Creating a Dialogue:
The Introduction of a New Educational Tool to Improve Patient-Physician Communications about High Blood Pressure

Cornelia Oehler, Chandler Chicco Agency
Christian Pflaumer, Chandler Chicco Agency

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Abstract

High blood pressure is a significant public health problem, affecting an estimated 72 million Americans, or nearly one in three adults. While it is easy to measure and can be successfully treated, in nearly 70 percent of patients, the condition is uncontrolled, potentially leading to complications such as heart attack, stroke, heart failure and kidney damage. Since most patients do not experience symptoms from high blood pressure, a key challenge is to motivate them to take their condition seriously and work to reach a healthier blood pressure goal. In response, Novartis, a leader in high blood pressure therapies, with the help of Chandler Chicco Agency, launched Dialogues in Hypertension Management, a novel tool designed to increase patient adherence to hypertension treatment, improve health outcomes and promote physician-patient communications. Using visual images created from real human data, the Dialogues tool enables doctors for the first time to show patients the potential damage uncontrolled high blood pressure can cause, supplementing their ability to verbally communicate the risks. The Dialogues tool was introduced to the medical community during the American Heart Association meeting in Chicago in November 2006. The event, which included the one-act play Balancing Act and an expert panel discussion, illustrated that communications specialists can successfully engage physicians in a discussion about sensitive professional issues, such as how to maximize physician-patient dialogue.

Introduction

High blood pressure affects an estimated 72 million Americans,¹ or nearly one in three adults.² It is a serious chronic disease that may result in complications such as heart attack, stroke, heart failure and kidney damage. High blood pressure was listed as a primary or contributing cause of death in approximately 277,000 U.S. deaths in 2002.¹ Although high blood pressure is easy to measure and can be successfully treated, nearly 70 percent of people with high blood pressure do not have the condition under control.² In addition, there is a critical lack of public awareness about this life threatening condition and approximately one-third of individuals with hypertension are not aware that they have high blood pressure.² High blood pressure is an asymptomatic disease, which according to the American Heart Association may in part contribute to the lack of public awareness about its severity.

Enhancing patient education and improving communication between physicians and patients are key and effective strategies to improve patient adherence to a recommended treatment.⁴ Novartis, a leading manufacturer of drugs to treat high blood pressure, believes that these strategies could play an important role in improving control rates for high blood pressure. The company has launched various efforts to improve patient education and physician-patient communication about high blood pressure. In 2004, Novartis created a national hypertension management program called the BP Success Zone. The program provides customized educational and motivational tools to help patients with high blood pressure work with their health care professionals to set a blood pressure goal, define a treatment plan and work together to reach and maintain that goal.

One of Novartis' initiatives is Dialogues in Hypertension Management, a tool designed to improve patient-physician communication, to facilitate patient education, and to motivate patients by bringing to life the risks of uncontrolled high blood pressure. The Dialogues tool, and the communication strategy used to introduce it to the medical community, are described in this case study.

Visualizing the Cardiovascular System

Chandler Chicco Agency (CCA) is a full-service, global healthcare public relations firm, which was founded in 1995. CCA provides healthcare clients, including pharmaceutical companies, hospitals and healthcare technology companies with communications strategies that build, enhance or protect brand value and further public affairs agendas.

To improve patient education about high blood pressure, Carrie Liaskos of CCA and her team facilitated a partnership between Novartis and the New York-based production company Anatomical Travelogue to create three-dimensional visualizations of the cardiovascular system from inside the bodies of actual patients, the first known images of their kind. The images were created using advanced imaging technology, including magnetic resonance imaging (MRI), computed tomography (CT) and electron microscopy. The resulting images show patients the consequences of uncontrolled high blood pressure, including heart attack, stroke, kidney damage and vision problems.

Creation of the images was underwritten by Novartis. To ensure medical and scientific accuracy during the development of the program, Anatomical Travelogue enlisted three cardiologists, a nephrologist, a neurologist and a hypertension specialist to serve as a scientific advisory board. The advisory board reviewed materials and provided scientific guidance on the project to ensure medical accuracy.

