2 Goal: Prevent 1 million heart attacks Million Hearts®Goal: Prevent 1 million heart attacksand strokes by 2017US Department of Health and Human Services initiative, co-led by:Centers for Disease Control and Prevention (CDC)Centers for Medicare & Medicaid Services (CMS)Partners across federal and state agencies and private organizationsMillion Hearts® is a national initiative, launched in January 2012 by the U.S. Department of Health and Human Services.It is co-led by CDC and CMS and focuses the efforts of federal agencies, states, regions, communities and individuals on a common goal—preventing one million heart attacks and strokes by 2017This goal is audacious and achievable only with the collective efforts of each of us as individuals and as members and leaders of our communities, workplaces, and organizations.HHS asked CDC and CMS to bring their collective strengths to lead this initiative, ensuring the coordination of public health, clinical care and policy approaches to this complex problem.We are delighted by the robust participation of private sector partners from states to health professional societies, health advocacy groups, and faith based organizations, and commercial payers to name a few.2
3 Overview of Presentation Burden of cardiovascular diseaseKey componentsAction stepsPublic/private sector supportResourcesWhat you can doThe slides that follow will describe the burden of cardiovascular disease including hypertension; review the key components of Million Hearts® in the clinical and community arenas; describe what support is needed from both the public and private sectors; and challenge you to consider what actions you can take to contribute to preventing a million heart attacks and strokes.
4 Heart Disease and Stroke Leading Killers in the United States More than 1.5 million heart attacks and strokes each yearCause 1 of every 3 deaths800,000 cardiovascular disease deaths each yearLeading cause of preventable death$315.4B in health care costs and lost productivityLeading contributor to racial disparities in life expectancyWhile we have seen a gradual decline in mortality from cardiovascular disease over the last 40 years, it remains the nation’s leading cause of death for men and women of all races and ethnicities.Each year more than 1.5 million people will have a heart attack or stroke.These heart attacks and strokes contribute to the almost 800,000 deaths (1 in 3 deaths) from cardiovascular disease a year, leading causes of preventable death in people under the age of 65.The trauma to families and communities is devastating; the cost to the US economy is $315.4 billion every year—that’s nearly $1 billion each day—in medical costs and lost productivity.In 2010, life expectancy for the black population was 3.8 years shorter than that of the white population, with heart disease mortality being the single cause of death that accounts for most of this disparity (over one year).Kochanek KD, et al. Natl Vital Stat Rep. 2011;60(3).Go AS, et al. Circulation. 2012:e2–241Heidenriech PA, et al. Circulation. 2011;123:933–4.NCHS Data Breif, June 2013.
5 200,000 Preventable Deaths from Heart Disease and Stroke Many of the deaths caused by heart disease and stroke are preventablePreventable deaths are those attributed to lack of preventive health care or timely and effective medical careAt least 200,000 of the 800,000 annual deaths occur in individuals under the age of 75.There is an excellent analysis of these preventable deaths in the September 2013 Morbidity and Mortality Weekly Report (MMWR) and Vital Signs, including this map that shows the variance in preventable deaths by county.More than half of these preventable deaths happen to people under 65 years of age.These deaths could have been prevented through changes in health habits, such as stopping smoking, more physical activity, and less salt in the diet; community changes to create healthier living spaces, such as safe places to exercise and smoke-free areas; and optimally managing high blood pressure, high cholesterol, and diabetes.This Morbidity and Mortality Weekly Review (MMWR) includes county specific rates of preventable death, showing that the risk of preventable death from heart disease and stroke varies by county, even within the same state.Counties with the highest preventable death rates were located primarily in the South census region.These state-level and county-level differences in avoidable death rates from heart disease, stroke, and hypertensive disease suggest the need for interventions that target areas with the highest rates and work with the resources, policies, and programs already existing in those areas.
