Circulation June 15, 2021 Issue

Join Mercedes Carnethon as she interviews authors Brendon
Bellows, Dhruv Kazi, and Kirsten Bibbins-Domingo to discuss two
articles published in the special issue: “Cost-effectiveness of
Hypertension Treatment by Pharmacists in Black Barbershops”
(https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.051683
) and “Scaling Up Pharmacist led Blood Pressure Control Programs
in Black Barbershops: Projected Population Health Impact and
Value”
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.051782.


Dr. Joseph Hill:


Welcome to Circulation on the Run. My name is Joe Hill and I'm
the editor-in-chief of Circulation. In recent months, we
witnessed horrific acts of discrimination and violence against
African-Americans. We are shocked and appalled, but yet we also
recognize that this is in many ways nothing new. At Circulation,
we are highly committed, longstanding commitment to shining a
bright light on these pervasive inequities. And we are not
willing to simply catalog the woefully longstanding racism that
pocks our society, but rather we intend to shine a bright light
on solutions. And with that, we are launching the first annual
issue on disparities in cardiovascular medicine. This will be
released in mid June corresponding to the date of Juneteenth,
which is the date in the 19th century when a group of slaves in
Galveston, Texas was apprised of the fact that they were no
longer slaves now for two years.


Dr. Joseph Hill:


I'm honored to have our three editors who are running this
podcast and this issue with us, they are Dr. Mercedes Carnethon
from Northwestern University, Dr. Karol Watson from UCLA, both of
whom are associate editors with the journal. And I'm pleased that
Michelle Albert, who is one of our senior guest editors at UCSF
will be joining us. These three professionals have led this
initiative and I would like to spend a few minutes talking with
them about this. First let's turn to Michelle if I may. Michelle,
what do you think is required from a workforce perspective to
make headway, to eliminate these disparities?


Dr. Michelle Albert:


Thank you, Dr. Hill. And I would first say that it is an honor to
have been able to participate in this disparities issue focused
on African-Americans and health. First, I think that it is
important for our audience to understand that the metrics
actually behind a workforce. In cardiovascular medicine, only 13%
of fellows are underrepresented fellows, meaning black or African
American, Hispanic, or Latinx, native Americans, Alaska natives,
and Pacific Islanders. And only 9% of faculty are UIM in
cardiovascular medicine. This stems from a pipeline or pathway
issues that go all the way back to kindergarten and middle
school. Indeed, over the last three decades only, although
there's been a 50% increase in applications for blacks and
Hispanics, the applications have only increased by 1.2% and there
has been a drop in Alaska native and American Indian applications
by 30%.


Dr. Michelle Albert:


So with regards to how improve these statistics, we have to have
multifaceted approaches related to understanding pipeline
barriers, which include things like lack of encouragement, lack
of role models and paying attention to recruitment, but not just
the only recruitment at the pre-medical level, immediate
pre-medical level, but way prior to the pre-med level, we have to
engage middle-aged and high school students in STEM and
thereafter at the pre-medical level, we have to make sure that
students get the appropriate advice to ensure successful careers
in college that would then engender successful applications to
medical school.


Dr. Michelle Albert:


Once we get into the actual medical institutional systems, we
have to address structural barriers to discrimination that exist,
that impede the progress through pathways in medicine. And these
barriers exist at the medical school level, the residency level,
fellowship level and faculty to leadership levels. I would say
just a couple of examples at the medical school level to address
would be actually paying attention to the fact that MCAT scores,
we need to pay attention to a whole range of MCAT scores that
focus on success in medical school and not just a specific hard
cutoff. In residency we need to focus on evaluation disparities
for UIM versus non UIM that then set the pathway again for a lack
of progress into extremely competitive specialties like
cardiovascular medicine. At the fellowship level we know that
only 6% of program directors actually value diversity as one of
the top three entities when ranking applicants. Duke School of
Medicine actually had a really innovative process of holistic
review and at all levels there should be holistic review that
pays attention to distance, travel and metrics as well as
attributes.


