The past decade has seen impressive advances in cardiovascular (CV) care and reductions in patient mortality from CV disease (CVD). Between 1997 and 2007 (the year for which most recent final data are available), the death rate from CVD declined by 27.8 %. The actual number of CVD deaths per year declined by 14.2 % over this period. Meanwhile, the death rate for stroke fell by 44.8 % in the same decade-long period.1
Despite these impressive gains, there is still considerable room for further improvements in CV care. The same article that reported the past decade’s reduction in CV mortality contained the following sobering facts:
- Blood pressure control remains elusive for many hypertensive people: 33.5 % of adults who are 20 years or older in the US have high blood pressure; 80 % are aware of their condition but less than half have their condition under control.1
- Decades of public health campaigns have produced considerable successes, but tobacco-use rates could be reduced still further: 23.1 % of men and 18.1 % of women are cigarette-smokers. More alarmingly, 19.5 % of students in grades 9–12 report current tobacco use.1
- A significant minority of US adults have high cholesterol: 15 % of people who are 20 years or older have total serum cholesterol levels of 240 mg/dl or higher.1
- Diabetes, a key risk factor, already afflicts many people, and there is the potential for this population to grow significantly: 8 % of adults have been diagnosed with diabetes mellitus; 36.8 % of adults are pre-diabetic.1
- Lastly, more than 67 % of adults in the US are overweight.1
Despite a decade of reduction in CV death rates, the economic impact of CVD in the US is staggering. One credible estimate of the total cost of heart disease and stroke in the US in 2007 (including health expenditures and lost productivity) was $286 billion, a higher toll than for any other diagnostic group.1 Another estimate put medical costs and productivity losses as high as $450 billion annually.2 Current projections are grim, with direct medical costs from major cardiac events set to multiply in the coming 20 years.1–3 Faced with an aging population, the US can and must address the clinical, the economic, and, most importantly, the human costs exacted by preventable major cardiac events.
A new response is now taking shape. In September 2011, the US Secretary of Health and Human Services Kathleen Sebelius announced the creation of the ‘Million Hearts’ initiative. The overall goal of the Million Hearts initiative is to prevent a million cardiovascular events across the next five years. Over two million Americans have a heart attack or stroke each year. Evenly distributed across five years, the Million Hearts initiative is aiming to reduce the current annual heart attack and stroke total by 10 % (200,000 events per year). Million Hearts will pursue this heart attack- and stroke-prevention goal through a focus on the four ABCS indicators: aspirin for people at risk, blood pressure control, cholesterol management, and smoking cessation. In an article accompanying the Million Hearts initiative’s launch, Thomas Frieden, Director of the Centers for Disease Control (CDC) and Donald Berwick, who was then the Administrator of the Centers for Medicare and Medicaid Services (CMS), cited research indicating that:
“Improving management of the ABCS can prevent more deaths than other clinical preventive services. Patients reduce their risk of heart attack or stroke by taking aspirin as appropriate. Treating high blood pressure and high cholesterol substantially and quickly reduces mortality among high-risk patients. Even brief smoking-cessation advice from clinicians doubles the likelihood of a successful quit attempt, and the use of medications increases quit rates further.”2
American College of Cardiology’s Commitment to Million Hearts
The American College of Cardiology (ACC) has long supported the goals articulated in Million Hearts. The ACC is a 39,000-member, nonprofit medical society comprising physicians, surgeons, nurses, and other cardiovascular clinicians. The ACC and its members have been working for more than 60 years to improve the quality of care provided to patients suffering from CVD and to reduce the incidence of CVD in the US. The goals of the Million Hearts initiative align perfectly with those of the College, and as such, we are enthusiastic supporters of this new initiative. Frieden and Berwick observed that “clinical and community interventions each contributed about equally to the 50% reduction in U.S. mortality due to heart attacks between 1980 and 2000.”2,4 The ACC is well-positioned to contribute to both types of intervention, although our strong suit will remain clinical interventions. In this article, we detail how the ACC will deploy three distinct assets in partnership with Million Hearts. We will:
- increase awareness among our 39,000 members by regularly communicating with them via our various communication channels;
- drive clinical quality improvement using our clinical registries; and
- engage patients with relevant, patient-centered offerings and information.
