1. Best Practices in the Prevention and Control of Hypertension Globally and Putting Evidence into Practice Mark Niebylski, PhD, MBA, MS October 22, 2014 World Hypertension League

2 Disclosure Statement of Financial Interest I, Mark Niebylski, DO NOT have a financial interest/arrangement or affiliation with any healthcare related companies that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. I am contracted with the World Hypertension League dedicated to the prevention and control of hypertension globally.

3 Objectives Review of a State of the Art Program – the Canadian effort Using lessons learned implement Knowledge translation to other populations Development of a Hypertension Resource Center

4 The Canadian Effort to Prevent and Control Hypertension. Can Other Countries adopt Canadian Strategies? Current Opinion in Cardiology 2010:25:

Changes in Management of Hypertension in Canada CHHS CHMS 2007/8 * As presented at the Canadian Cardiovascular Congress Oct 2007

Increase in total antihypertensive prescriptions

Increasing intensity of therapy over time Increase in use of 2 or more drugs (21% to 40%) Decreased discontinuation of antihypertensive drugs p< Hypertension 2005;45:

8 NPHS ( ): More Lifestyle Changes After Hypertension Diagnosis Are Needed. Can J Cardiol 2008;24;3:

2010 Global Burden of Disease Study - Canada Disability adjusted life years RankRisk 1DietDiet >1,000,000 2Smoking 3High blood pressureHigh body mass index 4 High blood pressure 5High blood cholesterolPhysical inactivity 6High plasma glucose 7Alcohol useHigh blood cholesterol 8Alcohol use

10 Cost in Canada 7.5 million hypertensive adult Canadians in a adult population of 26.4 million adults In 2010, 80 million antihypertensive prescriptions costing over $3.0 billion with linear increases annually. Almost half of all people in Canada over age 60 are taking drugs to control blood pressure Hypertension is the most common reason for an adult to visit a physician with over 21 million visits for hypertension in 2009

11 Canadian Hypertension Education Program (CHEP) Concept Development Poor hypertension control in Canada relative to United States led in the late 1990s to extensive discussions on how to improve blood pressure control CHEP in 2000 a more rigorous annually updated recommendations program with Team-based approach An evolving and extensive knowledge translation and dissemination program In 2003, a formal outcomes program added

12 Hypertension Canada (WHL operations mirrored after this effort) Outcomes Research Task Force Evidence-Based Recommendations Terms of Reference Implementation Task Force Public policy Oversight for National Hypertension Strategy Steering or Expert Committees

Evidence Based Recommendations Task Force Subgroups Office Measurement of BP Follow-up of BP Risk Assessment Self-measurement of BP Ambulatory BP Monitoring Routine Laboratory Testing Echocardiography Lifestyle Modification Pharmacotherapy of Hypertension in Patients Without Other Compelling Indications Pharmacotherapy for Hypertension in patients with Cardiovascular Disease Diabetes and Hypertension Renal and Renovascular Hypertension Endocrine forms of Hypertension Adherence Strategies for Patients Vascular Protection Hypertension and Stroke

The Annual Process Subgroups systematically review the literature using a Cochrane librarian and supplemented search with personal files Application of an evidence-based grading scheme Use of a Central Review Committee comprised of methodologists to improve consistency of grading 1 day conference to discuss recommendations and evidence Periodic teleconferences and presentations when appropriate Selection of theme and next steps National presentation of draft recommendations Voting and ratification of recommendations Development and revision of educational material Dissemination and Evaluation

Implementation The need to engage the public and patients –to understand the need for prevention, screening, diagnosis, treatment and control The need to engage ALL health care professionals –To ensure the public and patients receive consistent information The active participation of those directly involved in the management of hypertension (key individuals and organizations) The active participation of those who oversee the health care system.

