Diagnosing vein Thrombosis

Again, the only way to diagnose a deep vein thrombosis accurately or to exclude it, to say no, you don't have a deep vein thrombosis, is to get an ultrasound scan. Now the next slide is a little bit scary, I'm sorry, I keep meaning after these presentations to take it out and put a less scary slide in.  It is a little bit scary, if you're squeamish, look away.  Having said that, most people wake up at this stage and it's the slide they all want to see. 

This is a leg ulcer, this is the dreaded complication of varicose veins and reflux.  Once they develop this is quite a severe one once they develop, they are very difficult to heal, they are very difficult to eradicate.  Even when you do get them healed,they heal with a lot of scar tissue.  The area is quite vulnerable and it's never quite normal,so it's always a little bit more vulnerable to knocks and injuries.  So leg ulcers, once they're established, do tend to recur, even with the best available treatment, because of the vulnerability and the scar tissue.  So avoid leg ulcers if you can. I'm sure nobody wants a leg ulcer, but if you've got varicose eczema and you've got any complications from your veins, we know that early treatment will give better results and will reduce the risks of complications. So as I mentioned, many people go and see their doctor, they say "I've got vein problems"but the NHS doesn't treat them.  Why is this? Well, the NHS doesn't see veins as a priority and the majority of people, even with quite severe vein problems, don't get a major complication. The NHS is strapped for money, I think we have to accept that, and there are other,more pressing requirements. 

There's no national target for veins, there's no two-week wait for veins, and there's no targets as there are, as you'd expect, for an ambulance arriving. We all expect, if we're injured, that an ambulance will arrive within a certain time, we all expect that it will take us to a well-equipped hospital with an operating the atre if we need urgent surgery, and we all expect that if we suffer a heart attack, we're taken to coronary care and that we're looked after.  This all costs money, and obviously the NHS has limited resources.  I don't want to get too political, but you can imagine that if the majority of people don't get a major problem from their veins, the NHS can't treat everybody, it has to ration treatment.

The National Institute for Care and Health Excellence (NICE) last year 2012, or no 2013,earlier this year, only in the summer of this year, made several recommendations about the treatment of veins and it said specifically that anyone who's got symptoms from their veins should be referred to a vascular surgeon.  However, we know and I know that currently people, even with varicose eczema, are finding it difficult to get NHS treatment.  So although nice believes that people should have advice, the reality here in this area is that people are finding it difficult to get access to treatment.

Other reasons  thread veins are often regarded as cosmetic, when we now know that the majority of people, even with thread veins, have reflux.  Varicose veins are not a priority, as I've mentioned.  There are other, more pressing problems for the limited resources of the NHS.  I was going to say it's rationed by strict criteria, they seem to be getting stricter and stricter and access seems to be getting poorer and poorer as time goes by, and I see people who have had bad phlebitis or who have had varicose eczema who can't get treatment very difficult.  And, obviously, your doctor needs to keep up-to-date with all sorts of new developments in diabetes and blood pressure and child care and dementia.  He finds it very difficult to keep up-to-date with all the latest treatments on veins.  Not surprisingly,your GP may not be able to refer you to the local hospital for veins so, at the end ofa busy surgery, he's hardly going to spend hours reading up on the latest developments on veins.

When it is varicose veins?

 I came across a lady not so long ago who wouldn't take her children swimming because she felt so embarrassed about the sight of her legs, and the distress that some of these unsightly veins cause can be quite severe.  I say 'even' thread veins we now know that thread veins and spider veins are associated with this condition called reflux, so it's not surprising that even thread veins cause symptoms or are associated with symptoms. 

Until we knew a little bit more about the condition we didn't really, as doctors, believe people who say "well my thread veins hurt and they burn and they itch" but they do, and we now know that if you treat thread veins properly the majority of people get relief of their symptoms as well. So, as I say, a frequent question is "I've got bad varicose veins, will I get a problem". Well, the majority don't but if you do get medical problems they come under one of these four headings.  As I say, the majority will not. The first one I'd like to talk about is phlebitis. 

A frequent question is "I've got phlebitis,what is it and will it cause me any harm?".  Another condition is varicose eczema, a condition of the skin caused by reflux and these other conditions, deep vein thrombosis, bleeding and ulcers.  Let's talk about those very briefly in turn. Now phlebitis is often a misused term, both by the public and by doctors.  The strict medical definition of phlebitis is an inflammation in the vein, that's all it means really, doctors add the word 'itis' on the end of the word to indicate inflammation. 

I think 'phleb' is a Greek or Latin word that means vein and 'itis' means inflammation, so it's an inflammation of the vein.  It appears clinically, that is on the surface, as a hard, tender lump underneath the skin, so it's quite superficial phlebitis involves the superficial veins, it's superficial and it has all the features of inflammation, so if you've ever had inflammation elsewhere you'll know that it's red, warm, tender and it's quite a severe condition.  These people often can't go to work it's that painful, and it used to be thought to be quite a trivial condition so if you went to see your doctor he'd say "oh that's just a bit of phlebitis,take some painkillers and go away". We now know, however, that to diagnose phlebitis correctly, you should have an ultrasound scan.

People who are diagnosed as having phlebitis are often misdiagnosed, and when you look with an ultrasound scan there's another condition, so having an ultrasound firstly confirms that it is phlebitis because you can actually look at the superficial vein and the appearance on ultrasound is quite characteristic of the condition and you can make sure there's nothing else amiss, because we now know that phlebitis is frequently associated with deep vein thrombosis.

The clot that occurs inside these veins can extend further and into the deep veins and that can be quite a significant problem, quite a severe condition. Last week I saw a patient in Bristol who had been treated by his doctor with phlebitis and in fact he had a deep vein thrombosis all along so the diagnosis was wrong it would have been established with an ultrasound scan and he had quite a significant deep vein thrombosis that put him at risk. 

So phlebitis is not a trivial condition, it should now have an ultrasound scan, that's the recommendation of two very influential bodies, one in the United Kingdom and one in America, and that recommendation came out last year that all people with phlebitis should have an ultrasound scan.

Varicose vein : Doctors interventions

 In fact when I see people with thread veins, one of the important things is that you check very carefully for underlying reflux so that the problem is treated correctly. Are they simply cosmetic?

Well, a question I get asked a lot is "I've been to my doctor with my veins and he tells me that treatment is not available on the NHS" and often that person is told that they're simply cosmetic.  Well, they're not simply cosmetic as you can see from this slide, a healthy vein is nice and straight and it's got strong folds,strong valves in the lining that meet properly, keeping blood directed upwards from the leg back to the heart. 

On the right we have a varicose vein, it's wider than it should be,it's tortuous, it's wiggly and the valves, these little folds, are weak and floppy and they're allowing blood down in the wrong direction, so varicose veins are unhealthy veins with faulty valves and this condition called reflux.  So it's not simply a cosmetic issue. As you can see in this slide, we've got a leg where we've got a superficial vein, that's a vein underneath the skin that is refluxing and faulty, and the blood is coming down in the wrong direction from the top of the thigh down into these lumpy varicose veins and further down into these little spidery veins.  So the underlying problem is reflux, it's not simply a cosmetic issue, it's a shorthand way of saying the majority of people don't get major problems but to dismiss them as simply being cosmetic is not correct. This is a lady I saw a few years ago and she too was denied NHS treatment initially. 

She had quite bad reflux in the veins in her thigh, feeding into varicose veins in her calf, which were causing quite a lot of swelling of her leg, and they were causing quite a lot of thread veins and spidery veins around the ankle, and also after a little while were causing a condition called varicose eczema, which I'll come on to in a moment.  In her case they weren't simply cosmetic, she actually had to argue her case quite strongly and at that time had to appeal to the Primary Care Trust, the PCT.  Eventually she was granted NHS treatment but her operation was cancelled three times, twice on the day of her operation she'd been all prepared and got ready and in frustration she decided that she would have her veins treated privately and she was concerned, quite rightly, about the possibility of ulcers.

