While heart disease is the No. 1 killer for Americans, with nearly half having at least one of the top three risk factors—high blood pressure, high cholesterol or a smoking habit—many people are not getting the latest in evidence-based care for heart disease. A research initiative at the University of North Carolina at Chapel Hill is trying to change that.
Heart Health NOW! Advancing Heart Health in NC Primary Care equips providers throughout North Carolina with the tools they need to minimize heart disease in their patients and communities. The Agency for Healthcare Research and Quality (AHRQ) funded the research as part of the national EvidenceNOW initiative.
“AHRQ funded this study to show that primary care practices, especially small practices that don’t have support from larger health systems, would be really good at improving patient care if they had the right data and support,” says Samuel Cykert, MD, professor of medicine in UNC’s Division of General Internal Medicine and Clinical Epidemiology. As the principal investigator of Heart Health NOW!, Dr. Cykert says the study focuses on changes in health care related to payment system reform, value-based care and efforts to target the best care to a large population of patients.
“The old paradigm was that a doctor would take care of whatever patient showed up and do the best he or she could with that patient at that time,” he says. “The new paradigm is that you have a whole panel, a whole population of patients, and you not only have to pay attention to the data on the patients who are in front of you, but you also have to find ways to engage patients who aren’t doing well and who aren’t necessarily in front of you right now.”
Supporting Providers
Started in May 2015, the three-year project is working with 222 small practices across North Carolina. These practices all have 10 or fewer providers and are not receiving support from larger health systems. Dr. Cykert says about half of the practices are also in the “stroke belt,” or the swath of the U.S. where the rate of cardiovascular disease and stroke risk is higher than the national average.
Heart Health NOW! helps set up systems at participating practices to identify data needed to minimize heart disease risk in those communities.
“We built a data system where we get information from a practice’s electronic health records and risk-stratify every adult patient between the ages of 40 and 79,” Dr. Cykert says.
As a result, each person is assigned an atherosclerotic cardiovascular disease (ASCVD) risk score, which estimates the risk of a cardiovascular incident and the potential effects of varying treatments. “Then, we listed the things they could do to reduce their patients’ risk so they had that information available,” he says.
Those options include:
- Prescribing statin medications for people with a cardiovascular risk of 10 percent or higher, which will reduce risk by 25 percent.
- Encouraging people to quit smoking. “By doing that, you can reduce the risk by 15 percent within one year of stopping smoking and by 50 percent after four years,” Dr. Cykert says.
- Keeping blood pressure under control, which can reduce risk by 25 percent.
- Suggesting aspirin. “If your risk is greater than 10 percent, taking one aspirin a day can reduce the risk by 10 percent,” Dr. Cykert says.
Providers can also encourage their patients to make lifestyle changes such as improving their diets and following prescribed medication regimens at home.
Simultaneously, Heart Health NOW! deploys quality improvement coaches from the North Carolina Area Health Education Centers Program to practices across the state. The program, called Practice Support, brings coaches on-site to teach providers how to use tools and systems to implement recommendations for improving the heart health of their patients.
“With these quality improvement techniques, you take the data and figure out: Well, only 60 percent of my patients have their blood pressure controlled. So I want to use my electronic health records to identify the 40 percent who aren’t under control and whether or not they’ve been in the practice over the last six months,” Dr. Cykert says. “Then I create a list and decide, ‘How am I going to bring these people in, and how can I bring their blood pressure down more quickly?’”
The result is the establishment of protocols needed to support value-based care.
“It’s a combination of ‘I can measure how we’re doing,’ ‘I can identify the people who are doing poorly,’ then, with the help of a coach, because they don’t teach this in medical school, ‘I can design a system to bring in those patients who are doing poorly and work with them more closely to stop cardiovascular disease,’” Dr. Cykert says.
For doctors like James Early, MD, who runs East Asheville Family Health Care in Asheville, North Carolina, the system has helped him to do more than 500 face-to-face risk calculations.
“Some doctors see Heart Health NOW! just as one more thing to do, but I see it differently,” he says. “Yes, it is one more thing to do, but it puts all the information together for the patient and makes it more meaningful to them.”
Analyzing the Data
Although the physician intervention phase of Heart Health NOW! will end April 30, the project received a one-year, no-cost extension to look deeper into the data and its effects on the health of North Carolinians.
“One thing we look at is each patient’s baseline cardiovascular risk and how the overall cardiovascular risk in the practice changed over time,” Dr. Cykert says. That change is measured through the success of the risk-reducing options and self-management systems encouraged in the program.
While the data are still being monitored, both Dr. Cykert and Dr. Early think the initiatives in Heart Health NOW! could leave a lasting impact on not only smaller communities but also North Carolina as a whole.
“This is a great example of a population health study that truly impacts primary care,” Dr. Early says. “Eventually, what we’re looking at is being able to calculate how many cardiac and stroke events Heart Health NOW! has prevented. It’s a great way to really put prevention into practice.”
Dr. Cykert agrees, saying that reducing cardiovascular risk has huge public health implications. “On average, about 50 percent of patients with hypertension in North Carolina have their blood pressure controlled,” he says. “If we bump that number to 70 percent, that would literally save 5,000 lives a year.”
In fact, those kinds of results are already occurring.
For example, the recommendation to treat people for heart disease based on cholesterol level was published in 2013 by the American College of Cardiology and the American Heart Association. In 2015, when the Heart Health NOW! study began, less than a third of people with high risk were using a statin medication. But “within nine months of providing risk scores to practices, teaching them about these guidelines and then building systems through the coaches, that number went up to over 40 percent,” Dr. Cykert says. “Within only nine months, we saw a marked improvement in the adoption of this guideline, which is very important in helping prevent heart attacks and strokes.”
In Asheville, Dr. Early sees this change happening, too. “The population benefits from primary prevention. I think we’re making an impact and keeping people healthy,” he says. “That’s why I enjoy doing it; it really gets to the heart of primary care medicine.”
Learn more about the Heart Health NOW! initiative.