CVD Prevention Takes a Team Ed Havranek, MD Denver Health University of Colorado
CVD Prevention Potential Impact Modality # RCTs Outcome RR Aspirin 1 10 CV events 0.94 (0.88 0.99) BP control 2 68 All-cause mortality 0.90 (0.85 0.95) Cholesterol control 3 15 All-cause mortality 0.86 (0.80 0.93) Treatments have large effects Large numbers of people are affected 1 Aspirin for the Primary Prevention of Cardiovascular Events: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality; 2015. 2 Thomopoulos et al. Effects of blood pressure lowering on outcome incidence in hypertension. J Hypertension 2014. 3 Statin Use for the Prevention of Cardiovascular Disease in Adults: A Systematic Review for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality; 2016.
CVD Prevention Potential Impact A 70 year old black man: - Current smoker, ½ pack per day for 50 years - Systolic blood pressure 160 mm Hg on no meds - Total cholesterol 240, HDL 40, TG 150, LDL 170. Baseline 10-yr risk is 30.8% One year later: - successfully stopped smoking 8 months ago - blood pressure 140 mm Hg on meds - lipids are unchanged from baseline. 10-yr risk is now 11.4% Then: A reduction in LDL cholesterol to 100 would result in a 10 yr estimated risk of 8.5% Lloyd Jones DM, Huffman MD, Karmali KN, Sanghavi DM, Wright JS, Pelser C, Gulati M, Masoudi FA, Goff DC Jr. Estimating longitudinal risks and benefits from cardiovascular preventive therapies among Medicare patients: the Million Hearts Longitudinal ASCVD Risk Assessment Tool: a special report from the American Heart Association and American College of Cardiology. Circulation. 2016
CVD Prevention Team Approaches Pharm PCP Patients Community groups Gov t
Team Approaches Patient-Centered Medical Home Pharm PCP Patients Community groups Gov t
Team Approaches Patient-Centered Medical Home A model of care relying on primary care that is Patient-centered. Accessible. Team-based Comprehensive Coordinated Quality-focused Cochrane review of system design to improve BP control (2010): 72 RCTs. Adequate evidence for: an organized system of registration, recall, and regular review allied to a vigorous stepped-care approach self-monitoring programs. nurse- or pharmacist-led care was judged to be a promising way forward.
Team Approaches Medical Neighborhoods Pharm PCP Patients Community groups Gov t
Team Approaches Medical Neighborhoods A model of care in which PCMHs are adequately connected to acute and inpatient care outpatient specialty care Dependent on collaborative care agreements electronic communication relief from financial disincentives Aspirational. Role in preventive care unclear but potentially large.
CVD Prevention Community Engagement Pharm PCP Patients Community groups Gov t
CVD Prevention Community Engagement Who is responsible for population-based prevention? Science demonstrating the effectiveness of community participation is surprisingly thin. A recent systematic review concluded: Despite positive examples, community participation in health systems interventions was variable, with few being truly community directed. Future research should more thoroughly engage with community participation theory, recognize the power relations inherent in community participation, and be more realistic as to how much communities can participate and cognizant of who decides that. George AS, Mehra V, Scott K, Sriram V. Community Participation in Health Systems Research: A Systematic Review Assessing the State of Research, the Nature of Interventions Involved and the Features of Engagement with Communities. PLoS One. 2015; 10(10): e0141091.
Potential value on improved care delivery Culturally-concordant care Appropriate health literacy Appeal to social norms for behavior change Volunteer manpower CVD Prevention Community Engagement
A Simplified Approach to Team Care Agree with them on where you want to get to Give them good data Make them happy Get out of their way