So what problems can arise? 

One of the questions I get asked again quite a lot is "I've got bad varicose veins, will I get a leg ulcer, I'm worried about leg ulcers".  Well in fact the majority of people with even quite severe varicose veins do not come to any harm and i think this is the main reason why the NHS doesn't treat veins.  They do, however, cause a lot of ache, a lot of itch, swelling, these symptoms do tend to be worse in hot weather.

They tend to be worse at the end of the day and they are also very unsightly. I think it's sometimes difficult for us men to understand how much distress they cause to women particularly, and increasingly men.  It interferes with what you can wear, what sort of holidays you can take, what sort of social activities you might be involved in.

Varicose veins : Medical introduction

What are varicose veins? 

Well you don't need to be medically trained, you don't need to be a doctor, to look at your leg or somebody else's leg and know that there's something wrong with the veins.  So, for example, this person has a cluster of spider veins at the back of the leg with varicose lumpy veins to the side and medically they are abnormally large, they are wider and bigger than they should be, they are obviously twisty and they have a condition in them called reflux. 

Veins should be carrying blood up the leg back from the foot to the heart - if the little folds in the lining are not meeting properly and gravity is pulling blood down in the wrong direction then we give this the term 'vein reflux', and the underlying problem with these thread veins and these spider veins is that the direction of flow is wrong, the valves are not working properly and blood is coming down in the wrong direction, that's the medical underlying problem.

What causes varicose veins? 

Well, top of the list is heredity.  Unfortunately you can pick your friends but you can't pick your parents and most cases of vein problems are inherited or have a genetic basis.  It's been estimated that if both your parents have a vein problem,then you unfortunately have an 80% chance of developing a vein problem yourself.  It's not inevitable, but it's a high risk if you have a strong family history.  Other thing son this list don't actually cause varicose veins but they contribute, so if you've inherited a weakness of your veins and you have an underlying problem, often veins will appear for the first time during pregnancy because of the added strain on the vein circulation.

 It doesn't actually cause it but it's another risk factor which declares itself if you have an underlying problem and all these other things contribute. Having said that we know lots of people, don't we, who have had lots of children, who are possibly overweight and don't have a particularly healthy lifestyle - not a blemish on their legs, doesn't seem fair does it really but equally there are many young men who are quite athletic and very fit, obviously they've never had any children themselves, and they've got dreadful varicose veins so it does appear that heredity is the main risk factor.

What causes thread veins? 

Well, I've already mentioned that reflux is the underlying problem so it's not a surprise really, is it, that top of the list is heredity.  Again many people have not a blemish on their leg because they've inherited good veins from their parents. 

Others,unfortunately, haven't had any children, not overweight, very healthy and they're covered in spider veins and thread veins.  The underlying problem is a weakness of the veins and it's a problem called reflux, so heredity tops the list.  All these others are contributing or risk factors, they don't actually cause them, however I would say that reflux, which also causes varicose veins, varicose veins are often associated with thread veins.

Programming the intervention

Now, the programming, none of this can be possible without a strong team. So the programmer  and I,we used live survey, and live survey it's a free, open-source online survey, in which we use. This provided the adult participants the adult consent form.

Then we also use, is where the study participants, once they've chosen an avatar and named that avatar, all of that information was stored there and matched with their email address. So that was kind of the way. Again, this was apre-test/post-test study, so we needed a way to follow that through. We had to restrict access to this because second life is a virtual open world. Our island,we restricted it to--the only way you could get to our island was that once you receive that token,then that token allowed you to enter our island,so that our data was not skewed in any way. This type of research,this type of platform does require high-speed Internet,and Web hosting.

I've shared with you that my sequel and PHP was used as a Web hosting supporting browsers. There are many, from Firefox to MS Internet Explorer. The later the software the better this seems to run. Budget.  So in order to capture this and to maintain it we rented an island, a new island eight. We rented this island for--this study was 12 months in length. It costs us 1,100 dollars to rent this island,which is about 1000U. S.  dollars. The programmer I hired and the researchers I hired as OPS, hourly wage. The programmers used her instructional design along with my health care background to create the games,the platforms. I knew what I wanted. She knew how to make that happen in design. Each and everything that you saw in this platform took time. It wasn't like you could take wallpaper and kind of just put it up. Everything that instructional designer actually built. So she set up the domain,did the configurations,build and exhibited it,and then she hosted it the entire time that we were running this study. So as part of the--at the end again you see another token to exit it.

At that point they would email the survey,and the survey results with this pilot study provided me with useful information in the sense that the majority of the participants had no experience with second life,but again about more than 40 percent of them said that they found this type of platform for research very useful. Quickly, the next steps, i would like to now move from a pilot study to a feasibility study. This study was A-synchronized. I would like to use this amphitheater here to build a--if you can imagine it,it can happen. So I imagine making this more of a synchronized session,much like we're doing today,a set date, a set topic and invite the avatars,these person as to join the topic and dialogue real time with questions and answers and an information session. So that's the next step for second life and how I plan to use this as a research study.

Nothing happens alone. Nothing happens on our island by itself. This is the research group that I-- this is the research team that I had the pleasure of working with. is the programmer with  being there search assistant and my research team there. None of this would have been possible without the funding of the rebel,which scholars program. So with that said,I will turn it over to, and we'll open it up for questions. Thank you.

Technlological interventions

Once they interacted with these boards, walked away, within 10 seconds there was a timer that would re-close--that would recover the boards so the next person came through. For example,this is what I call an HPV patch. So within this HPV patch the minute lands there,the sensor senses her and provides me with information such as how long she's--how much time did she spend walking around this patch looking at genital warts on the pup as of a penis or within the anus?

Then as you look up,which you can't really see,but depicted here, again more information. That is  wanted to support what she was seeing,there was more visual information there. As long as was there the timers captured how long she was there. This is another example of an information board. This board actually showed external genital warts from mild to severe on the vulva of a female. Then when whomever was there,once they walked away,this board was automatically become covered again in ten seconds. So it was more than just kind of walking around and then reading information. We attempted to also make it interesting and find ways to make it stimulating. So this is a simulation,first it starts off with just kind of giving them information about the external warts. Then it gives instructions to walk into the simulation. It makes it clear to walking to the simulation of a vagina.

Once they reach the end of this vagina that there's a cervix with different stages,moderate to mild dysplasia. So the avatar again will enter this vaginal canal. Then they would end-up facing the cervix here. So the time and the minute they entered the canal, the timer started and I would then allow them to have the ability to capture how long they stayed and viewed this cervical dysplasia. Here's another example again where they were more interactive. So as they moved around,again this was a maze so they couldn't skip any part of it. They move from one area to the other. At a minimum they had to touch or interact with whatever's therefor seconds or minutes,however the timer was before they could move onto the next section. Here they were instructed to--they would tap here with HPV. Then they would try to match HPV with cervical cancer,or hepatitis B with jaundice. Each time they did this matching correctly, they earn points or their scores increase. This was again a test of their knowledge about viral STIs. Not only did I get the back to the correct number they got correct, but also the time that they spent there,and if they came backt o manipulate that. This was research study. This was the second part to a first--there was a first part where there was are search study. Then the control groups were invited to enter this pilot study. I don't expect that you can read this,but this is just a process flow as to how that research study went.

So there was who was a research assistant,would get the emails of these participants. The participants then would be emailed a URL. This URL was a token,in second life we use the term token. So once they received these tokens they could go in,register within second life and change their email to something other than their university email,and then this email was not tracked with their avatar. The avatar that they created is now their avatar going forth and forever. Then they would get the token, and once they received the token, created the avatar,they were now allowed to enter,and make sure that it was again clear,they would receive an adult consent form informing them that they were now agreeing to become part of a research study. That's kind of how the process went. Again, this was just a process flow to kind of give you an idea how this works.

