente usamos disponible y muy bien medicación que han estado por varios años, no es necesario usar lo más reciente pero los que ayudan con el costo. Esto puede ayudar nuestros miembroros. >> Es importante para anotar cuando miramos control, todos mirran un ritmo protocol cuidado. Mirran el base con un enfermera en todo tiempo, el ritmo cuidado es más superior del cuidado normal. Es importante para nottar como están enternados, nosotros, tratamos todos individualmente. Y no usar este tipo de ritmo pero enfermeras es en un base de cuidado. Lo más importante es preguntar, lo que uno tiene. Y también, si no pueden va al doctor para el cuidado individual. Esto resulta de más mejores resultados. >> Los tratamientos? >> Bueno, ritmo que susado por el propio cuidador licenciado en su estado es increíble. Y no sé porque la legistación no dejja que el paciente lo hagga. Esto, usando la medicación puede hacer más superior de cualquiera cosa. No soy sorprendido por lo que dijjo Dr. Campbell. Pero lo que nosotros hicimos, hacer la cosa más fácil. Cada uno puede decidir qué es correctora el paciente. Pero la mayor de la gente puede ser tratados en el similar manera. Tenemos material de educación, el resto de nuest programa están por la medicación y la decisión de apoyo, tenemos récord electrónico para la medicación que nosotros recomendamos.



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Lo hacemos muy fácil para usar la medicación que es correcto para la gente Hipertension. >> Dr. Campbell? >> Sí. Es una pregunta difícil para contestar ahora. Pero, si está en un recurso ambiente esto debe usarlo a los que lo necesitan más. Los que tienen y pueden tomar la mejor ventaja. Pero hay pocos experiencia global de como aplicar esto. Muchos son visto como en Kaiser Permanente y en Canadá y otros. >> Muy bien. Deberemos tenner estos tipos de medicación ante bloqueo y también, cómo llegamos a la medicación para el programa y nos pueden explicar el proceso Dr. Patel? >> Bueno [Inaudible] La medicación lista y incluen son excelentes. >> Gracias. Quier decir algo más en bloqueo de datos? >> Hay indentificación con problemas de corazón, tiene cosa similares pero en el más antiguo tienen menos. Dr. Silver? No sé lo que está pasando pero, no tenemos el audio donde están los presentadores. >> Ahora? Nos pueden escuchar? Bueno, gracias Dr. Jafee? Está bien el sonido? >> Sí. >> Te podemos escucharme >> La próxima pregunta. Y él pregunta, qué es la industria y haciendo drogas más baratas? Qué es un las mejores para asegurar que la gente tiene acceso para los necesidades? Dr. Campbell? >> Seguro. Yo lo mirro como una responsabilidad del gobierno para, que ellos los tengan disponible y reduce el costo, también, otros regiónes lo pueden hacer. Gobiernos pueden comprar los drogas para que están bajo costo. El escenario puede hacer más bajo para que unos pueden realizar este tipo de precio más bajo de uno que no es comprado.



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>> Gracias. Quiero ir adelante an una pregunta, como uno mira quién está controlando o no? Cómo mira en el espejo y como uno sabe que el programa está efectivo? Marc? >> Bueno, no hay una manera de sacer como uno está haciendo, nosotros pensamos que estuvimos haciendo bien hasta que nosotros recibimos la información. Y como humanos, tomando urgullo en lo que uno hace, no creo que nosotros no estuvimos organizados. Teniendo un sistema que no perfecta, y estamos trabajando en la perfecta. Pero, espero que organizaciones cuando puedan tomar un tipo, si es, la presión de sangre, o la medicación si solamente lo tiene por unos. Agarre algo para que usted pueda vigilar y es importante lo que uno puede hacer cuando uno, mira como lo hace. Y los dejja hacer cambios en su curso y si está haciendo diferencia. Es importante. >> Bueno recibimos una pregunta de la doctora. Dice que el 90% control no es realista. Y 80% es más razonable como hicieron esto? >> Bueno, nada sabe la respuesta. Y yo no la sé. Lo que queremos no tomamos un número del cielo. Pero tomamos nuestro información sobre lo que la que hacemos. Y no estoy seguro sabemos, pero el 100% es mucho y el 44% donde estuvimos hace 15 años era muy bajo pero, si es 80 o en el medio, depende de los años y edad. Pero, es algo que uno necesita tomar en mente pero les puedo decir, donde estuvimos hace 15 años eran muy bajos. >> Gracias. Y el 90% era lo que ustedes hicieron. Bueno, tenemos más preguntas sobre el equipo de cuidado. María Cristina Escobar dice cuál otros necesitan participar en estos programas de Hipertension FRM y esperanza dice, qué hacemos con usuarios? Smith dice, ussen trabajadores de la comunidad. Les pregunto, qué creen del usso de equipo de cuidado? Dr. Campbell? >> Seguro. En la ciudad donde yo soy hay un millón de personas y los bomberos ellos están educados para revissar esto. En otras comunidades son iglesias donde passa. Porque Hipertension es tan importante, es importante usar y usar los recursos de la comunidad y en unos casos, ritmos.



