Good morning, everybody, and welcome to our third and final day of Quality Summit. Before we get started this morning, I have a very important housekeeping question to address that has come up in a number of the sessions, and yes, the Florida Gators will defeat South Carolina this weekend. I'm confident of that. So with that taken care of, I'd like to go ahead and introduce our speaker this morning. He's a professor. He's an associate vice president for translational research at Wayne State University. He has dozens of NIH grants, hundreds of manuscripts, and he's leading a transformational program addressing population health that he's going to talk to us about today. Most importantly, he is an emergency room physician who always orders just the right amount of troponin. Dr. Phil Levy. Thanks, Dave. And you forgot to say, I'm one of your good buddies, and he always runs me into the ground every time we come on in these trips, so we didn't do that this time. But yeah, for the next 45 minutes or so, we're going to be talking about cardiovascular disease prevention at the population level, so let me get this going here. Okay, and as Dave mentioned, by way of disclosure, we have a lot of grant funding that has supported this endeavor. I'll be talking about this throughout the presentation, but just to wrap it all up and kind of put it in one package, we started this program that I'm going to discuss in April 2020 when the pandemic first hit, and as we built things out, it's brought in almost $60 million in funding during that time, including an NIH center grant, which I'll talk about, an American Heart Association center grant, and some other great funding from the state of Michigan. I don't say that to brag to you guys, because I'm certainly not. What I'm really trying to say is there's a lot of momentum behind this thinking. There's a lot of really new ways we can conceptualize cardiovascular disease prevention. And if you remember nothing of this talk, it's really a concept of disaggregating treatment and prevention. We force everything in healthcare right now through one funnel, and that funnel has a lot of backlogs. And if we could think differently about how we reach the masses and how we bring prevention services barrier-free to them, I think the population at large will benefit, and actually all of us in healthcare will benefit, because the system will be more efficient in delivery. So before we get going, what is population health? This is an older description from more than 20 years ago now that sort of breaks it down into very simplistic terms, but very digestible terms, right? So population health is health outcomes in a population, right? Very simple, and you can define that population any way you want. It can be cardiovascular disease patients. It can be underserved communities. It can be racial or ethnic minorities. It doesn't matter how you define a population, but what you're doing is taking something at a macro level and trying to determine and make better health outcomes for that group. And when you look at this, there are things that influence that. There's policies and interventions at the individual and social level, which you can see, and then there's patterns of health determinants and things that go into that, social determinants, biological determinants, that can affect those outcomes. And so the classic example is thinking about life expectancy, right? And so here's just a graphic from 2022 showing life expectancy, the highest in the world, 84.4 years in Japan, the lowest in Italy. I always joke that they may live the shortest, but they probably live the best, right? If you've ever been to Italy, boy, is that a good time, right? Who wouldn't want to go back there? But the United States is kind of in the middle, maybe towards the left side of this, not really achieving the best health outcomes, but what do we do from a policy side or an intervention side? We spend more money on healthcare than anyone else. Does that get us the best health outcomes? Absolutely not, right? Why is that? Because it's not a one plus one equation. It's not spend more money, get better health outcomes. Why? Because we see things like this. We know that income, not how much we spend on healthcare, but income at the individual level is an incredibly important predictor of life expectancy. These data from about 14 years or so of life expectancy charting and tracking in the United States shows this. It shows that at the lower end of the household income, people live maybe 75 years or so. At the higher end of the income, they can live almost to 90, right? I mean, is anyone to be surprised? Queen Elizabeth lived a long, long, healthy life, right? Every circumstance was put in place for that to occur. And you notice here, of course, women live longer than men. We talked about this very briefly yesterday in the chest pain session, but that probably has a little bit less to do with income and more to do with risk for cardiovascular disease and other factors. But nonetheless, when you see this, it's a very striking thing. But when you step back, you realize that this is important at a top level, but then you look at communities and neighborhoods, and it's different all across the country. So it can't be just one factor. It's not just individual income. Otherwise, you wouldn't see these changes across the country. The A panel up here shows men and women and life expectancy in the bottom income quartiles, right? And you can see that there are certain states where some people live longer, four or five years longer, despite having the similar income levels. And then you look at the high income quartiles on the bottom panel, you see the same things. You see patterns in communities like where I live in Michigan, in Detroit, up in the mitten over there, and you could see that both at the low income and high income areas in Detroit, people are living less, right? Less years. And so what else is going on? Well, we know race plays an important factor in this, right? Race is often a euphemism or a summative term for all the socioeconomic factors and other things that go in to the life circumstances of an individual. These data, again, looking at almost 20 years of life expectancy and changes over time, show a couple of the things. At the bottom, where you see in blue and orange, you see black and American Indian or Alaskan native populations consistently lower life expectancy than whites, Asians, and even Latinos, right? And so when you look at this, you say, all right, well, there's more that's going on, right? But again, you look at maps across the country and the amount of years of life expectancy that have increased over time is not equitably distributed, right? And again, so nothing can be distilled down to any single given factor. We have to think of this in a big compendium of risk. But when we step back and say, well, what's the most common cause of death across the country? It's heart disease. That's part of the reason why we're all here. It's part of the reason why we all do what we do. I apologize for this rather crude demonstration, but this is from Slate, and I kind of like this one because it's very easy to digest, right? It shows that heart disease, even though cancer and heart disease are the number one and number two killers in the country, heart disease by far affects more people in more states in this country than anything else. But again, all things are local, right? So when you look at heart disease deaths, I just downloaded this the other day from the CDC, it's not equitably distributed, right? So even though heart disease is the most common cause in every community, in every neighborhood, there are different rates of heart disease deaths. And again, all of that plays into the discussion of how life expectancy and outcomes occur. And I put all this as just a background, nobody's going to remember the data, I'm not putting it up here for that purpose, just trying to make the point, right? Like politics, healthcare outcomes are local, right? And what have we done as a nation, as a society, ACC, American Heart Association, we've come up with summative things like Life's Essential Eight, right, which are ways to help people get healthier, targeting heart disease, we know it's the number one cause of death. Things like eating healthier, exercise, if you have diabetes, controlling your blood glucose, losing weight, or at least trying to control your weight. Much easier nowadays with the injectables, right? Everybody, you