Reading through the clinical items that make up ABCS, it should be clear that the initial statistics listed above were not chosen at random. Perhaps these statistics may now even seem a bit less grim. Clearly, there is opportunity to improve performance in the four ABCS indicators, which would contribute to preventing a million major cardiovascular events. This can be seen as an encouraging re-framing, connecting a quantitative improvement in core performance measures with a direct impact on patients’ lives.
ABCS progress, in turn, will be assessed using Physician Quality Reporting System (PQRS) measures. PQRS is an individual provider-level quality-reporting program operated by the CMS. These measures, already being used to incentivize providers for reporting quality performance to the CMS, should prove to be a simple and consistent way of measuring the management of ABCS.2 Furthermore, many PQRS measures have been vetted by a range of quality-focused bodies, including the National Quality Forum (NQF), and are based on clinical evidence. Even more importantly, the selected measures are comprehensible across a wide range of care settings and broadly applicable to wide patient pools.
Table 1 shows the baseline measurements for the four Million Hearts indicators and the initiative’s goals for 2017. Million Hearts data are derived from national care surveys.5 We believe that these goals are achievable. However, success will not be automatic. It will require focus, resources, and, most challengingly, some level of behavioral change on the part of physicians, patients, organizations, and government entities.
Even in the best of times, the goals of Million Hearts, although achievable, would also be ambitious. Budgetary pressures almost certainly will further exacerbate the challenges over the next decade. Our goals will continue to be preventing major cardiovascular events, reducing patient mortality, and improving patient outcomes. However, our next wins, should they occur, will likely come in the context of reduced or stagnant reimbursements for care.
The focus on the ABCS measures should prompt cost-effective interventions. Blood pressure management, aspirin, smoking cessation, and statins are all relatively inexpensive,2 particularly compared with emergency department admissions, hospital stays, interventions, and rehabilitation associated with acute cardiac events.
The direct and indirect costs of hospital inpatient stays were estimated at nearly $50 billion in 2007 for heart disease and nearly $18 billion for stroke.1 The cost of hospital emergency room visits alone, counted separately from inpatient stays, was nearly $4 billion for heart disease and $600 million for stroke.1 By contrast, all prescriptions for heart disease totaled $8.5 billion in 2007.1 Aspirin and statins must surely be among the cheapest heart disease medication therapies included in this tally. Nonetheless, cost constraints associated with improving the ABCS performance indicators are a reality that is unlikely to diminish in the next five years.
Cost constraints directly relate to another prominent issue in cardiology, the use and adoption of health information technology (HIT) and electronic health records (EHRs). In addition to capital outlays, HIT adoption requires time and retraining of clinical staff. Providers, hospitals, and health systems are being pushed by a combination of government incentives and penalties to adopt EHRs, implement electronic prescribing systems, and adapt their practices to these new technologies. We are broadly supportive of these changes, but we should also acknowledge that they can impact both the bottom line and the operations of providers, certainly in the short term.
HIT adoption alone will not result in improvement in ABCS measures or patient outcomes.6 Instead, achieving the Million Hearts ABCS goals will require smart use of HIT, with a focus on prevention, patient education, wider measurement, use of recommended care guidelines, and better coordination of efforts. Wisely, initial statements indicate that the Million Hearts initiative encompasses all these aspects.2
Breaking Down Silos
One attractive aim of Million Hearts is to improve coordination and cooperation among organizations with a stake in reducing major cardiovascular events. Million Hearts is designed to function as a cross-agency program, linking government agencies with a host of key medical associations and private sector supporters. US government entities include the CDC and CMS, the Agency for Healthcare Research and Quality (AHRQ), the Food and Drug Administration (FDA), the Health Resources and Services Administration, the National Institutes of Health, the National Heart, Lung, and Blood Institute, and the Substance Abuse and Mental Health Services Administration.
