1
|
Ordunez P, Campbell NRC, DiPette DJ, Jaffe MG, Rosende A, Martinez R, Gamarra A, Lombardi C, Parra N, Rodriguez L, Rodriguez Y, Brettler J. HEARTS in the Americas: Targeting Health System Change to Improve Population Hypertension Control. Curr Hypertens Rep 2024; 26:141-156. [PMID: 38041725 PMCID: PMC10904446 DOI: 10.1007/s11906-023-01286-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE OF REVIEW HEARTS in the Americas is the regional adaptation of Global Hearts, the World Health Organization initiative for cardiovascular disease (CVD) prevention and control. Its overarching goal is to drive health services to change managerial and clinical practice in primary care settings to improve hypertension control and CVD risk management. This review describes the HEARTS in the Americas initiative. First, the regional epidemiological situation of CVD mortality and population hypertension control trends are summarized; then the rationale for its main intervention components: the primary care-oriented management system and the HEARTS Clinical Pathway are described. Finally, the key factors for accelerating the expansion of HEARTS are examined: medicines, team-based care, and a system for monitoring and evaluation. RECENT FINDINGS Thus far, 33 countries in Latin America and the Caribbean have committed to integrating this program across their primary healthcare network by 2025. The increase in hypertension coverage and control in primary health care settings compared with the traditional model is promising and confirms that the interventions under the HEARTS umbrella are feasible and acceptable to communities, patients, providers, decision-makers, and funders. This review highlights some cases of successful implementation. Scaling up effective treatment for hypertension and optimization of CVD risk management is a pragmatic way to accelerate the reduction of CVD mortality while strengthening primary healthcare systems to respond effectively, with quality, and equitably, to the challenge of non-communicable diseases, not only in low-middle income countries but in all communities globally.
Collapse
Affiliation(s)
- Pedro Ordunez
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA.
| | - Norm R C Campbell
- Department of Medicine, Libin Cardiovascular Institute, The University of Calgary, Calgary, AB, T2N 1N4, Canada
| | - Donald J DiPette
- University of South Carolina and University of South Carolina School of Medicine, Columbia, SC, USA
| | - Marc G Jaffe
- Department of Endocrinology, The Permanente Medical Group, Kaiser San Francisco Medical Center, San Francisco, CA, USA
| | - Andres Rosende
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA
| | - Ramon Martinez
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA
| | - Angelo Gamarra
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA
| | - Cintia Lombardi
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA
| | - Natalia Parra
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA
| | - Libardo Rodriguez
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA
| | - Yenny Rodriguez
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA
| | - Jeffrey Brettler
- Southern California Permanente Medical Group, Department of Health Systems Science, Regional Hypertension Program, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, USA
| |
Collapse
|
2
|
Ordunez P, Campbell NRC, DiPette DJ, Jaffe MG, Rosende A, Martínez R, Gamarra A, Lombardi C, Parra N, Rodríguez L, Rodríguez Y, Brettler J. [HEARTS in the Americas: targeting health system change to improve population hypertension controlHEARTS nas Américas: impulsionar mudanças no sistema de saúde para melhorar o controle da hipertensão arterial na população]. Rev Panam Salud Publica 2024; 48:e17. [PMID: 38464870 PMCID: PMC10924616 DOI: 10.26633/rpsp.2024.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/02/2023] [Indexed: 03/12/2024] Open
Abstract
Purpose of review HEARTS in the Americas is the regional adaptation of Global Hearts, the World Health Organization initiative for cardiovascular disease (CVD) prevention and control. Its overarching goal is to drive health services to change managerial and clinical practice in primary care settings to improve hypertension control and CVD risk management. This review describes the HEARTS in the Americas initiative. First, the regional epidemiological situation of CVD mortality and population hypertension control trends are summarized; then the rationale for its main intervention components: the primary care-oriented management system and the HEARTS Clinical Pathway are described. Finally, the key factors for accelerating the expansion of HEARTS are examined: medicines, team-based care, and a system for monitoring and evaluation. Recent findings Thus far, 33 countries in Latin America and the Caribbean have committed to integrating this program across their primary healthcare network by 2025. The increase in hypertension coverage and control in primary health care settings compared with the traditional model is promising and confirms that the interventions under the HEARTS umbrella are feasible and acceptable to communities, patients, providers, decision-makers, and funders. This review highlights some cases of successful implementation. Summary Scaling up effective treatment for hypertension and optimization of CVD risk management is a pragmatic way to accelerate the reduction of CVD mortality while strengthening primary healthcare systems to respond effectively, with quality, and equitably, to the challenge of non-communicable diseases, not only in low-middle income countries but in all communities globally.
