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TGIF: I have a @CircOutcomes #CQOSpotlight on a simulation study evaluating the impact of clinic-based processes to achieve Million Hearts 2022 goals. 
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD Manuscript was originally published in June 2019. I just needed some time to get myself organized. Link is here: ahajournals.org/doi/10.1161/CI…
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD Intro: The authors set out to evaluate knowing what we know, what are reasonable assumptions that would be required to achieve adequate blood pressure goals per the U.S. Million Hearts goal.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD The goal set was 80% hypertension control for all hypertensive Americans by 2022. That's quite optimistic. Like asking for 95% of office workers to never "reply all" to get off an email thread.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD Methods: I'm going to frame this in the simplest way possible. The manuscript provides a great general overview of the modeling approach and the supplement is key to further understanding with appropriate details.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD This simulation model is based on this figure. Everything else is based on a Markov Model run within @treeage and some work in #rstats
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage The key to simulation modeling is the assumptions. At each decision point. The authors need to model the probability of an event. To do this, the review the literature in detail and find the best source for their estimates.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage Even better, they demonstrate some validity of the simulation. To do this, they run their simulation to match patients in real cohorts: MESA, Valsartan Antihypertensive Long-term use evaluation trial (VALUE), ALLHAT. Then report the mean SBP, DBP, and control rates.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage The basis for the simulation model of the U.S. Population is NHANES data. NHANES provides the best estimates of hypertension rates, treatment and control rates. NHANES patients are sampled with replacement to generate a cohort of 10,000 people and repeated 1000x.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage Ok, now how are we going to get all these "people's" blood pressure under control?
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage Well, first if they come to clinic, what's the chance that their medication will be intensified. Second, if they start a medication, what the chance they will be adherent. Third, how soon will they come back to see if they need further titration.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage I forgot to mention that currently only half of Americans with hypertension and 72% of those on medication have blood pressures below JNC 7 goals.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage The authors simulate outcomes under both JNC 7 and 2017 AHA/ACC hypertension guidelines.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage The authors' BPCM model then makes adjustments to rates of these clinical process care. Ranging from usual care, best-observed and "perfect care"(100% utilization/adherence).
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage Results: Table 2 provides mean BP values using these assumptions as well as differences in guidelines that trigger intensification.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage Over the four years, the demonstrate how these clinic characteristics and guidelines goals influence the 2022 Million Hearts goal.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage Next they provide estimates on how changing intervals between clinic visits for medication titration influences achieving these goals, as well as the influence on expected adherence rates.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage Well, this might be somewhat disappointing. Even if we assume default free care with short-intervals of follow-up. We just barely met the 2022 goal.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage Why? Because we are still far from treating those unaware that they have hypertension, those that are aware but don't receive treatment, and some level of variation and patient non-adherence. Nothing can be perfect in the real-world or a simulation.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage The authors rightly highlight that the healthcare system with all its resources is limited in its ability to improvement public health with respect to hypertension control.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage They make mention that limiting dietary salt might increase the likelihood of reaching the 2022 goal but do not model those assumptions directly.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage The authors rightly acknowledge limitations of their assumptions and factors not considered. But simulations are very useful for understanding what is potentially possible and how we should allocate resources with respect to policy.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage One could theorize modeling the rising uninsurance rates recently reported as exacerbating rates of hypertension control and what the long-term risk of ASCVD events might be on mortality and healthcare resource utilization.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage We know the cost per QALY for hypertension control is incredibly low. How we get to better population health will require a big national perspective and studies like this are a tremendously helpful guide.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage *Wanted to include this supplemental table that demonstrates how the simulation models blood pressure trajectories using established cohort data.
@CircOutcomes @mad_sters @bnallamo @thebyrdlab @KBibbinsDomingo @CircAHA @jordanbking @markjpletcher @ValyFontil @ADAlthousePhD @treeage All right everyone, get out there and intensify!!
😭 broken thread:
