Is Rapid Health Improvement Possible?
2017; Lippincott Williams & Wilkins; Volume: 135; Issue: 18 Linguagem: Inglês
10.1161/circulationaha.117.027461
ISSN1524-4539
AutoresThomas R. Frieden, Janet S. Wright, Patrick H. Conway,
Tópico(s)Global Public Health Policies and Epidemiology
ResumoHomeCirculationVol. 135, No. 18Is Rapid Health Improvement Possible? Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBIs Rapid Health Improvement Possible?Lessons From the Million Hearts Initiative Thomas R. Frieden, MD, MPH, Janet S. Wright, MD and Patrick H. Conway, MD, MSc Thomas R. FriedenThomas R. Frieden From Centers for Disease Control and Prevention, Atlanta, GA, at the time this work was completed (T.R.F.); Centers for Disease Control and Prevention, Baltimore, MD (J.S.W.); and Centers for Medicare & Medicaid Services, Baltimore, MD (P.H.C.). , Janet S. WrightJanet S. Wright From Centers for Disease Control and Prevention, Atlanta, GA, at the time this work was completed (T.R.F.); Centers for Disease Control and Prevention, Baltimore, MD (J.S.W.); and Centers for Medicare & Medicaid Services, Baltimore, MD (P.H.C.). and Patrick H. ConwayPatrick H. Conway From Centers for Disease Control and Prevention, Atlanta, GA, at the time this work was completed (T.R.F.); Centers for Disease Control and Prevention, Baltimore, MD (J.S.W.); and Centers for Medicare & Medicaid Services, Baltimore, MD (P.H.C.). Originally published2 May 2017https://doi.org/10.1161/CIRCULATIONAHA.117.027461Circulation. 2017;135:1677–1680Five years ago, the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services, and partners launched a public–private initiative to prevent 1 million heart attacks and strokes by 2017.1 Although final results will not be known for several years, data suggest that the initiative made substantial progress and will achieve about half of its goal. Policies, partnerships, and programs prevented cardiovascular events and yielded important lessons. This article outlines the actions taken, progress made, and implications for health improvement in the United States.Cardiovascular disease (CVD) remains our leading cause of death, killing 800 000 Americans and costing $316 billion annually.2 CVD event and mortality rates have declined since the 1960s, but this decline decelerated around 2011.3 The Million Hearts initiative began in 2012 and faced the challenge of overcoming this trend. The purpose of the initiative was to scale effective interventions in order to prevent CVD events to resume and accelerate the decline.1 Communitywide goals were to reduce tobacco use and sodium intake and to eliminate artificial trans fat consumption. Clinical priorities were to improve management of the ABCS: aspirin use, blood pressure control, cholesterol management, and smoking cessation. More than 120 partners, including federal, state, local, and private sector organizations, are working to achieve targets.Through the first 2 years of the initiative, ≈115 000 events were prevented compared with what would have occurred had 2011 rates remained stable.4 Final data will be available in 2019; the initiative is projected to prevent ≈500 000 events over its first 5 years. The reduction in events cannot be attributed solely to the initiative, but the reduction is noteworthy given the flattening trend in CVD mortality and countervailing trends driven by increasing obesity and diabetes prevalence; strong actions by multiple partners appear to have contributed. Interim results suggest modest improvements in aspirin use, hypertension control, statin use, and smoking cessation treatment. Aspirin use, difficult to measure because over-the-counter medications are not captured reliably in electronic health records, was at 81% among high-risk patients in 2011 to 2012. By 2016, blood pressure control is projected to have reached almost 58%, compared with 53% in 2009 to 2010; statin use in those with clear indications is estimated to have reached 60%, compared with 50% in 2009 to 2010. Use of any combustible tobacco is at a historic low and projected to reach 22.9% in 2015 to 2016, down from 26.2% in 2009 to 2010; there were 10 million fewer adult cigarette smokers in the United States in 2016 compared with 2009. Sodium intake remains high at >3400 mg/d.Key limitations on the effect of the initiative were delayed federal action on sodium and difficulty with improving clinical performance rapidly. If voluntary guidance for gradual sodium reduction in processed and restaurant foods had been finalized promptly as anticipated, as many as 160 000 additional events could have been prevented. To meet the ambitious target for hypertension, control rates had to improve by 5% a year, as opposed to the 1% improvement observed. During this time, health systems and clinicians faced competing priorities as they implemented electronic health records and adapted to changes in healthcare delivery and payment. By year 4, each of the ABCS measures changed as a result of new guidance, specification, or data sources; this complicated measure implementation, reporting, and improvement.The initiative provided important lessons. The aim to prevent a million events was easily understood and resonated with diverse stakeholders, as did the concept of public health and health care working together toward a common goal. The 5-year time frame imparted a sense of urgency. Focusing on a limited set of proven, high-impact interventions helped partners prioritize; flexibility implementing interventions made diverse participation possible.Health systems that achieved hypertension control rates ≥70% were a rich source of lessons. Teams in these systems prioritized detection, treatment, and control; used algorithms to facilitate a team approach; reduced barriers to medication adherence; and reviewed data frequently, taking prompt action to improve performance. Across diverse practice settings, including the Indian Health Service, federally qualified health centers, and large and small practices in rural and urban areas, these strategies were associated with high rates of hypertension control. Many high performers also recognized the importance of finding patients within their systems with undiagnosed hypertension "hiding in plain sight." The Million Hearts initiative developed tools to help practices implement these approaches.Although key indicators have been slow to improve, many programs and policies are now in place to accelerate progress (Table). The US Food and Drug Administration's final determination, issued in 2015 and to be fully implemented in 2018, will eliminate artificial trans fat from the food supply. The Centers for Medicare & Medicaid Services now include and heavily weight ABCS measures in its Quality Payment Program, Medicare Advantage quality bonus, and accountable care organizations. The Centers for Medicare & Medicaid Services Million Hearts CVD Risk Reduction Model is the first program to pay for prevention at a population level. Increasing alignment of payment and quality in both public and private programs, along with widespread adoption of electronic health records, sets the foundation for more rapid improvement.Table. Million Hearts Initiative: Status of InterventionsApproachStatusLessons and Future DirectionsImproving clinical management of ABCSFocus on the ABCSABCS measures* were widely adopted by public and private quality reporting programs, including CMS' QPP.† The QPP will simplify reporting and reward performance on the ABCS.More than 125 000 physicians reported an average blood pressure control rate of 62% covering >17 million patients with hypertension in the Medicare EHR Incentive Program.Recognition programs identified exemplary health systems, including 59 CDC Hypertension Control Champions‡ serving 13.8 million patients who achieved average control rates of almost 80%.The Federal Office of Personnel Management upweighted the value of hypertension control in its health plan performance assessment,§ which covers 8.2 million people.HRSA recognized 226 FQHCs‖ serving 2.9 million adults for achieving ≥70% aspirin use, blood pressure control, and smoking cessation intervention in 2015.Adapt quickly to inevitable changes in clinical standards to minimize disruptions in measuring and achieving progress.Establish simpler, timelier, and larger incentives.Publicly report key CVD measures and benchmark results.Provide public education to increase awareness of importance of control of ABCS, including community-based and electronic programs to support self-monitoring of blood pressure.Health systems and hospitals can set performance goals for the ABCS for outpatient practices and cardiac rehabilitation referral/participation and reward teams for achieving them; adopt healthy food service guidelines and smoke-free campus policies; and provide medications with blood pressure monitors with no cost sharing for employees.Health information technologyEHR adoption in outpatient settings increased from 34% in 2011 to 87% in 2015.¶Improve EHR functionalities to provide population health--level data for rapid-cycle quality improvement.Using population health management health IT tools, >500 000 patients were identified as having potentially undiagnosed hypertension.#Empower patients with health information easily accessible in EHR systems.Embed common EHR-based CVD risk assessment tools in workflow and prepopulate with relevant patient-level data.Use clinical quality measure data to facilitate rapid-cycle improvements in outcomes.Increase use of healthcare data for real-time surveillance of cardiovascular events.Clinical innovationsImplementation of treatment protocols** by the Indian Health Service and CMS QIN-QIOs enabled at least 4 million patients to receive standardized, evidence-based hypertension care.AMGF's "Measure Up/Pressure Down"†† focused >140 large medical groups and health systems on hypertension control and achieved an average control rate of >70% in 3 years.AHRQ EvidenceNOW: Advancing Heart Health in Primary Care‡‡ is assisting at least 1500 small and medium-sized practices to improve the ABCS and cardiovascular health.Million Hearts CVD Risk Reduction Model§§ will test the effect of financial incentives for CVD risk management in 47 states, DC, and Puerto Rico and reach >3.3 million Medicare fee-for-service beneficiaries and nearly 20 000 healthcare practitioners.In 2017, many hospitals will begin participating in a bundled or episode-based payment for heart attack and bypass care and an incentive payment designed to increase participation in cardiac rehabilitation among eligible patients.Incorporate new guideline recommendations as quickly as possible into standardized protocols; anticipate and address resistance to use of protocols.Address scope of practice regulations and align incentives to increase team-based care, improve access, and improve quality while reducing cost.Analyze top-performing systems, identify common elements, and support rapid and widespread adoption of these elements.Reduce barriers to and increase use of fixed-dose combination therapy for hypertension and longer prescription refill policies (eg, 3–6 mo instead of 1 mo in Medicaid). Fill research gaps in use of combination medications.Expanding community initiatives to reduce smoking, improve nutrition, and reduce blood pressurePolicies and programs designed to reduce tobacco use and exposure to second-hand smokeFrom 2012 to 2015, CDC's Tips from Former Smokers campaign‖‖ helped at least 400 000 smokers quit for good.Fund a full-year media campaign to help an additional 75 000 smokers quit each year.The percent of the population covered by a local or state comprehensive smoke-free law increased from 48.1% in 2011 to 58.8% as of October 2016.Extend comprehensive smoke-free indoor air policies to all Americans.Provide additional assistance to smokers, including barrier-free access to evidence-based quit assistance.Target populations with disproportionately high smoking prevalence.Fund state tobacco control programs at CDC-recommended levels.Raise the price of tobacco at the state and federal levels.Policies for reducing sodium content of foodIn June 2016, the FDA released draft voluntary guidance¶¶ that aims to gradually reduce sodium in processed and restaurant foods, which would create more choices and put control of sodium intake increasingly in consumers' hands.Delay in guidance resulted in ≈160 000 more CVD events than would have occurred if guidance had been issued as anticipated.Reduce average sodium in processed and restaurant food to enable Americans to reduce their intake.Implement public and private procurement policies to improve the healthfulness of food provided to or purchased in schools, hospitals, public institutions, workplaces, and other venues.Policies aimed at eliminating artificial trans fats from dietFDA's final determination that partially hydrogenated oils are not generally recognized as safe## will eliminate industrially produced trans fat from the US food supply by 2018.Ensure no further delay in implementation; delay to date resulted in ≈20 000 more CVD events than would have occurred if determination had not been delayed.ABCS indicates aspirin use, blood pressure control, cholesterol management, and smoking cessation; AHRQ, Agency for Healthcare Research and Quality; AMGF, American Medical Group Foundation; CMS, Centers for Medicare & Medicaid Services; CVD, cardiovascular disease; EHR, electronic health record; FDA, US Food and Drug Administration; FEHB, Federal Employee Health Benefits; FQHC, Federally Qualified Health Center; HRSA, Healthcare Resources and Services Administration; IT, information technology; QIN-QIO, Quality Improvement Network–Quality Improvement Organizations; and QPP, Quality Payment Program.*https://millionhearts.hhs.gov/data-reports/cqm/measures.html.†https://qpp.cms.gov/measures/quality.‡https://millionhearts.hhs.gov/partners-progress/champions/list.html.§https://www.opm.gov/healthcare-insurance/healthcare/carriers/2016/2016-03.pdf.‖https://bphc.hrsa.gov/uds/datacenter.aspx#fnm.¶http://www.cdc.gov/nchs/ahcd/web_tables.htm.#http://mylearning.nachc.com/diweb/fs/file/id/229350.**https://millionhearts.hhs.gov/tools-protocols/protocols.html.††http://www.measureuppressuredown.com.‡‡http://www.ahrq.gov/evidencenow/index.html.§§https://innovation.cms.gov/initiatives/Million-Hearts-CVDRRM.‖‖https://www.cdc.gov/tobacco/campaign/tips.¶¶http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/ucm494732.htm.##http://www.fda.gov/Food/IngredientsPackagingLabeling/FoodAdditivesIngredients/ucm449162.htm.CVD remains the leading cause of preventable death and health disparities in the United States. High rates of obesity and diabetes mellitus threaten to stall or reverse decades of progress reducing CVD mortality.5 Communitywide programs to reduce sodium intake, to increase physical activity, and to further reduce tobacco use can prevent hundreds of thousands of events. Political will is needed to prioritize prevention and implementation of these proven interventions.5 Improving clinical performance is difficult but possible and necessary to prevent events among those with CVD risk factors. Payment policies can incentivize prevention and encourage team-based care, use of evidence-based protocols, and action based on real-time analytics. Initiatives to reduce barriers for patients can accelerate progress addressing the ABCS. The teams, technology, and processes developed to deliver high-value cardiovascular care can be applied to other health conditions. Although the progress possible has not yet been fully realized, with continued commitment among federal, state, local, and private partners and a resolute focus on high-impact actions, we can improve cardiovascular health rapidly and for generations to come.AcknowledgmentsThe authors thank Hilary Wall, MPH, and Kathryn Foti, MPH, for assistance in preparing and reviewing this article.DisclosuresThe findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services, or the Department of Health and Human Services.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Circulation is available at http://circ.ahajournals.org.Correspondence to: Janet S. Wright, MD, Centers for Disease Control and Prevention, 7500 Security Boulevard, Baltimore, MD 21244. 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May 2, 2017Vol 135, Issue 18 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.117.027461PMID: 28461412 Originally publishedMay 2, 2017 Keywordshypertensioncardiovascular diseasessmokingprimary preventionsodiumPDF download Advertisement SubjectsCardiovascular DiseaseCerebrovascular Disease/StrokeHypertensionMyocardial InfarctionPrimary Prevention
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