Million Hearts

Changing the Heart Health of the Nation

National Forum for Heart Disease and Stroke Prevention
Washington, DC
October 17, 2012

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"The National Forum for Heart Disease and
Stroke Prevention is a catalyst to drive multi-
sector action to prevent heart disease & stroke
Keith C. Ferdinand, M.D., FACC, FAHA
 Million Hearts

Goal: Prevent 1 million heart attacks

and strokes in 5 years

National initiative co-led by CDC and CMS

Partners across federal and state agencies and
private organizations

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 Heart Disease and Stroke
Leading Killers in the United States
Cause 1 of every 3 deaths
More than 2 million heart attacks and strokes each year
800,000 deaths
Leading cause of preventable death in people <65
$444B in health care costs and lost productivity
Treatment costs are ~$1 for every $6 spent
Greatest contributor to racial
disparities in life expectancy

Roger VL, et al. Circulation. 2012;125:e2-e220.

Heidenriech PA, et al. Circulation. 2011;123:9334.
 Status of the ABCS
People at increased risk
Aspirin of cardiovascular events 47%
who are taking aspirin

People with hypertension

B lood pressure who have adequately controlled 46%
blood pressure

People with high cholesterol

Cholesterol who are effectively managed 33%
People trying to quit smoking
Smoking who get help
23%

CDC. MMWR. 2011;60(36);124851.

 Key Components of Million Hearts
CLINICAL COMMUNITY
PREVENTION PREVENTION
Optimizing care Changing the context

Focus on
ABCS

Health
information
technology

Clinical TRANS
innovations FAT
 Community Prevention
Changing the Context: Tobacco

Comprehensive tobacco control programs work

Graphic mass media campaign
Smoke-free public places and workplace policies
Free or low-cost counseling and medications
 Raising the Price of Cigarettes
Through Excise Taxes Total = $6.86

Total = $5.26
Total = $4.64

Total = $3.39

Total = $1.58
 Decline in Smoking in New York City, 20022010
450,000 Fewer Smokers
NYC & NYS
tax increases

Smoke-free
workplaces
Free patch
programs Hard-hitting
start media
3-yr average 3-yr average 3-yr average campaigns
Adults (%)

NYS
tax Federal
increase tax
increase
NYS
tax
increase

New York City Community Health Survey.

 Community Prevention
Changing the Context: Sodium
About 90% of Americans exceed
recommended daily sodium intake

Menu labeling requirements in chain restaurants

Food purchasing policies to increase access to
low sodium foods
Public and professional education about the
impact of excess sodium
Publishing information on sodium consumption
CDC. MMWR. 2011;60(36);14137.
 Most Sodium Comes from Processed
and Restaurant Foods

Realistically, Processed
people cant and
control how restaurant
much sodium foods
they eat
77%

Mattes RD, et al. J Am Coll Nutr. 1991;10:38393.

Fast Foods in the U.S. Are Saltier
Than in Other Countries

Dunford E, et al. CMAJ. 2012;184:10238.

 44% of U.S. Sodium Intake
Comes from 10 Types of Foods
Rank Food Types %
1 Bread and rolls 7.4
2 Cold cuts and cured meats 5.1
3 Pizza 4.9
4 Poultry 4.5
5 Soups 4.3
6 Sandwiches 4.0
7 Cheese 3.8
8 Pasta mixed dishes 3.3
9 Meat mixed dishes 3.2
10 Savory snacks 3.1

CDC. MMWR. 2012;61(Early Release):1-7.

 Community Prevention
State Trans Fat Regulations
As of January 2012
WA

ME

OR NY VT
NH
CT
MA
MI RI

NJ
MD
OH DE
CA IL

KY

TN

SC
NM

TX MS

HI
Enacted or passed trans fat regulation in
food service establishments (FSEs)
Trans fat regulation in FSEs introduced,
defeated, or stalled
 Clinical Prevention
Optimizing Quality, Access, and Outcomes

Focus on the ABCS

Simple, uniform set of measures
Measures with a lifelong impact
Data collected or extracted in the workflow of care
Link performance to incentives
 Clinical Prevention
Optimizing Quality, Access, and Outcomes

Fully deploy health information technology (HIT)

Registries for population management
Point-of-care tools for assessment of risk for CVD
Timely and smart clinical decision support
Reminders and other health-reinforcing messages

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 Clinical Prevention
Optimizing Quality, Access, and Outcomes

Innovate care delivery

Embed ABCS and incentives in new models
Health homes, Accountable Care Organizations, bundled
payments
Interventions that lead to healthy behaviors
Mobilize a full complement of effective team members
Pharmacists, cardiac rehabilitation teams
Health coaches, lay workers, peer wellness specialists

