SUMMARY OF THE MEETING OF THE NATIONAL HIGH BLOOD PRESSURE COORDINATING COMMITTEE August 11, 1978 Bethesda, Maryland CONTENTS Introduction . Dr. Levy's Remarks . Seientifie Issues: Consideration of Draft Committee Position Statement on Dietary Management Hypertension in Rural Populations. FDA Analysis. Program Management Issues: National Conference Planning Update. Fifth Conference, 1979. Sixth Conference, 1980 . Hypertension in the Elderly. . . . .« « . Current Strategies and Activities of the NHBPEP HBP Month '79 Objectives and Theme. Dissemination of the Position Statement on Coin-Operated Devices by Member Organizations Establishment of the Interdisciplinary Task Force on Provider Roles . Information Sharing . Next Meeting Dates. Page Introduction Mr. Ward opened the meeting, Dr. Levy having been unexpectedly called to a meeting with Secretary Califano. Mr. Ward mentioned that, unless otherwise requested by Coordinating Committee members, courtesy information copies of the minutes, agenda, ete. of the Committee meetings are sent to the presidents of organizations represented by the delegates, when the president is not the representative. He also mentioned that the meetings are tape- recorded to aid in preparing the meeting summaries. If any member has any problems with these actions, or wishes to go off the record on a given issue, he need only let the chair know. Mr. Ward announced that three 3-year contracts supporting demonstration pro- grams on hypertension control in the work setting had been awarded. The recipients are: the University of Michigan, which will work with Ford Motor Company employees at four sites in southeastern Michigan; the Westinghouse Corporation, involving five of its plants throughout the country; and the University of Maryland, which will work with State of Maryland employees located in Baltimore. The contractors will focus on general HBP education programs for the employees and on voluntary counseling for known hypertensives. All will include cost-analysis so we will have improved data avail- able for discussions with management on investing in hypertension at the worksite. Dr. Levy's Remarks Dr. Levy, after assuming the chair later in the meeting, commended the news- letter published by the Citizens for the Treatment of High Blood Pressure. It contains results of the Program in terms of reduced morbidity and mortality. The newsletter also calls attention to a new bulletin from the National Center for Health Statistics which looks at ambulatory care in the United States. This publication reports that be- tween 4 and 5 percent of all physician visits in the U.S. are for hypertension. A copy is attached to these summary notes. Dr. Levy also reported on the meeting of the US/USSR Working Group in Hyper- tension. For the past five years a collaborative, exquisitely standardized study has been going on in 11 U.S. cities and two Russian cities, Leningrad and Moscow. Informa- tion was gathered primarily to look at demographic variables, nutrition, and lipoproteins and their relationship to cardiovascular risk, but hypertension information was also collected. A striking finding is that among males 40-59 in Leningrad and Moscow, the preva- lence of hypertension was found to be twice that in the United States. The levels of awareness and of effective treatment in the USSR were essentially equivalent to the 1971 U.S. level, as expressed in the 3x4x+ formula. It will be interesting to see over the next few years, whether in the Soviet Union the numbers will change as ours have. Dr. Levy noted that the distributed article preprint,"Pseudohypertension in the Elderly," by Spence, Sibbald, and Cape, has serious flaws and neither proves nor dis- at proves the measurement problem in the elderly. There are inadequate details about the generalizability of the patient sampling frame and the measurement conditions, and the data are not treated or analyzed adequately. SCIENTIFIC ISSUES: Consideration of Draft Committee Position Statement on Dietary Management Scheduling difficulties prevented a meeting of the members involved in drawing up a draft dietary management statement. A mail effort produced a very rough draft which has gone back to the members of the working group. Anyone who wishes may still provide input, either at this meeting, or by phone or mail. We plan to have a state- ment ready for formal discussion and action at the November meeting. mrs cccaneme ve ~‘ Hypertension in Rural Populations (preparation for November discussion) Hypertension in rural populations is an issue to be addressed because by and large, progress in HBP control seems to be taking place primarily in and around metropolitan areas. Rural areas, or those communities or general areas with a population of 50,000 or less, have special problems, including: ° _ Communication and health care access problems because the population is so dispersed. tee Lack of network of social services and social support organizations as found in metropolitan areas, because the communities are small. e Difficulties on the part of providers—mostly solo practitioners—because of lack of access to many things available to larger groups, e.g., continuing education. Dr. Krishan, joined by Dr. Hunt, will address these and other issues at the Novem- ber meeting. Mr. Ward presented the following outline of their presentation, as prepared by Dr. Krishan. Dr. Krishan plans to discuss and analyze the unique problems of health care in rural populations as they affect the planning and delivery of hypertension control ser- viees. He will describe, first, the peculiarities of rural health care in general, which will be based on experimental and survey data, including differing physician/patient ratios, differences in ambulatory care utilization, problems in the dispersal of care resources, and health status differences. Secondly, he will discuss specific experience with hypertension control programs in rural populations, looking at the impact of such unique