1 INTRODUCTION

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in the United States¹ with hypertension being the primary contributor.² This is particularly apparent among marginalized populations such as metropolitan Detroit, Michigan, USA, where for decades our team has conducted population health research that focuses on preventive care and chronic disease management. Circumstances changed, however, during the COVID-19 pandemic, which prompted a major overhaul of our approach. Here, we describe our experiences transitioning from a stationary operation to a mobile health unit (MHU) program that provides dynamic, individualized healthcare and referral resources among socially vulnerable communities. Our twofold aim is to describe the implementation of our program and explain the rationale for investigating new systems of community-based care for CVD risk reduction under a health equity framework.

1.1 Meeting people where they are

Prior to 2020, our team conducted CVD research by recruiting participants primarily via screening efforts in urban emergency departments (EDs). However, the emergence of COVID quite dramatically halted recruitment and related research activities. As such, the ever-changing pandemic required innovative and adaptable strategies to continue serving these communities. While we initially began conducting drive-through COVID-19 testing in fixed locations, we quickly learned that social vulnerability, particularly transportation challenges and low socioeconomic status, proved to be a steep barrier to adequate care, thus increasing chronic disease risk (especially hypertension) in this population.³ To help alleviate these barriers, we partnered with the Ford Motor Company (Dearborn, MI, USA) to develop a fleet of vehicle-based health platforms, now known as MHUs. These MHUs enabled us to bring testing services directly to local communities across the Detroit area while also targeting specific areas of greatest need and social vulnerability.

1.2 Addressing CVD risk in the community

Detroit communities suffer from the highest rates of hypertension in the state of Michigan (https://www.cdc.gov/places) as well as from extreme social vulnerability. Together, both conditions contributed to an excessively high rates of COVID-related morbidity and mortality during the initial wave of the pandemic.⁴ To address this serious problem, our MHUs began screening for high blood pressure (BP) shortly after implementing mobile COVID-testing. Our rationale was that in contrast to traditional healthcare models, MHUs are uniquely capable of accessing difficult-to-reach populations in areas with heightened social vulnerability that have high CVD rates. Mobile platforms fill crucial gaps in the existing healthcare system by bringing care directly to people where they work, worship, live, and play to promote cardiovascular health equity.

On average, our fleet of MHUs are deployed to six different sites per day with each one staffed by a registered nurse, site lead, patient service representative, and research assistant. In the first year, 3039 people were screened for hypertension; 63% had abnormal BP (≥120/80 mmHg), and about half (32%) met criteria for stage-2 hypertension.⁵ The MHUs currently offer an expanded suite of services that include multiple screenings to promote cardiovascular, metabolic, and renal health including BP measurement, onsite blood testing for diabetes, renal function, and hyperlipidemia, as well as immunizations, testing for HIV and hepatitis C, and (perhaps most importantly) linkages to primary care providers (PCPs) if needed.

1.3 Optimizing MHU deployment

Given our mission to increase access to preventive care in socially vulnerable populations, we further implemented a data-driven strategy to optimize the targeting of geographic deployment. We began using Wayne State University's (Detroit, MI, USA) PHOENIX (Population Health Outcomes Information Exchange) Prevalence Profiler (phoenix-data.wayne.edu)⁶ to identify and reach “hotspots” with high social vulnerability and increased chronic disease burden. By using spatial analysis and data-driven vehicle deployment, the fraction of patients presenting for care who resided in high vulnerability neighborhoods increased by more than 60% (i.e., from 25% to 41%).³ Indeed, Figure 1 overlays MHU program activity on a metric by metric matrix map that identifies areas with high hypertension prevalence rates and/or increased social vulnerability from March 2020 to October 2023.