In late 2005, the images of the cardiovascular system were unveiled through a book on high blood pressure and cardiovascular health, The InVision Guide to a Healthy Heart, published nationwide by HarperCollins. The book was accompanied by the launch of an interactive Web site, www.invisionguide.com/heart, which offers additional information on the prevention and treatment of cardiovascular disease, and links to the BP Success Zone Web site. The InVision Web site received the 2006 "Webby" award for best health-related site from the International Academy of Digital Arts and Sciences.⁵

Since the launch, the images have been incorporated into a variety of press and educational materials across the Novartis cardiovascular franchise, including a high blood pressure fact sheet, cross-franchise press kit and Joe Montana's Family Playbook for Managing High Blood Pressure, which features high blood pressure patient and former NFL quarterback Joe Montana and his family. The book, which uses the Anatomical Travelogue images to depict the consequences of uncontrolled high blood pressure, provides patients with information on risk factors for the condition and how to minimize them. In addition, the images became the design inspiration for the Novartis booth at major medical meetings and were featured in a corporate direct-to-consumer advertisement aimed at raising awareness about the importance of managing high blood pressure. Novartis has also made the images available to select physicians for use in medical presentations, symposia and grand rounds.

Dialogues in Hypertension Management Tool

Following the launch activities around the Anatomical Travelogue images, Novartis was interested in incorporating the images into educational materials to help physicians explain the importance of managing high blood pressure to their patients, and to help them reach patients who were diagnosed with high blood pressure but not taking the necessary steps to control the condition. The company conducted focus group research with physicians and patients to better understand the influence of the images and explore the most impactful way to present them to consumers.

In November 2004 and December 2005, Novartis conducted research with a total of 6 small consumer focus groups in Edison, NJ and Chicago, IL. Each focus group consisted of 2 men and 2 women, ages 45 - 64 years old, who took a prescription medication for high blood pressure, but their condition was uncontrolled (defined as blood pressure of 140/90 mmHg or higher, which is considered high blood pressure by national guidelines).⁶ Three two-hour, 4-person focus groups were conducted in each of the two markets for a total of 24 respondents. Consumer focus groups demonstrated that patients found the images to be powerful. Participants reported that seeing the effects of high blood pressure, rather than simply being told about the effects, would motivate them to make changes in their lifestyle, including diet, exercise and treatment compliance.

In February 2006, Novartis conducted focus group research with primary care physicians in Chicago, IL and New York, NY. All physicians were Board Certified in Internal Medicine or Family/General Practice, had been in practice 3-25 years, and spent more than 75 percent of their time treating patients in an office based setting. Thirty-nine physicians were interviewed in the two markets. A mix of 4 in-depth interviews and 4 triad/mini-groups were conducted in each market. Physicians believed that the images would be a powerful educational and motivational tool for patients, by providing them with a realistic view of the damage uncontrolled high blood pressure can cause each day.⁷ Importantly, physicians also believed that the images would more effectively enable them to discuss high blood pressure with patients within the typical time constraints for office visits.⁷ In addition, physicians noted that they have few resources with which to educate patients about high blood pressure and expressed a need for more illustrative educational materials.⁷ Repeatedly, they iterated the sentiment, "A picture is worth a thousand words,"and said that by using the images they would better be able to explain the risks and possible damage to organs and ensuing complications of high blood pressure, such as heart attack or stroke, to patients.⁷

Based on this research, Novartis developed a series of educational materials using the Anatomical Travelogue images. The Dialogues in Hypertension Management tool was designed to increase patient adherence, improve health outcomes and promote physician-patient communications. The Dialogues tool includes a desktop flipchart, tear pads, and a DVD. The desktop flipchart illustrates the potential consequences of uncontrolled high blood pressure, allowing physicians to quickly convey information to patients. The flipchart features images of hemorrhagic and ischemic strokes, the enlarged heart of a patient suffering from heart failure and the condition of a heart following a heart attack. It also visualizes the potential organ damage that may result from high blood pressure, by showing patients the difference between organs from healthy and unhealthy patients, including the kidneys, retinas and blood vessels. In addition, the flipchart provides patients with information on risk factors for high blood pressure, including diet, obesity, sedentary lifestyle, smoking and family history. At the end of the visit, physicians can provide patients with a sheet from the tear pad, customized with their current blood pressure and personal health goals, as a take-away.