know, seems to be on those that we know. Controlling lipids, controlling blood pressure, not smoking, and added to the Simple Seven, which made it Essential Eight is sleep, right? We all know that sleep is such an important factor, one of the hardest things, I think, for a lot of us to have good quality sleep. And this all originates, right, you know, going back a decade or so when we started to really try to standardize cardiovascular risk assessment and think about the pooled cohort equations, right, of how we think about atherosclerotic cardiovascular disease risk. Because even though heart disease is the number one cause of death, cardiovascular disease, or coronary heart disease, is the number one cause of heart disease and death, right? So we think a lot about trying to prevent coronary heart disease in this equation. And this originates, again, with the graphic here looking at the 10-year risk of the first hard ASCVD event in people who are asymptomatic. You guys have probably seen these data over the years. You certainly know the calculator, right? We all have seen this. And I think a lot of us use this on our patients. We routinely do this in our community screening, because it's really important. And you see the factors that go into it, right? Blood pressure, cholesterol, diabetes, smoking, treatment for these different conditions, statins, aspirin. And we can summarize it in something like this, overall cardiovascular health. These are scores that you can use to just get a general sense of how well are we doing. But at a population level, is this achievable? Is this something that we're able to do? If it were, we wouldn't be talking about this again in 2023, and probably 24, 5, 6, 7, 8, 9, right? Because we can't seem to do this at the population level. We cannot seem to get populations to do all the things that we know they should do. A lot of folks know they should do it as well, but the circumstances of their lives make it very hard, right? It's very difficult to sit in an office with somebody and say, lifestyle modification, go out there and eat healthier and do better if they can't afford food, or if they're making decisions between paying for their medications and buying books for their kids in schools, right? And so it really is important for us to step back and say, how can we do better? This idea of all health care flows through a doctor's office, one patient, one provider, doesn't work. It honestly doesn't work, right? And I think we have to question why first, but more importantly, come up with new solutions and new ways that we can approach this problem so that we can do better for the people that we serve. So of all the factors that go into this, high blood pressure is the single most important variable, right? It's the single most important population attributable risk factor for coronary artery disease, cardiovascular disease in general, and worldwide, right? We could save over 94 million lives over the next 25 years if we just achieved better blood pressure control, got more people with hypertension treated, and reduced sodium, all of that trying to reduce blood pressure. But I think two things jump out to me, 94 million, big number, 25 years, long time. This isn't a short game. This is a long game. And it's very hard for people and societies and fickle politicians, right, to turn around and say, I'm investing today in tomorrow or to tomorrow's future, right? And so it's a long game. We have to be in it for the long haul to make substantive changes to get there. But we're not doing a very good job in the United States when it comes to hypertension control. We're not doing a good job in the world. We're not doing a good job, but in the United States especially, right? And so when you look at blood pressure control among all adults in the A panel with hypertension, you could see we were improving. We went from 25% or so in the early 2000s, almost up to 50% in 2013 or 14, but it's dropped back down to about 40% right now. In Detroit, where I live, we estimate that the functional blood pressure control rate in the city is probably 15%, right? Detroit's a community largely black, a lot of hypertension, a lot of poor access, and we just can't seem to get past this problem. And when you see patients even who are taking antihypertensive medications, right, we're not at 100%. We were just below 60, climbed up to maybe 75, but then dropped back down again. That's because we have this inertia in clinical practice sometimes when it comes to antihypertensive uptitration. But we also, again, have challenges with medications, we have challenges with adherence, and none of that is really volitional, right? Patients don't come to your office or my office or the ER and say, you know, I'm just not going to take my medications today because, you know, I really don't want to be better. There's always circumstances behind this. And so that led the former Surgeon General, continuing nowadays, you know, with just the general concept, issue a broad statement, call to action to control hypertension, right? Very, very important thing, but particularly important for the black population, for communities like Detroit and anything similar to that, where high blood pressure, these data from the Jackson Heart Study, I know we have some folks from Mississippi down here, and the REGARD Study, two large longitudinal cohort studies funded by NHLBI, National Heart, Lung, and Blood Institute, which show that the population attributable risk for cardiovascular disease in blacks is almost 43%, anywhere 22% to 43%, depending on what specific thing you're looking at, but it's a big, big deal. And in Michigan, again, in Detroit, where I practice, right, the city is 84% black, and when you look at data like this from CDC places, you clearly see that hypertension prevalence is ubiquitous. We have a community where almost everybody, or at least every neighborhood in this area, these are all census tracts, shown in that block area surrounded by yellow, census tracts where you could see most of the city of Detroit has a prevalence of hypertension that exceeds 40%. And that's based on the prior definition of hypertension, which is 140 over 90. We're all aware in 2017, the AHA and other societies came together and redefined hypertension as greater than 130 over 80, and control is that level as well, and we look at that, almost 60% of the black population has high blood pressure. And what's the outcome and consequence of this? So I always put this graphic up and say this is my entire career motivation. These are the most common causes of death in the United States, the top, I think we're showing eight right here, but distilled down from the top 10. And we think about cancer, we think about heart disease, but when you look at the heart disease death rate in Detroit, which is an orange, versus the state of Michigan, which is in green, excuse me, Wayne County, which is in green, and the state of Michigan, which is in blue, and the rest of the country in purple, you see we got a big problem right there. People in Detroit are dying at almost twice the rate of others in the country related to heart disease. And this is age adjusted mortality, which here in this graphic is 285 per 100,000. We age adjust, right, so that you don't have over representation in a death rate by older individuals. Sorry to say, I'm not informing you guys of something you didn't know, but older people are closer to death than younger people, right? That's just a fact of life. I'm not an ageist or anything like that. I want to live a long, healthy life too, and I want all of you to as well. But we know this, right? And so when you age adjust mortality rates, the mortality rate typically goes down for pretty much any condition. When you age adjust mortality in Detroit, it actually goes up because it's young people dying and the younger folks are actually influenced in the death rate more than the older individuals. So it's a pretty sad circumstance. So when we step back and say, why is this, again, we saw all these graphics, right? It's income, but it's not just income. It's race, but it's not just race. So what else is going on? We know socioeconomic factors play into this. These data published a little bit ago from Yvonne Commodore-Mensa, good friend and colleague, look at hypertension, stage two hypertension, controlled blood pressure, social factors that can contribute to this. And we know, again, race, poverty, other things like that, where you get your care all play an