1.4 Applicability to hypertension research and CVD prevention

The first program we transitioned from focusing on patients identified in the ED to a broader MHU-focused recruitment was “Bring it Down.” This State-funded healthcare quality improvement project enrolled patients with systolic BPs ≥130 mmHg and connected them to PCPs and social services with follow-up health information captured. Of these participants, 42% had no previous diagnosis of hypertension, reiterating the urgent need for continued screening and disease identification in the community.⁵ Thereafter, the MHUs were deployed to enroll patients into “Linkage, Empowerment, and Access to Prevent Hypertension” (LEAP-HTN), a research project within the RESTORE Health Equity Research Network, funded by the American Heart Association. The principal goal of this study is to identify and halt the progression elevated BP to more severe stages (e.g., prevent new onset stage-1 hypertension) among Black adults living across vulnerable communities in Detroit.⁷ LEAP-HTN aims to alleviate the impacts of social vulnerability (e.g., lack of access to care, socioeconomic stress, allostatic load) on the risk for developing hypertension by directly addressing negative social determinants of health (SDoH).⁷ LEAP-HTN engages community health workers (CHWs) to be the community/patient-facing care provider who implements specific social interventions and life coaching to meet the needs of each individual.⁸ The novel CHW-led care plan we developed is termed PAL² – personalized pragmatic adaptable approaches to lifestyle and life circumstances. While PAL² is largely delivered via remote patient monitoring (RPM) platforms combined with remote visits (e.g., video, telephone) free of charge, in-person care at MHUs is also available if needed. Follow-up care by CHWs is overseen by physicians over a 2-year period, with the primary trial outcome being systolic BP change after year-1 between active versus usual care. Further details have been described previously.⁷

During this same period, we have also successfully launched an even larger more comprehensive program termed ACHIEVE GREATER (Addressing Cardiometabolic Health Inequities by Early Prevention in the GREAT lakEs Region), which is dedicated to reducing cardiometabolic health disparities in Detroit, MI as well as Cleveland, Ohio, USA. ACHIEVE GREATER consists of four individual projects and is funded by the National Institute of Minority Health and Health Disparities (NIMHD) Health Equity Action Network. Project 1 is a longitudinal cohort study to evaluate the effectiveness of MHU engagement, whereas project 2 focuses on asymptomatic stage-A heart failure (i.e., patients with high BP plus multiple comorbidities including diabetes and/or kidney disease) and mirrors LEAP-HTN with delivery of PAL²by CHWs. In addition, the active intervention group also receives team-based medical care, led by clinicalpharmacists who, under collaborative practice agreements, work to optimize the control of hypertension (and other CVD risk factors) through initiaion of guideline based medication therapy. Given the widespread shortage of PCPs and the promising role of CHWs in hypertension management, we believe that the PAL² template (with or without coupling to pharmacist-directed medical care) will pave the way for a more efficacious and cost-effective alternative care model for hypertension.^{8, 9} Project 3 aims to control CVD risk factors in socially vulnerable Black patients living across Cleveland OH using CHWs and team-based care and a personalized care plan based upon free-of-charge coronary artery calcium screening. Finally, project 4 focuses on reducing the high burden of recurrent admissions for heart failure over 30–90 days by decreasing exposure to fine particulate matter air pollution using portable air cleaners among patients recently discharged from Henry Ford Hospital in Detroit. Altogether the 4 projects in the ACHIEVE GREATER program should play a major role in addressing health disparities in 2 large urban metropolitan areas facing severe socially vulnerably.

1.5 The future of MHUs and expansion of community care

Just as the myth goes and the Phoenix was consumed by the flames before it was reborn again from the ashes, our existing hypertension and CVD research was forced out of urban EDs due to the adverse circumstances surrounding COVID-19, but was reborn in the form of MHUs that actively engage people in socially vulnerable communities. As we continue to evolve our program, we continuously seek innovative ways to improve cardiovascular health in community settings. We believe that our novel MHU program provides a framework and example for nationwide mobile health programs dedicated to filling gaps in preventive care and promoting health equity in socially vulnerable communities across the United States.

中文翻译：

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旨在预防弱势社区心血管疾病的新型移动医疗单元计划的起源

1 简介

心血管疾病 (CVD) 是美国发病率和死亡率的主要原因¹，其中高血压是主要原因。²这在美国密歇根州底特律大都市等边缘化人群中尤为明显，几十年来，我们的团队一直在该地区开展人口健康研究，重点关注预防保健和慢性病管理。然而，在 COVID-19 大流行期间，情况发生了变化，这促使我们对方法进行了重大改革。在这里，我们描述了我们从固定运营过渡到移动医疗单位 (MHU) 计划的经验，该计划为社会弱势社区提供动态、个性化的医疗保健和转诊资源。我们的双重目标是描述我们计划的实施情况，并解释在健康公平框架下研究新的社区护理系统以降低 CVD 风险的基本原理。

1.1 在人们所在的地方与他们会面

2020 年之前，我们的团队主要通过城市急诊科 (ED) 的筛选工作招募参与者来进行 CVD 研究。然而，新冠疫情的出现极大地阻止了招募和相关研究活动。因此，不断变化的流行病需要创新和适应性强的战略来继续为这些社区提供服务。虽然我们最初开始在固定地点进行免下车 COVID-19 检测，但我们很快了解到，社会脆弱性，特别是交通挑战和社会经济地位低下，被证明是获得充分护理的巨大障碍，从而增加了慢性病风险（特别是高血压）在这个人群中。³为了帮助缓解这些障碍，我们与福特汽车公司（美国密歇根州迪尔伯恩）合作开发了一系列基于车辆的健康平台，现在称为 MHU。这些 MHU 使我们能够直接向底特律地区的当地社区提供测试服务，同时也针对最需要和社会脆弱性的特定领域。

1.2 解决社区CVD风险

底特律社区的高血压发病率是密歇根州最高的 (https://www.cdc.gov/places)，而且社会脆弱性极高。这两种情况共同导致了大流行第一波期间与新冠病毒相关的发病率和死亡率过高。⁴为了解决这一严重问题，我们的 MHU 在实施移动新冠病毒检测后不久就开始筛查高血压 (BP)。我们的理由是，与传统的医疗保健模式相比，MHU 具有独特的能力，能够接触到社会脆弱性较高且心血管疾病发病率较高的地区的难以接触到的人群。移动平台通过直接为人们工作、礼拜、生活和娱乐的地方提供护理，以促进心血管健康公平，从而填补了现有医疗保健系统的关键空白。

平均而言，我们的 MHU 车队每天部署到六个不同的站点，每个站点配备一名注册护士、站点负责人、患者服务代表和研究助理。第一年，3039人接受了高血压筛查； 63% 的血压异常（≥120/80 mmHg），约一半 (32%) 符合 2 期高血压标准。⁵ MHU 目前提供一系列扩展服务，包括促进心血管、代谢和肾脏健康的多项筛查，包括血压测量、糖尿病、肾功能和高脂血症的现场血液检测，以及免疫接种、艾滋病毒和丙型肝炎检测，以及（也许最重要的是）与初级保健提供者 (PCP) 的联系（如果需要）。

1.3 优化MHU部署

鉴于我们的使命是增加社会弱势群体获得预防性护理的机会，我们进一步实施了数据驱动的战略，以优化地理部署的目标。我们开始使用韦恩州立大学（美国密歇根州底特律）的 PHOENIX（人口健康结果信息交换）患病率分析器 (phoenix-data.wayne.edu) ⁶来识别和触及社会脆弱性高且慢性疾病负担增加的“热点”。通过使用空间分析和数据驱动的车辆部署，居住在高脆弱性社区的就诊患者比例增加了 60% 以上（即从 25% 增加到 41%）。³事实上，图 1 将 MHU 计划活动叠加在逐个指标矩阵图上，该地图确定了 2020 年 3 月至 2023 年 10 月期间高血压患病率高和/或社会脆弱性增加的地区。