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 CMS Programs Supporting Million Hearts
Office of Clinical Standards and Quality
Physician Quality Reporting System
Medicare and Medicaid Electronic Health Record Incentive Program
(Meaningful Use) as drivers of core quality measures

Medicare Advantage Plan Star Ratings and Quality Bonuses

Medicare Part D Plan Star Ratings

Quality Improvement Organizations (QIO)

Part D Medication Therapy Management

Annual Wellness Visit, Health Risk Assessment, and Personalized Preventive Plan
Services

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 CMS Programs Supporting Million Hearts

Center for Medicaid, Childrens Health Insurance

Program, and Survey and Certification
Medicaid Core Quality Reporting Measures
Medicaid Electronic Health Records Incentive Program
Medicaid Incentives to Prevent Chronic Disease
Medicaid Smoking Cessation Services
Medicaid Health Homes

Center for Consumer Information and Insurance

Oversight
ABCS in Essential Health Benefits

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 CMS Programs Supporting Million Hearts

Center for Medicare and Medicaid Innovation

Test of Innovation: Promoting Adherence to Cardiovascular Medicine

Demonstration of Scale: ABCS Improvement quarter to quarter

Innovation Advisors Program Call for Advisors Tailored to ABCS and

Allied/Team-Based Care

Health Care Innovation Challenge

Medicare-Medicaid Coordinating Office

Targeted State Demonstrations and Innovations

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 Public-Sector Support
Administration on Community Living
Agency for Healthcare Research and Quality
Centers for Disease Control and Prevention
Centers for Medicare and Medicaid Services
Food and Drug Administration
Health Resources and Services Administration
Indian Health Service
National Heart, Lung, and Blood Institute,
National Institutes of Health
National Prevention Strategy
National Quality Strategy
Office of the Assistant Secretary for Health
Substance Abuse and Mental Health Services
Administration
U.S. Department of Veterans Affairs
 Private-Sector Support
Academy of Nutrition and Dietetics
Alliance for Patient Medication Safety
Americas Health Insurance Plans
American Academy of Nurse Practitioners
American College of Cardiology
American Heart Association
American Medical Association
American Nurses Association
American Pharmacists Association and
Foundation
Association of Black Cardiologists
Association of Public Health Nurses
Georgetown University School of Medicine
Kaiser Permanente
Medstar Health System
National Alliance of State Pharmacy Assns
National Committee for Quality Assurance
National Community Pharmacists Assn
National Consumers League
National Forum for Heart Disease and
Stroke Prevention
Ohio State University
Preventive Cardiovascular Nurses
Association
Samford McWhorter School of Pharmacy
SUPERVALU
UnitedHealthcare
University of Maryland School of Pharmacy
Walgreens
WomenHeart
YMCA of America
Maryland Dept of Health and Mental Hygiene
New York State Dept of Health
Commonwealth of Virginia
 A Network of Networks
RHA

RHA
RHA Puerto Rico
RHA
RHA
RHA RHA
RHA

U.S. Virgin Islands

RHA
RHA

State Node
Regional Health
RHA Administrator
 Getting to Goal
Clinical
Intervention Baseline Target target

Aspirin for those at high 47% 65% 70%

risk
Blood pressure control 46% 65% 70%

Cholesterol management 33% 65% 70%

Smoking cessation 23% 65% 70%

Sodium reduction ~ 3.5 g/day 20% reduction

Trans fat reduction ~ 1% of calories 50% reduction

Unpublished estimates from Prevention Impacts Simulation Model (PRISM).

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Prevalence of Hypertension Control among
U.S. Adults with Hypertension

67 million adults with hypertension (30.4%)

(35.8M)

CDC. MMWR. 2012;61(35):7039.

Awareness and Treatment among Adults
with Uncontrolled Hypertension

M
M

CDC. MMWR. 2012;61(35):7039.

Prevalence of Uncontrolled Hypertension,
by Selected Characteristics

Yes No Yes No None 1 2

Usual source of care Health insurance No. times received
care in past year
CDC. MMWR. 2012;61(35):7039.
 It Doesnt Take Much to Have a BIG Impact
Small Reductions in Systolic BP Can Save Many Lives

Whelton, PK, et al. JAMA. 2002;288:1882; Stamler R, et al, Hypertension. 1991:17:I16.

All-Cause Hospitalization Risk Declines as
Adherence Increases

Sokol MC, et al. Med Care. 2005;43(6):52130.

Total All-Cause Health Care Costs Decrease as
Medication Adherence Increases, Even with the
Increase in Drug Costs

Sokol MC, et al. Med Care. 2005;43(6):52130.