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Donde yo trabajo, se puede hacer trabajado en Canadá, el control en la comunidad son realizados por enfermeras. >> Dr. Patel? >> Yo vengo de la mundo de SIDA, nuest programa, que ha siddo importante en el tratamiento donde hay también, problemas con el número de expertos para trattar el SIDA. Es una enfermidad complicada pero han enentrenados enfermeras y son efectivos. Si nosotros miramos estás lecciones y aplicamos con la Hipertension es posible para usar este tipo de tratamiento en el mundo. Y también, necesitamos pensar creados y la tecnología que tenemos, en estos paises, la gente tiene su celular y usarlo para usarlo como tratamiento se ussa en Africa y no sé por qué no la podemos usar aquí? >> Y estoy en acuerdo. Seguro, diferente partes tiene diferente regulación y licencia pero si hacemos algo de inicio, no creemos que tenemos un control Hipertension, yo estoy en acuerdo no es como uno deseja el sistema. Hipertension control es directo como hemos hablado. Cuidado y fácilmente acceso para un medicamiento de presión de sangre. Yo soy seguro que alguien va a tenner un modelo y lo trabajamos y no va a hacer todos miembroros del equipo y no solamente los que están arriba. >> Gracias. Tenemos otro grupo de preguntas de como puede desarrollarse. Dr. López, usted cree que pueden usar universal o hay diferencia? Y también, pregunta qué son las oportunidades para experimentar en otros paises como en Turquía? >> Seguro. Estamos trabajando para este tratamiento y dice en realizar esto para mejorar el control de presión de sangre. Esperamos que el paquete llegue an estos paises y estamos contentos para ayudar asistencia de tecnología y esperamos crear una herramienta que sea fácil para que todos qué es lo mejor manera que lo hagaba. Algo más, esperamos que haggan una base de donde ellos están y debe incluir de cuál medicamientos están disponible y qué necesitamos para mejorar estos medicamiento y mirarlo que su Hipertension necesitidades son. Identificar donde [Inaudible] >> Yo estoy teniendo problemas escuchando al Dr. Partel. >> Espero que ustedes vayan al sitio de Internet que San a bajo en la pantalla. Tenemos varios recursos en el herramienta de medicamiento.



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>> Gracias. La última es, si quieren mirar el tratamiento de donde trabaja y su paises, qué es su opinión? Y los pasos para que empieza? Dr. Campbell? >> Seguro. Lo que hemos hablado anterior, identificando el líder, el efectivo compañeros, qué se puede usar y que se quede simple. Manejador el riesgo y el tratamiento y sabben que se va a necesitar más que una drogga. >> Dr. Patel? >> Que la comunidad participe para que seppan sobre el Hipertension, es una enfermedad silencioia. >> Marc? >> Sí, yo tomaba mi equipo y después ver a quién vamos a trattar. Adoptar y crear una guía de evidencia, y después, crear maneras de respuestas. También, pensando de práctica usando todo miembro del equipo y también, manejador medicamiento. >> Gracias. Vamos an acabar la mesa redonda. Esperamos que esto sea, una primera de serias de Web que podemos usar y ayudando el Hipertension global. Quiero decir gracias a nuestros resentadores por su ayuda. No solamente aquí pero Hipertension control global. Y también donde uno trabaja, ustedes son increíble ejemplos y inspiración para todos. Y esperamos que, la gente que estén en el Web, sean los futuros y generación de líder PRAES Hipertension control. Quiero decir gracias. Perdón si no llegamos a su pregunta por el tiempo. Y ahora, la presentación ha enseñado que, se necesita. Esperamos que ustedes, sea más efectivo y nos compañeros están trabajar con ustedes, gracias.

public health institute dialogue4health …...rough draft transcript not a verbatim record 1 monday,...

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