important part in what happens. And our city in Detroit is among the most disadvantaged in the country, okay? And these are data that I've used in grants writing before, and you can imagine how well this is received when you're talking about the significance of a problem when you write a grant, right? So looking at this, children in poverty, income inequity scores, racial segregation scores, unemployment, take your pick on there. Detroit is worse than the national average in just about every single category. So it's not surprising people in Detroit where this comes together are doing worse for things like heart disease death. And I showed some data on this before from the systematic analysis of life expectancy, but the summation of all of this is at the bottom line, the interpretation. Disparities in life expectancy among racial and ethnic groups are widespread and enduring. We know this, right? Local level data are crucial to address the root causes of poor health and early death among disadvantaged groups in the U.S., eliminate health disparities, and increase longevity for all, right? So what you know about your community matters a lot more than what I can tell you about my community, although the lesson about how I do this and how we've been going about it is a really important one, right? So know your community, know what's going on, and really understand that every time you walk into the room to a patient that you see or that you work with, the circumstances of that individual are different than perhaps other areas. And everything that we read about and all the data that we try to distill at a macro level down to the individual may not apply if the circumstances of your local community are different than where those data were derived from, right? So you can't always take what you read or take what we publish on a national level and say that's applicable to my patient because of these reasons. So this is another graphic that's a really important one. Phoenix is a program that I'm going to talk about in a bit that we developed in Detroit called the Population Health Outcome Information Exchange to try to bring together the confluence of information here. What this graphic shows right here is deviation from life expectancy in the state of Michigan in southeast Michigan where Detroit's located. Anything in green, people are dying younger than the state average. Anything in yellow, people are living longer than the state average. What you see here in Detroit across the city, those are census tracts again displayed, is there are many communities where people are dying 5 to 15 years younger than the state average, right? That's terrible. That's deplorable in a country as wealthy as we are, as a country that spends as much on health care that we do, people are dying of conditions like this, like heart disease. As we saw, a lot of that is traceable to hypertension, which doesn't get controlled effectively, which leads to early onset heart disease, which leads to premature death, which saps a community of vibrancy, which saps a community of taxpayers, right? Not saying we want to distill it down to that, but if you want things in your neighborhood, people have to live there, pay taxes, and that's how things get done, right? When people are dying younger, it just can't happen. So what do we have? In Detroit, a lot of communities like this, we have communities that are plagued by early vascular aging. People are dying too young, and the preventable point of that march towards death is not being addressed adequately. So if you look at this red graphic right here, you can see that steep curve right there. People go through elevated blood pressure to subclinical heart disease to symptomatic cardiovascular disease much quicker. That leads to them dying much sooner. You move to an average life course, you can see that you want to start to bend that curve perhaps in early adulthood. You're not waiting until somebody comes in with hypertension. There's no magic threshold of blood pressure where everything is okay until you hit 140 over 90 and things start to go awry. What's happening with hypertension is that you're constantly accumulating vascular injury and insults, small blood vessels in the kidneys, in the brain, in the heart, in the back of the retina, right? Which is really a window, if you will, into the ongoing vascular damage. And so we know that cardiovascular risk doubles for every 10 millimeters of mercury that someone rises above 115 systolic, right? But we don't think about starting blood pressure control or at least maintaining blood pressure at a certain level at 115. We wait until they hit a magic number, 130 nowadays, right? We got to think differently about this. How can we intercede early and prevent that slow march to accumulated vascular insult so that people don't develop symptomatic or clinical disease and then die young, right? And if we want to achieve an idealized life course where people don't ever develop hypertension and don't ever develop problems, we got a lot of work to do, right? That's a very big vision and a very big dream that I don't think any of us are going to be able to tackle and achieve, at least in our lifetimes. But it's an important thing to think about just to put this stark contrast. And then when you see on the right side here how to go about this, right? Once you develop symptomatic disease, once you're at the point where you have clinically overt problems, you need your doctors, you need your nurse practitioners, you need your whatever, the team-based care to help an individual patient. But if you're trying to change dynamics at a population level, you gotta back up and say, what are the circumstances, what are the systems that need to be in place so I can reach as many people as possible? So for the population that I'm talking about, it's the city of Detroit. It doesn't matter if they're black or white in the city of Detroit. To me, it's this community that I live in that I care for that I wanna change. This is something that started with my work almost two decades ago, 15 years ago, from the emergency department. My initial vision around all of this is that all patients come through the emergency department and get a blood pressure, and we're missing the opportunity to do something about these elevated numbers. We know that about 50% of people who come through ERs have elevated blood pressure, but most of the time, myself, my colleagues, we don't pay a lot of attention to that because we're trying to solve or at least alleviate the acute suffering or the acute problem that that person came in. But we have a lot of information that we could do things about. So I got a little fed up with this and started to develop programs in the emergency department to try to better address this. Things like, can we look for people who have subclinical hypertensive heart disease? These data we did echo in the emergency department on 160 people, 146 of them ended up having some type of structural or functional abnormality in their heart and were completely asymptomatic. These were all hypertensive patients with poorly controlled blood pressure. We started to design studies where we took patients in the emergency department who have left ventricular hypertrophy and subclinical hypertensive heart disease and ran them through protocols similar to SPRINT, lower blood pressure versus higher blood pressure goals. We've done studies looking at vitamin D and doing cardiac MRI in emergency department patients and doing longitudinal studies. The answer though was always the same. It didn't matter what else you did, as long as you controlled the blood pressure, patients got better, were able to regress left ventricular mass within three months. Dramatic changes in ventricular thickness just by controlling blood pressure, which really speaks to the fact that we can do all of these different things, but how do we get to that point where we just get better blood pressure control so it doesn't end up being trials, it doesn't end up being studies per se. It's creating circumstances for better outcomes. You guys have seen this graphic in various forms. These data were published by Robert Wood Johnson Foundation, not really data, but just a summative representation. At this point, probably 10 years ago or so, that talks about the breakdown of what happens in health and health outcomes. So initially coming at it from the perspective of, oh, it's a healthcare related problem. If we only had better healthcare, patients would do better. As this graphic shows, health outcomes are only responsible, healthcare is only responsible for about 20% of health outcomes. So much more that happens with that patient is beyond the four walls of our discussions. 