 The BP Control Battle Plan

Improve the identification of people with HTN who

are not yet diagnosed
Increase the proportion of people with HTN who are
under control
Enhance individuals ability to prevent & control
HTN
Increase measurement and reporting on HTN by
healthcare systems, professionals, communities,
states, and others
Decrease the sodium intake of the population
 BP Control Attack Plan

Identify the undiagnosed

Move the treated to controlled
Coach self-management
Drive measurement and reporting
Educate and activate about high Na intake
 BP Control Attack Plan

Identify the undiagnosed 14 Million

Move the treated to controlled
Coach self-management
Drive measurement and reporting
Educate and activate about high Na intake
 BP Control Attack Plan

Identify the undiagnosed 14 Million

Move the treated to controlled 16 Million
Coach self-management
Drive measurement and reporting
Educate and activate about high Na intake
 BP Control Attack Plan

Identify the undiagnosed 14 Million

Move the treated to controlled 16 Million
Coach self-management 67 Million
Drive measurement and reporting 67 Million
Educate and activate about high Na intake 67M
Million Hearts Team Up. Pressure Down.
Tools
2012 Million Hearts BP Control Champions
Kaiser Permanente Colorado and Ellsworth Medical Clinic
 2012 ICVH Driver Diagram
KP Colorado Integrated Prevention & Cardiovascular Health Driver Strategy 2012

ICVH DRIVER DIAGRAM(Prevent 1 KPCO Million Hearts Campaign

Million MIs and strokes over next 5 years)
Value:
PM/PM
Avoidance:
Population Major Coronary Events (MCE) Hospital procedures
Stratification Major Cardiovascular Events-Stroke/Stoke Events (MCVE) Hospital costs
Screening, Risk Assessment & Stratification

MIs & Procedures/Surgeries for CAD/STROKES

CAD Rates per 100,000 members age & gender adjusted

CAD
Equivalents:
DM PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY PREVENTION
PAD
CKD Test the Untested Treat the Un-Under treated Treat the Un-Under treated
Stroke/TIA
AAA
PEDIATRIC CV RISK Planned
Framingham: Diabetes
Care
High >20% Acute
Mod 11-20% CV PREVENTION Coronary
Low 5-10% HTN Cardiology Syndrome
Very low <5% Mgt
PRE- DM
Unknown risk:
Age-
70-80
TOBACCO CPCRS
55-69
40-54
18-39
EXERCISE - VITAL SIGN
Engaged Member Coronary
Artery
Disease

Children at PRIMARY CARE CPS

risk
Recurrent
ADULT LIFESTYLE Events
MCVE
EMPLOYEE HEALTH
& WELLNESS

PREVENTION CARE CONTINUUM

POPULATION AND PREVENTION SERVICES (CARE COORDINATORS, CPCRS, DISEASE MANAGEMENT TEAMS)
Evidence Based Treatment Strategies with Engaged Integrated Teams
Self
Self Mgt
Management
& Shared
Smoking Cessation TLC-Diet Phys Activity Chol Mgt BP Control Glucose Depression hsCRP Statins Creat Beta Blocker ACE/ARB ASA
Decision
Education
Making
Healthy Communities
Healthy Schools Live Well Heart & Stroke Healthy Communities Community Benefit 3.8.12
Ellsworth Team Million Hearts
Million Hearts Will Mean
 Needs and Seeds
Prevention, Detection, Treatment, Control
Awareness of performance gaps and actions
Skills to measure, analyze, improve
A blanket of BP monitors
Standardized protocol or algorithm
Timely, low-cost loop of measurement and advice
Effective team care models
Access and persistence to meds
Business case
 The Future State
Adding web-based pharmacist care
to home blood pressure monitoring
increases control by >50%

Lower sodium foods are abundant and inexpensive

BP monitoring starts at home and ends with control
Data flows seamlessly between settings
Professional advice when, where, how, and
from whom it is most effective
No or low co-pays for medications
High performance on BP control is rewarded

Green BB, et al. JAMA .2008;299:285767.

 Resources

Vital Signs: Wheres the Sodium?

www.cdc.gov/VitalSigns/Sodium/index.html
Vital Signs: Getting Blood Pressure Under Control
www.cdc.gov/vitalsigns/Hypertension/index.html
Team Up. Pressure Down.
http://millionhearts.hhs.gov/resources/teamuppressuredown.html
Community Guide: Team-Based Care
www.thecommunityguide.org/cvd/teambasedcare.html
SDOH Workbook: Promoting Health Equity, a Resource to Help Communities Address
Social Determinants of Health
www.cdc.gov/nccdphp/dach/chhep/pdf/SDOHworkbook.pdf
Program Guide for Public Health: Partnering with Pharmacists in the Prevention and
Control of Chronic Diseases
www.cdc.gov/dhdsp/programs/nhdsp_program/docs/
Pharmacist_Guide.pdf
Data Trends & Maps
http://apps.nccd.cdc.gov/NCVDSS_DTM
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