6 Key Components of Million Hearts® Keeping Us HealthyChanging the environmentTRANSFATExcelling in the ABCSOptimizing careFocus on the ABCSHealth tools and technologyInnovations in care deliveryHealth DisparitiesIn order to prevent a million heart attack and strokes, we know there is work to be done in changing the environments in which we live, work and play and in achieving excellence in our healthcare.By increasing smoke free environments, decreasing sodium in the food supply, and eliminating trans fat, we would change our environment in ways that keep people healthier and less likely to need health care. Were you aware that when communities go smoke-free, there is an immediate decrease in the number of hearts attacks seen in those communities? (“50 Years of Progress: A Report of the Surgeon General, 2014 page 442)In addition to changes to our environment, we also need to help patients, healthcare professionals and systems achieve excellence in the care delivered. In the clinical arena, we can reduce heart attacks and strokes by:Focusing the attention of patients, healthcare professionals and the systems in which they work, on the ABCS (Aspirin when appropriate, Blood pressure control, Cholesterol management, Smoking cessation);Harnessing the power of health information technology to improve health outcomes;Developing, testing, and deploying new models of care that recognize and reward outcomes and value.As a nation, we can and must do better. For certain segments of our nation, the burden is even greater. As we work on changing the environment and optimizing care, we need to make sure we are addressing the needs of those who are disproportionately affected by cardiovascular disease.Glantz. Prev Med. 2008; 47(4):How Tobacco Smoke Causes Disease: A Report of the Surgeon General,2010.
7 Health DisparitiesAfrican-Americans develop high blood pressure more often, and at an earlier age, than whites and Hispanics do.African-Americans are nearly twice as likely as whites to die early from heart disease and stroke. American Indians and Alaska Natives die from heart diseases at younger ages than other racial and ethnic groups in the United States. 36% of those who die of heart disease die before age 65.As was mentioned in an earlier slide, heart disease and stroke are the greatest contributors to racial disparities in life expectancyFor example:African-Americans develop high blood pressure more often, and at an earlier age, than whites and Hispanics do.African-Americans are nearly twice as likely as whites to die early from heart disease and stroke. American Indians and Alaska Natives die from heart diseases at younger ages than other racial and ethnic groups in the United States. 36% of those who die of heart disease die before age 65.Source:Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation. 2013;127:e6–245.Morbidity and Mortality Weekly Report (MMWR): Vital Signs: Avoidable Deaths from Heart Disease, Stroke, and Hypertensive Disease — United States, 2001–2010SS Oh, JB Croft, KJ Greenlund, C Ayala, ZJ Zheng, GA Mensah, WH Giles. Disparities in Premature Deaths from Heart Disease—50 States and the District of Columbia. MMWR 2004;53:121–25.
8 The ABCS to Prevent Heart Attacks and Strokes AspirinPeople who have had a heart attack and stroke who are taking aspirinBlood pressurePeople with hypertension who have adequately controlled blood pressureThis slide provides an overview of the ABCS that will prevent heart attacks and strokes.CholesterolPeople with high cholesterol who are effectively managedSmokingPeople trying to quit smoking who get helpSources: National Ambulatory Medical Care Survey, National Health and Nutrition Examination Survey
9 Getting to Goal Aspirin for those at risk Blood pressure control InterventionMeasure Value2017 TargetClinical targetAspirin for those at risk54%65%70%Blood pressure control53%Cholesterol management33%Smoking cessation22%Smoking prevalence26%10% reduction(~24%)Sodium reduction3580 mg/day20% reduction (~2900 mg/day)Trans fat reduction (artificial)0.6% of calories100% reduction(0% of calories)This table provides an overview of the Million Hearts® population goals and clinical targets for the ABCS of clinical care (i.e., Aspirin when appropriate, Blood pressure control, Cholesterol management, and Smoking assessment and cessation treatment). It can be used by clinicians and public health practitioners to describe the Million Hearts® ABCS and the most current values, population goals, and clinical targets for each measure.In conjunction with other Million Hearts® efforts, by meeting the population goals for these evidence-based interventions the United States could experience more than 1 million fewer heart attacks, strokes, and other related events during 2012–2016. Each ABCS measure is described in more detail in subsequent figures.The population goal represents the minimum value desired for the entire US population described within each ABCS measure. The clinical target refers to the minimum value desired for health care systems and clinics as they treat their patient populations described within each measure. For example, the population goal for all U.S. adults aged 18 years or older who have hypertension (i.e., elevated blood pressure) is to have hypertension control (i.e., blood pressure <140/90) rates of at least 65%. This includes people who have access to regular health care and health insurance and those who do not. However, the target for health care systems and clinics is higher at 70%. In theory, these groups work with a population that has greater access to regular health care and are better positioned to make larger gains in hypertension control; therefore, their target is higher.Sources: National Ambulatory Medical Care Survey, National Health and Nutrition Examination Survey, National Survey of Drug Use and Health.