Collapse
Affiliation(s)
- Pedro Ordunez
- Departamento de Enfermedades no Transmisibles y Salud MentalOrganización Panamericana de la SaludWashington, D.C.Estados Unidos de AméricaDepartamento de Enfermedades no Transmisibles y Salud Mental, Organización Panamericana de la Salud, Washington, D.C., Estados Unidos de América.
| | - Norm R. C. Campbell
- Departamento de MedicinaInstituto Cardiovascular LibinUniversidad de CalgaryCalgaryAB T2N 1N4CanadáDepartamento de Medicina, Instituto Cardiovascular Libin, Universidad de Calgary, Calgary, AB T2N 1N4, Canadá.
| | - Donald J. DiPette
- Universidad de Carolina del SurFacultad de Medicina de la Universidad de Carolina del SurColumbiaEstados Unidos de AméricaUniversidad de Carolina del Sur y Facultad de Medicina de la Universidad de Carolina del Sur, Columbia, Estados Unidos de América.
| | - Marc G. Jaffe
- Departamento de EndocrinologíaThe Permanente Medical GroupCentro Médico de San Francisco de Kaiser PermanenteSan FranciscoEstados Unidos de AméricaDepartamento de Endocrinología, The Permanente Medical Group, Centro Médico de San Francisco de Kaiser Permanente, San Francisco, Estados Unidos de América.
| | - Andrés Rosende
- Departamento de Enfermedades no Transmisibles y Salud MentalOrganización Panamericana de la SaludWashington, D.C.Estados Unidos de AméricaDepartamento de Enfermedades no Transmisibles y Salud Mental, Organización Panamericana de la Salud, Washington, D.C., Estados Unidos de América.
| | - Ramón Martínez
- Departamento de Enfermedades no Transmisibles y Salud MentalOrganización Panamericana de la SaludWashington, D.C.Estados Unidos de AméricaDepartamento de Enfermedades no Transmisibles y Salud Mental, Organización Panamericana de la Salud, Washington, D.C., Estados Unidos de América.
| | - Angelo Gamarra
- Departamento de Enfermedades no Transmisibles y Salud MentalOrganización Panamericana de la SaludWashington, D.C.Estados Unidos de AméricaDepartamento de Enfermedades no Transmisibles y Salud Mental, Organización Panamericana de la Salud, Washington, D.C., Estados Unidos de América.
| | - Cintia Lombardi
- Departamento de Enfermedades no Transmisibles y Salud MentalOrganización Panamericana de la SaludWashington, D.C.Estados Unidos de AméricaDepartamento de Enfermedades no Transmisibles y Salud Mental, Organización Panamericana de la Salud, Washington, D.C., Estados Unidos de América.
| | - Natalia Parra
- Departamento de Enfermedades no Transmisibles y Salud MentalOrganización Panamericana de la SaludWashington, D.C.Estados Unidos de AméricaDepartamento de Enfermedades no Transmisibles y Salud Mental, Organización Panamericana de la Salud, Washington, D.C., Estados Unidos de América.
| | - Libardo Rodríguez
- Departamento de Enfermedades no Transmisibles y Salud MentalOrganización Panamericana de la SaludWashington, D.C.Estados Unidos de AméricaDepartamento de Enfermedades no Transmisibles y Salud Mental, Organización Panamericana de la Salud, Washington, D.C., Estados Unidos de América.
| | - Yenny Rodríguez
- Departamento de Enfermedades no Transmisibles y Salud MentalOrganización Panamericana de la SaludWashington, D.C.Estados Unidos de AméricaDepartamento de Enfermedades no Transmisibles y Salud Mental, Organización Panamericana de la Salud, Washington, D.C., Estados Unidos de América.
| | - Jeffrey Brettler
- Southern California Permanent Medical GroupDepartamento de Ciencias de Sistemas de SaludPrograma Regional de Hipertensión, Facultad de Medicina Bernard J. Tyson de Kaiser PermanentePasadenaEstados Unidos de AméricaSouthern California Permanent Medical Group, Departamento de Ciencias de Sistemas de Salud, Programa Regional de Hipertensión, Facultad de Medicina Bernard J. Tyson de Kaiser Permanente, Pasadena, Estados Unidos de América.
| |
Collapse
|
3
|
Abdalla M, Bolen SD, Brettler J, Egan BM, Ferdinand KC, Ford CD, Lackland DT, Wall HK, Shimbo D. Implementation Strategies to Improve Blood Pressure Control in the United States: A Scientific Statement From the American Heart Association and American Medical Association. Hypertension 2023; 80:e143-e157. [PMID: 37650292 PMCID: PMC10578150 DOI: 10.1161/hyp.0000000000000232] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Hypertension is one of the most important risk factors that contribute to incident cardiovascular events. A multitude of US and international hypertension guidelines, scientific statements, and policy statements have recommended evidence-based approaches for hypertension management and improved blood pressure (BP) control. These recommendations are based largely on high-quality observational and randomized controlled trial data. However, recent published data demonstrate troubling temporal trends with declining BP control in the United States after decades of steady improvements. Therefore, there is a widening disconnect between what hypertension experts recommend and actual BP control in practice. This scientific statement provides information on the implementation strategies to optimize hypertension management and to improve BP control among adults in the United States. Key approaches include antiracism efforts, accurate BP measurement and increased use of self-measured BP monitoring, team-based care, implementation of policies and programs to facilitate lifestyle change, standardized treatment protocols using team-based care, improvement of medication acceptance and adherence, continuous quality improvement, financial strategies, and large-scale dissemination and implementation. Closing the gap between scientific evidence, expert recommendations, and achieving BP control, particularly among disproportionately affected populations, is urgently needed to improve cardiovascular health.
