Season 2, Episode 4 - Dr. Phillip Levy, assistant vice president of Translational Science and Clinical Research Innovation, on the critical importance of research and innovation in treating hypertension in underserved communities
Dr. Phillip Levy talks about efforts to address long-standing issues surrounding hypertension in African American and underserved communities in Detroit.
Dr. Phil Levy joins host Darrell Dawsey to discuss his groundbreaking efforts to research and address hypertension in underserved local populations, especially African American communities in Detroit.
Phillip Levy, M.D., M.P.H. is the Edward S. Thomas Endowed Professor at Wayne State University, where he currently serves as assistant vice president for translational sciences and clinical research innovation, and associate chair for research in the Department of Emergency Medicine; in addition, he is also the chief innovation officer for the Wayne State University Physician Group. Levy has overseen more than 90 funded studies from various entities since his arrival at Wayne State in 2002, including the CDC, NHLBI, NIMHD, PCORI, AHRQ, EMF, and Robert Wood Johnson Foundation. Related to this work, Levy has published more than 220 manuscripts and textbook chapters over the past decade and has been an invited lecturer on cardiovascular disease more than 220 times. While most of his research has focused on uncontrolled hypertension, hypertensive heart disease and heart failure (and related health disparities), he has also been at the forefront of efforts to better understand the evolution in biomarker evaluation of myocardial injury.
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Welcome to Today@Wayne Podcast. I am Darrell Dawsey. Hypertension remains a leading health risk in America, most especially among underserved and minority populations. As home to one of the largest Black populations in the country, Detroit has certainly not been immune to the dangers posed by hypertension. Recently, the American Heart Association took yet another step toward addressing the problem when it awarded $20 million in grants to five scientific research teams around the country, including a $2.6 million grant to Wayne State University. The funding will help drive a four-year project at Wayne State known as LEAP HTN, which stands for "Linkage Empowerment and Access to Prevent Hypertension." LEAP HTN deploy Wayne Health mobile units to provide direct, personalized health care and coaching to Black people with high blood pressure living in select under-resourced neighborhoods in Detroit. Community health workers will help people in the study develop and follow a personalized, flexible health plan and, throughout the year, researchers will regularly compare hypertension and other health factors of people in the program to those of people in the community who also have high blood pressure but didn't take part in the program.
The lead researcher on the project is Dr. Phillip Levy, professor of emergency medicine and assistant vice president of translational research here at Wayne State. And we're fortunate to have Dr. Levy here with us on the Today@Wayne Podcast to talk about this gift and the groundbreaking effort to address hypertension here in Detroit. Welcome Dr. Levy.
My pleasure to be here, Daryl, and you're hired as a spokesman. You got it. You got it all in on that one reading.
Well, it's a fantastic program and we're always very proud to promote the great things that we do. And let's just jump into it. Tell us a little bit about, first of all, just your work in general. I know that you've been involved in working with underserved populations around issues of cardiac issues for a long time. So just, maybe, give us just a quick overview of your work and then let's talk a little bit about Leap HTN; what it is and how this, how this [inaudible 00:02:28]
Absolutely. And again, I appreciate the opportunity to share this information with the Wayne State University campus. So, I'm an emergency physician, as you mentioned, and have been so for about 20 years here in Detroit, working at Detroit Receiving Hospital. I came from New York City. I trained at Bellevue Hospital and I was indoctrinated with the concept that emergency departments aren't always just for emergencies in communities like Detroit — underserved communities — especially where primary care may be limited. Emergency departments serve a broader function. And that often is in the area of public health or population health where people go to the ER, because they've often, sometimes, no place else to go. So I've always been in this mindset that the emergency department plays an important role, not just in the moment, but beyond and [in] the whole health care continuum. And so my work has largely focused on the concept of hypertension, high blood pressure.
Like you mentioned, as an ER doc, I always started treating heart attacks and strokes and acute heart failure and the like, but the problem behind the problem was always high blood pressure. And so we started setting up a whole infrastructure in the emergency departments of the Detroit Medical Center, screening people for high blood pressure, trying to link people who come to the ER with high blood pressure to ongoing care. We've received a number of grants over the years, but when COVID hit, people stopped coming to the emergency department, right? And we know people were very sick. They came in, but people who were using it for this purpose stopped coming for this purpose. And all of a sudden, people couldn't get this level of care that they needed. They couldn't go into primary care offices because many were not open or, again, the access issues that plagued our community prior to COVID were only exacerbated and made worse by COVID.
