Improving Blood Pressure Improving Blood Pressure Treatment in the Community: A Treatment in the Community: A Joint Project of the NHBPEP and Joint Project of the NHBPEP and ALLHAT Collaborative Research ALLHAT Collaborative Research

GroupGroup

Chuke E. Nwachuku. MA, MPH, DrPHChuke E. Nwachuku. MA, MPH, DrPHClinical Application and Prevention ProgramClinical Application and Prevention Program

Division of Epidemiology and Clinical Division of Epidemiology and Clinical ApplicationsApplications

ALLHAT/JNC7 Dissemination Plan

U.S. Department of Health and Human

Services

National Institutes of Health

National Heart, Lung, and Blood Institute

ALLHAT/JNC Dissemination PlanALLHAT/JNC Dissemination Plan

Why is a dissemination plan needed?– Background

Facts about health innovations and applicationNHLBI Dissemination PolicyALLHAT’s unique place in the context of NHLBI dissemination infrastructure

ALLHAT/JNC Dissemination PlanALLHAT/JNC Dissemination Plan

What does the proposal comprise?What does the proposal comprise?– Review the broad based multipronged Review the broad based multipronged

approach previewed in a recent Lancet approach previewed in a recent Lancet and at the AHAand at the AHA

Update on current ALLHAT Update on current ALLHAT Dissemination activitiesDissemination activities

ALLHAT/JNC Dissemination PlanALLHAT/JNC Dissemination Plan

What is the process going forward?What is the process going forward?– NHLBINHLBI– ALLHAT Dissemination Committee and ALLHAT Dissemination Committee and

ALLHAT Steering CommitteeALLHAT Steering Committee– Executive Committee of the JNCExecutive Committee of the JNC– Field implementationField implementation– CoordinationCoordination– Ongoing reviewsOngoing reviews

Grol R and Grimshaw J; Lancet 2003 36Grol R and Grimshaw J; Lancet 2003 362: 1225-302: 1225-30

Facts about health innovation and Facts about health innovation and their applicationtheir application

Research shapes innovation for Research shapes innovation for clinicians and patientsclinicians and patients

10,000 new randomized trials included in 10,000 new randomized trials included in MEDLINE annually MEDLINE annually

350,000 trials have been identified by the 350,000 trials have been identified by the Cochrane CollaborationCochrane Collaboration

General Internists would need to read 20 General Internists would need to read 20 papers every day of the year to keep pacepapers every day of the year to keep pace

Guidelines such as JNC-7 and systematic Guidelines such as JNC-7 and systematic reviewsreviews

@Stone S J.R. Soc Med 2001;94:278 +@Stone S J.R. Soc Med 2001;94:278 +Ellerbeck et al JAMA 1995Ellerbeck et al JAMA 1995

Facts about health innovation and Facts about health innovation and their application their application (Cont’d)(Cont’d)

Clinicians are consistently slow to Clinicians are consistently slow to apply evidence in their practicesapply evidence in their practices

Benefits of hand hygiene well known since Benefits of hand hygiene well known since Ignaz Philipp Semmelweis over 100 years Ignaz Philipp Semmelweis over 100 years ago, yet compliance remains a problemago, yet compliance remains a problem@@

The benefits of fibrinolytics first documented The benefits of fibrinolytics first documented in 1986, yet the best estimates are that in 1986, yet the best estimates are that about 10 years later only 70% of “ideal” about 10 years later only 70% of “ideal” received lyticsreceived lytics++

Oliveria et al, Arch Intern Med 2002;162Oliveria et al, Arch Intern Med 2002;162

Facts about health innovation and Facts about health innovation and their application their application (Cont’d)(Cont’d)

Knowledge and awareness are not the Knowledge and awareness are not the same as doingsame as doing

About 76% aware and agree with JNC-VIAbout 76% aware and agree with JNC-VI

About 76% report usually following JNC About 76% report usually following JNC recommendationsrecommendations

About 61% report being satisfied with control About 61% report being satisfied with control of BPof BP

Yet only 35% of patients have SBP < 150 Yet only 35% of patients have SBP < 150 mmHgmmHg

There are questions about measurementThere are questions about measurement

CAREGAP is reported to be about 41%CAREGAP is reported to be about 41%

Selected Factors that Influence Selected Factors that Influence Dissemination and Implementation of Dissemination and Implementation of

InnovationInnovationSystems of Care Systems of Care

Access to careAccess to care

CoverageCoverage

Marketing influencesMarketing influences

ProviderProviderLack of knowledgeLack of knowledge

Lack of convictionLack of conviction

ForgetfulnessForgetfulness

Innovation biasInnovation bias

Marketing influencesMarketing influences

Patient LevelPatient LevelPreferencesPreferences

SymptomsSymptoms

Marketing InfluencesMarketing Influences

The Lancet. 362 October 25, 2003The Lancet. 362 October 25, 2003

Most Common Influencing FactorsMost Common Influencing Factors

Marketing Marketing InfluencesInfluences

The Lancet. 362 October 25, 2003The Lancet. 362 October 25, 2003

Marketing InfluencesMarketing Influences

NHLBI Dissemination PolicyNHLBI Dissemination Policy

Evolved and finalized during ALLHATEvolved and finalized during ALLHAT

Realization that traditional Realization that traditional approaches not fully effectiveapproaches not fully effective

Requires a detailed dissemination Requires a detailed dissemination plan for trials with potential for plan for trials with potential for immediate public health applicabilityimmediate public health applicability

Includes a requirement for evaluation Includes a requirement for evaluation of dissemination planof dissemination plan

ALLHAT First and UniqueALLHAT First and Unique

Unique features and challengesUnique features and challengesFirst trial completed under the new policyFirst trial completed under the new policy

ALLHAT Steering Committee packaged and ALLHAT Steering Committee packaged and published recommendations based on trial published recommendations based on trial resultresult

NHLBI has an existing HBP education NHLBI has an existing HBP education infrastructure (NHBPEP)infrastructure (NHBPEP)

JNC has packaged recommendations based JNC has packaged recommendations based on a synthesis of all available evidence in on a synthesis of all available evidence in HBP prevention and treatmentHBP prevention and treatment

Dissemination plan Dissemination plan mustmust meld both meld both

Branding of the Dissemination Branding of the Dissemination ProjectProject

Improving Blood Pressure Improving Blood Pressure Treatment in the Community: A Treatment in the Community: A Joint Project of the NHBPEP and Joint Project of the NHBPEP and ALLHAT Collaborative Research ALLHAT Collaborative Research

GroupGroup

Dissemination Proposal Dissemination Proposal FeaturesFeatures

Furthers traditional approachesFurthers traditional approachesPress release/press conferencePress release/press conference

Media coverage (usually short bursts)Media coverage (usually short bursts)

Presentation at scientific meetingsPresentation at scientific meetings

Publications in peer-reviewed journalsPublications in peer-reviewed journals

Utilizes academic detailing approaches Utilizes academic detailing approaches and based on intervention mapping theoryand based on intervention mapping theory

Health care providersHealth care providers

Formulary systems approachFormulary systems approach

Patient-oriented approach through PSAsPatient-oriented approach through PSAs

Prespecified evaluation componentPrespecified evaluation component

Dissemination Proposal Dissemination Proposal FeaturesFeatures

Health Care ProvidersHealth Care Providers– ALLHAT Regional OfficesALLHAT Regional Offices

200 Investigator Educators (15 details each)200 Investigator Educators (15 details each)

39,000 providers (13 contacts per detail)39,000 providers (13 contacts per detail)

Cues to action (Office posters and script Cues to action (Office posters and script cards)cards)

Direct to Patient ApproachesDirect to Patient Approaches– PSAPSA

Patient cue to provider on BP levelPatient cue to provider on BP level

Patient cue to provider on use of diureticsPatient cue to provider on use of diuretics

Dissemination Proposal Dissemination Proposal FeaturesFeatures

Formulary System ModificationFormulary System Modification– Persuasion through personal contactPersuasion through personal contact

10 major health plans10 major health plans

MedicaidMedicaid

Medicare (eventually)Medicare (eventually)

Professional Community InfluenceProfessional Community Influence– Persuasion via peer contactPersuasion via peer contact

Personal lettersPersonal letters

Association newslettersAssociation newsletters

Dissemination Proposal Dissemination Proposal FeaturesFeatures

Prespecified measures of successPrespecified measures of success– Process EvaluationProcess Evaluation

Deliverable program componentsDeliverable program components

– Outcomes EvaluationOutcomes EvaluationTrend analysis of prescribing practices Trend analysis of prescribing practices (nationally and within a specific health (nationally and within a specific health system) system)

Blood pressure control rates (specific health Blood pressure control rates (specific health system)system)

Update on Current ALLHAT Update on Current ALLHAT Dissemination Activities Dissemination Activities

200 presentations200 presentations

ManuscriptsManuscripts15 published15 published

37 in process37 in process

Dissemination aidsDissemination aidsReprintsReprints

SlidesSlides

NewsletterNewsletter

Dear colleague Dear colleague lettersletters

Frequently asked Frequently asked questionsquestions

MediaMediaPrintPrint

RadioRadio

TVTV

Internet messagesInternet messages

Guideline InputGuideline InputNHLBI JNC-7NHLBI JNC-7

Canadian BP Canadian BP GuidelinesGuidelines

NKF GuidelinesNKF Guidelines

Update on Current ALLHAT Update on Current ALLHAT Dissemination ActivitiesDissemination Activities

ALLHAT WebsitesALLHAT Websites– 89,000 users89,000 users– 2,230,341 hits2,230,341 hits

NHLBINHLBI

NHBPEP Coordinating Committee NHBPEP Coordinating Committee member organizationsmember organizations

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

Q1-02 Q2-02 Q3-02 Q4-02 Q1-03 Q2-03 Q3-03

ACEIs TotalACEIs Total

CCBs TotalCCBs Total

Diur TotalDiur Total

To

tal P

resc

rip

tio

ns

To

tal P

resc

rip

tio

ns

ALLHAT

*Source: IMS Health, National Prescription Audit Plus TM, 2003*Source: IMS Health, National Prescription Audit Plus TM, 2003 #Projected Q3-03#Projected Q3-03

Drug Utilization by ClassDrug Utilization by Class

#

#

#

Update on Current ALLHAT Update on Current ALLHAT Dissemination ActivitiesDissemination Activities

ALLHAT/JNC Dissemination PlanALLHAT/JNC Dissemination Plan

What is the process going forward?What is the process going forward?ALLHAT Dissemination Committee and the ALLHAT Dissemination Committee and the ALLHAT Clinical Trials Center revising ALLHAT Clinical Trials Center revising proposalproposal

ALLHAT Steering Committee will review ALLHAT Steering Committee will review revisionsrevisions

NHLBI will review proposalNHLBI will review proposal

JNC-7 Executive Committee group will JNC-7 Executive Committee group will review the proposed core messages review the proposed core messages

Field implementationField implementation

ALLHAT Dissemination PlanALLHAT Dissemination Plan

ALLHAT Dissemination PlanALLHAT Dissemination Plan

Dr. Paul K. Whelton, Chair of ALLHAT Dr. Paul K. Whelton, Chair of ALLHAT Dissemination Committee, quoted in a Dissemination Committee, quoted in a recent Lancet on the subject of ALLHAT recent Lancet on the subject of ALLHAT disseminationdissemination