Collapse
|
4
|
Prado P, Gamarra Á, Rodríguez L, Brettler J, Farrell M, Girola ME, Malcolm T, Martínez R, Molina V, Moran AE, Neupane D, Rosende A, Valdés González Y, Mukhtar Q, Ordunez P. [Monitoring and evaluation platform for HEARTS in the Americas: improving population-based hypertension control programs in primary health carePlataforma de monitoramento e avaliação do programa HEARTS nas Américas: melhoria dos programas de controle da hipertensão de base populacional na atenção primária à saúde]. Rev Panam Salud Publica 2023; 47:e90. [PMID: 37223327 PMCID: PMC10202337 DOI: 10.26633/rpsp.2023.90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 07/15/2022] [Indexed: 05/25/2023] Open
Abstract
HEARTS in the Americas is the Pan American Health Organization flagship program to accelerate the reduction of the cardiovascular disease (CVD) burden by improving hypertension control and CVD secondary prevention in primary health care. A monitoring and evaluation (M&E) platform is needed for program implementation, benchmarking, and informing policy-makers. This paper describes the conceptual bases of the HEARTS M&E platform including software design principles, contextualization of data collection modules, data structure, reporting, and visualization. The District Health Information Software 2 (DHIS2) web-based platform was chosen to implement aggregate data entry of CVD outcome, process, and structural risk factor indicators. In addition, PowerBI was chosen for data visualization and dashboarding for the analysis of performance and trends above the health care facility level. The development of this new information platform was focused on primary health care facility data entry, timely data reporting, visualizations, and ultimately active use of data to drive decision-making for equitable program implementation and improved quality of care. Additionally, lessons learnt and programmatic considerations were assessed through the experience of the M&E software development. Building political will and support is essential to developing and deploying a flexible platform in multiple countries which is contextually specific to the needs of various stakeholders and levels of the health care system. The HEARTS M&E platform supports program implementation and reveals structural and managerial limitations and care gaps. The HEARTS M&E platform will be central to monitoring and driving further population-level improvements in CVD and other noncommunicable disease-related health.
Collapse
Affiliation(s)
- Patric Prado
- Organización Panamericana de la SaludWashington, D.C.Estados Unidos de AméricaOrganización Panamericana de la Salud. Washington, D.C., Estados Unidos de América.
| | - Ángelo Gamarra
- Organización Panamericana de la SaludWashington, D.C.Estados Unidos de AméricaOrganización Panamericana de la Salud. Washington, D.C., Estados Unidos de América.
| | - Libardo Rodríguez
- Organización Panamericana de la SaludWashington, D.C.Estados Unidos de AméricaOrganización Panamericana de la Salud. Washington, D.C., Estados Unidos de América.
| | - Jeffrey Brettler
- Departamento de Ciencias de Sistemas de SaludFacultad de Medicina Bernard J. Tyson de Kaiser PermanentePasadenaEstados Unidos de AméricaDepartamento de Ciencias de Sistemas de Salud, Facultad de Medicina Bernard J. Tyson de Kaiser Permanente, Pasadena, Estados Unidos de América.
| | - Margaret Farrell
- Resolve to Save LivesNueva YorkEstados Unidos de AméricaResolve to Save Lives, Nueva York, Estados Unidos de América.
| | - María E. Girola
- Organización Panamericana de la SaludWashington, D.C.Estados Unidos de AméricaOrganización Panamericana de la Salud. Washington, D.C., Estados Unidos de América.
| | - Taraleen Malcolm
- Organización Panamericana de la SaludPuerto EspañaTrinidad y TobagoOrganización Panamericana de la Salud, Puerto España, Trinidad y Tobago.
| | - Ramón Martínez
- Organización Panamericana de la SaludWashington, D.C.Estados Unidos de AméricaOrganización Panamericana de la Salud. Washington, D.C., Estados Unidos de América.
| | - Virginia Molina
- Organización Panamericana de la SaludCiudad de MéxicoMéxicoOrganización Panamericana de la Salud, Ciudad de México, México.
| | - Andrew E. Moran
- Resolve to Save LivesNueva YorkEstados Unidos de AméricaResolve to Save Lives, Nueva York, Estados Unidos de América.
| | - Dinesh Neupane
- Departamento de EpidemiologíaEscuela de Salud Pública Bloomberg de la Universidad Johns HopkinsBaltimoreEstados Unidos de AméricaDepartamento de Epidemiología, Escuela de Salud Pública Bloomberg de la Universidad Johns Hopkins, Baltimore, Estados Unidos de América.
| | - Andrés Rosende
- Organización Panamericana de la SaludWashington, D.C.Estados Unidos de AméricaOrganización Panamericana de la Salud. Washington, D.C., Estados Unidos de América.
| | - Yamilé Valdés González
- Hospital Universitario General Calixto GarcíaComisión Nacional Técnica Asesora del Programa de Hipertensión ArterialLa HabanaCubaHospital Universitario General Calixto García, Comisión Nacional Técnica Asesora del Programa de Hipertensión Arterial, La Habana, Cuba.
| | - Qaiser Mukhtar
- División de Protección de la Salud MundialCentros para el Control y la Prevención de EnfermedadesAtlantaEstados Unidos de AméricaDivisión de Protección de la Salud Mundial, Centros para el Control y la Prevención de Enfermedades, Atlanta, Estados Unidos de América.