Novartis is currently developing a DVD that features anatomically accurate visualizations of the body and leads patients on a journey through their cardiovascular system. The DVD is intended to help patients understand what is going on inside their bodies and show them the potential consequences of uncontrolled high blood pressure. It also will show patients how they can manage their high blood pressure and reduce their health risks.

Balancing Act: Launch of the Dialogues Tool

In 2006, Novartis was interested in hosting an event to introduce the Dialogues tool to the medical community, in order to demonstrate that the company understood the challenge of communicating with hypertension patients. During focus group research with physicians, CCA and Novartis learned that physicians are skeptical about attending seminars with communications experts to learn how to have a dialogue with patients.⁷ Many physicians view this as an indictment of their abilities to practice medicine and to communicate effectively. Despite their reluctance to attend a seminar on communications, physicians in the Novartis focus groups also indicated that they needed educational tools to help them communicate more quickly and effectively with patients. Therefore, CCA faced a challenge in designing an event that would introduce the Dialogues tool to physicians and nurse practitioners and encourage them to use it, without criticizing their current communications techniques.

Carrie Liaskos and Joy Brownstein of CCA proposed hosting a symposium at the American Heart Association's (AHA) Scientific Sessions, one of the largest medical meetings focused on heart health, attended by more than 17,000 physicians. The symposium, which did not provide physicians with continuing medical education (CME) credit, consisted of Balancing Act, an original one-act play examining the complexities of the patient-physician dialogue, and a "Talk Back" panel discussion with the audience following the production. This arts-based learning approach, called StageRight, was developed by CCA as a means to capture and convey the emotional aspects of a disease area. This technique has been successfully implemented by CCA in several disease areas including Attention Deficit Hyperactivity Disorder, Overactive Bladder and Epilepsy. Balancing Act was designed to reflect the everyday challenges physicians face, without faulting them, and to offer the audience a chance to consider their own professional and personal obstacles and goals. The play was also designed to convey information in a way that was memorable, entertaining and different from traditional, lecture-based conference symposia.

The primary audiences for the event included primary care physicians and cardiologists who treat patients with high blood pressure, as well as nurse practitioners, who often play a role in patient education. In addition, the seminar was intended for key opinion leaders and third party organizations, such as members of the American Society of Hypertension and Association of Black Cardiologist, who could help raise awareness about the Dialogues program among clinicians.

Tactical planning for Balancing Act commenced in April 2006, when CCA partnered with a production company, Class Productions, to begin coordinating the logistics for the event. The first step was identifying the right playwright. Following several interviews, Novartis commissioned the award-winning playwright Kathleen Tolan to develop a script for the play. Tolan was charged with developing a thought-provoking play that examined the complexities of patient-physician dialogue, but was given artistic freedom to include her own vision.

The script development process was more challenging and time consuming than originally anticipated. It was important that the script was entertaining and compelling, but also that it accurately and realistically reflected the patient-physician relationship. To facilitate the script development, Tolan shadowed a primary care doctor who treated patients with high blood pressure and interviewed several patients who suffered from high blood pressure, kidney damage and heart failure. This interview process took several weeks to complete. Once the first draft was finished, the script was reviewed by a group of doctors who served on the panel that would follow the play. In June 2006, CCA and Novartis began assembling this group of doctors to oversee the symposium development and provide insights into the real-life challenges physicians face. Input from these physicians greatly enhanced the play and content of the panel discussion, but CCA did not anticipate the amount of time it would take to revise and refine the script, particularly when the playwright was receiving feedback from many reviewers.

Collaborating with the production agency, Carrie Liaskos and her team were involved in the audition process, which resulted in the casting of six Broadway- and television-experienced actors. Agency staff were also present during rehearsals prior to the performance.