1.4 对高血压研究和CVD预防的适用性

我们从关注急诊科确定的患者转向更广泛的以 MHU 为重点的招募项目是“Bring it Down”。这个国家资助的医疗质量改善项目招募了收缩压≥130 mmHg 的患者，并将他们与 PCP 和社会服务联系起来，并获取后续健康信息。在这些参与者中，42% 的人既往没有高血压诊断，这再次表明社区迫切需要继续筛查和疾病识别。⁵此后，MHU 被部署将患者纳入“预防高血压的联系、赋权和获取”(LEAP-HTN)，这是 RESTORE 健康公平研究网络内的一个研究项目，由美国心脏协会资助。本研究的主要目标是识别并阻止居住在底特律弱势社区的黑人成年人血压升高至更严重的阶段（例如，预防新发的 1 期高血压）。⁷ LEAP-HTN 旨在通过直接解决健康的负面社会决定因素 (SDoH) 来减轻社会脆弱性（例如，缺乏护理机会、社会经济压力、稳态负荷）对患高血压风险的影响。⁷ LEAP-HTN 让社区卫生工作者 (CHW) 成为面向社区/患者的护理提供者，实施特定的社会干预措施和生活指导，以满足每个人的需求。⁸我们开发的新颖的社区卫生工作者主导的护理计划被称为 PAL ^2——针对生活方式和生活环境的个性化务实适应性方法。虽然 PAL ²主要通过远程患者监护 (RPM) 平台与免费远程就诊（例如视频、电话）相结合来提供，但如果需要，也可以在 MHU 进行现场护理。社区卫生工作者的后续护理由医生监督，为期 2 年，主要试验结果是第一年后积极护理与常规护理之间的收缩压变化。先前已经描述了更多细节。⁷

同一时期，我们还成功启动了一项规模更大、更全面的计划，名为 ACHIEVE GREATER（通过早期预防解决大湖地区心脏代谢健康不平等问题），该计划致力于减少底特律、密歇根州和克利夫兰的心脏代谢健康差异，美国俄亥俄州。 ACHIEVE GREATER 由四个单独的项目组成，由国家少数民族健康和健康差异研究所 (NIMHD) 健康公平行动网络资助。项目 1 是一项纵向队列研究，旨在评估 MHU 参与的有效性，而项目 2 侧重于无症状 A 期心力衰竭（即高血压加上糖尿病和/或肾脏疾病等多种合并症的患者），并将 LEAP-HTN 与由社区卫生工作者交付 PAL ²。此外，主动干预组还接受由临床药剂师领导的基于团队的医疗护理，他们根据合作实践协议，通过启动基于指南的药物治疗来优化高血压（和其他心血管疾病危险因素）的控制。鉴于 PCP 普遍短缺以及 CHW 在高血压管理中的前景广阔，我们相信 PAL ²模板（无论是否与药剂师指导的医疗护理相结合）将为更有效和更具成本效益的替代护理模式铺平道路对于高血压。^{8, 9}项目 3 旨在利用社区卫生工作者和基于团队的护理以及基于免费冠状动脉钙筛查的个性化护理计划，控制居住在俄亥俄州克利夫兰的社会弱势黑人患者的 CVD 风险因素。最后，项目 4 的重点是通过使用便携式空气净化器减少最近从底特律亨利福特医院出院的患者接触细颗粒物空气污染的机会，从而减轻 30-90 天内因心力衰竭反复入院的沉重负担。 ACHIEVE GREATER 计划中的 4 个项目应在解决面临严重社会弱势的两个大城市地区的健康差距方面发挥重要作用。

1.5 MHU 的未来和社区护理的扩展

正如传说中的凤凰被火焰吞噬后又浴火重生一样，我们现有的高血压和心血管疾病研究由于COVID-19的不利环境被迫退出城市急诊室，但以这样的形式重生积极让社会弱势社区的人们参与的 MHU。随着我们不断发展我们的计划，我们不断寻求创新方法来改善社区环境中的心血管健康。我们相信，我们新颖的 MHU 计划为全国移动医疗计划提供了一个框架和范例，致力于填补美国社会弱势社区预防保健方面的空白并促进健康公平。