So what we started doing early on in the COVID pandemic was working with the Ford Motor Company to create mobile outreach, initially focused on testing people for COVID, bringing testing into communities of color, into the neighborhoods of Detroit, Hamtramck, Dearborn, you name it, trying to get into communities to take testing to people.
As things evolved, we became a pillar of the state's health disparities task force, which was created to try to reduce the impact of COVID on communities of color. And the state funded us — along with many philanthropic contributors — to purchase a number of vehicles. We now have five of them fully up-fitted beautiful vehicles from Ford, on the Ford Transit platform. And we realized that not only could we take these vehicles and do COVID testing — now COVID vaccinations — as we transitioned to that point to the pandemic, but we could also treat people and bring in other aspects of health care. We could measure blood pressure like the program we were doing in the ER, we could take this into the community and start doing this for mobile units.
We could start screening for things like kidney disease and diabetes and high cholesterol. We can do blood tests in the field. And so we started really rethinking, 'What is health care and what is health care post COVID?' And what happened with all of this is we got a lot of traction. We had a lot of interest in the community. People have come out and really espoused or really enjoyed the idea that they could walk out of their house and go down to their neighborhood church or some other location that's in the center of where they live and get screened for COVID, get vaccinated for COVID, get linked to hypertension care, get other things going on.
We have community health workers and patient health navigators on our vehicles that not only assist people with making appointments for medical problems follow-up ,like hypertension, but also linking them with social service resources. Like, 'Hey, my water's going to get shut off. Can you help me with that? Or right. You know, I face eviction or foreclosure. Can you help me with that? I need food assistance. Can you help me with that?' And so we've really rethought this and that was the beginning of this grant. And so as we were at that point trying to think of how we can further expand our mobile outreach, this AHA grant opportunity arose, and we partnered with the four other institutions, like you mentioned, to go ahead and create the Leap Hypertension Project.
Okay. Now, now tell me about the project. About how many people, certainly here in Detroit, but how many people will it involve, how many people will it touch?
So the project itself is aimed at reaching 500 people. And in the parlance, the language of research, it's a randomized control trial. The reason that you want to do that, you want to eliminate any potential bias or influence on outcomes. And if you randomize people, then you sort of smooth everything out. And so we're going to randomize 250 people to a new form of care, which is a mobile health outreach care project. Like you said, it's linkage and it's access and it's empowerment. So that's all the words of LEAP. And basically what we're trying to do is tell folks, 'You can come to us. We have people onsite who are not only going to focus on your medical concerns, but they're going to focus on the whole picture, because we know that medicine and what happens in the four walls of the doctor's office oftentimes is not enough to really cure the ills of the person or society in general. Right?'
And people need things like healthy food. We know food is medicine, right? And if you can't do that, then how are we ever going to control your blood pressure, prevent it from rising? We can't just throw pills at every problem. So that's part of it. So I have the group. Two hundred and fifty people will get randomized care this way. The other half of the group, 250 people, will get randomized to usual care. They'll all get referred to a doctor and we'll see what happens. And then at the end of the year, we'll see what's the difference in blood pressure between the two groups. And what's really neat about this project is, unlike most of the work that focuses on hypertension — meaning treating people who have already established high blood pressure — we're actually going upstream and we're taking people who have elevated blood pressures.
A normal blood pressure is considered anything less than 120 over 70, right? And so now, about three years ago, the American Heart Association redefined what is hypertension, and it's considered a blood pressure greater than 130 over 80. So you can see that leaves a little bit of a gap. You have people 120 to 130, 70 to 80, systolic and diastolic blood pressure numbers. And so, if you fall into that gap right now, there's not a lot that gets done, but we know that those folks who are in that gap are more likely to go on to develop high blood pressure. This sort of creeping up in those numbers. And we're trying to forestall that while the numbers are in that intermediate range. And we're trying to prevent people from actually developing high blood pressure.
