Focus on Cardiovascular Disease

Introduction

Great progress has been made during the last decade in the prevention of heart attack and death resulting from cardiovascular disease (CVD). In 1995, the American Heart Association (AHA) published a consensus statement on secondary prevention, which emphasized the need for comprehensive management of multiple risk factors in patients with established CVD.

Progress in lowering CVD mortalities can be attributed to a number of factors, among them greater public awareness of risks and symptoms, changing guidelines, use of measures and feedback, and better therapies. An important step involved the launch of Get With the Guidelines^SM - the AHA/American Stroke Association’s (ASA) QI program designed to close the gap in the acute care of patients with CVD and to ensure broader use of preventive therapies at the time of hospital discharge. And recently, the hospital-focused efforts initiated by the Get With the Guidelines program have been extended to the outpatient setting with the launch of the Heart/Stroke Recognition Program by NCQA and AHA/ASA. This program focuses on recognizing primary care and specialty physicians who successfully work in the outpatient setting to achieve better results with their patients in secondary prevention of heart disease and stroke. Thus, with both hospital and office-based programs focusing on secondary prevention, and with the active support and participation of health plans and health care providers, significant progress toward the secondary prevention of CVD is a reality.

To be truly successful in reducing the burden of CVD, however, progress in secondary prevention must be matched by progress in primary prevention. To make a difference, we can’t just wait to see who survives a heart attack or stroke and then react. We must, at the very least, look for and aggressively manage the major treatable risk factors for CVD before a first cardiovascular event occurs. Recently, two major studies reporting observations from nearly 500,000 patients have emphasized the importance of multiple risk factor management by establishing that over 80% of patients with coronary heart disease have at least one of the major risk factors. Also, to emphasize the need for primary prevention of CVD, the AHA updated its consensus statement in 2002 to incorporate new information about the benefits of prevention across major risk factors and to encourage a comprehensive approach to patient care. Clearly, early diagnosis and active management of multiple risk factors are the goals of cardiovascular care; too many people remain undiagnosed and untreated for these conditions while the evidence shows that CVD is preventable.

Health plans--who have made preventive care an important part of health benefits--must continue to work with clinicians and their enrolled members to help improve the quality of their primary prevention programs. This includes measuring the impact of these programs not just on isolated risk factors (eg, cholesterol levels or blood pressure), but also on multiple risk factors. Only in this way can we be truly successful in improving the quality of cardiovascular care and reducing the toll associated with CVD. This issue of Quality Profiles is an important and useful tool for health care organizations that want to move their CVD management programs along the continuum toward optimal patient care.

Get With the GuidelinesSM is a registered service mark of the American Heart Association

After two editions of Quality Profiles, National Committee for Quality Assurance (NCQA) and Pfizer are pleased to take the next step in the evolution of this resource. Quality Profiles: The Leadership Series can help health care organizations move quality even further along the continuum toward optimal patient care (see graphic below). Although NCQA’s Health Plan Employer Data and Information Set (HEDIS®) has successfully driven improvement by leveraging the power of performance measurement and accountability, too many people still suffer and die each year because the health care system has not consistently delivered care we know to be effective. In fact, the health care industry should bring about a fundamental paradigm shift from tertiary to secondary and primary prevention of disease. Because of unparalleled access to key health care stakeholders (eg, practitioners, members, employers), health plans, disease management organizations, and medical groups can continue to assume a leadership role in the transformation of health care into an evidence-based, patient-centered coordinated system

Although great progress has been made in moving cardiovascular care from tertiary prevention to secondary prevention, health plans must continue to drive cardiovascular care further along the continuum toward primary prevention of cardiovascular disease (CVD). CVD risk factors should be managed not only after a coronary event has occurred, but also before the onset of such and event. Ideally, health lifestyles should be promoted with all patients so that risk factors for CVD never develop. In this way, CVD care can be moved from the inpatient setting to the outpatient setting.