The 3D World for Medical interventions

We know that HPV is a virus,with that being said,there's no cure. What we do know is that HPV is strongly linked,and HPV high-risk strains are strongly linked to cervical, anal, oral and penile cancer.

  We're learning more and more every day about orthogonal cancer. We also know that it's linked to genital warts. We do have prophylactic vaccines, Bivalent and Quadrivalent vaccines. The Bivalent vaccine is actually marketed as an orthogenic vaccine, not licensed for men. The Quadrivalent vaccine is marketed as orthogenic and wart prevention that is marketed for men and both women. While we're here today is to talk about second life,and how this internet-based application plays a role in cancer prevention,specifically the sequel of HPV. Well, there's 20 million users of second life as of today,20 million or more. Among those 20 million each one has a unique avatar. Avatars are digital person as in which once they enter the3D world, they can become an animal, the can stay a person,a female can become a male,ethnicity, gender,anything that you can image can be changed within your personal, which works well for me because my population was college students. My hope is that for them to take on a different persona that was actually made them comfortable moving around within this environment to learn about this viral STI. The great thing is that the Internet is everywhere and anywhere.


You can be at a park,you can be at coffee shop,you can be in your own bedroom. When we're talking about this platform,sexually transmitted infections are a private matter. So wherever you want to gain this information,increase your knowledge,it's that person's call. It's real time. Second life is real time. It also allowed me to get real time information and immediate response from my study participants as they move through this first pilot test. So again just a little bit about the sample, the majority of them were females within their second year of college.

Again, this is just a depiction of some of the personal person as that the college students took on while they were in this virtual world. Here you can see,this is when you first come into second life and going to our island,this is the entrance into our platform. Before you could actually enter this, because it was a study,a research study,I did provide a disclosure. As you can read here,we talked about stages of diseases, and we talked about several different viral STIs. Today we're going to focus on HPV. So before the study participant can enter this 3D world,they had to read and accept that Not everyone is familiar with second life,and how to manipulate your avatar. Again, there was a video that was embedded into second life so that the study participants could learn to walk,and learn to fly around in second life. Putting one foot in front of the other is not that easy in second life if you do not have some experience with it. So within that this video was embedded and it could go forward, fast-forward through itor repeat any sections that they felt the need to,to learn how to use the avatar within this world. Once they entered the world,there was one entrance and one exit.

The 3D world was setup like a maze. So as they move through it there were invisible sensors there. I use the sensors to capture my data. I could tell how long they would stay at certain teaching are as or teaching platforms within this. There were educational boards.

(AYA) Adolescent and Young Adult Clinics

We're continuing to explore communication and dissemination of the app with our partners and collaborators, including a number of advocacy groups and nurses in AYA clinics. Our app is a hybrid,and we can continue to explore building hybrids,but kind of in a reversal.

We're now building light versions of the apps with the main elements and functionality to be kept in databases. So we actually can have more access to the information,kind of lessons and learned and next steps for us. You need to plan for ongoing maintenance and updates. Apps aren't a build once and forget about it. There's always something that needs to be improved or updated. You want to keep it fresh and add new functions to engage the users. Given this, it's important to choose your technology partner wisely. It's also a good idea to keep your own copy of the code so that you can change or adapt the app if for some reason you need to find a new technology partner. As I suggested there is kind of a lack of data for researchers from the native apps or apps that run on the phone, which is why we're advising our health behavior researchers and those who want to create apps to look at hybrid models that include some light weight apps that can be marketed and downloaded on the iPhone app store and the Android Plus. This also provides for greater security and privacy of data in case the user loses his phone.

In talking about where we're going, in the meantime since AYA was developed,we developed two additional apps for cancer survivors using geographic information technology or GIS. I can fit is a research project that encourages goal setting and provides a GIS locator for healthy places for physical activity. The locator,which was developed for life beyond cancer foundation,is an interactive mobile map for non-clinical resources. We're also beginning to look at sensors and using sensors and GIS together. I think that have great potential for health behavior change,and we think it kind of gives us a brave new world. I hope that all of you are considering it,pursue them,and I'll always be glad to provide any guidance or help that I can. That concludes my presentation. So what I'd like to do now is turn the slides over to Dr.  Versie Johnson-Mallard from the University of South Florida.

Versie Johnson-Mallard: thank you so much. That is such an exciting and useful technology. Please allow meto introduce myself again. 

I bring to you greetings from the University of South Florida and our. I have no conflicts to share. I'm going to spend a few minutes talking about technology, specifically second life that I've used to--as a virtual environment to increase knowledge around HPV. HPV is strongly linked to cervical cancer,and we'll talk a little bit about this just briefly.

Health behavior change theories of Interventions

This is not unusual for cancer survivors. This area of the app has two functions; one is routine screenings. Again, these came from the documents of the cancer--the children's oncology group. They are the evidence-based guidelines for AYA screening.

For example,female AYAs who had mental or chest area radiation have a startling high incidence of breast cancer as a second cancer. They need to be screened eight years after treatment or at age 25,whichever is later.


They may not know this. So again, this was an educational aspect. Eventually the children's oncology group generously allowed us the use of their help links. Here, it's probably kind of hard to see, but the help links are easily accessed. They're kind of one-page briefs,written in very plain language on a variety of late effects that may be experienced by AYAs. Many of these are available in both English and Spanish. Again, the ability to disseminate and communicate these broadly to this audience was really a very, very important thing.

We are so enormously grateful to the children's oncology group for allowing us to put these directly into the hands of the AYAs. The other element,one of the other functions with the app is encourage the survivors to develop their own survivorship plan. Actually, this is an area that's being updated in the next few weeks. We originally planned for the survivors to use a cloud-based database to log-in and create their survivorship plans,but our concerns for HIPPA compliance and Texas-specific legislations, and concerns for privacy and security changed our minds. Now what we do is we provide links to both the Live Strong and the Journey Forward plans. So, this is a screen shot from Live Strong,which they can link directly to,or they can link directly to survivorship care plans by Journey Forward.

We also wanted to have a community. Again, this is based on social behavior theory,for them to respond to. We thought about at first creating a private social network, but in the end it is like using Facebook. So the users have a Facebook page they can go to and they share information on the app and on other things. Our current utilization,remember that I had said with the app being native it's only so much information that you actually gets slim.

This is a snapshot of current utilization. We have 650 users. Fifty-three users have downloaded. I hope we have more after today. Sixty-six percent of them use the assessment. Users take an assessment on the average 2. 12 times. Some of them take it a lot more;some of them take it,never go back to it. The average user visits the app about 2. 87 times. So, kind of in summary,the AYA app is really an example I think of pragmatic research,and it's an intervention that applies evidence-based functions, and applies a number of health behavior change theories in trying to provide increased health related quality of life for AYA survivors.

Intervention on individual's assessment history

So if the user had a high BMI, well it'd kind of look like the Michelin Man. We didn't think that was quite user appropriate. So what we ended up with was just a scale showing the different ranges of BMI and the weight status.

Actually, this is one of the more popular--from feedback we've heard that this is one of the more popular areas of the assessment. The individual's assessment history itself--so these are the opening page,and then the final assessment score on the right;the app keeps the very first assessment the user makes,the most recent one and then the current assessment. So three different scores are available at all times once the user starts. It allows the users the ability to track improvements or changes over time. There's a score--if you look at the--on the right hand side you'll see on the bottom their scores for each of the areas. Then those are kind of combined together in an algorithm that provides the user with an overall assessment of their healthy survivorship. Following their assessment,they get a page of tips and kudos.