Our belief is that in the people who are randomized to the intervention and the group that's receiving the community health worker approach, having somebody like the community health worker, who's there for you, who's there to say, what do you need? How can we help you reduce the stress in your life? What can we do to make your life easier so that you can be healthier?
We really believe that this is going to be a new way, new day, in health care, and not only doing it with community health workers, but doing it in your neighborhood, right? Making sure you don't need to make a special appointment. You don't need to travel on a bus or two buses if you don't have a car or take half a day off from work to go in and get an appointment with your doctor. We can come and bring all that care to you. And we really think that this is going to be a well-received approach to health care and a very effective and efficient approach to health care.
Generally speaking, how have the mobile units been received? I mean, I know that there's oftentimes some skepticism, particularly in the African American community, about medicine, the medical industry, so on and so forth. I know we were doing testing in places like the African World Festival, for instance. And, there were a lot of concerns that were raised by passersby. How do you think, and I know that this is dealing with hypertension as opposed to COVID and vaccines and that kind of thing, but, how do you plan to penetrate that kind of skepticism and what inroads have you already been successfully in making in that regard?
So, I think what you bring up is perhaps the most important issue in all of this. We don't ever want people to perceive that care or usual care is somehow not being provided to people and that we're providing some inferior or lesser care. In fact, it's quite the opposite. What we're really saying is that the biggest barrier to people's successful journey in health and wellness and health care is really access. And we're just flipping the script and saying, 'You don't need to come to us, we're going to come to you.' And so just that narrative was one that was very well received initially. But what we did was establish trust in the community. And we did that by working with many, many community partners.
Since we started this program in April 2020, we've now done more than 600 events across the region. We partnered with more than 250 different community partners. You name the church, you name the pastor, they all know us. We're actually now working very closely with the Detroit Caucus, the Legislative Caucus, both the state senators and representatives because they're trusted members of the community as well. And what we're starting to do now is say, 'Look, we want to work with you to further help our penetration and depth into communities.'
We're thinking of things a little bit differently too, in that when we first started this whole thing, we would work through church groups. We work through community organizations, which are fantastic, but we want now people to see this as part of their everyday life. And so we're starting to take the vehicles and put them into people's regular, daily living. So, in surface parking lots, next to convenience stores, next to supermarkets. We're talking with the State of Michigan [about] going into the SOS [Secretary of State] offices where they're located in their parking lot.
So if you're going to get your driver's license done, hey, you can go get your health care while you're at it at the same time, or at least get a screening. And I think that's what people are really seeing is that, ' Wait, I can get convenient, quality health care with someone who really cares about me and not asking for an appointment. I don't need to have an insurance. I don't need even to have an ID' just some way to say who you are. We're good with that. And it's really health care on people's terms. And so, instead of what often happens with these community outreach programs, where somebody kind of almost helicopters in — I don't mean literally helicopter — but we pick this location. It's great. We're going to host a big event on a Saturday and then we'll be back in a year on a Saturday. We're not about that anymore. What we're saying is we want these mobile units everywhere and people can pick and choose which ones they go to.
But the bottom line is that they can get care their way in a convenient location. And that has been the key. It's really been the trust. And because we haven't let anyone down, we've reached almost 50,000 people at this point between testing, vaccinations and all the other work that we're doing. And everyone we've talked to just really appreciates the opportunity to have someone come to them for care.
I think that's fantastic field. Now, you guys are talking about this for four years right now, right now. This is a four-year project. What happens at the end of four years?
Well, what we're really hoping is that this provides the evidence and the proof to change health care in general. We're now talking with payers. So the Medicaid managed care organization payers, private insurance, we're starting to work with some small to medium-sized businesses, coming to manufacturing plants, where you have people who are, they're making a living, but they can't take a day off of work to go get their health care taken care of because they may not get paid for that half a day they take off from work. So, if you've got a choice between making money and taking a day off to go get your blood pressure check, what are you going to do? You're going to stay working, right? And so, now what we're trying to do is get our vehicles or take our vehicles to businesses and we'll come there every couple of months and make sure your employees are healthy.
And we want this to be normalized as part of what health care is. I'm pushing every day and fighting every day with, not fighting, because we got good receptivity, but pushing every day to really say, 'Let's think of this differently. Can we create new reimbursement models?' Because that's the key, right?