In addition to the ACC, medical society partners in Million Hearts include the American Medical Association, the America’s Health Insurance Plans, the American Pharmacists’ Association and the American Pharmacists’ Association Foundation, the National Alliance of State Pharmacy Associations and the Alliance for Patient Medication Safety, the National Community Pharmacists Association, the YMCA, and the American Heart Association.
Even within organizations, silos exist. The ACC recently completed a Million Hearts inventory, cataloging all the existing programs and committees already at work on the ABCS measures. This process allowed us to identify our own opportunities for improvements, hopefully expanding the impact of initiatives that are in place by sharing tools already developed with other Million Hearts partners. One example is worth mentioning here. For years, our clinical registry operations and our continuing medical education (CME) divisions have operated largely independently of each other, at least at an ACC staff level. Now, through our lifelong learning portfolio, we have dedicated resources toward building the technological infrastructure necessary to drive CME programs using clinical data collected in our registries. We now offer two educational programs through which providers can earn maintenance of certification (MOC) part IV credit using registry data. We plan to expand these offerings in coming years and could even use CME channels to drive ABCS improvements.
Particularly in a time of cost constraints, organizations such as the ACC need to break down silos, internal and external, and coordinate their offerings. We look forward to working together with our members, the patients they serve, and with other medical specialty societies toward our shared aims of reducing cardiovascular events and improving the health and productivity of Americans. Million Hearts offers a powerful vehicle for guiding these efforts.
Communications are likely to prove a key aspect of reaching providers and patients and of improving inter-entity coordination under the auspices of Million Hearts. ACC media channels have already begun distributing announcements of our participation in the Million Hearts campaign, raising the visibility of the initiative among our constituencies. These outlets include regular publications with tens of thousands of subscribers, our CardioSource website7 (over 227,000 monthly page views), and regular email newsletters to membership groups. As a membership organization, we assiduously solicit member feedback and ideas for ways to contribute to Million Hearts in these communications.
Although most of our 39,000 members are cardiologists, nearly 4,500 of them are Cardiac Care Associates—a designation that includes nurse practitioners, physician assistants, and pharmacists. Members of the cardiac care team can be specially targeted with toolkits, communications, and education materials. We will also seek to partner with other related groups already committed to participating in Million Hearts in the development of materials for these specific segments of ACC membership.
A significant portion of the reduction in CV mortality over the past decade can be attributed to better adherence to evidence-based medical therapies.1,2 One ACC asset that can be immediately aligned with the Million Hearts initiative is the PINNACLE Registry® and its sister organization the PINNACLE Network™.8,9 The PINNACLE Registry is the largest ambulatory database and quality improvement program in the US, focusing on the treatment of the four major managed cardiovascular conditions: coronary artery disease, hypertension, heart failure, and atrial fibrillation. The PINNACLE Network is a related community of outpatient providers committed to quality improvement and best practice sharing. The registry now boasts nearly three million individual patient care records and collects data from more than a thousand cardiology providers around the US (see Figure 1).
The PINNACLE Registry has been qualified as a PQRS reporting option since the inception of registry reporting in 2008. For the 2010 PQRS reporting period, the registry submitted data to CMS for nearly 600 cardiology providers, covering 14 outpatient quality performance measures.
Patient data elements collected by the PINNACLE Registry include information on aspirin and other antiplatelet prescriptions, blood pressure measures, smoking status and cessation consulting, height and weight, lipid panels, and diabetes screening. The PINNACLE Registry and PINNACLE Network provider communities will receive regular communications around our shared performance improvement goals.
Furthermore, the PINNACLE Registry’s flexible technology platform could be employed to show early results of the Million Hearts initiative, beginning with a pre-intervention national report on target measures and followed by regular reporting at six-month intervals. Preliminary work on this approach, focused on ABCS measures, opportunities for alignment, and possible baseline reporting, has already begun in conjunction with CDC scientists.
