"THE HEART OF THE MATTER"
a special program of the National Emergency Medicine Association (NEMA)


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Week: 593.7 

Guest: Martha Hill, PhD, Health information, Behavioral Sci. Johns Hopkins,New President, American Heart Association. 

Topic: American Heart Association goals 

Host/Producer: Steve Girard 

NEMA: For the first time, a non-physician has been elected president of the American Heart Association. Martha Hill is a PhD, a nurse, research director and professor at Johns Hopkins School of Nursing in Baltimore. After serving a year as the AHA president-elect, she’ll be president for a year...and we wanted to talk with her about her outlook on the task ahead, and the role of the American Heart Association  

HILL: The mission of the American Heart Association is to reduce death and disability due to heart disease and stroke...and we’re trying to do that by giving information to people. Information that ‘s based on scientific results, on research studies, that tell us what people can do to reduce their risk of heart disease and stroke. Or if they have the conditions, what they can do to manage them most effectively. So, we have information that’s directly available to patients and their families, we have information for the public at large...which we sort of view as made up of well people who want to stay well, as well as patients and their families. And then we also provide a great deal of information directly to physicians, nurses, pharmacists, nutritionists and other health professionals, so they will have up to the minute information on how to provide care.  

NEMA: As the new president of the organization, what areas of research or information dissemination do feel you should focus on?  

HILL: Well, the president of the American Heart Association is the chief scientific officer, and there’s also a chairman who represents the so called, "lay" side of the volunteer organization. And traditionally, in the entire 74 years of the association, the president has always been a physician, and predominantly the presidents have been cardiologists. I am the first person to be president who is not a physician...I am however, a scientist. I am a nurse with a doctoral degree in the behavioral sciences, and I’m very, very interested in the behavior of patients and the behavior of providers, and how these relate to health. So, my own work looks at factors that influence whether or not people get into care, stay in health care, and whether or not they follow treatment recommendations. And we also then look at whether or not the care they’re receiving is consistent with what the scientific evidence tells us is beneficial and helpful for people. So, my interest is bringing the social and the behavioral sciences forward in the Heart Association. Because you can have many spectacular discoveries in the laboratory or in the hospital that make an enormous difference in people’s lives, but if their daily lives, when they’re not in the hospital, are not helpful, then a lot of our scientific discoveries will not be utilized, and will not bring about benefits in the health of the public.  

NEMA: I guess there are many reasons that people aren’t getting the benefit of the mounds of information on healthy living that organizations like the AHA are providing...  

HILL: Well, for some people, it’s a matter of ..they don’t know what to do. Other people...they know what to do, but they’re not motivated to do it, because they’re perception is that the benefits are too few, or too elusive. For other people, they know what to do, and they understand the benefits, it’s just that there are a lot of other barriers that get in the way. For example, they don’t have health insurance, they can’t get time off from work to keep appointments because all the appointments are 9 to 5, five days a week. And they’re concerned that there may be adverse effects to the treatments that will complicate their lives in ways that seem worse than the benefits that may be gained. So it’s a combination of resources and skills, and those resources and skills include knowledge and attitude and perception of risk and benefits. So this again, you see, puts it in the realm of the social and behavioral sciences...and an excellent example of what ‘s very important today is we now have some wonderful new medications called the ‘clot buster’ drugs that are very beneficial to people who are in the very early phase of heart attack or stroke. But if the average person at their home or in their job, doesn’t recognize that they’re having a heart attack or stroke, they don’t know the warning signs and the symptoms, and they don’t know what to do about it....or if people don’t recognize those symptoms in their friends and their family and take action, then people won’t benefit from these new drugs, because they won’t get to the hospital in time. If they’re not there within a couple of hours, then the benefit is not realized. So, recognizing the signs of heart attack and stroke and taking the appropriate action, is now an extremely important message for people.  

NEMA: I know you believe that there is a lot in studies and research that don’t make it into practice in a timely manner...  