Dr. Michelle Albert:


And at Duke for example, what they did was they tripled actually
their UIM enrollment in cardiology fellowship from 9% to 33%
after employing a holistic review process that focus less on
metrics and more on a combination of metrics, distance traveled,
et cetera. Once folks are in the pipeline we have to set up
systems of support to help trainees and faculty thrive in
clinical learning and work environments because we noted small
differences and assess clinical performance, amplify to large
differences and evaluations, grades, and awards that have gone
toward consequences for our workforce. And then I would say these
are not my recommendations here or not all inclusive. But two
other things I think that we really need to pay attention to
besides the mentorship and sponsorship is actually stemming
isolation for trainees and faculty within our structures and
systems as well as ensuring that we all have implicit bias
training and also the effect of implicit bias training is
measured over time on the impact on healthcare outcomes and our
pipeline outcomes. I know that was a mouthful, Joe, but this is a
very complicated topic.


Dr. Joseph Hill:


Well, it certainly is Michelle. And I think all our listeners
know that you have been and are a major leader on an
international scale around these topics. Thank you for your
leadership. My next question has to do with building trust with
black patients in terms of their willingness to engage with their
physician and also participate in research studies and trials.
Karol, Dr. Watson from UCLA, maybe you can comment on that.


Dr. Karol Watson:


Yes, I would be happy to. And I have to piggy back on what
Michelle just said. You start off talking about trust, there has
to be a trust between the patient and the provider, the
researcher and the participant, and that trust really it's
multifactorial as Michelle states, but it really does rely on
having a workforce that looks like the patient population, having
principal investigators that look like the participants. We have
an issue with trust in medicine in many areas, but one of them is
lack of trust amongst African-Americans. When surveys are done
and they ask patients to endorse or not endorse certain
statements, the statement I trust my healthcare provider, it's
less likely to be endorsed by African-American patients than
others. And much of that mistrust is well earned. We're all aware
of some horrific medical injustices that were meted out to
certain communities, including African-American communities.


Dr. Karol Watson:


We're all aware of the Tuskegee syphilis study, but there are
many others. So without trust, there really cannot be a healthy,
collaborative care model that ensures optimal patient outcomes.
So I think one of the most important things that we have to stop
doing is thinking of blaming the patient for being, "Nonadherent,
non-compliant, difficult," because many things go into that
equation and much of it is on our backs. And as Michelle says, we
have to diversify our workforce to start off. And I think there
are so many other levels of Michelle really nicely laid out, but
there are really so many other levels and including getting more
African-Americans into clinical trials and we can't just do the
same thing we've always done and expect to get different results.
So we say, "Oh, African-Americans just won't up for research."
Well, maybe we're not making that research relevant, appropriate,
and easy for them.


Dr. Karol Watson:


If we ask people to come to our research centers between 8:00 and
5:00, Monday through Friday, when they're working three jobs and
they have to watch their grandkids and they have no one to help.
That's a very difficult ask, when you're asking people who are
struggling for basic needs and basic survival to do extra things.
It's a very difficult ask and we have to make it easier for them
because I am of a firm belief that everyone wants to do the right
thing. They want to help medical professionals get the research
needed, do the right thing to care for their own health, but it
has to be accessible and that's something we haven't done a great
job doing.


Dr. Joseph Hill:


Well, thank you. What a challenge and that's why I think this
issue that the three of you have spearheaded has helped move that
needle around those sorts of questions. So my last question is a
broad one and maybe even the hardest one that I will throw to Dr.
Carnethon and that is what are the biggest remaining threats?
What does the future look like when you put your headlights on
high beam to solve these problems?


Dr. Mercedes Carnethon:


Well, thank you so much Dr. Hill, and it's great to follow my
colleagues who've offered wonderful insights from multiple
perspectives. When we think about the path forward, we have to
really consider how we got here. And we didn't get here solely
through faults in one system, for example, academic medicine, we
got here because of the broader systemic and structural issues
that have led to differences in access, that have led to the
mistrust we're talking about and that have led to fewer
opportunities for academic advancement for black adults within
this country. And the path forward is going to have to be a
collaborative path. It can't just be the researchers and
clinicians within academic medicine making a change because we
can't make those changes and reach out in isolation of the
context in which the patients who were seeking to help live in.
So it requires partnerships with individuals at the community
level, so that we can think about how we roll out effective
interventions.


Dr. Mercedes Carnethon:


So those interventions that work one-on-one how do we get those
out to the people who need them the most? That requires
partnerships with the community and even changing the
environments in which people live, making them healthier. It
requires partnerships with academic institutions building off of
the point that Dr. Albert made about needing to start and bolster
the pipeline early so that we can get researchers and clinicians
who look like the patients that they're trying to serve. And
ending as well with Carol's point, when we run a study and we
don't have representation from across a range of socioeconomic
status from multiple individuals, black individuals, white, other
races and ethnicities, we don't know how well those therapies are
going to work, or whether there are unique situations that are
going to lead them to be less effective in one group versus
another. So I think I would end really with the point that the
path forward to promoting equity is one that's going to involve
partnerships across multiple different domains. And I do feel
very hopeful that we can get there, especially as we're calling
attention to these important issues right now.


Dr. Joseph Hill:


Well, I will end by saluting the three of you because you are in
fact pointing away to a path forward and concrete things to make
a difference. And it is my pleasure and honor to work with the
three of you leaders. And I'm so proud of this issue, which will
be a recurring issue and in June of every year. And thank you
again for what you've done, you're making an important difference
in our world.


Dr. Karol Watson:


And thank you so much for Dr. Hill for spearheading and
supporting this effort. It is so important.


Dr. Mercedes Carnethon:


Yes, thank you.


Dr. Joseph Hill:


My pleasure.


Dr. Michelle Albert:


It's indeed an honor. And we have to lead by example, and I hope
that we do.


Dr. Mercedes Carnethon:


Thank you so much.


Dr. Mercedes Carnethon:


I'm really excited as we move past our discussion amongst the
editors to have an opportunity in this podcast to also speak with
a team of authors who submitted two papers to our very special
issue we have with us today, Dr. Brandon Bellows, Dr. Kazi and
Dr. Kirsten Bibbins-Domingo who are sharing their findings about
pharmacist led interventions to manage blood pressure among black
Americans in barbershops. So thank you so much for submitting
your important work to Circulation. I'd like to start with
questions for you, Dr. Bellows. So your particular manuscript is
addressing the cost effectiveness of hypertension treatment by
pharmacists in black barbershops. Thank you for working on this
very important work, because it really extends some of what we
talked about earlier, which is the need to scale up and
disseminate what we know to be effective interventions in
populations. So can you tell us a little more about what you
studied and what was unique?


Dr. Brandon Bellows:


Yeah, thank you so much. So we studied the value of a program to
bring clinical pharmacists into black owned barbershops as you
mentioned, and have the pharmacist partner with the barbers to
manage hypertension in black men. As we know, black men are
disproportionately impacted by both hypertension and
cardiovascular disease. So our work was based on a randomized
trial that was performed in barbershops in Los Angeles County.
And this was led by the late Dr. Ron Victor. So we're really
building upon his great foundation. In that trial they found that
the pharmacist-barber collaborations substantially reduced
systolic blood pressure by over 20 millimeters of mercury,
relative to Barber's providing education alone over one year. So
given that having pharmacist drive around barbershops and Los
Angeles is a very expensive proposition, but we wanted to know if
the potential benefits long-term would outweigh some of those
high upfront costs and would it be a cost-effective to do this in
Los Angeles? So really focused on the trial.