80% of health outcomes are attributable to socioeconomic factors and the physical environment someone lives in, the health behaviors that go with it. If you live in an impoverished community and I as a doctor tell you to go exercise and you tell me I can't walk outside of my house because I'm afraid of crime or I'm afraid of whatever, or you live in a community that's right near an incinerator or has a lot of industrial complexes nearby and there's a tremendous amount of air pollution and PM 2.5, they can't do what we want them to do. So it's the circumstances that they live in are so much more important than what happens within our walls and how do we start to think about that? So like I said, we developed something called the Phoenix Program, the Population Health Outcome and Information Exchange a few years ago as a way to say, okay, we want to understand how blood pressure affects populations and what the upstream mediators and moderators of blood pressure, blood pressure control and developing premature disease are. And we said, well, we're in the emergency department, we aggregate blood pressures all the time on patients, what if we took those blood pressures, attach geocodes to take everyone's address, to attach a geocode and aggregate data at a geospatial level to understand which communities are at highest risk and what are the other factors that go into this and make them at high risk? This was developed from a concept in the HIV world called community viral load. And because of Ryan White funding, all HIV care is essentially funded by the same bucket of money. And so there's a lot of data on how well we do with HIV care. And your community viral load is how well does your community manage HIV? We started to conceptualize community pressure load. How well does our community manage blood pressure and how can we understand the impact of reducing blood pressure at a population level? This is a logic model right here, which looks at input, action, output and outcomes for our concept of Phoenix. And on the left, you can see in the inputs, you can take in data from electronic health records and other available sources, mix in social determinant data that exists from publicly available resources. We all think social determinants, assessing social determinants, standardizing social determinant assessment is a lot of conversation these days, but we know a lot more about our populations than we think, right? And you can take aggregated population level data and understand the risks in communities, right? So some communities, right, who have a low income level, a lot of socioeconomic stress, those communities, the folks that live there are likely to reflect those same circumstances that you get at macro level data. Sure, some wealthier individuals may live in lower socioeconomic status communities, but it's not common, right? We know this. And so we kind of pretend on some level when we talk about this that we don't know enough about our population. We know a lot. We just don't have or haven't had before we started doing this a way to pull those data in. So what we do is pull in data from all these different sources, mix them together in a cloud computing environment from Google called BigQuery. And in BigQuery, we're able to match up geospatially, temporally, space and time information on neighborhoods, on populations so that we can understand where we wanna go and what we wanna do when we get there. We can hotspot communities. We can target programs and interventions. We can look at trends and incidents and change over time, ultimately with the goal of improving public health and for this conversation, population health, right? Because if we improve public health, and I'm not talking about the tragedy of the commons, right, you guys all know that. That's where they discovered in England in the 1700s or so that people were getting diarrheal illness because they all went to the same pump in the town, right? The tragedy of the commons. That's one thing, right? But again, we're talking about population level things through public health and looking at the public health lens as cardiovascular disease risk reduction. So the initial iteration of our Phoenix program was this, a hypertension dashboard to look at population level blood pressure. And these data are over 550,000 individual encounters over a 26 month period in Detroit mapped out. The box that I show there is where Wayne State University is located. And as you can see here, this is a community where over that period of time, almost 4,500 people went to emergency departments and the mean blood pressure was 137 systolic. So the mean blood pressure of an entire population above normal. Now we know emergency departments are somewhat stressful situations and blood pressure can be a little bit higher there than it is in other circumstances. But it gives a good window, again, good vision into what is really going on potentially and how can we look at changes over time? The other things that are kind of astonishing when you look at this is the median age of this population is 29, all right? So you have a median population age of 29 with a mean blood pressure of 137. That's a recipe for disaster and that's just one census tract in the city of Detroit. Median household income, 13,764. Poverty level, 60.9% of people living below poverty, right? 35% unemployed, but only 12% uninsured, right? So it means that there's opportunity here to intercede. It's not like everybody doesn't have some form of support, at least if we wanted to deliver healthcare interventions. Life expectancy, 72. So a full five years younger than the state average, 12 years younger than they're living in Japan. A non-white population, 96%. And then the ADI, the Area Deprivation Index, is something you guys may have seen. It was developed in the University of Wisconsin a few years ago. And basically, it's a summative measure, much like the Social Vulnerability Index, or SVI. It's a summative measure to see how vulnerable, how deprived from a socioeconomic status certain communities are. This area in Detroit is the worst that it possibly could be. So how do you approach that problem? How do you think differently about it? So we started doing all of this, and then COVID hit. And this map was developed on March 29th, 2020, when Sinai Grace Hospital, some of you guys may have seen this on CNN, was suffering. Detroit was the worst of the worst in the very beginning of the pandemic until New York and other places, unfortunately, started to catch up. And what we saw around Sinai Grace Hospital is we had a lot of people coming in there who were dying of COVID. And we wanted to understand why, and realize that if we just waited at the hospital to find these individuals, we were gonna be too late, because we couldn't get out there before this occurred. So how do we think about this differently? We know, again, older individuals, higher risk. So we started adding on maps, circles right there, that show population over 65, densities of that area. The orange around Grace Sinai Hospital, Sinai Grace, it's really called, that shows the prevalence of COVID in that area. But then we started to put in social vulnerability before people really were even talking about this during COVID. And we put social vulnerability index, which goes up to one, at 0.95, because most of the city of Detroit is greater than 0.7, or very high social vulnerability. So we wanted to find communities that were particularly afflicted by social circumstances. And as you can see, Sinai Grace Hospital was surrounded by this. So we said, what can we do? We can't wait at the hospital. We gotta get out into communities. Great Motor City story, Detroit, the home of the automotive industry. I reached out to the Ford Motor Company, who came together and donated, or lent us four Ford Transit vans. And we started taking these Ford Transit vans into the communities using that geospatial analysis to say, where's our density of older individuals, social vulnerability, and high prevalence of COVID, so we could test people in the community and then keep them away from others, who may be equally vulnerable, but haven't yet got the illness. And so this is the beginnings of our setup. You can see we have the van. It's kind of a janky