I asked this question at lunch, and we had a bunch of people raise their hand that said they've engaged in renal artery. For all those people, who have an active hypertension program at your institution? Alright, better than the lunchtime session. So Tiffany, you know, you got something to work with here, I think. So I mean, I think that that, you know, going back to one of our questions we had the last session of the importance of the team-based management for hypertension and renal denervation being one tool. I mean, Tiffany, if you had to, you know, that was such a fantastic talk, if you had to summarize for people leaving SC&I today where to start, you know, you did a really nice assessment of the landscape at your institution, we all practice differently, where was the hardest barrier? Was it really the administrative buy-in to putting resources into this? Where did you find the biggest barrier to getting your center started? The biggest barrier for me was really just buying my time, right? So it's more profitable for me to see 22 patients who've had MIs and have an EF of less than 15% than it is for me to see a 30-year-old whose blood pressure is 160 and has no other problems, right? And so getting our administration to really buy into that was more of a mental block for me. I didn't think they would be as receptive as they actually were. I'm fortunate that we have really good relationships with our administrative team, and when we bring to them things that are going to improve patient care, we did okay with that. But I can see how it could be a challenge, for sure. Yeah, I think a value proposition—update, please. I'm just going to add, I'm surprised that we don't have more hypertension specialists than what we have in the United States today. Third-party payers recognize this is a huge cost center for them. It's not just hypertension, but it's all the comorbidities and coexisting illnesses that are concomitant with hypertension. We're going to show data tomorrow, no embargo broken here. It's very cost-effective to do renal denervation therapy if you can translate to the clinical benefit that you observe, and I just see this as evolving as a multidisciplinary approach with cardiovascular practitioners, nephrologists, endocrinologists, and others that there are subtleties in the management of hypertension that I've learned over the many years that as a general cardiologist, I wouldn't appreciate. Not all ARBs are alike. Not all count—almost certain it's different than others. Nifedipine is much different than amlodipine, right? I mean, there's nuances and tricks of the trade here that dedicated specialists can achieve meaningful benefits beyond what most practitioners can. And I think most practitioners don't even realize the modest reductions in blood pressure that are achieved with most medications. What drugs are approved on are not 20-millimeter reductions in systolic blood pressure. And so it seems like, you know, we could keep an FTE full-time busy with hypertension alone. We have this for lipids right now. We have people where they need a PCSK9 inhibitor and you got to jump through so many hurdles that we say, just go see this individual in our program. I just don't know why we don't see more of this for hypertension. And that has been a bigger challenge, I think, than convincing my cardiology colleagues because at the end of the day, when half the adult population has hypertension, I'm not—one of me is not enough, of course, right? I think we have to make sure that we are very, very prescriptive about setting the guidelines for the rest of the system. Helping right now, one of the things is hypertension for us has been a true North metric this year. And so we're embedding our algorithm into Epic. We are, you know, implementing things across the system with pharmacy follow-ups and things like that. It's really a matter of not just what is your hypertension center doing, but what is your system at large doing to better manage hypertension. You know, I couldn't agree more with all the comments I've heard so far. As somebody who's, you know, run a hypertension center for a long time, I think we—one of the things that we need to do is really reach out to our primary care colleagues and ask them to be—step forward and become the specialists in our communities. I had this own personal experience where I run a—I direct a vascular medicine center and hypertension and lipids are a big part of it. And for years, I was trying to get our administration to hire me a partner, an MD partner. It's a multidisciplinary clinic. I have four nurse practitioners, seven clinical pharmacists, some research people who work with me. But we always had five open cardiology positions. And the institutional priority was always to fill those cardiology positions before filling my vascular—my vascular medicine hypertension position. And one day, and it was really one day, it just struck me, why am I trying to hire—why am I trying to get them to hire a cardiologist? This is not rocket science. I'm the first one to say it. I've been a hypertension specialist for a long time. It's not that hard. Family practice folks are the specialists in hypertension in our communities. They're the ones who see most of it, you know. And for them, for a cardiologist, it often requires a cut in reimbursement to become a hypertension specialist. For a family practice doc, like the one we ended up hiring, it's a pay raise for the institution. So I think there's a whole group of individuals that aren't at the table that I think really, really need to be and can be great partners as you look to set up a clinic. So before we break, I'll end with a very provocative endeavor at our institution that reaches 90% of the state of Georgia. It's the largest health care system, and compensation for many of you here as practitioners is based on productivity, but in our model, we have productivity and we have some quality bonus metrics. And the primary care physicians have elected to use one of their metrics as achievement of blood pressure goals as part of their quality bonus. So if 10% of your additional salary were dependent on a certain percentage of your patients achieving a blood pressure, now they're going for 140 over 90, but hey, it's a start. But how many of you would do that? How many of you would sign up for that? I think that's ambitious, so check back with me next year about whether the doctors are wealthier or not. Yeah. I'm going to ask one more question before, Florian, this one's for you. One thing that we came into when we launched our program was a lot of the cardiologists said, well, I manage hypertension, like why do you want my patients? You know, patients are currency in the hospital. How do you show the value proposition to your cardiology or other specialty colleagues who feel that they're doing a job that we all know they're probably not doing that great job with, or maybe not the sophistication as Dave laid out there? Yeah. I think it's key to make sure the referring physician is, it's very clear that it's going to be co-management initially, maybe a little bit more heavy on my side, but the patient will go back. I do not want your patient long-term. They can stop in once a year if they want, but this co-management idea I think is key to keep the referral stream coming and not, you know, make it appear like we're trying to take away patients and we're not trying to be the smarter docs or anything like that. I mean, I would rather split it and say, how do you stop people from sending all their hypertension? That's true and I actually, me and my pharmacist, we kind of screen the chart a little bit before we get the referral and we do pick the more severe cases and if it's a very, a patient with a clinic blood pressure documented at 138 on one blood pressure medication that just wants the specialty sort of recommendation, I usually refer to one of my junior partners and they see the patient. They know our protocols. They still get put on the right medications in our point of view and the patient's just as happy. We also do the same and I'll review most of our, sometimes I don't have time, but I try to review all of our referral services in hypertension clinic and oftentimes it's just offering a bit of advice. Why don't you try this before you send them over here and primaries are super, super appreciative of that. They don't always have to physically have their patient be seen in your center in order to get your advice. One thing that is that like I have a couple of OBGYNs who send all the patients to me who are very easily managed, but I look at it as though they need help, right? The patient isn't getting what they need, where they are, and so I tend to just go ahead and see them. Now I do have a long wait list and we're having to make some changes, but one of the things that we're doing is bringing in an APP who can see a lot of those patients who are not challenging to us, but who clearly aren't getting what they need, where they are. And these are not people that you have to see forever, but one time, two times, fix them. I think it's still worth it if they're not getting what they need, where they are. I was just going to add, I think, really reflecting everything everybody else has said, but we also screen all our patients for the hypertension clinic, but I think, for example, I mean, two of my colleagues are here from cardiology at Penn, but people send us the patients because treating hypertension is hard. It takes a lot of effort and it's not the most well-reimbursed, as we've said. So most people don't want to do that. They know, even if they think the patient could have primary ALD or whatever, they send them to us because they know we're going to do a good job and they want the patient in and out. So it's not really an issue of where they follow up. I mean, if we get good control, they will go back to their primary or cardiologist or they stay with us. But I think, you know, we get referrals from endocrine, from everybody because they, you know, it takes effort and you need the supporting network to get good control.

hypertension

team-based management

renal denervation therapy

primary care physicians

specialists in hypertension