Implementation Develop resources that actively engage people Remove all identified barriers to accessing resources Agreement of other national organizations to harmonize hypertension recommendations Networks of health care professional organizations and training schools

Key messages Know the current blood pressure of all your patients Encourage the use of approved devices and proper technique to measure blood pressure at home Assess and manage CV risk in hypertensives including: high dietary sodium intake, smoking, dyslipidemia, dysglycemia, abdominal obesity, unhealthy eating, and physical inactivity. Sustained lifestyle modification is the cornerstone for the prevention and control of hypertension and the management of CV disease. Treat blood pressure to <140/90 mmHg In people with diabetes target to <130/80 mmHg and more than one drug is usually required including diuretics to achieve BP targets

19 The need to evaluate To determine how well the program is working To assess where care gaps remain To ensure the sustained enthusiasm of those contributing Standardized evaluation and nomenclature

20 Results from Best Practices? Improvements in awareness Improvements in treatment Changes mirror Committee recommendations Increasing intensity of therapy over time Improvements in BP control Improvements in outcomes Expand model to CVD risk or other chronic non communicable diseases /risks especially in low to middle income nations More countries aiming for 70% control

21 The WHL is a charitable organization comprised of national and regional hypertension societies Dedicated to the Assessment, Prevention, and Control of Hypertension Globally Campbell, Norm RC, Niebylski, Mark, and World Hypertension Executive “ Prevention and control of hypertension: Developing a Global Agenda”, Current Opinion in Cardiology, Vol 29, No. 4, Prevention and Control of Hypertension: Developing a Global Agenda 21

22 The WHL is a charitable organization comprised of national and regional hypertension societies Dedicated to the Assessment, Prevention, and Control of Hypertension Globally “An epidemic of chronic nocommunicable diseases in threatening national healthcare systems’ sustainability and the economy of many countries. Increased blood pressure is the leading risk for premature death and disability and accounts for approximately 10% of healthcare spending. Four of nine recent United Nations’ targets for reducing chronic noncommunicable diseases relate directly or indirectly to hypertension.” Campbell, N, Niebylski, M. “Prevention and Control of Hypertension: Developing a Global Agenda.” Current Opinion Vol 29, No. 4,

23 The WHL is a charitable organization comprised of national and regional hypertension societies Dedicated to the Assessment, Prevention, and Control of Hypertension Globally 23 Recommended public health actions for national hypertension organizations Increase awareness that hypertension is largely preventable but is a constant threat to wellbeing as the world’s leading risk for death and disability Increase awareness that hypertension is largely caused by unhealthy eating (especially high dietary salt), physical inactivity, obesity, Advocate for effective healthy public policies that if implemented could largely prevent hypertension from occurring  Most important is for countries and communites to have an effective and comprehensive strategy to reduce dietary salt and to ensure a healthy food supply  Increase awareness that hypertension can be inexpensively, easily detected and clinically managed  Communites need programs for all adults to have regular blood pressure assessments linked to effective hypertension management  Affordable antihypertensive drugs accessible to all

24 The WHL is a charitable organization comprised of national and regional hypertension societies Dedicated to the Assessment, Prevention, and Control of Hypertension Globally 24 Key aspects of effective health care systems that national hypertension organizations can advocate for 1. Ensure regular blood pressure checks are provided to the adult population utilizing community resources 2. Ensure those indentifed with high readings are informed and linked to people who can make a diagnosis and provide effective treatment 3. Make affordable antihypertensive drugs accessible to all 4. Monitor and evaluate the system to ensure people with hypertension are being identifed, treated and controlled to national standards 5. Ensure the health care system facilitates and supports the development and implementation of health public policy

25 The WHL is a charitable organization comprised of national and regional hypertension societies Dedicated to the Assessment, Prevention, and Control of Hypertension Globally 25 Thank YOU, our Members, Partners, and Volunteers!!! Resource Center evolving on our website:  Journal of Clinical Hypertension as home journal of WHL (open access)  BP Train the Trainer Module  BP Screening video – evidence based (translation into other languages)  Power point slide sets adoptible to target Populations (exa: fact sheets; how to use GBDS specific to your nation)  Recent publications, quarterly newsletter, success stories  2015 WHL awards and recognition for notable achievements accepting nominations until Feb 2015