10 Only Half of Americans with Hypertension Have It Under Control 72 MILLIONADULTS WITH HYPERTENSION (31%)I’ve already described how devastating cardiovascular disease is for our nation, and how much of this devastation is preventable. Lets take a closer look at HTN, one of the risk factors for having a heart attack or stroke.Nearly one in three, or about 72 million adults in the U.S. have hypertension.Of those Americans with hypertension, about half are not yet under control, defined as systolic blood pressure less than 140 mmHg and diastolic less than 90 mmHg.35 million adults, or about 48%, have uncontrolled hypertension.NOTE TO PRESENTER: The 52% represents NHANES data for blood pressure control.(35 M)SOURCE: National Health and Nutrition Examination Survey
11 Awareness and Treatment among Adults with Uncontrolled Hypertension 35 MILLIONADULTS WITH UNCONTROLLED HYPERTENSIONOf the approximately 35 million adults with uncontrolled hypertension13 million do not know that they have high blood pressure17 million are aware that they have high blood pressure and are being treated with medication but are still not under controlAn additional 5 million are aware of their high blood pressure but not taking medication for itSOURCE: National Health and Nutrition Examination Survey
12 Prevalence of Uncontrolled Hypertension by Selected Characteristics 89%85%74%Looking at this table, you can see that the vast majority of these adults with uncontrolled hypertension have health insurance and a usual care provider, and most have received health care in the past year.89% of those with uncontrolled hypertension have a usual source of health care.85% have health insurance74% have seen a health care provider at least twice in the past year.So what can be done if so many people have access to care? I’d now like to outline the proven community and clinical strategies that we know will prevent heart attacks and strokes.Yes NoUsual Source of CareYes NoHealth Insurance≥ None# Times Received Care in Past YearSource: National Health and Nutrition Examination Survey612
14 Targets for the Environment InterventionPre-Initiative Estimate( )2017 TargetSmoking prevalence26%10% reduction(~24%)Sodium reduction3580 mg/day20% reduction (~2900 mg/day)Trans fat reduction (artificial)0.6% of calories100% reduction(0% of calories)How are we going to get to the 1 million events?On the environmental side -We need to reduce the number of people who are smoking (i.e., cigarettes, cigars, or pipes) from 26% to 24% of Americans by 2017, a 10% reduction.To reduce sodium consumption by 20%, we need to reduce the current intake of sodium consumed per person per day from 3580 mg to about 2900 mg of sodium by 2017.And we need to eliminate artificial trans fat consumption by 100%.National Survey on Drug Use and Health, National Health and Nutrition Examination Survey
15 Keeping Us Healthy Changing the Environment: Tobacco Comprehensive tobacco control programs workGraphic mass media campaignSmoke-free public places and workplace policiesFree or low-cost counseling and medicationsThe last twenty years have taught us that comprehensive tobacco control programs can bring down both smoking rates and deaths. Comprehensive programs include media campaigns, attention to policies, assistance for those who want to quit and surveillance of smoking prevalence.CDC ‘s “Tips from Former Smokers” campaign, is a great example of an effective media campaign that is driving people to quit lines.Pictured here is Roosevelt – an African-American man who had a heart attack at age 45. I encourage you to listen to his story, and the other stories on the TIPS web site.
16 450,000 Fewer Smokers in NYC, 2002–2010While we know we have set ambitious goals, there is good evidence that the Million Hearts® goals are achievable. This slide shows one city’s dramatic drop in adult smokers using a multi-pronged, comprehensive tobacco effort, including tax increases, workplace policies, free patch programs, and media campaigns shown by the purple arrows.Before 2002 the prevalence of smoking was at 21% for a decade in New York City. By 2010, the prevalence fell by more than a third to 14%, which represents 450,000 fewer smokers in New York City.The rate for smokers under 18 parallels the adult curve.New York City Community Health Survey.
17 Keeping Us Healthy Changing the Environment : Sodium About 90% of Americans exceedrecommended daily sodium intakeIncrease consumer choice – make more lower sodium options availableImplement strategies to lower sodium content of meals and snacks (lower sodium products and recipe modifications)Food purchasing guidelines to increase access to lower sodium foodsIncrease public and professional education about the impact of excess sodiumMonitor sources of sodium, sodium intake and related health outcomesWith 90% of the US population consuming too much sodium, it’s clear that action needs to be taken to reduce sodium consumption. There are roles in sodium reduction for state and local governments; places that produce, sell, or serve food; and individuals.In order for us to reach the goal of 20% reduction in sodium, it is clear that we need to:Make more low-sodium options available to individuals,Speak clearly about the impact of excess sodium and and the health related outcomes so people will understand the relationship between sodium intake and cardiovascular disease riskMonitor and report on how much sodium is in the food supply and being consumedCDC. MMWR. 2011;60(36);1413–7.