setup. We're quite happy that we were able to get the funding from Ford for this. But as we were starting to launch this, testing wasn't available. The resources weren't available, and there was restrictions placed on how we could go out and do testing. Fortunately, that started to loosen up, and we really pushed the gauntlet and started creating a testing for anyone program. Initially in Michigan, and probably in other states, the only people who could get tested in the beginning were first responders, doctors, nurses, police officers, firefighters, what have you, and essential workers. We really challenged the state to say, no, that's an important thing to get the workforce back to its feet, because at one point, for instance, in Detroit, 50% of the police force was out on COVID exposure after the beginning of the pandemic. You can't have that, right? But it's not just the police force who's at risk. It's all the community. So how do we start to take things into the community? So we started doing big events. This was the first blood draw for COVID antibodies in Detroit, and that was something that came and went in terms of the pandemic and its importance, but it gave us a clue as to where we were gonna go in the near future, which we'll get to in a second. The state of Michigan developed a racial disparities task force to try to understand why brown and black communities were suffering disproportionately from COVID, and because of the initial work that we did, we became a centerpiece of that. The state of Michigan took CARES Act dollars, invested in a program that we developed for mobile health outreach for COVID, with an idea that we would start doing COVID testing, but ultimately wanna do COVID vaccines and do other things that bring services out into the community. State of Michigan funded several vehicles for us, and we're able to have Ford Motor Company engineers come on site, work with us on form and function and upfit vehicles so that they can become high throughput drive-through COVID testing sites and vaccination centers. And fast forward now, we've now done almost 90,000 encounters in the community with this program. Over 60,000 individual patients have come through, a lot of vaccines, a lot of COVID testing. We now have a beautiful fleet of eight vehicles that we deploy on a daily basis, six to eight of them every day, six to seven days a week. And went from a team of zero to a team of more than 80 employees, all of whom work entirely on the mobile health unit program. And it's important, right? Because these data, similar to what I showed you before from 2019, 2021, COVID, third leading cause of death in the country, something very important to reflect on. But cardiovascular disease didn't go away. Heart disease death didn't go away. In fact, it got worse, right? The age adjusted mortality rate for heart disease death went from 285 to almost 325 during that period. Why is that? Because not only was COVID affecting people as a pulmonary condition, it's a vascular condition as well. But more important than that, it affected the way people interacted with healthcare. You couldn't get into your doctor's office. You couldn't go get your medication refills. People weren't getting their blood pressure routinely checked. Labs weren't getting screened on people. And so what happened? Control of these conditions got worse. People died more of heart disease. So we said, wait a second, we got to move on from what we're doing. We have a pandemic response, but we've learned something here. Can we do a model of portable population health? Where we're not out there just to screen for COVID, we're out there incorporating things like blood pressure measurement, lab testing. We figured if we're gonna be drawing antibodies and sticking a needle in someone's arm, why don't we get lipids, A1C, kidney function assessments? We had run the largest HIV testing program in the state through the emergency department, but emergency department visits plummeted during COVID. And we didn't have folks coming in because people were scared to go to the hospital. So we started doing HIV testing in the community. We started saying, let's get routine vaccinations in. But perhaps most importantly, we started assessing the social needs of the population through standard social determinant of health, intake assessment, and then providing linkages to services right on site with patient health navigators and community health workers. Doing things like giving out fresh food or produce on site if somebody has food insecurity, which was the number one social need of our population at that time and still to this day. But we started to say, we really are onto something here because we worked with the population to do things differently during the pandemic. And maybe we can apply this to other ways of thinking about healthcare. Said another way, right? Anybody in this room go to their doctor for this first COVID test? Did anyone in this room go to their doctor for their first vaccination? No, you went to some centralized location or you went to some distributed care model that didn't exist before COVID. And now we're getting towards the end of COVID or COVID is still lingering, but it's not like it was. We worked with the population to deliver care a different way that was effective at the time. Now we wanna peel things back and go back to the way things were, which was never really good to start with. Otherwise, I wouldn't be standing here before you talking about the poor health outcomes that we have in relation to heart disease. So we started saying, can we use mobile health units for mass hypertension screening in socially vulnerable communities across Detroit? Here's Nikina, one of our community health workers measuring blood pressure in someone's front seat of their car, which as it turns out is the perfect position to measure blood pressure. Your arm is at heart height, you're sitting down with both feet on the floor, even though it's not the ground, it's a ground, right? And so you're in a perfect position to measure someone's blood pressure. So we started doing that, like I said, in the first 3000 people or so whose blood pressure we measured, 63% were abnormal, including a third of them who had blood pressures in the stage two range with a median systolic of 152. If we're not there measuring these blood pressures and we're not there providing this inlet to service, who's gonna do it? But said another way, if we are there doing this, can we identify people early in the process, link them to care and do things very different than we've been doing them before? So we started writing about this, Dr. Rob Brooke, a colleague of mine, somebody I recruited down from University of Michigan to West Wayne State, which never ever happens, I promise you, nobody leaves Ann Arbor to come to work at Wayne State. But Rob, who was leading hypertension research, was the director of hypertension programs at U of M left because he had a whole career doing studies of 200 people comparing drug A to drug B, yet we still had these massive problems with hypertension and worse blood pressure control than ever. So I convinced him to say, drop what you're doing there, come down and work with me in Detroit because we've got bigger problems to address than what you're doing. So he came down and again, we started to do this program where we're measuring thousands of blood pressures. So in addition to the 3000 that I mentioned before, we've done another 7500 blood pressures over the past year plus. And as you can see on the left, we chart all of this. Normal blood pressures, elevated, stage one, stage two hypertension, and we also do a lot of screening labs. And I have an arrangement with LabCorp, they charge me $14, they direct bill me for this, and I have philanthropy that covers it, but they direct bill me and I get a comprehensive metabolic profile, a hemoglobin A1C and a lipid panel. They charge your doctor's office when you do that almost $1,000, right? Ridiculous, right? But they'll do it for me for $14. And imagine if you scale that type of program, how many people you can screen and test. Here you show we've done an aggregate 15,000 labs, we do about 400 or so a month, free, completely free. Our program has always been free, you don't need insurance, you don't need an identification, you don't need an appointment, you just need to come. And we're happy to be there. And I have a team waiting for you at any one of our sites to do this. But as you can see, when we do this stuff, 