| | - Pedro Ordunez
- Organización Panamericana de la SaludWashington, D.C.Estados Unidos de AméricaOrganización Panamericana de la Salud. Washington, D.C., Estados Unidos de América.
| |
Collapse
|
5
|
Harrison TN, Zhou H, Wei R, Brettler J, Muntner P, An J, Ong-Su AL, Reynolds K. Blood Pressure Control Among Black and White Adults Following a Quality Improvement Program in a Large Integrated Health System. JAMA Netw Open 2023; 6:e2249930. [PMID: 36607636 PMCID: PMC9856959 DOI: 10.1001/jamanetworkopen.2022.49930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE A higher percentage of non-Hispanic Black (hereinafter, Black) adults vs non-Hispanic White (hereinafter, White) adults with hypertension have uncontrolled blood pressure (BP) contributing to racial and ethnic disparities in cardiovascular disease. In 2010, Kaiser Permanente Southern California began implementing quality improvement (QI) strategies aimed at reducing this disparity. OBJECTIVE To examine the change in BP control between Black and White patients before and after the implementation of a QI program. DESIGN, SETTING, AND PARTICIPANTS A QI quasi-experimental, difference-in-difference analysis was conducted of Kaiser Permanente Southern California patients 18 years or older included in the population care management hypertension registry. The study was conducted from December 31, 2008, to December 31, 2019. Data analysis was performed from November 20, 2020, to November 7, 2022. INTERVENTIONS Quality improvement program implementation began in 2010. MAIN OUTCOMES AND MEASURES Blood pressure control (systolic BP <140 mm Hg and diastolic BP <90 mm Hg) was assessed using the last outpatient BP measurement in each calendar year. Changes in BP control between Black and White patients from before (2008-2009) to after (2016-2019) implementation of the QI program were examined using a difference-in-difference analysis. Blood pressure control disparities from 2008 through 2019 by age, sex, race and ethnicity, and factors associated with BP control were examined. RESULTS The number of patients with hypertension increased from 624 094 in 2008 (mean [SD] age, 61.8 [13.5] years; 330 551 [53.0%] female patients; 89 407 [14.3%] Black and 284 116 [45.5%] White patients) to 855 257 in 2019 (mean [SD] age, 64.5 [13.6] years; 444 422 [52.0%] female patients; 107 054 [12.5%] Black and 331 932 [38.8%] White patients). Blood pressure control increased an absolute 4.6% (95% CI, 4.3%-4.8%) among Black patients and 2.1% (95% CI, 2.0%-2.2%) among White patients from before to after the QI program implementation (difference-in-difference: 2.5%; 95% CI, 2.2%-2.8%). The largest reduction in BP control disparity between Black and White female patients was for those aged 50 to 64 years (difference-in-difference: 3.8%; 95% CI, 3.2%-4.4%) and for those aged 18 to 49 years between Black and White male patients (difference-in-difference: 4.2%; 95% CI, 3.0%-5.5%). The proportion of BP control among Black male patients aged 18 to 49 years was the lowest throughout 2008-2019 compared with male and female patients in other age and racial and ethnic groups. In 2019, uncontrolled BP was more common among Black vs White patients (prevalence ratio: 1.13; 95% CI, 1.12-1.14). CONCLUSIONS AND RELEVANCE This QI program noted that disparities in BP control between Black and White patients were decreased but not eliminated following implementation of QI strategies aimed at reducing disparities in BP control. These findings suggest that more focused interventions may be needed to increase BP control among Black individuals.
Collapse
Affiliation(s)
- Teresa N. Harrison
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Hui Zhou
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Rong Wei
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Jeffrey Brettler
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
- Kaiser Permanente West Los Angeles Medical Center, Los Angeles, California
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham
| | - Jaejin An
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Angeline L. Ong-Su
- Kaiser Permanente Panorama City Medical Center, Panorama City, California
| | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| |
Collapse
|
6
|
Reynolds K, Harrison TN, Zhou H, Wei R, Brettler J, Su ALO, An J, Sanders M, Muntner P. PS-P03-2: RACIAL AND ETHNIC DISPARITIES IN HYPERTENSION CONTROL IN AN INTEGRATED HEALTHCARE SYSTEM IN THE UNITED STATES, 2008–2019. J Hypertens 2023. [DOI: 10.1097/01.hjh.0000915192.04460.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|
7
|
Prado P, Gamarra A, Rodriguez L, Brettler J, Farrell M, Girola ME, Malcolm T, Martinez R, Molina V, Moran AE, Neupane D, Rosende A, González YV, Mukhtar Q, Ordunez P. Monitoring and evaluation platform for HEARTS in the Americas: improving population-based hypertension control programs in primary health care. Rev Panam Salud Publica 2022; 46:e161. [PMID: 36133432 PMCID: PMC9484330 DOI: 10.26633/rpsp.2022.161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 07/15/2022] [Indexed: 02/07/2023] Open
Abstract
ABSTRACT
HEARTS in the Americas is the Pan American Health Organization flagship program to accelerate the reduction of the cardiovascular disease (CVD) burden by improving hypertension control and CVD secondary prevention in primary health care. A monitoring and evaluation (M&E) platform is needed for program implementation, benchmarking, and informing policy-makers. This paper describes the conceptual bases of the HEARTS M&E platform including software design principles, contextualization of data collection modules, data structure, reporting, and visualization. The District Health Information Software 2 (DHIS2) web-based platform was chosen to implement aggregate data entry of CVD outcome, process, and structural risk factor indicators. In addition, PowerBI was chosen for data visualization and dashboarding for the analysis of performance and trends above the health care facility level. The development of this new information platform was focused on primary health care facility data entry, timely data reporting, visualizations, and ultimately active use of data to drive decision-making for equitable program implementation and improved quality of care. Additionally, lessons learnt and programmatic considerations were assessed through the experience of the M&E software development. Building political will and support is essential to developing and deploying a flexible platform in multiple countries which is contextually specific to the needs of various stakeholders and levels of the health care system. The HEARTS M&E platform supports program implementation and reveals structural and managerial limitations and care gaps. The HEARTS M&E platform will be central to monitoring and driving further population-level improvements in CVD and other noncommunicable disease-related health.