Table 2 shows baseline measurements of the four Million Hearts indicators, the initiative’s goals for 2017, and the values of comparable PINNACLE Registry performance measures for the 12 months ending in the second quarter of 2011.10 The PINNACLE data are based on the nearly 3-million ambulatory patient visits now in the registry database.
Looking at the 2017 goals of Million Hearts compared with current PINNACLE measures in Table 2, it immediately becomes apparent that those practices and providers currently submitting data to the PINNACLE Registry are already outperforming the 2017 goals of Million Hearts. The goals of Million Hearts are determined at population level. PINNACLE patients are, by definition, receiving care, so some elevation of rates in these patients is to be expected. Nevertheless, as the Million Hearts initiative moves forward, we can undertake formal efforts to learn from the higher rates of ABCS measure adherence and performance seen in these cardiology practices, using top-performing PINNACLE sites as a source for modular best practices around ABCS. Once practices are identified, the PINNACLE Registry and PINNACLE Network providers offer a forum for the further collection, standardization, and refinement of piloted quality interventions. These interventions would then be available for export to other settings, including primary care.
Even though PINNACLE practices are on average outperforming the goals of Million Hearts, the standard deviations across practices remain substantial. This indicates that, even within this highly engaged practice cohort, some practices are lagging behind while others are leading. We choose to see opportunity here. Leading practices could prove fertile ground for identifying and developing the modular best practices around ABCS mentioned above. Lagging practices are obvious candidates for educational initiatives, focused both on clinical improvements and on better documentation.
Using the data elements already collected, the PINNACLE performance measures can be harmonized with the designated ABCS measures used by the Million Hearts initiative. PINNACLE reporting of ABCS measures would provide accurate, swift, and regular indications of progress toward the goals of Million Hearts. This reporting would also contribute to the identification of best clinical practices and to the development of targeted, data-driven quality improvement toolkits.
Data collected in the PINNACLE Registry and used to calculate performance measures can and should be used to drive the next generation of educational interventions. The ACC already offers several performance improvement-continuing medical education (PI-CME) programs based on providers’ own clinical registry data. These types of programs, based on actual data, are increasingly possible when coupled with EHR data collection and extraction, and can significantly improve performance.
The third ACC asset aligned with the goals of Million Hearts is CardioSmart™, a patient-focused web-based offering. CardioSmart is a comprehensive program that provides everyday strategies for healthy living to patients and consumers.11 By empowering patients and consumers to take ownership of their lifestyle and medical treatment, the CardioSmart program can help increase positive outcomes and raise the level of care in the US. CardioSmart focuses on the choices people make throughout their day relating to diet, exercise, adherence to medication, and smoking cessation, and how those choices impact health and wellness. CardioSmart reaches nearly seven million patients and care-givers, a number that continues to grow as the program introduces new offerings.
Within CardioSmart, the CardioSmart National Care Initiative focuses on everyday strategies for heart health and educates consumers about their daily choices—diet, exercise, habits, medication—that impact their health and wellness. The aim of this initiative is to facilitate partnerships between patients and providers to achieve positive heart health outcomes, a goal that aligns closely with those articulated in Million Hearts.
The plans outlined in this article are our first responses and contributions, proposed and actual, to Million Hearts. Given that the ACC is a member-driven organization, we are certain that more ideas will be forthcoming as news of the ACC’s support for Million Hearts reaches our members. The Million Hearts initiative offers the promise of positively impacting the life of hundreds of thousands of patients each year. It is an opportunity for specialty societies and primary care providers to learn from each other. The goals are ambitious and the challenges, particularly around reducing cost and affecting behavioral changes, are considerable. However, we are optimistic. Million Hearts helps us connect adherence to guidelines and performance in clinical practice back to our reason for being: our patients, their families and friends, their quality of life, and our health as a nation. We hope our partners in Million Hearts would agree and we look forward to working together with them on this important initiative.