Again, this is where we began working more with the whole idea of mobile persuasion providing tips and information to drive change or to encourage change. The algorithm that works with the tools and the information in the assessment also drives a tailored tip and kudos. So in this one the tip is related to changing one's diet and eating more healthy fruits and vegetables. The kudos is based on something that the user did well or had a higher score in. So the tips and kudos are again example sof building on the theory and the evidence to make the app a driver of health behavior change and mobile persuasion.
Additionally, the user can choose or can agree to be delivered with a daily phone set. These pop up on the phone onetime a day.

They're in each of the areas,well-being, physical activity,diet and nutrition. They're kind of in your hand reminders tips of things the users can do. This is about using fat free milk. There's also one on using the stairs,which I find is very influential. This gives you the example of really one--what I believe is one of the most powerful aspects in functionality and health. The phone's in your hand,it's in your purse or pocket,these reminders can come to you in a moment,and actually may change or influence behavior change. Actually, this was another area where our users gave us valuable feedback. The tips used to be delivered at 11 pm.

 One of the users in the advisory group called,and asked me if we could make a change to the time of delivery of the daily tip. I said sure, what time and by the way why do you want it to change?She said, he slept with his phone and the tip woke him up,and it pings whenever it was delivered, and he felt he just had to pick it up and look at it.

So we knew they were using them. Now, this is--I skipped this earlier,but I want to come back to it,I mentioned how important and how critical the late effects are for cancer survivors,and many of them have almost a PTSD syndrome where they constantly think that there's something wrong with them, that the cancer is going to reoccur.

Interventions : BMI Calculator

  You're not getting the same kind of information. Not all the functions and the capabilities of the app were available to us. So with that, let's take a look at the app itself. I spoke about our collaborators, and again we wanted to recognize them in the app. This is an information page on the app.

Once the user downloads the app from the Apple app store,it opens to a disclaimer page and the user has to agree to the terms of use, privacy and security to go forward. Then they never see that page again,but they can find information on it again on the iPage. Building healthy survivorship really did take a village. We engaged with a great number of collaborators,both in developing as we continue to disseminate the AYA app. I think that all of these groups deserve,and continue to deserve a lot of credit. Many of their materials were used throughout the app. This is the homepage,the screen shot of the home page if you will of the app.

So it shows the iPhone functions, and health,which kind of gives the user guidance on how to use the app,the survivorship assessment, screening and late effects, survivorship planning tool sand tips and community. We've spent a lot of time on the look and the feel of the app. We really wanted to have a clean, modern image. Our advisory groups weighed in on almost every element,what the functions would be,what the icon looked like, what colors were used. We really wanted the assessment questions to be user friendly,unlike some of the health assessments that you might see in a hospital or any kind of clinic. We want it to be something that the users would actually engage in and think about. We built the app in about 80 days.

For the most part, we would build one section at a time, send it out, test it,play with it, us it, make adjustments,and then go onto the next section. I think that my having a software development background helped immensely, and being able to make the trade-offs and negotiate among what the AYA survivors told us they wanted,what the advisors and oncologists thought we should do, the opinions and suggestion sof the graphic designer,and the technology co-developers who worked with us.

It was constant conversation. I'm going to skip this one and come back to it. So these are some screen shots of three of the app areas.

The health assessment,you'll notice that there are different icons in the upper corner. So there was an icon for well being,there was an icon for healthy habits,one for healthy diet and physical activity. Healthy habits,we consider things like not smoking,not binge drinking;achieving energy balance,things like that. In the healthy diet connection and healthy diet group of questions, I think there area bout 27-30 questions overall. We provided a BMI calculator. As an example of the kind of discussions we had,the technology group wanted to show a little figure in the results that would shrink or swell based on the user's BMI.

Structural Interventions : The chronic disease center

First of all, very impressive series of presentations and ambitious campaign. That could talk more ability about how you built community support in new york city for what is obviously very impressive series of tax increases around tobacco. i think there was sort of a collective ah in the room whenyou said $11 a pack. talk to us a little bit about that, would you, please?

Most of the tax increases occurred before i got there. but i will say that once a group had a part in it. let me say that it got beyond a certain point where legislature saw there wasn't that much resistance to raising tobacco taxes and it was a good source of revenue. so the last tax increase that occurred in new york state happened without a lot of public health encouragement. they just saw it as pure revenue move, which is surprising. it's good in many ways. it's not good if that means they don't also use some of that funding to support tobacco control programs. but i think we've gotten past a certain point now with tobacco tax increases, it's limited.

As well. good to see that what you taught us in the classroom has actually been implemented in practice. i do have one question i am a big proponent of structural information and policy changes, introducing in law. we saw in new york, taxes that came in the form of policy change, tax increases. but our national agenda, we focused a lot on education. do you think we need like a shift in our focus and we should shift more -- shift our focus more towards structural intervention and, as you state in the prevention, focus on changing the shifting the cost instead of cutting the cost. what do you think about that? i do think that policy and environmental change is the best way to reduce rates of disease that are population wide, Cardiovascular disease.

I think we need to look much more at that. now, i will say this, it's a lot easier at the local level than it is at the state level. at the state level and national level. our experience is that the push back for the resistance from industry lobbies are less at the local level and at the state or national level. we have opportunities in new york city that we simply don't have at the national level but we certainly want to take all the opportunities and hopefully set examples for the rest of the country. and then it makes it easier for other places to do it.

Dr.  conway, or anyone, what do you think we can do to help the health care system improve their performance rapidly,because we know how diverse the pavers are, providers,challenges of clinical inertia. how do you think we could get as rapid an improvement addss possible?where should we focus our attention in improvements in our health? first, aligned incentives which you're already working on in doing, but i think further that alignment across payers,across private health and medical system to focus, wha tyou're doing, focus on priorities. i used to do external reporting. they all wanted different things.

Focus and alignment go together. third, i think we haven't fully harnessed the models. i applaud places like million hearts, drive improvement, set goals that are aligned and measures that are aligned but then allow localities, states, to innovate to achieve those goals. Thank you. i am going to ask a final question, if i don't -- any envision questions?nope. i'll warn the speakers, this question is going to be about scalability. i'll give you a chance to think about that as i rattle for a moment more. we know that there is a chunk of the country that is between San Diego and new york city. and for those of us who live and work there, i'd like for each ofyou to address either what you think how your models can get scaled to the rest of the country or what's in the way of that scalability.

I guess i go first. everybody missing looking. i was sing looking back, but everyone else was looking at me. so, we had hoped from the very beginning that what we were doing would be applicable to export. and so we tried to design the program that way. i think that there's nothing that we've done in San Diego to this point in time that couldn't be adopted by every other community. the university of best practices is a great model for communities to rally around, and there is evidence that a similar group that's starting up in Sacramento now that's been in touch with us, and they're not close to the ocean, although not in the great flyover.

You know, i think we've been fortunate in terms of philanthropy, but our patient activation campaign, we will share with anyone who wants it. we think it's -- we think it's a good strategy. we think that the material that's been prepared is very effective. so everything we've done is to share with other people or anyone who is interested.
I want to address some of the policy changes and the scalability of those. i think we learned in tobacco control you can be far more innovate innovative, move more quickly at the local level than national level. smokes most smoke free air is at the local area. trans fats, state health departments regulate restaurants so they have the ability to have a hand in our food supply right now. and so those localities shouldn't wait for changes at the national level because just the politics are far more difficult at the national level. i would encourage them to look at what the best examples are anywhere in the country and pick them up locally.

I literally think that's the central question of transforming health care in America, so that will be a short answer. carolyn clancy and i wrote a couple of papers int transformation front line. more of a medical care framework, but i think apply more broadly, as well. essentially, i think the question is how do you decrease the cycle time of learning. how do you test new approaches, rapidly evaluate what works, and then scale that. and i think in this case, you know, it is it's not easy or we would have done it before. but i think the central question is that cycle time of learning,i think with the innovation center at the cms level we're trying to think about how we think about the cycle time in our office and quality improvement and i would encourage all of those in the audience and cdc to work with us and how do we really rapidly evaluate programs and scale and program and learn when they don't work in local -- different local contexts, why don't they work and why do they need to be modified at a local and a state level.