Collapse
Affiliation(s)
- Patric Prado
- Pan American Health Organization. Washington, DC, USA
| | | | | | - Jeffrey Brettler
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, United States of America
| | | | | | - Taraleen Malcolm
- Pan American Health Organization, Port of Spain, Trinidad and Tobago
| | | | | | | | - Dinesh Neupane
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | | | - Yamilé Valdés González
- University Hospital General Calixto García, National Technical Advisory Committee on Hypertension, Havana, Cuba
| | - Qaiser Mukhtar
- Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, United States of America
| | - Pedro Ordunez
- Pan American Health Organization. Washington, DC, USA
| |
Collapse
|
8
|
Rosende A, DiPette D, Brettler J, Rodríguez G, Zuniga E, Connell K, Ordunez P. HEARTS in the Americas appraisal checklist and clinical pathway for comprehensive hypertension management in primary care. Rev Panam Salud Publica 2022; 46:e125. [PMID: 36071921 PMCID: PMC9440731 DOI: 10.26633/rpsp.2022.125] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/16/2022] [Indexed: 01/10/2023] Open
Abstract
ABSTRACT
Cardiovascular diseases are the leading cause of mortality and morbidity in the Region of the Americas, and hypertension represents its main risk factor. However, population hypertension control rates in the Region are poor. Global Hearts is the World Health Organization's flagship initiative to reduce the burden of cardiovascular diseases. HEARTS in the Americas Initiative is its regional adaptation that seeks to be the cardiovascular disease risk management model, including hypertension and diabetes, in primary health care throughout the Americas by 2025.
HEARTS in the Americas is being implemented in 22 countries and over 2 095 primary care centers. All implementing countries have defined their treatment protocols, and HEARTS in the Americas has supported continuous improvement. Because WHO recently released the 2021 Guideline for the Pharmacological Treatment of Hypertension in Adults and HEARTS in the Americas introduced the key drivers for hypertension control, the initiative generated a methodology to help countries update and strengthen their treatment protocols.
This article describes the process of developing the treatment protocol appraisal checklist and defines the resulting clinical pathway. This tool can help countries and primary care centers to improve their protocols by identifying the improvement points and upgrading clinical pathways.
Collapse
Affiliation(s)
- Andres Rosende
- Pan American Health Organization, Washington, D.C., United States of America
| | - Donald DiPette
- University of South Carolina, Columbia, United States of America
| | - Jeffrey Brettler
- Southern California Permanente Medical Group, Los Angeles, United States of America
| | | | - Eric Zuniga
- University of Antofagasta, Antofagasta, Chile
| | | | - Pedro Ordunez
- Pan American Health Organization, Washington, D.C., United States of America
| |
Collapse
|
9
|
Harrison TN, Reynolds K, Hahn EE, Munoz-Plaza CE, Yi DK, Fischer H, Luong TQ, Sim JJ, Brettler J, Handler J, Mittman BS, Singh H, Kanter MH, Danforth KN. Laboratory monitoring to reduce adverse drug-related events: a mixed methods study. J Manag Care Spec Pharm 2022; 28:16-25. [PMID: 34949121 PMCID: PMC10398702 DOI: 10.18553/jmcp.2022.28.1.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Therapy with angiotensinconverting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) requires laboratory monitoring to avoid hyperkalemia and acute kidney failure. OBJECTIVE: To assess the frequency of recommended annual serum potassium and creatinine monitoring and determine potential factors associated with care gaps among adults dispensed an ACEI or ARB. METHODS: This mixed-methods study integrated findings from a retrospective cohort study and individual patient interviews. Adults aged 21 years and over within Kaiser Permanente Southern California with at least 180 treatment days of an ACEI and/or ARB in 2015 were included. Patients invited for qualitative interviews included those who did and did not complete the recommended laboratory tests. We assessed the proportion of patients completing both recommended laboratory tests, factors associated with not receiving laboratory monitoring, and patients' insights into barriers and facilitators of recommended monitoring. RESULTS: Of 437,544 patients who received an ACEI or ARB, 9.0% did not receive both a serum potassium and creatinine laboratory test during treatment (defined as a care gap). Lower risk of a care gap was observed for patients with increasing age (rate ratio [RR] per 10-year increase = 0.78, 95% CI = 0.77-0.79); diabetes mellitus (RR = 0.62, 95% CI = 0.60-0.64); hypertension (RR = 0.71, 95% CI = 0.71-0.74); Charlson Comorbidity Index score of at least 2 (RR = 0.62, 95% CI = 0.60-0.64); those who changed medication classes (RR = 0.53, 95% CI = 0.51-0.56); and patients with a cardiologist (RR = 0.81, 95% CI = 0.73-0.90) or nephrologist (RR = 0.60, 95% CI = 0.52-0.69) as their prescribing provider. Twenty-five patients completed the qualitative interviews. Patients often lacked knowledge about the need for laboratory monitoring, cited logistical barriers to accessing the laboratory, and deemed the reminders they received through an outpatient safety program as a facilitator to completing tests. CONCLUSIONS: Given the large patient population on ACEI and ARB medications, monitoring and support strategies such as electronic clinical surveillance could be important in addressing care gaps and potentially reducing adverse drug effects. DISCLOSURES: This project was supported by grant number R01HS024437 from the Agency for Healthcare Research and Quality. The funder had no role in the design of the study; collection, analyses, or interpretation of the data, or decision to submit this manuscript for publication. Harrison, Reynolds, Hahn, Munoz-Plaza, Yi, Fischer, Luong, Sim, Brettler, Handler, and Mittman are employees of the Southern California Permanente Medical Group. Danworth was employed by the Southern California Permanente Medical Group at the time of this study. Singh was partially supported by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN13-413). Reynolds reports grants from Novartis, Amgen Inc., and Vital Strategies, Resolve to Save Lives, unrelated to this work. Yi reports grants from Novartis unrelated to this work. Kanter has nothing to disclose.
Collapse
Affiliation(s)
- Teresa N Harrison
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, and Department of Health Systems Science, Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA
| | - Erin E Hahn
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Corrine E Munoz-Plaza
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - David K Yi
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Heidi Fischer
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Tiffany Q Luong
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Jeffrey Brettler
- Kaiser Permanente West Los Angeles Medical Center, Los Angeles, CA
| | - Joel Handler
- Southern California Permanente Medical Group, Yorba Linda
| | - Brian S Mittman
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center; Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Michael H Kanter
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Kim N Danforth
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| |
Collapse
|
10
|
An J, Luong T, Qian L, Wei R, Liu R, Muntner P, Brettler J, Jaffe MG, Moran AE, Reynolds K. Treatment Patterns and Blood Pressure Control With Initiation of Combination Versus Monotherapy Antihypertensive Regimens. Hypertension 2020; 77:103-113. [PMID: 33190560 DOI: 10.1161/hypertensionaha.120.15462] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Many patients with hypertension require 2 or more drug classes to achieve their blood pressure (BP) goal. We compared antihypertensive medication treatment patterns and BP control between patients who initiated combination therapy versus monotherapy. We identified adults with hypertension enrolled in a US integrated healthcare system who initiated antihypertensive medication between 2008 and 2014. Patient demographics, clinical characteristics, antihypertensive medication, and BP were extracted from electronic health records. Antihypertensive medication patterns and multivariable adjusted prevalence ratios (PRs) of achieving the 2017 American College of Cardiology/American Heart Association guideline-recommended BP <130/80 mm Hg were evaluated for 2 years following treatment initiation. Of 135 971 patients, 43% initiated antihypertensive combination therapy (35% ACE [angiotensin converting enzyme] inhibitor (ACEI)-thiazide diuretics; 8% with other combinations) and 57% initiated monotherapy (22% ACEIs; 16% thiazide diuretics; 11% β blockers; 8% calcium channel blockers). After multivariable adjustment including premedication BP levels, patients who initiated ACEI-thiazide diuretic combination therapy were more likely to achieve BP <130/80 mm Hg compared with their counterparts who initiated monotherapy with ACEI (PR, 1.10 [95% CI, 1.08-1.12]), thiazide diuretic (PR, 1.21 [95% CI, 1.18-1.24]), β blocker (PR, 1.17 [95% CI, 1.14-1.20]), or calcium channel blocker (PR, 1.25 [95% CI, 1.22-1.29]). Compared with initiating monotherapy, patients initiating ACEI-thiazide diuretic combination therapy were more likely to achieve BP goals.
Collapse
Affiliation(s)
- Jaejin An
- From the Kaiser Permanente Southern California, Pasadena, CA (J.A., T.L., L.Q., R.W., R.L., K.R.)
| | - Tiffany Luong
- From the Kaiser Permanente Southern California, Pasadena, CA (J.A., T.L., L.Q., R.W., R.L., K.R.)
| | - Lei Qian
- From the Kaiser Permanente Southern California, Pasadena, CA (J.A., T.L., L.Q., R.W., R.L., K.R.)
| | - Rong Wei
- From the Kaiser Permanente Southern California, Pasadena, CA (J.A., T.L., L.Q., R.W., R.L., K.R.)
| | - Ran Liu
- From the Kaiser Permanente Southern California, Pasadena, CA (J.A., T.L., L.Q., R.W., R.L., K.R.)