18 U.S. Dietary Guidelines for Americans Recommendations for Sodium Intake Current average intake in adults is ~ 3,400mg/day2,300 mg/day for general population1,500 mg/day for specific populations≥ 51 yearsAfrican AmericansHigh blood pressureDiabetesChronic kidney diseaseUSDA and HHS. Dietary Guidelines for Americans, th edition. Washington, DC: Government Printing Office; 2010CDC. Usual Sodium Intakes Compared with Current Dietary Guidelines — United States, 2005–2008. MMWR 2011; 60(41);The 2010 Guidelines for Americans recommended less than 2300 mg per day for the general population and a further reduction to 1,500 mg/day for people ≥51 and older, African Americans, and those who have high blood pressure, diabetes, or chronic kidney disease—that is nearly half the U.S. population and the majority of adults.A CDC study found that, among persons aged 2 years and older with a 1,500 milligram (mg) daily sodium intake recom mendation, 98.6% consumed more than the recommended amount, including 99.4% of persons age 18 years and older. Among those who are recommended to consume less than 2,300 mg of sodium daily, 88.2% consumed in excess of the recommendation, including 95% of those age 18 years and older. (CDC. Usual Sodium Intakes Compared with Current Dietary Guidelines — United States, 2005–2008. MMWR 2011; 60(41); )~1/2 U.S. population andthe majority of adults
19 44% of U.S. Sodium Intake Comes from Ten Types of Foods RankFood Types%1Bread and rolls7.42Cold cuts and cured meats5.13Pizza4.94Poultry4.55Soups4.36Sandwiches4.07Cheese3.88Pasta mixed dishes3.39Meat mixed dishes3.210Savory snacks3.1More than 75% of the sodium in ourfood is already there and mostly invisible in processed and restaurant foods.In the US, the problem of excess sodium intake is related to our food supply. The majority of sodium consumed comes from packaged, processed, and restaurant foods and is in the product at the time of purchase.More than 75% of the sodium in our food is already there and mostly invisible in processed and restaurant foods. Only 12 percent is naturally occurring. And about 11% is added in cooking and at the table.44% of US sodium intake comes from just ten types of foods, excluding the salt added at the table. They are bread and rolls, cold cuts, pizza, fresh and processed poultry, soups, sandwiches, cheese, pasta mixed dishes, meat mixed dishes such as meatloaf with tomato sauce, and savory snacks such as chips and pretzels.Some contributors like bread and poultry may not taste salty but because we consume a lot of these food groups they add up to significant sources of sodium in our diets..CDC, MMWR;2012;61:92-98
20 Keeping Us Healthy Changing the Context: trans fat Eliminating artificial trans fat in the American diet could prevent 20,000 heart attacks, 7,000 deaths—every yearTrans fats are harmful, changing cholesterol patterns for the worse. The Centers for Disease Control and Prevention (CDC) estimates that eliminating artificial trans fat from processed foods could prevent 20,000 heart attacks and 7,000 heart-related deaths each year.In 2013 IOM recommended reducing trans fat intake as close to zero as possible.Also that year the FDA released a preliminary determination that use of partially hydrogenated oils, the primary source of artificial trans fat in foods is not generally recognized as safe. A final determination has not yet been made.A 2003 FDA ruling required the labeling of trans fats content was helpful in accelerating the reduction of trans fat. Shortly after this 2003 ruling the food industry voluntarily reformulated foods.We know that reducing artificial trans fats is feasible and can be done without changing the flavor or texture of food. Consumers can reduce their intake of trans fat by checking the Nutrition Facts label on food products for trans fat and by avoiding products that include partially hydrogenated oils. The federal government is monitoring trans fat levels in population.Citing new scientific evidence and findings from expert scientific panels, FDA takes first step to eliminate artificial trans fat from processed foods*Federal Register comment period ended Jan. 2014Dietz WH, Scanlon, KS Eliminating the Use of Partially Hydrogenated Oil in Food Production and Preparation. JAMA. 2012;308(2):*FDA. Tentative Determination Regarding Partially Hydrogenated Oils; Request for Comments and for Scientific Data and Information. Federal Register Volume 78, Issue 217 (November 8, 2013)
21 Pre-Initiative Estimate Targets for the ABCSInterventionPre-Initiative Estimate( )2017 Population-wide Goal2017 Clinical TargetAspirin when appropriate54%65%70%Blood pressure control53%Cholesterol management33%Smoking cessation22%What are our targets on the clinical side?This slide shows that we have a lot of room for improvement on the ABCS. For example, only half of people with hypertension have their blood pressure controlled. Only one-third of people with high cholesterol have it controlled and 22% of people who are trying to quit smoking get the help that they need.To achieve the goal of preventing one million heart attacks and strokes, Million Hearts set a 65% population-wide goal for each of the ABCS. These goals include people who do not have a usual source of care. To reach the 65% population-wide goal, it is important for clinical systems to reach a 70% target.National Ambulatory Medical Care Survey, National Health and Nutrition Examination Survey21