I'm going put one last pitch in to go to this website and show your support by taking the pledge. I think this was a scientific heaven, so i am asking you to give one more applause to the five people you met at cdc. and we'll see you in four weeks, same time, same place. thank you.

San Diego : Interventions stories

We've created a patient activation campaign that we plan to be the centerpiece of our effort, that will be the centerpiece of our advertising in the media, in the shopping paul, ones buses and what night. i would like to show a bu of them here with you. first, a grandfather and grandson.

Teaching him how to serve, very San Diego appropriate pendant and the saying reads "his first perfect wave, be there. "we also plan to focus very closely upon minorities and undeserved and here you see an African American fathers dancing with his father at her wedding. the saying reads "it's her time to shine, be there.

We intend to get more intention in our messaging as we go along. here you see a picture of a daughter sitting next to her father whose picture is ghosted out, indicate that he's deceased. the bring reads, the ring i mess most is our heart to hearts. there's a little saying on the father that says every five hours someone in San Diego dies of stroke. the last example here shows the son playing chess with his father who is ghosted out. and the saying reads "dad, you never let me win. now i would do anything to have you beat me just one more time. "and the saying on the bottom, "heart disease kills over 100californians each year. "we hope that these kinds of messages will incentive people to take care of themselves so that they can be there for loved ones. so, to summarize, we have initiated a call to action to eliminate cardiovascular disease from San Diego, although we aim for heart attack and stroke-free zone, a more realistic but still audicious goal would be to reduce heart attacks and stroke by 50% in five years. thus far, the entire medical community has been organized. we've been fortunate to receive philanthropic support. activation campaign is fully developed and we have a strong integration with San Diego county health programs. we hope that what we're doing in San Diego and the program that we are creating will be one that can be translated to other communities throughout the country and, in fact, throughout the world.

Thank you very much for giving me the opportunity to bring you up to date on what we've been doing to eradicate heart disease in San Diego.

Now back to Janet. I want to thank all our speakers and encourage those of you who have questions to go to the microphone at either end and ask your question. and tony, i spent more than a couple of decades in northern California. you spent time there, too. i just have a tip for you guys in southern California.
That surf board lesson, it actually works better in the ocean than the beach. so, anyone have a question?i do -- while you're thinking of yours, you know, it strikes me that you all, each in your own way, touched on this concept of behavior change, the the need for behavior change. individual level, system level. where i'm going here is to ask your thoughts for the group about the incentives, either the carrots or sticks that you've seen in your work so far or your building into your work. how do we shake behavior through incentives. question  just, two incentives we're looking at with physicians, one of them is having the feedback. the second is whether reimbursement actually makes a difference or physicians are motivated not to i'm profit their quality of care the patients, financial incentive doesn't make a difference. we have a study going on now.

We don't have the results yet. looking at the early data it looks like we will need both. there may be additional benefit with financial incentives around quality improvement. quickly name four things. one, reporting and feedback, so we think this is critical for clinicians also informing patients. two, patient incentives, so we're moving away from a fee for service model. three, and i was remiss not to hit on this more during the talk. make a lining the public health and the medical care enterprises come from a background of collaborative improvement model, thinking about community and population health. i think the more cms, cdc and others can bring that public health and clinical care together as dr.  friedens alluded to is critically important. i think the last, which i -- is, i think, basically aligning with professionalism. i think we have a lot of ability to work with professionals,whether it be public health professionals or clinical professionals and utilizing that intrinsic motivation for improvement.

Interventions on the right care initiatives

The right care initiatives soon grew to something called the be there campaign. in this be there campaign we developed what we think is a really audacious goal of eliminating heart disease and stroke and something we called making San Diego a heart attack and stroke-free zone. what would make us consider such an audacious goal?

We thought by going for a goal and making San Diego heart attack and stroke free that we would capture the attention of the public, we would cut through the background of health oriented messages that people are always receiving. we extend our program to every citizen of San Diego. and we would involve them in their own health care. in fact, our strategy was to contain ownership of this program to the community at large rather than to the doctors and nurses. and we wanted to exploit the community the arrogance of people from San Diego, who believe they live in the very best place in the  world and they are uniquely blessed. and so exploit that arrogance to get information to work together to reduce heart attacks and strokes, and our program was aimed at activating patients to becomes screened and then in listening and recruiting physicians to implement the optimal medical care and to ensure comply plainsman over a long period of time. we had funding from jack and Judy, $660,000.

We formed a committee between the private sector and between government, especially San Diego county, to move forward in this project. we understood from the beginning that facts alone are not often enough to get people to change behavior. to be most effective the changing behavior you need an emotional touch. and so we -- we were focused on a saying by Robert some time ago, when something is missing in your life, it usually turns out to be someone. and so we felt that we would be more effective in driving change in behavior by appealing to individual's choice to benefit a loved one than to benefit themselves.
So that doing things for a loved one would be more likely to happen than doing things per yourself. and that generated the be there campaign. now, i understand that names are not usually allowed at this meeting, but we've been granted this exception because we think we have an unusual convergence of virtually every health care provider in San Diego. as you can see from the list of our steering committee, if you see San Diego, the crypts of the American heart association, the health plan. we have representatives of the naval hospital, on the VA hospital, the California crime and care coalition, and very importantly, the San Diego medical society.

Perhaps of greatest importance, we have the full participation of the San Diego county public health and human services department. so our be there campaign is aimed also at exploiting the robust technology industry we have in San Diego. we have a very, very vibrant wireless medical technology. and we plan to join with them in this effort so that our be there campaign can act as a test tube of development and evaluation of some of these technologies and to en-hang patience patient compliance. cardiogram through wireless technology or utilizing pills that after following could emit a signal that would be detected. or various denials we departments that we could ensure in long-term compliance.

We've already began and we have a variety of activities that are under way. i told you about your university of best practices, which is our vehicle to enlist physicians. we planned a number of screening events at shopping malls,pharmacies, schools. and especially in the faith-based groups that exist in San Diego will distribute pamphlets, pens, and other types of materials. in fact, we plan to have an extensive multimedia campaign that will involve all meeting platforms.

San Diego medical Interventions

It's a pleasure to be here to tell you what we've been doing to eradicate heart attacks and strokes. there's a number of medical factors that underlie what we're trying to do and they're well-known, too. they've been covered already in the discussions. cardiovascular disease continues to be the number one cause of death in our society.

In fact, in San Diego,  from heart attack alone account for nearly 5,000 persons per year. now, there are a number of risk factors that predispose the cardiovascular disease. you've heard about them already. in fact, there are several therapies that have been documented to be effective in reducing heart attacks. i often think of what ken cooper used to say. everyone's got to die at something, but there's no sense of dying something stupid. and, in fact, if we know that there are risk factors that we can reduce and we have methods to reduce them, it seems to usthat if we just implemented the strategy in San Diego that we could, in fact, reduce, if not totally eliminate, the number ofheart attacks. and so our effort in San Diego falls under the umbrella, theoverall effort of the san diego county health and human services department that has had a long-standing improvement toimprove that long-standing commitment to improve the healthof the citizens of san diego that's called live well.

San Diego county has been, we believe, uniquely effective in translating federal initiatives into local action. and we've been fortunate enough to acquire a couple of grants to help us in this regard. two of them funded by the cdc, the communities putting prevention to work grant, which is particularly focused on reducing chronic diseases by increasing hygienic life styles with physical activities, nutrition, and working in the schools. and the community transformation grant also funded by cdc focused upon making San Diego tobacco-free and reducing hypertension and cholesterol levels. San Diego has also been blessed with the beacon grant, health information grant. and the beacon grant is an award given to communities to initiate health information technology to improve the quality of healthcare. so how did we get started in well, it actually started as achieve the 90 percentile goals as regards to optimal blood pressure and optimal lipid levels. to do this we originated something we called the university of best practices. the university of best practices is a gathering of representatives of virtually every medical organization in San Diego.