| | | | - Jeffrey Brettler
- Southern California Permanente Medical Group, Los Angeles (J.B.)
| | - Marc G Jaffe
- The Permanente Medical Group, San Francisco, CA (M.G.J.)
| | - Andrew E Moran
- Resolve to Save Lives, an Initiative of Vital Strategies, New York City (A.E.M.).,Division of General Medicine, Columbia University Irving Medical Center, New York City (A.E.M.)
| | - Kristi Reynolds
- From the Kaiser Permanente Southern California, Pasadena, CA (J.A., T.L., L.Q., R.W., R.L., K.R.).,Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA (K.R.)
| |
Collapse
|
11
|
DiPette DJ, Goughnour K, Zuniga E, Skeete J, Ridley E, Angell S, Brettler J, Campbell NRC, Coca A, Connell K, Doon R, Jaffe M, Lopez-Jaramillo P, Moran A, Orias M, Pineiro DJ, Rosende A, González YV, Ordunez P. Standardized treatment to improve hypertension control in primary health care: The HEARTS in the Americas Initiative. J Clin Hypertens (Greenwich) 2020; 22:2285-2295. [PMID: 33045133 DOI: 10.1111/jch.14072] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/03/2020] [Accepted: 09/13/2020] [Indexed: 01/12/2023]
Abstract
Hypertension is the leading risk factor for cardiovascular disease (CVD) worldwide. Despite the availability of effective antihypertensive medications, the control of hypertension at a global level is dismal, and consequently, the CVD burden continues to increase. In response, countries in Latin America and the Caribbean are implementing the HEARTS in the Americas, a community-based program that focuses on increasing hypertension control and CVD secondary prevention through risk factor mitigation. One key pillar is the implementation of a standardized hypertension treatment protocol supported by a small, high-quality formulary. This manuscript describes the methodology used by the HEARTS in the Americas program to implement a population-based standardized hypertension treatment protocol. It is rooted in a seamless transition from existing treatment practices to best practice using pharmacologic protocols built around a core set of ideal antihypertensive medications. In alignment with recent major hypertension guidelines, the HEARTS in the Americas protocols call for the rapid control of blood pressure, through the use of two antihypertensive medications, preferably in the form of a single pill, fixed-dose combination, in the initial treatment of hypertension. To date, the HEARTS in the Americas program has seen the improvement in antihypertensive medication formularies and the establishment of pharmacologic treatment protocols tailored to individual participating countries. This has translated to significant increases in hypertension control rates post-program implementation in these jurisdictions. Thus, the HEARTS in the Americas program could serve as a model, for not only the Americas Region but globally, and ultimately decrease the burden of CVD.
Collapse
Affiliation(s)
- Donald J DiPette
- School of Medicine, University of South Carolina, Columbia, SC, USA
| | - Kenneth Goughnour
- Women Influencing Health, Education and Rule of Law (WI-HER), Vienna, VA, USA
| | - Eric Zuniga
- Health Service of Antofagasta, University of Antofagasta, Antofagasta, Chile
| | - Jamario Skeete
- Department of Internal Medicine, Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | | | - Sonia Angell
- California Department of Public Health, California, IL, USA
| | | | - Norm R C Campbell
- Department of Medicine, Physiology and Pharmacology and Community Health Sciences, O'Brien Institute for Public Health and Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Antionio Coca
- Department of Internal Medicine, Hypertension and Vascular Risk Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Kenneth Connell
- Faculty of Medical Sciences, The University of the West Indies, St Michael, Barbados
| | - Rohit Doon
- Ministry of Health, Port of Spain, Trinidad and Tobago
| | - Marc Jaffe
- Division of Endocrinology, Kaiser Permanente, San Francisco, CA, USA
| | | | - Andrew Moran
- Resolve to Save Lives, An initiative of Vital Strategies, New York, NY, USA.,Columbia University Irving Medical Center, New York, NY, USA
| | - Marcelo Orias
- Sanatorio Allende Córdoba, Universidad Nacional de Córdoba, Cordoba, Argentina
| | | | | | - Yamilé Valdés González
- National Technical Advisory Commission on Hypertension, Havana, Cuba.,University Hospital "General Calixto García", Havana, Cuba
| | - Pedro Ordunez
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA
| |
Collapse
|
12
|
Victor RG, Blyler CA, Li N, Lynch K, Moy NB, Rashid M, Chang LC, Handler J, Brettler J, Rader F, Elashoff RM. Sustainability of Blood Pressure Reduction in Black Barbershops. Circulation 2019; 139:10-19. [PMID: 30592662 DOI: 10.1161/circulationaha.118.038165] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND We developed a new model of hypertension care for non-Hispanic black men that links health promotion by barbers to medication management by American Society of Hypertension-certified pharmacists and demonstrated efficacy in a 6-month cluster-randomized trial. The marked reduction in systolic blood pressure (BP) seen at 6 months warranted continuing the trial through 12 months to test sustainability, a necessary precondition for implementation research. METHODS We enrolled a cohort of 319 black male patrons with systolic BP ≥140 mm Hg at baseline. Fifty-two Los Angeles County barbershops were assigned to either a pharmacist-led intervention or an active control group. In the intervention group, barbers promoted follow-up with pharmacists who prescribed BP medication under a collaborative practice agreement with patrons' primary care providers. In the control group, barbers promoted follow-up with primary care providers and lifestyle modification. After BP assessment at 6 months, the intervention continued with fewer in-person pharmacist visits to test whether the intervention effect could be sustained safely for 1 year while reducing pharmacist travel time. Final BP and safety outcomes were assessed in both groups at 12 months. RESULTS At baseline, mean systolic BP was 152.4 mm Hg in the intervention group and 154.6 mm Hg in the control group. At 12 months, mean systolic BP fell by 28.6 mm Hg (to 123.8 mm Hg) in the intervention group and by 7.2 mm Hg (to 147.4 mm Hg) in the control group. The mean reduction was 20.8 mm Hg greater in the intervention (95% CI, 13.9-27.7; P<0.0001). A BP <130/80 mm Hg was achieved by 68.0% of the intervention group versus 11.0% of the control group ( P<0.02). These new 12-month efficacy data are statistically indistinguishable from our previously reported 6-month data. No treatment-related serious adverse events occurred in either group over 12 months. Cohort retention at 12 months was 90% in both groups. CONCLUSIONS Among black male barbershop patrons with uncontrolled hypertension, health promotion by barbers resulted in large and sustained BP reduction over 12 months when coupled with medication management by American Society of Hypertension-certified pharmacists. Broad-scale implementation research is both justified and warranted. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT 02321618.