To ensure that Balancing Act was well-attended by physicians, Novartis extensively promoted the play to AHA conference attendees before and during the conference. Two months prior to the conference, attendees received a pre-mailing inviting them to attend the symposium. Onsite at the conference, the event was promoted through bus banner ads and mobile billboards. Physicians were encouraged to pick-up complimentary tickets to the event at the Novartis booth, driving traffic to the booth. The Anatomical Travelogue images, which are the centerpiece of the Dialogues tool, were incorporated into all of the advertising and promotional materials, as well as featured on the Novartis booth.

Novartis decided to host Balancing Act at the historic Drury Lane Theatre in downtown Chicago, which seats more than 500 guests and has a classic Broadway-style atmosphere. The one-act play examined the complex life of a physician working to meet the challenges of a thriving practice and the needs of his patients. The main character, who had recently suffered a heart attack himself, was working to maintain his own health, while attending to his patients and handling a busy family life.

An official "show bill," which contained a detailed overview of the Dialogues program, was distributed to each attendee at the beginning of Balancing Act, along with an evaluation form on the content of the play and the panel discussion thereafter. In addition, all attendees received a free copy of the Anatomical Travelogue book, The InVision Guide to a Healthy Heart.

Immediately following the performance, cardiologist Dr. Marc Pfeffer of Brigham and Women's Hospital hosted "Talk Back," an interactive panel discussion with the audience. Dr. Pfeffer was joined on the panel by playwright Kathleen Tolan, cardiologist Dr. Elizabeth Ofili of Morehouse School of Medicine, and behavior and communications specialist Dr. Michael Goldstein of Brown Medical School and The Institute for Healthcare Communications. These doctors were chosen to serve on the panel because of their areas of expertise and their ability to contribute to a panel discussion about communication. In addition, these physicians are well known in the medical community and Novartis and CCA anticipated that their participation in the event would increase audience attendance. The panel discussion with the audience offered an opportunity to examine in more detail the challenges physicians face when communicating with their patients. The content of the discussion focused on possible solutions for motivating patients to change their behavior and for engaging patients in the management of their own health. The panel discussion was designed to be a conversation among doctors about their common challenges rather than a seminar on how to communicate.

During a post-theater reception, attendees were given the opportunity to preview the Dialogues tool, which was presented as a possible solution to some of the challenges depicted in the symposium. Novartis sales representatives demonstrated how to use the tool and answered questions about the Anatomical Travelogue images, which were displayed in the lobby. Physicians were given the opportunity to sign up to receive more information about the Dialogues tool.

On-camera interviews were conducted with attendees as they left the event to record the audience's reactions to the play and panel discussion. The comments were compiled into a highlights reel that was shown at the Novartis booth the following day, increasing the buzz and excitement around the event.

Results and Implications For Other Public Health Communication Initiatives

There was an overwhelming interest in the symposium and more than 530 tickets were distributed, making it a sold-out event. Of the 215 attendees who pre-registered for the event, 73 percent were medical professionals. More than 400 attendees picked up their tickets for the event at the Novartis booth, significantly driving booth traffic. In fact, although overall attendance at the AHA conference was down in 2006, U.S. physician traffic at the Novartis booth increased 25 percent over 2005.

Sixty-five medical professionals (roughly 15 percent of the audience) requested more information about the Dialogues tool by entering their contact information on a sign-up sheet. Novartis was pleased with this response from doctors. Nearly 100 attendees (approximately 22 percent) completed evaluation forms. The average overall rating for the symposium was 4.¹ out of a possible 5.0, with 79 percent rating the event a 4 or 5. Several respondents also included positive comments on their evaluation form, such as "enjoyable forum for learning" and "very powerful insight and communication." Many attendees said they were moved to tears by the play and were willing to share their feelings on camera.

The launch of the Dialogues tool illustrates that it is possible for communications professionals to engage physicians in a discussion about sensitive professional issues, such as the doctor-patient dialogue. The key to Balancing Act's success was an innovative approach that was entertaining and respectful of physicians by avoiding a "lecture" feel. The early involvement of doctors during the development of the play ensured that it realistically depicted common everyday challenges for physicians in balancing the demands of patients and their own personal lives. In addition, the participation during the post-play panel discussion of doctors judged to be well-known to the target audience added to the event's impact and credibility.