22 Increase in Percent of Patients with Controlled Hypertension Kaiser Permanente Northern California hypertension control rates*87%Hypertension control reports every 1-3 months and evidence-based hypertension control protocolWe know it is feasible for many health care systems to dramatically improve their HTN control rate. Hopefully you remember the slide earlier, that showed the declining smoking rates in NY City. Here is a comparable visual – looking at the clinical side – and showing how we can achieve increased blood pressure control rates.In 2000, Kaiser Permanente Northern California developed a large-scale program that improved blood pressure control from 44% in 2001 to 87% in They started with the development of a system-wide hypertension control registry.In 2001 they generated hypertension control reports every 1 to 3 months for quality improvement and performance measures and developed an evidence-based hypertension control protocolAnd in 2007 all Kaiser Permanente Northern California medical centers developed a medical assistant follow-up visit for follow-up measurement.There are numerous stories like this from the Million Hearts Hypertension Control Champions. With a focus on improving hypertension; using EHR’s and care protocols that allow everyone on the team to know how they can intervene; and frequent provider feedback we are seeing individual providers and large provider systems substantially improving their hypertension control – many to over 80% control.Percent of patients with controlled hypertension44%*NCQA: National Committee for Quality Assurance; HEDIS: Healthcare Effectiveness Data and Information Set; KPNC: Kaiser Permanente Northern CaliforniaSource: JaffeMG, et al. Improved blood pressure control associated with a large-scale hypertension program. JAMA August 21, 2013, Vol 310, No. 7
23 Clinical Quality Measures Clinical quality measures help measure and track performance in the ABCSMillion Hearts® focuses on:Simple, uniform set of measuresData collected or extracted in the workflow of careLink performance to incentivesIn the future public health and clinical quality data will be available via electronic medical records and Health Information ExchangesThe full deployment of meaningful EHR technology allows for use of clinical quality measures to track the quality of care delivered. Million Hearts® is acutely aware of the measurement burden being placed on clinicians at this time. As a result, Million Hearts has been working hard with numerous public and private partners to align the clinical quality measures used to assess the ABCS.Why Report on the Million Hearts® Clinical Quality Measures:Simplified, increasingly uniform set of measuresCollected and reported the same wayEmbedded in the flow of care to minimize burdenHigh performance linked to recognition and reward for clinicians, systems, and patientsAnd most importantly, these measures matter when it comes to preventing heart attack and strokeWhile clinical guidelines continue to evolve, Million Hearts® remains committed to providing leadership and coordination to maintain a small set of focused measures and assembly alignment across federal institutions.13
24 Clinical Quality Measures ABCSNumberMeasureAPQRS 204NQF 0068Ischemic Vascular Disease (IVD): Use of Aspirin or Another AntithromboticPercentage of patients aged 18 years and older with Ischemic Vascular Disease (IVD) with documented use of aspirin or other antithromboticBPQRS 317Preventive Care and Screening: Screening for High Blood PressurePercentage of patients aged 18 and older who are screened for high blood pressurePQRS 236 NQF 0018Hypertension: Controlling High Blood PressurePercentage of patients aged 18 through 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement yearC(EHR)PQRS 316Preventive Care and Screening: Cholesterol – Fasting Low Density Lipoprotein (LDL) Test Performed AND Risk-Stratified Fasting LDLPercentage of patients aged 20 through 79 years whose risk factors have been assessed and a fasting LDL test has been performed AND who had a fasting LDL test performed and whose risk-stratified fasting LDL is at or below the recommended LDL goalHere is a list of the Million Hearts® Clinical Quality Measures for reference.PQRS = CMS Physician Quality Reporting System, NQF = National Quality Forum, EHR = electronic health record
25 Clinical Quality Measures (cont’d) ABCSNumberMeasureC(No EHR)PQRS #2NQF #0064Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes MellitusPercentage of patients aged 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg/dL)PQRS #241NQF #0075PQRS Measure #241 (NQF 0075): Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low Density Lipoprotein (LDL-C) ControlPercentage of patients aged 18 years and older with Ischemic Vascular Disease (IVD) who received at least one lipid profile within 12 months and who had most recent LDL-C level in control (less than 100 mg/dL)SPQRS 226NQF 0028Preventive Care and Screening: Tobacco Use: Screening and Cessation InterventionPercentage of patients aged 18 years or older who were screened about tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco userPQRS = CMS Physician Quality Reporting System, NQF = National Quality Forum, EHR = electronic health record