30% of our patients have elevated cholesterol, 50% have abnormal kidney function, 12% have elevated hemoglobin A1Cs. We pick up on a lot of abnormalities and then do linkage to care for patients, refer them either back into PCPs that we work with or back into their own PCP and provide the data unfettered and readily accessible. And here's just a highlight of some of that lab stuff that I was talking about. Again, showing that if you bring the screening to the people, people will come out and you can identify a lot of pathology early on before it becomes a problem. So we've also been growing what we've been doing with our Phoenix program. And you can now look at this. If you search Phoenix at Wayne State, our website will come up. We've now incorporated 70 different databases into the Phoenix program, which include hundreds of data elements. This is just some very small font that I don't expect you to be reading from where you are on this. But if you have the slides on your computer, you should be able to see a little bit better. And we break the data down into clinical, social, built environment, natural environment, policy, regional, state, what level is it displayed at? Again, you can see all the different sources we have. And it enables us now to create a map like this. So Phoenix has expanded to include population level data for the entire Midwest. I can show you and you can go free, no charge, no barrier, no sign in or any type of a firewall to get to the data. You can go and look in the Midwest and soon to be the entire United States using CDC places data, the prevalence of hypertension. And we also incorporate a number of different related variables here, historic redlining, air pollution. What is the actual blood pressure in that neighborhood if we know it because we have the patient level data, hypertension, medication use, what have you. But again, we have hundreds of variables. We only display a handful of them just to give people a little teaser in terms of what they might wanna think about in their communities. We can limit the data if we wanted to focus on minority populations, right? We can zoom in and actually look at communities like this one in Detroit that's got 3,100 residents and a mean systolic blood pressure from December 2018 to March 2023 of 136. And again, you could see the socioeconomic factors on the left side that we can coordinate with that. And we use this information to deploy our mobile units. So this is an overlay of social vulnerability and hypertension prevalence and where we've deployed mobile units. We've now done more than 3,500 events. I have over 250 different community partners. And as you could see, this coloration shows vehicles that represent actual mobile unit programs that we've done or events. And the people that we've screened in those locations for hypertension. And as you could see of the 10,000 plus blood pressures we've done, many of these, in fact, most of them are done in communities where there's a high social vulnerability risk and a high prevalence of hypertension, so we're really targeting and reaching the population. And perhaps the coolest thing about Phoenix that we've developed is that we have the ability, for the first time ever, to look at changes in blood pressure at a neighborhood-by-neighborhood level by limiting the data to a certain period of time. So if we look at April 2022 to March 2023, we can see that same neighborhood I showed, the blood pressure based on our aggregated ER data went up by three millimeters of mercury. Why is this important? Because data show that if you just reduce the population-level blood pressure by two millimeters of mercury, you can prevent, excuse me, almost 50% of incident heart failure in the black population. These data are from ERIC, the Atherosclerotic Risk in Communities Longitudinal Cohort Study. Black circles represent black populations, white squares, white populations. Up to 50% of incident heart failure and almost 25% of incident stroke and coronary heart disease with lower numbers in the white population but similar trends. And that's not me going from 136 to 134 when I'm done with this lecture. This is all of us if we wanted to define a population or all of the entire community of Orlando going down by two millimeters of mercury. A monumentous task, right? Because someone's gonna go up 10, someone's gonna go down 40, what have you. But all you need to do is move that number at a population level by this little. How do you ever track that? That's what we developed here. So you can really start to look at not just the individual benefit of reaching people, but the population benefit of really doing big things. And the nice thing is as we started to gain traction around this, a couple of grant funding mechanisms came out. The American Heart Association through its Health Equity Research Network developed one of their first programs aimed at preventing hypertension. We at Wayne State worked with colleagues at NYU, Benga Ogedebe, who some of you guys may know, a leading figure in the hypertension world. We worked with him, the folks from Johns Hopkins, University of Alabama, Birmingham to develop a center program, something we call Restore, where there are five different projects focused on better outreach and management to prevent either worsening hypertension or development of hypertension. And a key feature of all of this is taking the lessons that we learned from the pandemic, which is better access to care mixed with direct attention to social determinants using community health workers to deliver on those social determinants and improve patients' stress, right? De-stress an individual so that they don't have all of these factors that may be contributing to their control of blood pressure, but also creating personalized programs for this. We developed something called PALS2, which is Personalized Pragmatic Adaptable Approaches to Lifestyle and Life Circumstance Intervention. Why? Because again, we often talk to people about modifying their lifestyle, but the life circumstances preclude that or facilitate it, and you have to know what those are. And personalized because we want the community health workers to work with our patients to come up with specific actions that they're willing to take or not willing to take. Are you willing to stop smoking? Are you willing to exercise? Are you willing to cut down on sodium? And then the community health workers can support them on that journey. And if they're not willing to do that, right, what are they willing to do? And if it's not working, are they willing to change? Is it adaptable? And it's gotta be pragmatic. We can't throw a bunch of new money into the equation. We have to be able to use what we have and what resources are available. So we've set up a system, probably all of you guys have this connection in your community with United Way 2-1-1, right? United Way 2-1-1 is an incredible resource that links out all the social support services in a given community. But we've now worked with our local United Way 2-1-1 to actually make it that we can refer direct through our EHR to our food bank to start with, Cleaners, Forgotten Harvest, to put an order in for food service support. When that person shows up, they can close the loop on that food service support and it reports back to us just like a lab would. So a lot of innovative ways to think about how to reach populations and deliver services to them. The grant success from the AHA led to another one that we became one of 11 centers in the United States funded by the National Institute of Minority Health and Health Disparity to intercept chronic disease in black communities. Again, focusing on the work that we're doing with the mobile units in Detroit and adding on a project at Case Western University looking at coronary artery calcium screening. Again, ways to think about how we prevent disease. Three projects built into this program. One focused on early intervention for lower risk hypertensives. Project two focused on intervention for higher risk patients. Patients who we would call stage A heart failure, people with hypertension but also diabetes, chronic kidney disease, what have you. And a big part of the goal of both of these projects is the social determinant support, but also right sizing evidence-based medication usage. One of the things we know in populations, impoverished populations, racial minority populations, things like SGLT2 inhibitors are way underutilized. It's estimated that about 5% of