It's not only physicians but nurses and administrators and health care workers and pharmacists who attend this and at monthly meetings we focus on discussing strategies that have been most successful in achieving the goals. now, for the first time we are about to share data between groups. we feel this is really an enormous step forward. you know, we joke that these university of best practice meetings, the only place that people can come and leave their guns at the door. these are all competing medical groups, and we get together to enhance the health of San diegans.

Health : Food companies and urgent interventions

 We asked food companies to meet these targets this their sales weighted averages. so far 28 companies represented both package food companies and restaurant companies have committed to meeting at leas tone of our sodium reduction targets.

This includes food giant, such as Unilever, Kraft, camp-bell's,and major restaurant chains including subway and Starbucks. now i'll turn to our clinical initiative. our main approach is what we call the primary care information project. the goal of this project is to improve the quality of care through health information technology. this project we have developed with a vendor, prevention oriented electronic health record, and employed it to more than 3,000 providers serving 3 million patients. key prevention systems of this health record include clinical decision support system which gives alert to providers about the services needed that are actionable.

That is they lead a specific responses of the providers. and the ability to generate condition-specific list of patients in need of specific care such as blood pressure control. in addition, the providers get quality dashboards, they can use track performance and compare it to their peers. transfer performance of hypertension and blood pressure is controlled shown here compared to peer providers in gray. and percent of patients whose smoking status over time is shown here. in this case compared to the meaningful youth target in green.

It also presents automatic recommendations. in this case, improving the percent of patients with testing. providers receive these dashboards by e-mail with the link of the health department website, which has information on all of the measures included in the dashboards. we're tracking the information for services across all pcip providers and trends are positive. we have seen as you can see here increases over time and the percent of eligible pashs receiving aspirin, the percentage of patients with hypertension whose blood pressure is controlled and the percent of smokers receiving smoker cessation intervention. what is the impact of all of these actions stand on cardiovascular disease?during the time period we've seen substantial decreases immortality from cardiovascular disease in new york city. including 33% decrease and a 16% decrease in cerebral vascular disease mortality. i can't say to a degree this which it caused the change butit certainly is encouraging. over the same time period life expectancy at birth in new york city has been increasing and increasing faster in the u. s.  asa whole. in 2009 expect taps si in new york city was . 4 years higher than it was nationally.

Now, this slide shows life expectancy at age 40. unlike life expectancy at birth this measure reflects improvement of mortality in older adults. this measure also substantially outpaced in the united states,especially in the last five years. in summary, new york city, our efforts to address cardiovascular disease are showing signs of success. the interventions we use are characteristics of implementation on a mass scale which is what we need because cardiovascular disease is so common. let me just finish with a thought that mass disease require massive remedies. thank you very much.

Varicose eczema and Medical intervention

I don't know if anyone here in the audience has had phlebitis and whether they had an ultrasound scan but I think now if you have been told, or you suspect you have got phlebitis, you should have an ultrasound scan.

Varicose eczema this is a condition that affects the skin, usually just above the ankle. Now this is a term that is misleading, you might think well varicose eczema, it's a skin problem and indeed I see many people who are treated with creams, often steroid creams. These conditions are very itchy, they can drive you mad and they can keep you awake and cause a lot of distress, and there's no doubt that there is inflammation of the skin and there's no doubt that if you put steroid cream on you will feel better, the itching will go, your leg will feel better and it will give you some relief. 

But varicose eczema is not principally a skin condition, it's due to this problem called reflux and what this indicates is that the skin is being damaged by this faulty vein circulation.  It looks like eczema but it actually indicates that there's damage to the skin and that that skin is vulnerable and at risk of ulceration, so this condition is often the precursor of a leg ulcer.  Not tomorrow, not the day after, it takes time, but the skin is vulnerable and at risk and this should be treated to prevent an ulcer.  It's not a skin condition,it shouldn't really be treated with steroids, in fact steroids, if you put them on long-term, they actually thin the skin and they make the skin more vulnerable, more liable to ulceration.

So varicose eczema should be treated by a vein specialist or a vascular surgeon, not a dermatologist, not with skin creams. Deep vein thrombosis well, this is the fear of most people, in fact it's not very common as a complication of veins, it's only recently that we are confident now to be able to say that varicose veins are a risk factor for deep vein thrombosis, there's now good evidence in the medical literature to support that.  It doesn't mean you're going to get one inevitably but, if you have an additional risk factor, varicose veins will contribute. So, for example, if you were to go into hospital and have major surgery, say a hip replacement or a major operation for bowel cancer, and you had bad varicose veins, it would slightly increase your risk of a deep vein thrombosis.  If you were to go on a long-haul flight with bad varicose veins, it would add to your risk.

It doesn't cause it but it is a risk factor,and anyone under those circumstances coming out of hospital after surgery, stepping off a plane after a long-haul flight who has one leg more swollen than the other, this should ring alarm bells, have I got a deep vein thrombosis. 

Intervention researchers theory

Additionally, the population also has the highest adoption of what we call (in-health) or mobile health apps for physical activity and diet.

We approached our app development with a desire to look at both evidenced-based interventions,and a strong theoretical grounding. The elements of current health behavior and communication theories and framework such as social cognitive theory,health behavior change,and elaboration likelihood provided us with a strong theoretical background for many of the behavioral elements functionality and aspects of the Healthy Survivorship Act,including the assessment,the daily tips,and the provision of health education materials.

As we were developing this app,we really became aware that the current se tof theories don't quite support some of the behavioral aspects of the app design.
Mobile health or M-health as I'll refer to it,includes a range of functionalities and capabilities that didn't really exist when any of our theories were being developed. Functions like, individual tailoring,ecological momentary involvement,that means that they've got their phone in their hands,and their getting messages and acting on the min the moment, tailors feedback in their own time and sensitive interactive and adaptive aspects of mobile-enabled health behavior tools,suggest that there may be need for new theoretical paradigms,that our current set just aren't quite up to the task. That said, we did look at a lot of interventions and researching M-health from other chronic disease areas including cancer,asthma and diabetes.

Our development process is what I would consider extremely iterative. The initial funding for the project came as a grant from the Texas A&M School of Public Health, TTX cares,which is a CDC cancer prevention and control network project. The CTX cares PI, principal investigator The Dr.  provided the funding, and was absolutely vital to the development of the project all the way along. We were able to leverage the initial 40K,40,000 with an additional 2,000in marketing funds from a  health care facility grant for AYA professional and public education. Our technology decision to use IOS platform was based partially on the budget amount. We didn't have the funds to do both an iPhone and an Android app.
We knew we wanted to reach the largest possible audience. So this was two years ago,and at that point in time there were more iPhone apps than there were Android apps. Actually, that continues to be the place, the situation. We also wanted to make sure that some of our applications;our functionality was available to a broader audience at times when they might not have their phone. So we developed what we call a hybrid approach to native phone app. Native means that the application is native or lives on the phone,and most of the activities occur on the phone. We mixed it with a responsive Web site.

Responsive in a Web site means that the Web site can be seen and used by both mobile devices,using mobile browser,or a desktop or laptop. What the responsive Web site does is it actually tailors the size of the image to the device that you're using.
Most importantly we leveraged the professional and advocate and survivor AYA support groups from our  grant,and they provided us guidance and insight into the design,and helped us as we developed our requirements and our use cases for the project. Our health care professionals included nationally recognized AYA cancer researchers and oncologists. Our advocates included AYA survivors and cancer advocates from groups like Live strong, Critical Mass, Komen,and I'm Too Young For This. I really cannot say enough about the value and the insights from these advisory groups in the development of the app.