Collapse
Affiliation(s)
- Ronald G Victor
- Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA (R.G.V., C.A.B., K.L., N.B.M., M.R., F.R.)
| | - Ciantel A Blyler
- Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA (R.G.V., C.A.B., K.L., N.B.M., M.R., F.R.)
| | - Ning Li
- Department of Biomathematics at University of California, Los Angeles, David Geffen School of Medicine (N.L., L.C.C., R.M.E.)
| | - Kathleen Lynch
- Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA (R.G.V., C.A.B., K.L., N.B.M., M.R., F.R.)
| | - Norma B Moy
- Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA (R.G.V., C.A.B., K.L., N.B.M., M.R., F.R.)
| | - Mohamad Rashid
- Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA (R.G.V., C.A.B., K.L., N.B.M., M.R., F.R.)
| | - L Cindy Chang
- Department of Biomathematics at University of California, Los Angeles, David Geffen School of Medicine (N.L., L.C.C., R.M.E.)
| | | | | | - Florian Rader
- Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA (R.G.V., C.A.B., K.L., N.B.M., M.R., F.R.)
| | - Robert M Elashoff
- Department of Biomathematics at University of California, Los Angeles, David Geffen School of Medicine (N.L., L.C.C., R.M.E.)
| |
Collapse
|
13
|
Victor RG, Lynch K, Li N, Blyler C, Muhammad E, Handler J, Brettler J, Rashid M, Hsu B, Foxx-Drew D, Moy N, Reid AE, Elashoff RM. A Cluster-Randomized Trial of Blood-Pressure Reduction in Black Barbershops. N Engl J Med 2018; 378. [PMID: 29527973 PMCID: PMC6018053 DOI: 10.1056/nejmoa1717250] [Citation(s) in RCA: 329] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Uncontrolled hypertension is a major problem among non-Hispanic black men, who are underrepresented in pharmacist intervention trials in traditional health care settings. METHODS We enrolled a cohort of 319 black male patrons with systolic blood pressure of 140 mm Hg or more from 52 black-owned barbershops (nontraditional health care setting) in a cluster-randomized trial in which barbershops were assigned to a pharmacist-led intervention (in which barbers encouraged meetings in barbershops with specialty-trained pharmacists who prescribed drug therapy under a collaborative practice agreement with the participants’ doctors) or to an active control approach (in which barbers encouraged lifestyle modification and doctor appointments). The primary outcome was reduction in systolic blood pressure at 6 months. RESULTS At baseline, the mean systolic blood pressure was 152.8 mm Hg in the intervention group and 154.6 mm Hg in the control group. At 6 months, the mean systolic blood pressure fell by 27.0 mm Hg (to 125.8 mm Hg) in the intervention group and by 9.3 mm Hg (to 145.4 mm Hg) in the control group; the mean reduction was 21.6 mm Hg greater with the intervention (95% confidence interval, 14.7 to 28.4; P<0.001). A blood-pressure level of less than 130/80 mm Hg was achieved among 63.6% of the participants in the intervention group versus 11.7% of the participants in the control group (P<0.001). In the intervention group, the rate of cohort retention was 95%, and there were few adverse events (three cases of acute kidney injury). CONCLUSIONS Among black male barbershop patrons with uncontrolled hypertension, health promotion by barbers resulted in larger blood-pressure reduction when coupled with medication management in barbershops by specialty-trained pharmacists. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT02321618 .).
Collapse
Affiliation(s)
- Ronald G Victor
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Kathleen Lynch
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Ning Li
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Ciantel Blyler
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Eric Muhammad
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Joel Handler
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Jeffrey Brettler
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Mohamad Rashid
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Brent Hsu
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Davontae Foxx-Drew
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Norma Moy
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Anthony E Reid
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Robert M Elashoff
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| |
Collapse
|