eligible black patients who could receive SGLT2 inhibitors get them. So that's incorporated and we have pharmacists working with us under collaborative practice agreements to manage the medications on their own with us supporting them. Doing smoking cessation on their own without having a physician order go in, but giving the autonomy to the pharmacist to work with the patients right in the community. Patients don't have to come back to an office appointment. We do all of this place-based. Like I said, the third project is based out of Cleveland, which is focused on work that Sanjay Rajagopalan's done to do free coronary artery calcium screening in the community. Prior to this grant, he'd done 60,000 free CAC screens in the community, but again, only a handful of those individuals were low income black patients. And so while we're going out for the main projects in Detroit using mobile health units, he's working with the Cuyahoga Metropolitan Housing Authority to bring screening into the housing projects, 21 of them in Cleveland, and then bring people back in for coronary artery calcium screening, all free. And this aligns very well with an evolving understanding of cardiovascular disease risk. While we have the ASCVD risk score and we know that hypertension is so critically important as a single variable, there are other things that can go into this, right? Biomarkers, we all want to know about that. Coronary artery calcium is a really important one. And so when we look at things like predicting global CVD events, right, we know that a host of things can be very impactful, right? Different biomarkers, high sensitivity C-reactive protein, NT-proBNP, troponins, but the single most important or the single highest odds ratio in adjusted models is coronary artery calcium screening, right? So I talked about this very briefly in the chest pain center session yesterday where low risk patients who go home, if you want to do any residual screening on them, CAC is probably the best of those tests, not a stress test or anything like that, but important to think about. And then when you're looking at atherosclerotic events, specifically NT-proBNP, strong predictor, no matter what you're looking at, even more so than troponin. So that's the way we think about as we're designing these things. And so future models when we're thinking about population health screening can look to incorporate things like routine natriuretic peptides, routine coronary artery calcium screening in the community. A side project that I'm working on is actually putting a CT scanner in a van, not an 18-wheeler, but a van. I see Arco is a company that makes very small portable CT scanners using cone beam technology. So we now have two vehicles that we're gonna be deploying, starting in the Denver area and branching out for there, where we're gonna be able to do community-based screening using coronary artery calcium in vans. And this is important, right, to some degree, right? Because when you look at things like C-statistic, you guys are all probably familiar with this in some way, shape, or form, area under the curve, C-statistics. If you have the basic things that we would include in our routine screening, blood pressure, cholesterol, what have you, your predictive model is about 0.78 for global CVD, almost 0.8 for atherosclerotic disease. You add in these other factors, you get some improvement, but it's not like it goes all the way to perfect prediction, okay? So the point I'm making here is that the bulk of the prediction that we can do doesn't require anything fancy. From a population scale level, it requires basic, very basic lab tests that we do, and blood pressure incorporating with social determinants of health. And when you look at this right here, right, the cumulative incidence of disease, if you have some of these biomarkers, some of these other lab abnormalities, some of these other radiologic abnormalities, the more you have, completely independent of those other factors, the worse outcomes are over time, right? So again, this just provides evidence and support to think of things like this. You can get your ASCVD risks from the pooled equations, but if you add on other components, you may enhance the risk prediction that you're able to do for certain individuals and do better prevention type stuff. But again, it all goes back to the basic stuff of reaching people where we're at, they're at. We're not the first to do this, right? You guys are all familiar with the barbershop trials that Ron Victor led in the LA area, where they showed a 20 millimeter of mercury reduction in systolic blood pressure between those treated in barbershops and those treated in other locations. And the secret sauce here was a combination of the barbershop being the location to reach people in the community and pharmacists managing blood pressure, pharmacists embedded in the barbershops, okay? So thinking about these distributed models, how do we reach people? How do we change populations? And I'd be remiss if I didn't talk about the political determinants of health, right? So this graphic was taken from a book by Daniel Dawes who spoke at the ACC Health Equity Summit about how the politics, how political determinants, not just social determinants affect this. And if we go back to the first graphic that we talked about, what is population health? These are the policies and interventions at a macro level, right, that affect our outcomes. It's things like should we lower the national sodium recommendation or not? Should we limit access to sugary sweetened beverages or not? And those types of things. And I can say one of the most gratifying things of the work that we've done is we've actually knocked down some of the barriers in the political level. So the first thing I showed you that was similar to this was the initial report of the state's Racial Disparities Task Force. This was the summative report after two years of effort. This is where we work closely. That's Lieutenant Governor Garland Gilchrist, and I'm doing some gyration with my hands about something. I forget what I was talking about. But that's Garland Gilchrist coming out to support one of our events, leading into the governor signing documentation to provide direct appropriation from the state budget to support mobile health units and the work that we started during the pandemic. So almost $50 million in directed funding, 7 million of which is going towards a mobile health unit program. And we're looking to build out a workforce in the state of Michigan, the Michigan Mobile Health Corps, where we all work collaboratively, not competitively, multiple different mobile programs using similar data streams to deploy units to different areas of the community. And times of pandemic, we can flex up to be responsive, but it doesn't mean we shouldn't leverage this infrastructure we built for the greater good. And perhaps most importantly and gratifying to me is we've gotten the payers on board. So Molina is the largest Medicaid managed care organization in the city of Detroit and in Wayne County that cover more than 90,000 lives. When we first started doing the pandemic work, they said, we see you're doing blood pressure work, we want you to help us reach our uncontrolled blood pressure patients. I said, terrific, how many of those do you have? They said, we have 5,000. So you cover 90,000 lives in a predominantly black community and you think you only have 5,000 uncontrolled blood pressure patients? I said, how did you become an uncontrolled blood pressure patient in your definition? Oh, you need two HEDIS measures. You guys all know this, right? HEDIS measures. I said, how many have no HEDIS measures? It was 45,000 people, right? So they had people that they thought they knew information on, but most of the people who were at risk weren't engaging with healthcare. So what we did is said, why don't we develop a program where you give us the location of where these non-engaged individuals live and we'll deploy units into those communities. What you see here is a map from Molina that we developed for Molina showing census tracks where they have one, two, 300 plus individuals who haven't engaged in healthcare in the last one to two years. Remarkable, right? And we've gotten them now to pay us $350 a person that we go do bundled screening services in those communities, which include blood pressure, lab work, social determinants, urinalbumin creatinine ratios, fundoscopy, things that tie into HEDIS measures that they're