So this is a screen shot of the Web site,healthy survivorship dot org. Dr. Ross Glasgow recently of NCI and now with the University of Colorado,I think considers projects like this as pragmatic research. We wanted to be able to quickly test whether and if cancer survivors were interested in using health behavior change apps. We wanted to explore how best to engage diverse groups of researchers, advocates, oncologists and technology professors in the creation of the app. Pragmatic research by its nature implies trade-offs, so you learn that some things--you learn some things,you can gather some data,some metrics, but it's notl ike a randomized and controlled trial.

Medical intervention on Cancer survivors

We were so delighted by the strength of the submissions that we decided to hold a two-part series on this important topic.

Today's session will highlight two diverse programs that use software as a median for community research and education. With the ubiquity of smart phones most of us use mobile applications or apps designed to run on smart phones, tablets and other mobile devices on a daily basis. Some may be familiar with second life,a free virtual world where users can socialize,connect and create and share services using voice and text chat. Today's cyber seminar will highlight how these platforms have been used to engage audiences around key cancer control initiatives of the Texan A&M school of world public health,and the Texas Life Science Foundation will join us to share an over view of the AYA healthy survivorship app. Designed for adolescents and young adult cancer survivors, this application allows users to assess their health habits using theory-based interactive tool, and gives survivors individual scores for lifestyle,nutrition and well-being among other indicators. Dr.  Versie Johnson-Mallardof the University of South Florida will demonstrate the virtual environment second life and how it was used as educational intervention to increase the knowledge of HPV. Dr.  Johnson-Mallard will discuss the ethicacy of second life as an educational intervention in improving knowledge of HPV,a virus linked to causing cervical cancer.

The final part of the Webinar will be dedicated to Q&A and discussion,and will offer you the opportunity to engage with the presenters and share your own experiences,thoughts and lessons learned. Full bios for each of today's speakers are also available on the research to reality dot cancer dot gov,where you will also be able to engage in discussion form on today's topic,as well as view the archive of our previous cyber seminars. As always, the final part of this call will be devoted to your questions and comments. At any time during the presentation please press star one to be placed in the queue to ask your question live during question and answer portion of this seminar,or if you prefer,you can also submit your questions using the Q&A feature at the top of your screen,just type in your question and hit ask. We thank you all for joining us today,and look forward to this important and informative topic. With that I'll turn it over to Miss to start us off.
What I'd like to do is kind of walk through today's discussion. First of all I'll provide background on AYA,or adolescent young adult cancer survivors, and why we selected this population for our application development. I'll give a brief overview of the emerging field of (M-health) and the application of health behavior theories;and also discuss some opportunities for what we believe are the need for some new the heretical or framework development. I'll review the development of the app itself including the budget, the technology and our collaborators,and how we worked interactively with them. Then we'll give a brief tour of the app itself,and finally some of our lessons learned and the next steps.
So why an app for AYAs, adolescent young adults,which I continue to refer to as AYAs, are cancer survivors in the ages ranging from 15to 39 years of age,which is a pretty broad group. They've been a focus of national investigation in the U. S. and actually internationally for the past eight years,since the National Cancer Institute and Live Strong Foundations first joint progress review group on young adolescent young adult oncology was convened.

FYI, this group was reconvened on a member of it,and there will be a new report coming out soon. In the U. S.  we diagnose about 75,000 AYAs a year. We think there about 20 million of them globally. Overall, unlike older and pediatric cancer survivors,there has been little improvement in survivorship among AYAs in the past two decades. The cause of this lack of survival continues to be explored with consideration of both biological and social factors that affect survivorship. Clearly, quality of life among AYA survivors is an area of concern,especially duet o the lasting effects of chemotherapy and radiation treatment,and the effects especially on younger bodies. If you consider that older cancer survivors that are diagnosed generally around the ages of 60 to 65,may only have 20 years of survivor. That's important survivor ship too. It's concerning. For the AYAs diagnosed in their teens or twenties may have 40or 50 more years of survivorship.

There is a longer period of time for late effects to emerge and require attention. Clearly, we believe there is some health behavior changes that can improve the quality of life among AYAs. That was one of our rationales for selecting that population,or this population for the app development. The other is clearly mentioned how ubiquitous smartphones are for all of us. In the U. S.  smart phone adoption, and also globally is among the highest in this age group according to the Internet and American lifer e-search study.

Clinical Experience for good interventions

In working with clinicians we're measuring and encouraging improvement measures such as tobacco use and cigarette cessation. medication reconciliation, providers may earn an incentive for reporting. as a reminder, clinical prevention strategies will focus on access of care and outcomes. we are launching models of care through the center and payment program such as bundling. the fostered team-based care coordination and patient centered care including care outside of the traditional office visit. through the qio program we're launching learning in action networks. these are drivers of quality and improvement and collaborative learning. the quality improvement organizations run and will convene in innovative learning and action network locally and every state they serve and may be accomplished or in person meetings, web access, phone conferences and other modalities that qios work with beneficiaries and providers. we just included the mechanism and we look forward to report to think collaborative improvement model in is really a knew phase in the qio program.


Cms calls upon qio toss serve on the boots on the ground and important role as conveners, organizers, change agents. by providing a call of action throughout to reach education and social marketing, serving as a trusted partner with February beneficiaries and stakeholders. execution of the following three drivers of quality, first,supporting and convening learning in action networks. second, providing technical says tans including quality improvement expertise, feedback and data shs and supporting clinicians. third, partnering with beneficiaries and providers to approve care and achieve better health at a lower cost. we are looking at additional ideas such as testing changes to medication copay's or allowing nurses and pharmacists to achieve blood pressure goals. we've already in the hospital setting lowered regulatory burdens so people can practice the full extent and proposed rule are working to finalize that rule. this all boils down to communications support partnerships. everyone working together to achieve the million hearts goal of preventing one million heart attacks and strokes. it is critical that we work together as partners. some ways at million hearts can help is support existing and already released enter vepgs intervention,proposed new interventions that cms should work on, align existing cms interventions across the federal family, and include million hearts and abcs and outreach and communications.

As a practicing clin ngs i can't tell you how proud i am to be working with the cdc and on behalf of cms, we really value our partnership and our ability to transform care in the u. s. The commissioner of the new york city department of health and mental hygiene. Since 2002 reduced cardiovascular disease. i'll be including the environmental initiatives,smoking prevention, trans fat restriction, and sodium reduction and clinical initiatives focusing on a prevention or sorry oriented record and quality improvement and technical assistance. first, our smoking program. the key policy change in our smoking program has been the smoke free air policy. in 2002 new york city passed the smoke free air act which prohibits smoking in indoor workplaces including restaurants and bars. no 2011 it was extended to outdoor parks and beaches. in this year, 2012, the university of new york will make all of the 23 campuses in the city completely tobacco free. another important policy change has been increase in cigarette prices through tax increases. in 2002 the city passed a tax increase of $1. 50 per pack. bringing the total tax on a pack of cigarettes in 2003 to over$3. additional state and federal tax increases that occurred between2002 and 2010 brought the total tax on a pack of cigarettes to$6. 86. a pack of cigarettes in new york city now costs about $11, the highest price in the nation. we've also extensively used mass media. we developed many of our own messages in which we keep fresh by providing new information or developing new ways of preventing old information, and in some cases providing testimonials testimonials. we have focus groups of smokers and place them on television and on subways. once a year we link a new campaign with the distribution of free nicotine patches and gum. this this is an example of a recent campaign. it emphasizes the suffering that smokers will endure, rather than death, which smokers don't fear very much.