We can't be living on grants and philanthropy forever. I want this to be changed so that there is a reimbursement structure around this. Not that this is all about making money, right? Because it's not, but it's about right-sizing the expenditures in health care and saying, 'What do we really spending money on? Are we spending money on doctor's visits and appointments and offices? Or should we be spending money on blood pressure control?' If that blood pressure control takes food service delivery to your home and a discounted gym membership, that's a hell of a lot better than paying some doctor every 30 days just to pop in the office where they're going to tell you to eat healthy and exercise, and you're going to walk out saying, 'How the heck am I going to do that? Because I work a job where I'm there all day and I don't have the money to do the rest of it.' So we're trying to flip the script on health care
And when all these numbers persist, obviously something different does need to happen because, I mean, hypertension has been an issue in the African American community, certainly, for a very, very, very long time. And you let me know, it doesn't seem like things are necessarily getting better. I mean, your approach, all these other things aside, I mean, it just doesn't. And can you talk a little bit about why the problem seems to persist?
Yeah. So not only is it not getting better, it's getting worse. In fact, so the government has set various goals over the years in terms of something called Healthy People 2020,2030. Here's a goal is to [determine] how do we get people healthier. And one of the goals that's consistently set is a percentage of the population achieving hypertension control. The goals are above 60% ward, less than 40% in some communities, maybe 45% in some areas. Why doesn't it get controlled? Because it's sometimes difficult to do the things that we want people to do, right? So, things that are called lifestyle changes, right? So eating healthy, exercising and all of that, that's difficult for people. If you have life circumstances that preclude that, right? If you're trying to decide between putting food on the table and paying for medication, the choice is obvious, right? And oftentimes, that food that you're putting on the table may be not the most helpful food options you're buying what you can based on what you have.
And so what we're really trying to say in all of this is [say], 'Let's think of it differently and let's help people with their circumstances to help their lifestyle, get that set.' And then we're probably better off trying to get the rest of it done. And also, let's think about what medications we're using and let's think about the approach to all of this, to make it not burdensome, to get your pills not expensive, to have copays and all of that. That's where we see kind of this model going in the future, right? Putting it all in one package. What we're really striving for is something called capitated payments, right? We want insurance companies and businesses and whomever to say, 'Okay, what's the price that we're willing to pay to control someone's blood pressure,' not, 'how many visits again can we bill for?' And if we figure out what the right price for that care is, the prevention care, let's go for it, right? Because, we can change the way we do this.
And that's, I think, the thing that I keep on saying here, but this is a big problem. I think you hit the nail on the head. It's a big problem all over the country, but it's been a very big problem for the Black community, especially in Detroit. In Detroit, people are twice as likely to die of heart disease as the rest of the country. And that all traces back to hypertension, high blood pressure, things like diabetes, kidney disease, smoking, obesity, all of that. But at the core, high blood pressure is the single most important health risk to our community.
And that's saying it, even understanding COVID because the outcomes that we saw early on with COVID were related to uncontrolled hypertension, which led to underlying damage to your heart, to your kidneys, that when you superimpose COVID on top, it's an added stress that your body just can't handle. And that explains a lot of what we see. So we really have to get ahead of this and really start to think, 'How are we going to get blood pressure to stop rising? How are we going to take these people with elevated blood pressure net, that intermediate range that we mentioned, how are we going to keep them from becoming hypertensive?' And then once they're hypertensive, how are we going to make sure we get that number down, those numbers down to get them under control? But it is, it is the single most important issue it's going to be here long after COVID has gone.
Yeah, it's got it. Got to be addressed. You're absolutely right. Phil, I want to say thank you again. I really appreciate you taking your time to sit down with us here on the Today@Wayne Podcast. And I'm wishing you all the absolute best with your research and with the work that you're doing. And, we want to say thank you for the efforts you make.
And thank you Darrell, once again for highlighting our work and speaking with me during this time.
Absolutely. Very happy to and hope to have you back again real soon.
Be my pleasure.
All right. Dr. Levy, joining us here on the Today@Wayne Podcast. I'm your host Darrell Dawsey. Thank you.
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