rewarded for, but things that are beneficial to the patient population. Motivation for this, I think it's because they wanna do better healthcare for their constituents, but I think it also, I know this, right? They get better reimbursement when HEDIS measures are met, but they also get better reimbursement when patients are properly phenotyped and case-mix adjusted. So this is the approach that we're going with now and our vision for changing population health. The initial prevention screening that's barrier-free, cost-free, accessible to everybody in neighborhoods where you look at social determinants, clinical risk, and then you combine them together to figure out what the needs of the patient are. The bundled prevention screening is where we've gotten through to the payers. On the other side of the equation, we wanna be able to do this all under capitated per member per month pricing. Why? Because it's very hard to get reimbursed for the social sides of care, but if you just incorporate that into the model and you account for the cost of a CHW, you account for the cost for the social services, because that's more important perhaps than the 15-minute worker that you encounter with the physician who can't address the social needs that are the most important barrier to what's preventing this person from staying healthy. Thinking about care delivery different. And so this is how we do things. We take our mobile units, we go out to areas. Powerhouse Gym, this is the first one in the country in Highland Park. We go out there and do this type of work, screening communities. We reach the population by doing things like television commercials. I need to get my blood pressure checked, but I'm short on time. No worries. Have you heard of the Wayne Hill mobile unit? They're in our neighborhood and there's no cost to you. No cost. But how do I find them? Just check their website. You can get your blood pressure checked hassle-free right here in our community. That's perfect. I'll definitely check them out. Let's do it right now. Find out when the Wayne Health mobile unit is in your neighborhood. Go to waynehealthcares.org or scan the QR code at the bottom of the screen. So reaching the population, making sure they're aware of the programs. And the other thing that we're really trying to do is say, it's great to have these resources available, but how do you get the unmotivated person motivated? And one of the things that we started to do was rethink the concept of the health risk assessment. You guys may all know this because you get like 10 bucks from insurance when you fill one of these things out. But they're typically onerous, 15 minute long process. We said, we're not really interested in the data, nor do I care about the $10 reimbursement. I want to get people motivated. So we created a health risk assessment that actually takes two to three minutes to do. And at the end of it, it spits out this. And what's more impactful than telling somebody that you're currently 52, but you're really 58 physiologically, or you're really 60. And if you don't do something, you're gonna die 10 years younger than you should. This we find to be incredibly motivating. So we started doing this as a way to get out into the community and do a lot of different things to get people motivated. But really this is all about how do we change population health? How do I make my career that graphic of heart disease death with a goal of diminishing that orange bar for the city of Detroit and creating a lesson, an opportunity for the rest of the country to learn from. With that, I appreciate you guys listening to me for 55 minutes, and thank you for your time. Bill, thanks so much, that was absolutely fascinating, what you've been able to accomplish, which you probably want to take a seat, sit for a minute. You know, I'm sitting in the audience thinking, you know, what could I do when I go home if I wanted to even begin to embark on something that's, you know, even 1% of what you've accomplished. And so, what might you suggest? What would be, if I'm going to go home and I'm really enthusiastic about doing something like this, where might I start, do you think? So while we approach it from getting out into the community and the population, Ben Sirica and others have done things, this concept of hypertension, hiding in plain sight. There are some people who are hiding and never know, you won't find them, that's what we're doing in the community. But there are a lot of people in your health systems who have very clearly documented uncontrolled blood pressures, high cholesterols, and they're not getting addressed. How do you systematically screen for those individuals, identify them, and then pull them back in to the health system? People haven't come back to some of the primary care stuff since the pandemic started. Things have changed in the way we engage in health care, but start with the information you already have. Look amongst your own population because there's a lot of individuals you can do a lot of good for just starting there. Fantastic. Do you have anything from the audience you want to share with us? Yeah, we'll just take a couple minutes here. There's a lot of questions around follow-up and education. Yep. So, everybody who comes through our program, not only do we educate them on site with our community health workers. So, our program on site is medical assistant, patient service representative, a nurse or a pharmacist, and a community health worker. And a lot of time is spent training our community health workers to be able to educate patients on a level they're going to understand about their risk. Some people want to come through and just get a COVID vaccine, but having a community health worker who shares the same lived experience as that individual and is a trusted member from the neighborhood makes a lot of headway towards education. And when we talk about education, it doesn't have to be a handout, a pamphlet, things that we think of. It just has to be reaching the person. How do you reach that individual so they have a better understanding of what they can do to control their own destiny? And so, everybody goes through that process and every individual who we send lab tests on I have a dedicated nurse team that follows up with them either by phone call or through telehealth and then we offer them either remote management if they get in one of our trials, they can get randomized to one arm or another. We offer them remote management with a pharmacist and a community health worker or they can come back in and get referred directly into the health system. The nice thing about what we've done with our program is it's part of Wayne Health, which is our physician practice group, and perhaps not the nice thing in case I ever end up in an orange jumpsuit is I have 90,000 encounters under my NPI right now over the last two and a half years, which is quite high volume. But the reality is we're not billing necessarily for all of that care today. But the key point in all of this is that we've created a system that it's not just disconnected community-based screening, it's fully integrated, so the follow-up is easy for us to do and the education is delivered on the terms and in the language of the patient we're trying to help. Maybe I can ask just one more quick question and I'm wondering if you or your team are thinking about going even earlier in life stages to primordial prevention in school kids and younger individuals? Yeah, no, absolutely. We already work closely with the Detroit Public Schools. I wear an unfortunate hat that I probably don't need to, which is the interim medical director for the Detroit Public Schools helping them with their vaccine program. But as part of the reason to do this is because we want to get into the schools to educate to screen. As I was saying, the vascular insults start early. And if you're a 15-year-old kid with a blood pressure of 110, that's a little too much. So what do we do to help you at that point? So yeah, we work closely with the public school system and absolutely see that as part of that bigger vision of truly achieving an idealized lifespan. Well, thank you so much for sharing your story with us and congratulations on all the success. Thank you. Good. 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population health

cardiovascular disease prevention

social determinants of health

hypertension

Phoenix program

high-risk communities

community interventions

COVID-19

underserved communities