problems as dispersal of popu- lations and lack of facilities. Third, he will discuss the studies done at the Mayo Clinic on problems and poten- tials for hypertension control in rural populations, including specifically the use of para- professionals. a Dr. Krishan and Dr. Hunt will conclude by attempting to develop some specific recommendations for the Program for your consideration. If the Committee decides to adopt them, Program staff and the participating organizations will move forward on that basis. , Issues not in this outline that any member considers important and wants included should be sent to Dr. Krishan either directly at the Mayo Clinic or through the Program Office at NIH. FDA Analysis The FDA analysis was not ready in time for this meeting, but is expected for the November meeting. Sponsored jointly by NHLBI, FDA, and AMA, this mail survey of physicians on their approach to hypertension went out last spring to approximately 6000 physicians (a national probability sample). The return, a weighted 65 percent, has been under analysis for the past three to four months. Because of the size of the question- naire, the complexity of the questions, and the addition of three supplementary ques- tionnaires, the analysis of the results has taken a great deal of time. A preliminary analysis presented at the Fourth National Conference indicates that physicians are tending to follow a stepped-care approach, although they tend to initiate that approach at slightly lower blood pressure levels than those recommended by the Joint National Committee. PROGRAM MANAGEMENT ISSUES: National Conference Planning Update Fifth Conference, 1979 Dr. Kaplan reported that the 1979 Conference Planning Committee met on July 17, set the outline for the 1979 meeting and developed specific recommendations for the Coordinating Committee's consideration. Plans call for three major parts of the pro- gram: plenary sessions, continuing education panels, and abstracts and posters. These are detailed on the National Conference materials enclosed in the packet distributed for this meeting. About 25,000 "Call for Abstracts" cards have been mailed out. The theme of the Fifth Conference, "Evolving Approaches to High Blood Pressure Control," was approved, as were the topic areas for the plenary sessions, continuing education panels, and abstracts. The banquet speaker will be Dr. Henry Blackburn, from the University of Minnesota, who is expected to speak on overall cardiovascular risk factors. The Planning Committee proposes that in addition, a keynote speaker be sought, and that this speaker be a high political figure, who would help the conference get good press. This address is scheduled for the first morning of the conference. The Planning Committee requested the consent of the Coordinating Committee to invite a figure such as Senator Kennedy, Senator Brooke, Secretary Califano, or Ambassador Richardson. interest in high blood pressure, provides various kinds of information and materials, and supplies technical assistance to local efforts and national coordination of these efforts and of approaches developed or implemented locally. Mr. Ward first outlined the Program target areas. "Current priority" areas in- elude: long-term maintenance of antihypertensive therapy; development and adoption of the most current recommendations for detection, evaluation, and treatment; improve- ment of coordination at all levels; definition and promotion of nonphysician roles in patient management; and encouragement of phigh blood pressure eontrol programs in the work setting. Program target areas of "emerging interest" include: dietary management of HBP; high blood pressure control among the elderly and among rural populations; stand- ards for blood pressure measuring devices; and international activities. NHLBI activities extend to education research projects, state demonstration projects, work setting projects, the Ad Council activity, and the coordination of the NHBPEP. Mr. Ward's presentation focused primarily on the Institute's coordination of the NHBPEP, including working with the Coordinating Committee, the Interagency Tech- nical Committee of the Institute, HBP Month, and the National Conference on HBP Control. Objectives and activities were presented in detail for the following areas: professional and patient education, community program development, information dissemination, minority support, selected studies, and program evaluation. The complete text of Mr. Ward's presentation is being prepared for later distribution. HBP Month '79 Objectives and Theme Ms. Pat Bandy reported on 1978 HBP Month and plans for 1979. Coordination of 1978 Month, based on the institutionalization of Month programs within many of the organizations and community agencies, focused on the Program's providing tech- nical assistance and information to participating organizations. The 1978 marketing effort assigned staff members a small number of organiza-~ tions to contact and work with. The Month handbook was redesigned as an informa- tional wall poster for program planning. ~ Evaluation of 1978 Month showed the following: e 56 percent of participant responders did more in 1978 than in 1977; 2 percent did less e 79 percent indicated year-round activities e new participants were highest among civic organizations, universities and professional schools, and nonhealth community organizations oc participants among health eare providers, volunteer groups, and drug com- - panies appears to have leveled off, i.e., they showed relatively little first- time participation this year @ | overwhelming approval of the poster format for the Month kit e in addition to the 60,000 Month kits distributed this spring, over 1.1 million publications were sent out in response to Month inquiries, ©" Plans for 1979 call for essentially the same techniques, with refinements. The theme will again emphasize the ustay on treatment" idea and groups will be encouraged to work together on joint projects. The Coordinating Committee's role will again be one of sponsorship. 1978 Month seems to have marked a turning point: it has become a Program tool and is no longer an end in itself. Dissemination of the Position Statement on Coin-Operated Devices by Member Organizations Dr. Levy asked for the members' opinion on whether this document should be used only to respond to inquiries, or should it be disseminated. In his opinion, it is now too old a document to publicize. The Committee agreed. No update is available on the activities of the FDA and ANSI regarding standards for BP measurement devices. Establishment of the Interdisciplinary Task Force on Provider Roles Dr. Levy announced that this task force is about to be established and that ideas from the Coordinating Committee are most welcome. Questions include what the task force should address, the definition of a "provider," whether to include in the definition administrators and physician assistants, ete. At this stage, Dr. Levy noted, no one is necessarily excluded or included, and the members are encouraged to send in their thoughts on this question and on the charge that should be given fo this task force. a Information Sharing * Dr. Williams (National Medical Association) ‘ The National Medical Association just completed its convention in Washington, D.C., and had very good panels and a good exhibit on hypertension. Mr. Gorman (Citizens for the Treatment of High Blood Pressure) Citizens for the Treatment of High Blood Pressure now publishes three newsletters. The group found a tremendous response to its efforts in Michigan. Dr. Richardson (American College of Physicians) There are problems getting information on what medical schools are teaching on hypertension. Dr. Levy suggested that Mr. Ward, Dr. Moser, Dr. Richardson, and he get together on this subject. Dr. Vidt (American College of Chest Physicians) The American College of Chest Physicians is coordinating the efforts of an inter- national commission to develop a six-unit teaching package on risk management of the hypertensive patient, and have set the dates for a national postgraduate course on hypertension to be held in June 1979, aimed at the practicing or primary physician. TT Ms. Moore (American National Red Cross) Agreement has been reached with the Red Cross Blood Service to Put Peae ,/ the blood Gonors who were found to be hypertensive. C A, kK © I) Ms. Paul (American Heart Association) The American Heart Association has been engaged in the following: 0 Fy Morking with HEW regional staff and Program staff to bring about a more cooperative program between state and local health departments and between “state and local planning organizations. e Cooperating with hypertension programs for federal Civil Service employees. =) Developing guidelines on the role of the dentist and pharmacist in hyper- tension detection and control. e Together with American Nurses’ Association, sponsored a national confer- ence on nurses’ functions and training. @ ,/ Cooperating with Blue Cross/Blue Shield on development of model programs. ® Developed guidelines for program planning in minority and other ethnic communities. e Developed program kits to accompany the film HBP--If Only It Hurt a Little. Mr. Klobnak (American Osteopathie Association) In April, the American Osteopathic Association produced and released to 500 TV stations a PSA emphasizing the stay-on-treatment theme. The response was / better than 60 percent, and stations requested more of the same kind of material. The Association is also evaluating the HBP activities and efforts of their students. Dr. Gutensohn (American Osteopathic Association) The Wisconsin Osteopathic convention had two talks on hypertension, plus a report on the Coordinating Committee. Dr. MeQuarrie (American Optometrie Association) ee ceweeeeé eee The American Optometric Association has been working with 50 state affiliates to integrate greater awareness regarding hypertension into the Association's con- tinuing education system. The Association is also attempting to establish what ‘the level is in the schools and colleges of optometry. Dr. Weinstein (National Kidney Foundation) The Kidney Foundation of Iowa dane saunches a program encouraging home blood pressure measurement. The pro es industry -Brocpeedymog es, and public schools education activities. \ Ue On Dr. Guyther (American Academy of Family Physicians) The American Academy of Family Physicians will be very interested in the mate- rial on hypertension in rural populations. Dr. Kaplan will speak on hormones and hypertension at the national meeting in Septenibor: there will be an exhibit on hypertension and nine clinical seminars and a 4-hour course on hypertension as part of the continuing education program. The Academy is also focusing on patient education in hypertension as well as other areas and its house of delegates has included on its agenda the recommendations on consumer-administered BP measurement. Next Meeting Dates The next meeting will take place on November 6; March 5 was agreed upon as the tentative date for the first meeting of 1979. The meeting adjourned at 1:30 p.m. 10 ATTACHMENT ADVANCEDATA NO. 22 March 22, 1978 Office Visits by Persons Aged 65 and Over: National Ambulatory Medical Care Survey, United States, 1975 NATIONAL HIGH BLOOD PRESSURE COORDINATING COMMITTEE Bethesda, Maryland November 6, 1978 AGENDA SCIENTIFIC ISSUES Old Business e Dietary Management Statement e High Blood Pressure Control in the Elderly Ch, ‘ Ahfed) = * mn 4 New Business e FDA Physicians Survey @e High Blood Pressure Control in Rural Areas e Report on Cardiovascular Mortality Decline workshop x2 Ott -2.9 1999) PROGRAMMATIC ISSUES e Interdisciplinary Task Force: Review Charge to Task Force e HBP Month Update e National Conferen e 1979 Update 1980 Chairman e New Joint National Committee: Review Charge to Committee e Review of Homework for Next Meeting stil e Set Date for the Summer 1979 Meeting (Spreng Medi anol [ Ore tg e Information Sharing /