26 Excelling in the ABCS Optimizing care: Health Info Technology Goal: Full deployment of health information technologyElectronic Health Records (EHRs)Patient registriesClinical decision support toolsE-prescribingMedication adherence and other patient remindersPatient portalsMillion Hearts® encourages the full deployment of EHR technology that includes population health management tools like patient registries, guidelines-based clinical decision supports, and patient reminders.These can be a powerful tools for proactively managing populations of patients and identifying quality improvement opportunities throughout the care continuum.Patient portals can be useful for helping patients manage their health information and facilitate remote patient-clinician interactions such as patients uploading home blood pressure readings and clinicians providing feedback on needed medication titrations or lifestyle changes.NOTE TO SPEAKER: This glossary is not part of slide talking points but is made available as a reference for speakers as needed.An Electronic Health Record (EHRs) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. [From HIMMS]A patient registry is an electronic or manual system which compiles and manages information on identified subsets of a practice’s patient population, which share relevant characteristics. Ideally, a patient registry: tracks patient appointments; classifies patients according to severity of disease; generates reminders for patients and/or physicians and office staff to perform certain tasks; and identifies opportunities for possible quality improvement.[From AMA]Clinical decision support (CDS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools. [from HealthIT.gov]E-Prescribing is a prescriber's ability to electronically send an accurate, error-free and understandable prescription directly to a pharmacy from the point-of-care. [from CMS]A patient portal is a secure online website that gives patients convenient 24-hour access to personal health information from anywhere with an Internet connection. [from HealthIT.gov]
27 Excelling in the ABCS Optimizing care: Care Innovations Team-based careUtilizing full scope of practiceCollaborative Drug Therapy ManagementSelf-measured BP monitoring with clinical supportPayment for improved health outcomes from innovative models of careTeam-based care models use all clinicians working at the top of their license, including nurses, pharmacists, nurse practitioners, and physician assistants, in order to reach the populations at risk and support healthy behaviors like medication adherence and self- monitoring.New payment models can encourage use of care innovations such as remote treatment and counseling. This kind of payment reform can specifically support interventions aimed at improving the ABCS. For example, home blood pressure monitoring has been shown to effectively control blood pressure when combined with clinical feedback that is delivered outside of an office visit by phone, , or internet.
28 Million Hearts in Action: Maryland Million Hearts Implementation Plan bringing all stakeholders to a common table to:Improve clinical careStrengthen tobacco controlPromote a healthy dietEncourage workplace wellnessIncentivizing local public health actionData-driven approach with Maryland’s StateStatMaryland was one of the first states to take up the Million Hearts banner and develop their own state specific implementation plan.Some specific efforts they have taken in hypertension control include establishment of a patient recall for patients with elevated blood pressure but no diagnosis and public reporting of a pharmacy supported worksite hypertension program.
29 YOU CAN PREVENT HEART ATTACKS AND STROKES BY…. Being able to meet the audacious goal of preventing 1million heart attacks and strokes takes the concerted effort of many public and private partners across the country.The next series of slides outline action steps for a variety of sectors and stakeholders.YOU CAN PREVENT HEART ATTACKS AND STROKES BY….
30 Action Steps: State and Local Governments Achieving Excellence In The ABCS Convene and collaborate with stakeholders across public health and healthcare in order to enhance effectiveness and efficiency of efforts to prevent heart attack and strokeIncrease awareness of preventability of heart disease and stroke and their risk factorsAdopt and report on the Million Hearts® Clinical Quality MeasuresIncrease efforts to reduce sodium and eliminate trans fats in the food supplyPromote smoke-free air policies, effective tobacco package labeling, restricted tobacco advertising, and higher tobacco prices to help smokers quit and keep nonsmokers tobacco-free.State and local governments role in engaging government, health care providers, consumers, and other groups is vital to the success of Million Hearts®.Governments have the ability to convene state and local stakeholders from a variety of sectors such as Quality Improvement Organizations, health systems and employer organizations to develop a well-rounded and comprehensive approach to heart disease and stroke prevention. They can also influence change in the community by adopting strategies that reduce sodium and increase smoke-free air policies.State and local public health departments are well situated to empower citizens to take control of their heart health through education, wellness, and recognition programs.
31 Action Steps: Healthcare Systems Achieving Excellence in the ABCS Adopt and report on the Million Hearts® Clinical Quality MeasuresProvide timely feedback on performance to the clinical teamsRecognize and reward high performing teamsImplement systems to alert clinicians of patterns of high blood pressure, high cholesterol, and smoking status of patients.Support titration of hypertension and cholesterol medications by clinical team members via a physician-approved protocolHealthcare systems have the ability to make widespread improvements in health by implementing a systems approach to health care delivery.For example, healthcare systems that use health information technology to adopt and report on the Million Hearts® Clinical Quality Measures and to implement evidence-based treatment protocols will find it easier to identify and monitor patients cardiovascular health. This kind of system change will help track the quality of care delivered.
32 Action Steps: Clinicians Achieving Excellence in the ABCS Use registries to identify and proactively target patients with gaps in control of the ABCSAdopt a standardized treatment approach for the ABCS; protocols and algorithms can help the team help patientsTrain patients to use validated home blood pressure monitors and incorporate readings into decision-making.Assess all patients for tobacco use; provide medications, counseling, and encouragement to use quit linesAdvocate the use medication reminders like pill boxes, alarms, vibrating watches, and smart phone applicationsClinicians play a key role in helping patients achieve excellence in the ABCS and reducing their risk for heart disease and stroke by focusing their interactions to assure preventing heart attacks and strokes never takes a back seat.Some of the important actions steps for clinicians include:Using protocols and HIT to support clinical interactions and engaging entire teams in these efforts.Training patients on the use of validated home blood pressure monitors and incorporating readings into electronic health records to help track blood pressure control is found to be a effective strategy to improve blood pressure control.Making sure to assess patients and even an entire patient registry to assure clinicians are aware of all those that smoke, have hypertension, or have a history of cardiovascular disease.
33 Action Steps: Payers Achieving Excellence in the ABCS Place blood pressure medications and statins in a no- or low co- pay tierAnalyze pharmacy claims data to identify non-adherent beneficiaries with hypertension; follow-up with reminders to improve adherenceProvide coverage of validated home blood pressure monitorsProvide coverage with no or low out-of-pocket costs for FDA- approved prescription tobacco cessation medications and over- the-counter nicotine replacement productsSupport team-based models that promote patient self-monitoring of blood pressure and medication adherenceHealth insurance companies may be the sector best equipped to measure and incentivize performance on the ABCS, and to collect and share data for quality improvement.Offering no copays for blood pressure medications can support behavior change among patients at risk for heart attack and stroke.Payers can also play a significant role in increasing blood pressure monitoring and control by offering coverage for self-measured home blood pressure monitors
34 Action Steps: Pharmacists/Pharmacies Achieving Excellence In The ABCS Develop policies and systems to allow for 90-day prescription refillsProvide medication therapy management (MTM) that supports the ABCSTrack prescription refills and alert prescribers when necessaryAs state laws permit, implement collaborative drug therapy management agreements with cliniciansEncourage policies that expand the use of generic medications when clinically appropriate.Provide blood pressure screening with clinician referrals for follow upSell validated home blood pressure monitorsPharmacists play an important role in promoting team-based care. Patients often engage with pharmacists more frequently than clinicians. This gives pharmacists the unique ability to closely monitor medication refill patterns and blood pressure levels of patients and share information with clinicians to improve the ABCS.Million Hearts® encourages pharmacists to improve medication adherence by tracking and monitoring patient prescription refills, providing medication therapy management, and referring patients to clinicians for follow up.
35 Action Steps: Employers Achieving Excellence In The ABCS Provide health insurance coverage with no or low out-of-pocket costs forhypertension or cholesterol medicationshome blood pressure monitoring devices with clinical supportprescription tobacco cessation medications and FDA- approved over- the-counter nicotine replacement productsProvide one-on-one or group lifestyle counseling and follow-up monitoring for employees with high blood pressure or prehypertension, or high cholesterolHave a written policy banning tobacco use at worksitesMake most of food and beverage choices available in vending machines, cafeterias, snack bars, or other purchase points be healthier food items.To curb rising health care costs, many employers can turn to their workplace health programs to make changes in the worksite environment, help employees adopt healthier lifestyles and, in the process, reduce their risk for heart disease and stroke.For example, they can provide health insurance coverage for home blood pressure monitoring devices and for blood pressure control, cholesterol control and smoking cession medications.Employers can also provide healthier food and beverage choices.