This particular campaign has an emphasis on emphysema and stroke. potential of family members may have to provide care for smoker which is something we found particularly disturbing to smokers. let me see if i can show you this, one of these ads. as you can see we find it with subtlety. so what's been the effect of our smoking prevention program?this slide show transits smoking prevalence in new york city from1993 to 2010. before 2002 for about a decade the smoking prevalence in new-york city was steady at 21%. since then the prevalence has fallen more than a third to 14%. now represents 450,000 fewer smokers in new york city. next are our emphasis on trans fat. we restricted the use of trans fat based upon the rational that trans fat is an artificial chemical that increases heart disease risk. four gram consumption of trans fat or typical amount in a portion of french fries increases heart disease risk by23%.

in 2006 the new york city board of health prohibits the use of trans fats by restaurant. in 2007 they began enforcing it by issuing violation fines during restaurant inspections. by 2008, more than 90% of  restaurants were in compliance. this idea has now spread to other cities. this slide shows other cities and states which are considered trans fat restrictions since that time if states and cities are shown in blue and the states and cities that have consider resurgence is shown in red. following the approval of new york city health code amendment more than 50 restaurant chains have announced or reiterated their intention to discontinue the use of artificial trans fats in their foods. new york city also led to initiative to reduce sodium called the national salt reduction initiative. it's far too high and reduction of 1200 milligrams per day on average in an American consumption could save tens of thousands of lives per year nationally. the goal of this initiative is to reduce sodium intake by 20%over five years. through meetings with food companies we have classified packaged food in the 65 categories. restaurant food in 424 categories. we set reduction targets for each of the categories in 2012012 and 2014. with the average deduction of 25%.

Fda : rulling clinical arena

in 2003 the fda ruling required the labeling of trans fats on foods and consequently thereafter the food industry started to reformulate foods leading out trans fats. we know that reducing artificial trans fat is feasible. it doesn't change the flavor or the texture of food. our taste buds don't know the difference. monitoring the trans fat levels in the population and encouraging the food industry to eliminate them is critical. move on to the clinical arena now. million hearts has chosen these three priority areas. first, we want to draw the attention of the health care professionals and assistance in which they work to the a, b, cs. second, we want health information technology to work magic for busy practicers and the patients they care for. and finally, we want to develop and test new models of care that recognize and reward outcomes and values.

So million hearts work in clinical prevention is to develop a simple uniform measure set for the abcs and to ensure that the data that's used to calculate those measures move seamlessly within the flow of care, minimizing the burden of collecting and reporting on those measures. high performance on those measures should be linked to reward for clinicians for the health systems and for their patients. currently we're tracking some 47 interventions across the federal family that include and reward performance on one or more of the abcs. these interventions could range from an action that takes place in the physician's office to a program in the community, and to a policy. our second strategy is to fully deploy health information technology. clinicians need the registry functionality to be able to identify gaps in care, to intervene, and to track progress of people with high blood pressure or high blood lipids. point of care risk assessment tools ensure that the interventions are designed and targeted to the individuals most likely to benefit. clinical decision support, that is specific to the patient,ensures that the right care is delivered the first time and every single time. and for those of white house take medications and need a little help adopting and sticking to new health habit,hit can provide the nudges we need to get and to stay healthy. we live in historic times. it's when new care delivery models are being two and launched. million hearts is working to embed the abcs in these new models and to recognize and reward value over volume and outcomes. thus new models recognize the contributions of a large variety of pain member, pharmacist, cardiac rehab teams, health coaches, community health worker, pure wellness specialists are all among behavior change agents, powerful agents, to support and advise in the appropriate use of medications. so let's look to the future where the clinical and the community world converge. in this new world, and we want it to the not to be very long from now, we want -- we will have lots of lower sodium foods from which to choose. our taste buds actually prefer them and our wallets don't suffer as a result. blood pressure cups are everywhere. and readouts are simplified in red, yellow, and green, along with numbers for those of you who want them. a person can designate readings are automatically sent to a professional so advice and, if necessary, dose can be easily accomplished. access to medications is no longer an obstacle to control. this is not a fantasy. in fact, studies have shown that adding web-based pharmacy care to home blood pressure monitoring increased the control by over 50%. and in high risk folks. so here's the nation's current population wide performance on the abcs under the column marked baseline. under target is our goal for the population, by January 1st of2017, the numbers under the clinical target column reflect the goals of assistance care, those already in assistance care, and they are held to a higher standard. es that are the audacious goals that will prevent a million heart attacks and strokes by 2017. a goal that requires focused at text tension by all of us. we all have a piece to play in achieving the million hearts goal and creating a new future of cardiovascular health in the country. our next speakers will describe how these groups are building the new future. every agency on this slide is deeply engaged in substantive work to prevent heart attacks and strokes. we're delighted to have a wide array of private partners as-well including medical professional society, retailer, erer health plan, consumer groups with more coming in every day. so i ask, what will each of your groups do?i encourage you to visit the million hearts website, pledge your support, and encourage others to do the same. if you're hosting a viewing party today, please write us at million hearts at hhs. gov to tell us about it, we ask you to join us. it's now my pleasure to introduce my esteemed colleague dr.  patrick conway. the cms chief medical officer and director of office of clinical stand dards and quality. cms is very excited to partner with the centers of disease control and other agencies and community to achieve our million hearts goal. today i will briefly discuss cms' overall purpose and healthcare society, cms' role in million hearts and build off the clinical prevention you heard from dr.  janet wright. cms is the largest purchaser of health care in the world and provides health care coverage to approximately 150 million beneficiaries through medicare, medicaid, and the children's health insurance program. medicare alone pays out over 1. 5 billion in benefit payments per day, combined medicare and medicaid pay one-third of the health expenditure and a small proportion is focused on prevention. we want to increase our focus on health transportation and prevention. this is why a program like million hearts is so important. millions of consumers will see health coverage through healthcare exchanges authorized by the affordable care act and led out of cms. cms' aim is to provide better care for individuals and lower-costs through improvement. you can see that our aim is tied directly to the goals of million hearts. cms' partner with cdc, the offices of national coordinator for health information technology, health resources and services administration, communities and many, many more. we have convened meetings to identify agency wide standards,measure sets for 201 working collaborative with the cdc. one of our specific contributions is the development of the first measure that is monitored entirely via electronic health records by cholesterol screening and control. utilizes risk factor information for coronary heart disease to determine the appropriate ldl levels for each patient. many of our offices including my own office of clinical standards and quality is supporting million hearts through a number of programs and initiative. in the next few slides i'll highlight a few offices programs supporting million hearts and cms and in a later slide you will see greater detail of the work and quality and improvement organizations around the country. cms' center for medicaid ship and state services are working on medicaid smoking cessation and medicaid incentives to prevent chronic disease through programs like million hearts and these initiatives we can ensure smokers in the medicare system will do this. we include the essential health benefits in insurance exchanges. through the innovation center we're launching the care intervention exchange. we received an abundance of applications. we look forward to seeing the impact of these grants will have on our communities such an increasing use of registry,shared decision support tools and improving population health. for the rest of my speaking time i'll discuss cms' efforts and clinical preventions to optimize care for those who need it. the measures for these abcs have been identified and more detail is on this website. there are several measures used. there's enormous value in having line measures that cover the abcs for many providers. we need measures to set goals, Monday it or process. cms was with the national foreign quality measure 18 for blood pressure control and inclusion of physician supporting system and other programs in hospitals and outpatient settings through rule making and comments. electronic health records can improve the quality, safety, and efficiency of clinical care. cms are working together to incentive working together. they require providers to submit data and includes a number of proven features such as patient registries and computerized subscriptions. cms included the million hearts abc as part of the reporting requirement which will allow us to monitor the quality of care provided to patients can cardiovascular disease. we're also looking at these as core measure requirements. they will reduce redundancy and improve pop plar health all in a protected and secure fashion. one powerful requirement is the use of clinical decisions support tools. these tools make use of specific clinical information that is entered during a patient's visit and provide real time recommendations that support decision making. amp examples are alerts for high-blood pressure or cholesterol and require them to act on those values. these are efforts going on as part of the million hearts to develop evidence and guidelines-based clinical support tools that support the abcs. we look for more work in this area in the future. now let's talk about launching new models of innovation and care delivery.