HILL: There is very good evidence that much of the findings from research studies are not being integrated into a regular part of routine care. And this goes all the way from something as simple as giving patients pre-appointment reminders...you know, mailing out postcards or telephone calls to remind people of their regular visits? You know, we’ve known for over thirty years that that dramatically increases the proportion of made appointments that people keep. And dentists learned this a long time ago, when they shifted their practice from one that took care of symptoms, you know, people with abscesses or painful teeth....when they went into preventive care, they learned that you really need to become very customer focused and help people participate in their care. So, something as simple as pre-appointment reminders, all the way up to the fact that we know that even in people who have had heart attacks, they need to have their risk factors...for example their blood pressure and their cholesterol levels...very carefully managed. But some recent studies have shown that only a third of the patients who are discharged from hospitals after a bypass or PTCA or myocardial infarction actually have all their risk factors evaluated and monitored and treated. And in a recent study of women with heart disease, who had high blood cholesterols, only 9% of those women had their cholesterol levels treated to goal levels. So, you might say, "Well...why is this"? Well, in part it’s because patients don’t know...but in greater part, it’s because of, I think, challenges that face physicians and nurses and others...and also the health care system. That we need to have, for example, computer systems that automatically monitor and track these things...there’s a lot of technology we could be using to help us with these preventive aspects of care.  

NEMA: Let’s talk about some of the research you’re interested in at Hopkins....  

HILL: Well, there have been many studies done for decades about how to treat high blood pressure. And much of the attention was given to older people, because they have more of it. But one group that has been very, very little studied...that has very serious high blood pressure problems...are young males who are African American. We are interested in learning about ways to improve the care that they get and to improve their health. There are a variety of issues: one is that high blood pressure doesn’t have any symptoms, that people who have it tend to feel very well, until they’ve developed advanced complications. And for young men who are otherwise healthy, it’s not part of their gestalt, you know, to go to the doctor routinely..So, we found that very often these men who have high blood pressure don’t know they have it. We also have a high rate of unemployment in the inner city among this group, and therefore they don’t have health insurance, and these are additional barriers to their getting care. So, we are looking at culturally relevant ways of improving the care that they get. They are quite familiar with the problems high blood pressure causes. Almost every single one of them has someone in their family who have had it and suffered strokes or kidney failure or heart disease from it. And so, we are looking at using nurse practitioners and community outreach workers to help us understand how we can adapt the care, so that it’s sort of culturally salient and relevant, and we can provide the care in a way that will be acceptable. And this calls from some major changes in the way that care is delivered.  

NEMA: What is the degree of the problem? I didn’t know that high blood pressure strikes so early and builds as you’ve described...  

HILL: Well, it does...now we find, for example that if we go over to the emergency room and check the records of young men from the inner city who’ve been there...and they all have their blood pressure measured, no matter what reason they come to the emergency room. If we invite them back and remeasure those blood pressures, about 40% of them will still have an elevated blood pressure several weeks later. Some of them knew they had high blood pressure, some of them didn’t. And so we measure it multiple times to see whether or not those levels are sustained...that’s the first thing and that’s a very important part of getting an appropriate diagnosis. And some of the men are in care, and they can tell us that they have seen a doctor, and they can tell us that they’re receiving medication. But being in care doesn’t mean that they are in care consistently. They drop in and out, they go on and off the medication and even if they’re on it...they’re either not on enough, or they’re not on the appropriate regimen. And so more...in less than half of them is the blood pressure controlled.  

NEMA: And the primary goal of your research now....?  

HILL: At this point, we’re not into primary prevention, we’re not trying to prevent the high blood pressure. We are trying to find men who have high blood pressure, and we’re trying to increase their being in care and getting their blood pressures under control by following the right treatment recommendations. And thereby trying to lower the blood pressures, get them down to goal level, and consequently we hope to prevent strokes, heart disease, for example, enlarged hearts and also any problems with real damage. So we have, in this particular study, two groups of men...half of them randomly assigned to a very special treatment group, the other half are being monitored very carefully as well, but they’re not...we’re not providing the treatment. We do refer them to care, but it’s up to them whether or not they go. In this way we’re able to compare whether or not all the additional things we’re doing really will make a difference.  

NEMA: Kind of a behavioral control group there...  

HILL: You know, you have to do that because...if we show that these outreach workers and nurses made a difference over a year or two...the first question someone’s going to ask us is, "well, in comparison to what"? And so if you don’t have this comparison group, then you’re not able to say that these additional services really make a major difference. My argument is ..."if we can keep one man off of dialysis for one year, if we could just delay that...the money we save on dialysis could be used to help a lot of other men stay well.  

NEMA: Our thanks to Martha Hill, PhD. and professor at Johns Hopkins School of Nursing, and the new president of the American Heart Association.  

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NEMA: Thanks for joining us for today’s program. If you have any comments or suggestions, contact this station. Or visit our home page at:

www.nemahealth.org/

...for a look at transcripts of this or past programs, or to find out more

about the National Emergency Medicine Association. I’m Steve Girard at The Heart of the Matter.