36 100 Congregations for Million Hearts ® Action Steps: Faith Based Organizations Achieving Excellence In The ABCS100 Congregations for Million Hearts ®Designate a Million Hearts® Advocate among membership to serve as a resource for heart health information.Focus on two or more of these action steps for the next year and share progress:Deliver pulpit and other leadership messagesDistribute wallet cards and journals for recording blood pressure readingsFacilitate connections with local health professionals and community resourcesFaith-based organizations can also support Million Hearts® as part of the 100 Congregations for Million Hearts®, a program designed to help members of faith based organizations toward a heart-healthy lifestyle.As part of this program, Million Hearts® asks that congregations designate a Million Hearts® advocate from their membership to serve as a resource for heart health information.Congregations are also being asked to focus on two or more of these action steps for the next year and share progress.
37 Public Partners Centers for Disease Control and Prevention (co-lead) Centers for Medicare & Medicaid Services (co-lead)Administration for Children and FamiliesAdministration for Community LivingAgency for Healthcare Research and QualityEnvironmental Protection AgencyFood and Drug AdministrationHealth Resources and Services AdministrationIndian Health ServiceNational Heart, Lung, Blood InstituteNational Institute of Neurological Disorders and StrokeOffices of Minority HealthOffice of the National Coordinator for Health Information TechnologyOffice of Personnel ManagementSubstance Abuse and Mental Health Services AdministrationU.S. Department of Veteran’s AffairsState and Local governmentsMillion Hearts is supported across the U.S. Department of Health and Human Services with all of the agencies lending their support to the initiative. This engagement is real and dynamic as evidenced by coordination of staff, funding, and activities focused on the ABCS. Additionally, other federal agencies outside of HHS, like the VA, are also engaged.State and local government partners across the country have also made strong commitments to support Million Hearts.
38 Private Support Heath care systems Clinicians Professional organizationsFaith-based organizationsCommercial payersPharmaciesEmployersHealth advocacy groupsMillion Hearts® is delighted to have numerous private partners supporting the initiative.Organizations interested in being recognized as Million Hearts® partners can make formal commitments to the initiative. For more information, and to see a full list of organizations who have made specific commitments, visit the Partner page on the Million Hearts® website.
39 Million Hearts has a wide variety of resources for different type of audiences - Spanish, Faith-based, clinician community;All available materials can be found on the Million Hearts website under the resources link.TOOLS & RESOURCES
40 Million Hearts® Resources Hypertension Treatment ProtocolsHypertension Control: Action Steps for CliniciansHypertension Control ChampionsSelf-Measured Blood Pressure Monitoring GuideGrand Rounds:Million Hearts® Grand RoundsHypertension Grand Rounds: Detect, Connect, and ControlCardiovascular Health: Action Steps for EmployersMillion Hearts® E-updateSpanish language website100 Congregations for Million Hearts®Team up. Pressure down. programVisit to find other useful Million Hearts® resources.Here is a list of some of the Million Hearts® resources.
41 ReferencesParekh A, Galloway J, Hong Y, Wright J. Aspirin in Secondary Prevention of Cardiovascular Disease. NEJM. 2013; 368; 3.Wright JS, Wall HK, Briss PA, Schooley M. Million Hearts – Where Population Health and Clinical Practice Intersect. Circ Cardiovasc Qual Outcomes. 2012;5:Holmes DR. Zeroes, San Jose, Phoenix, Dallas, San Diego. J Am Coll Cardiol. 2012;59(1):88-89.Frieden TR, Berwick DM. The “Million Hearts” Initiative – Preventing Heart Attacks and Strokes. NEJM. 2011;365:e27.Tomaselli GF, Harty MB, Horton K, Schoeberl M. The American Heart Association and the Million Hearts Initiative : A Presidential Advisory From the American Heart Association. Circulation. 2011;124:1-5.Valderrama AL, Loustalot F, Gillespie G, George MG, Schooley M, Briss P, Dube S, Jamal A, Yoon PW. Million Hearts: Strategies to Reduce the Prevalence of Leading Cardiovascular Disease Risk Factors --- United States, MMWR ;60(36);
42 Thank You! Thank you for listening to me today. Earlier in the talk, I mentioned the former smoker named Roosevelt, and encouraged you to hear his story. We were very glad to have captured his advice. He has since died. Unfortunately there are way too many Roosevelts, way to many people that are needlessly suffering heart attacks, strokes and premature death. Please join our efforts to prevent a million heart attacks and strokes. Our goal is achievable only with the collective efforts of each of us as individuals and as members and leaders of our communities, workplaces, and organizations.Does anybody have any questions?Thank You!