Dr. Brandon Bellows:


So to do this, we combined the data from the randomized trial
with our computer simulation model to try and project long-term
clinical outcomes. So upto 10 years, so for both blood pressure,
cardiovascular disease events, as well as the economic outcomes.
So total healthcare costs, costs of the program and so on. So
what we found was that having pharmacists work with barbers and
these black owned barbershops was a cost-effective way to reduce
blood pressure in black men. Over 10 years, we projected that the
program would cost about $2,400 more, and that's total healthcare
costs than barbers providing education alone so they enter the
control arm in the trial, and we found that they would prevent
about 30% of cardiovascular disease events over 10 years. So the
incremental cost effectiveness ratio or ICER, which is how we
define cost-effectiveness was $43,000 per quality adjusted life
year gained.


Dr. Brandon Bellows:


And this is below the threshold recommended by the American Heart
Association of $50,000 per quality adjusted life year gained to
define something as highly cost-effective. So doing this with a
highly cost effective way to improve blood pressure in black men.
So one thing that makes our study unique is that our computer
simulation model allows us to explore different designs of the
program to see how that might impact the cost effectiveness. So
for example, if we were to use only generic antihypertensive
medications, or if we were to decrease the length of the
intervention from one year to six months, the pharmacist barber
program was even more cost effective. So given the long-standing
disparities in cardiovascular disease that have been experienced
by black men in the United States, we're really hoping that how
our research can help motivate healthcare payers to adopt these
kinds of non-traditional approach delivering hypertension care,
because if nobody's paying for it, then there's not going to be
uptake in the community.


Dr. Mercedes Carnethon:


Yeah. Brandon, thank you so much for sharing that and sharing the
details about what you found. I love this line of work because
quite often we've spent a lot of time discussing and describing
disparities, but less attention considering ways in which we can
reduce disparities by reaching people where they are. So that
brings me to you Kazi. So your study uses the same population,
but addresses a slightly different question that I think is very
relevant to our audience as we seek to try to promote
cardiovascular health equity. So tell us a little bit about what
you did in the same population and what you found.


Dr. Dhruv Kazi:


I want to also start out by acknowledging that the study is
anchored in the vision and genius of the late Dr. Ron Victor, who
ran the barbershop based blood pressure controlled studies in
Dallas, and then in Los Angeles. And kind of motivated by his
pragmatic optimism, this idea that we have a problem where others
high rates of uncontrolled blood pressure in black men, but it is
a problem that can be addressed through a novel intervention that
will then have to be contextualized. He was open-eyed about the
need for contextualization that even though there's a large 20
millimeter mercury reduction in blood pressure, any intervention,
when we go beyond Los Angeles would have to be contextualized for
geography and for payer. Would treating blood pressure in Dallas,
or San Francisco, or Detroit, or Atlanta would look different
from both the economics and the practical aspects of delivering
this care in Los Angeles?


 


Dr. Dhruv Kazi:


So we set out to ask the question that if we were to make these
barbershop based pharmacists led blood pressure control programs
more widely available across the country in urban areas,
metropolitan areas, and were able to enroll black men with
uncontrolled blood pressure into these programs, what would the
clinical impact be and what would the economic constraints be for
these programs to be sustainable? We estimated that about 950,000
black men could be enrolled in a program of this nature. So
that's about a third of black men with uncontrolled hypertension
and that doing so on an annual basis would reduce about 8,600 or
8,600 major adverse cardiovascular events. That's about including
1800 MIs and 5,500 strokes. So quite a large number of events,
but 40% of events in enrolled populations. And we then set out to
ask, "Well, that's great. If we could deploy these programs at
scale, there's the potential for substantial clinical impact,
what would the economic constraints have to be for this program
to be sustainable?"


Dr. Dhruv Kazi:


So if we imagine that this were not a delivery program but rather
a pill, and you were willing to pay $100,000 to reduce per
quality adjusted life here for blood pressure control medication,
how much would we be willing to pay for this barbershop based
program? And we found that approximately it would have to be
delivered at a cost of $1,400 per patient per year. Now, $1,400
per patient per year is a substantial amount of money when you
scale it up across the entire eligible population, but at the
same time would require innovation and delivery that goes beyond
pharmacists driving from one barbershop to another. So what we
hope is that our work will stimulate this conversation around how
can we take this intervention that is highly effective, that is
potentially scalable and adapted in a way that we can afford to
deliver it nationwide without losing effectiveness that we saw in
the Los Angeles trial?


Dr. Mercedes Carnethon:


Thank you so much Dr. Kazi. And this just generates a lot of
discussion as we really think about how we can bring
interventions to people and how we can have an impact. So
Kirsten, I'm so pleased that you were also able to join us as one
of the senior authors, senior members of these research teams,
because we really value your perspectives as well about where do
the findings from this study situate us in the field. How do we
move forward to achieve our goals of achieving equity and
particularly among black patients and black adults in this
country who we know have experienced significantly higher rates
of hypertension and hypertension related disorders, we have a
significant need here. So tell us how do we use this important
information in order to make a difference?


Dr. Kirsten Bibbins-Domingo:


Thank you so much for having us and congratulations on this
really important issue.


Dr. Kirsten Bibbins-Domingo:


I think what we see here in why these papers and this work is
important is that it is really trying to take the important
science that we're producing, trying to aim that addressing
disparities and put it in the context that we could ideally
rapidly translate it to actually help and address this issue. And
with hypertension, we have both the urgency of declining rates of
blood pressure control in the US as well as the persistent
disparities that we see. So we have this effective intervention
marrying a care provided by clinical pharmacists with
community-based venues and partnership with black barbershops
that is highly effective. The detailed studies led by Brandon
really suggest that even in LA, pharmacists driving around this
is a cost-effective intervention and that if we were to scale it,
it could actually reach a lot of black men in the US and even
though $1400 per person per year is a lot of money, it's actually
not out of context of other things that we do that are high
priority for our healthcare systems.


Dr. Kirsten Bibbins-Domingo:


So what we hope is that these two papers together help us to
start to bring more people to the table to how we can translate
now an effective trial, a trial that can effectively scale in a
cost-effective way to thinking about what we could actually do.
So how might this look? We think this is something that we hope
health systems start to engage in. When they see disparities in
the care for their members, for their patients, how could they
think more creatively?


Dr. Kirsten Bibbins-Domingo:


How could payers, how could Medicaid for example, think about
incentivizing different ways of delivering hypertension care? How
could we think in other contexts about departments of public
health or cities that really want to have a population-based
approach to improving cardiovascular health? And money isn't
everything, but is an important thing that many of these entities
are thinking about and understanding both that this is a
cost-effective intervention and that the amount per person to
actually achieve this important role in cardiovascular health is
not out of scale for other things that we prioritize in terms of
health I think is important and that's what we hope people will
take away from these important studies.


Dr. Mercedes Carnethon:


Wow, I really appreciate the time and attention that your team
put into designing these really high impact research studies that
achieve what our goal is, is to really think about ways in which
we can address and eliminate disparities. I've really loved
hearing about this work, and I hope that a broad audience
receives it and really thinks about some of what we talked about
before, which are the multiple different parties and disciplines
that are required to come to the table for us to effectively
address disparities. So thank you so much for spending time with
us at our Circulation on the Run podcast, Dr. Kirsten
Bibbins-Domingo from University of California at San Francisco,
Dr. Brandon Bellows from Columbia University College of
Physicians and Surgeons and Dr. Kazi from Beth Israel Deaconess
Medical Center. So thank you so much for spending time with us
today.


Dr. Dhruv Kazi:


Thank you for having us.


Dr. Brandon Bellows:


Thank you. It's been a pleasure.


Dr. Mercedes Carnethon:


And finally, I'd like to end by thanking our listeners for
spending time with us today. We hope that you enjoyed the
podcast, and we hope that you will enjoy the issue even more.


Dr. Greg Hundley:


This program is copyright of the American Heart Association,
2021. The opinions expressed by speakers in this podcast are
their own, and not necessarily those of the editors or of the
American Heart Association. For more, visit ahajournals.org.