While the 1999 and 2001 editions of Quality Profiles compiled model QIA profiles across several health care areas (chronic illness, women’s health, preventive care, behavioral health, and service), Quality Profiles: The Leadership Series will examine a specific health care area in each installment. In this way, the clinical content can be expanded, providing background and commentary on the implications of quality improvement (QI) in the area under discussion, the rationale for the need to improve, and the challenges of improving quality. For example, in this issue of Quality Profiles: The Leadership Series, the management of CVD and overall cardiovascular risk is explored in depth, including discussions of comprehensive cardiovascular risk reduction, treatment guidelines, and room for improvement in the management and prevention of CVD.

Individual QIA profiles will be integrated into this augmented clinical discussion so that relationships between the clinical content and the activities themselves can be more easily understood and applied. In addition,Quality Profiles: The Leadership Series will be provided to our audience more frequently. Regular Leadership Series installments will help ensure that health plans and others have a rich, up-to-date collection of QI studies and resources to draw upon as they develop their own programs.

Although they have been integrated into the clinical and quality discussion, the QIA profiles continue to follow the same format applied in previous editions. This well-established approach to the description of QIAs was originally developed with the goal of making the profiles easy to understand, adapt, and implement. As such, the following information is presented in each profile:

• Selecting the activity: Description of the identification of the quality issue and its relevance to the plan’s population and choice of intervention to improve quality
  


• Setting the parameters: Discussion of the QIA methods (eg, population identification, data sources and collection, quantitative measures, data analysis, goals, and barriers to optimal disease management)
  


• Implementing the initiative: Review of the interventions and outcomes (eg, how interventions were selected, carried out, evaluated, adjusted as needed; performance versus goal; and barriers to the QIA)
  


• Epilogue: Analysis of the overall impact of the QIA and how the plan attempted to sustain the activity through subsequent interventions and measurements
  

In addition, the profiles present “Quality Lessons,” which elucidate key points and offer important insights and observations about the QIA under discussion. Also integrated into each QIA are “Quality Options,” which are examples taken from other health plans’ QIAs that aim to expand learning around the quality issues facing similar patient populations. And, finally, the appendix presents templates and tools used in the QIAs, including telemonitoring surveys, screening tools, treatment guidelines, and newsletters, among others.

Methodology

Cardiovascular disease QIAs from plans receiving NCQA accreditation decisions between May 2000 and April 2003 were considered for inclusion in Quality Profiles: The Leadership Series. These QIAs were then screened in a two-phase selection process. In the first phase, QI initiatives were evaluated against the following criteria:

• Accreditation status: The managed care organization must have attained an accreditation status of Excellent, Commendable, or Accredited
  


• Meaningful improvement: Meaningful improvement: NCQA’s Review Oversight Committee must have determined that the specific initiative under review had demonstrated meaningful improvement (ie, improvement has occurred and is likely to result in a better outcome for the affected population; is attributable to the strength, duration, and quality of the plan’s action and not to cofounders; and has an impact on high-volume, high-risk, or high-cost conditions)
  


• Health care area: The QIA must have addressed a quality issue in the management of CVD

QIAs selected during the first phase were then reviewed during the second phase of the selection process by specially trained independent consultants using the following criteria:

• Nature of the QIA
• Health impact
• Evidence of sustainability

This process yielded the six top-screening initiatives from five health plans, which are included in this issue of Quality Profiles: The Leadership Series. Health plans were also interviewed to gather additional information on the QIA methodology, barriers to the initiative, adjustments to interventions, the progress of the initiative since submission, and subsequent results. Any information or data that were not reviewed or validated during the NCQA accreditation process and were not subject to the same two-phase selection process described earlier are not included in quantitative graphs and tables.

NCQA and Pfizer: The Quality Profiles Partnership

Quality Profiles: The Leadership Series is intended to serve as a useful resource for health care organizations undertaking QI initiatives. Providing organizations with the clinical rationale for QI and examples of model initiatives drawn from the experiences of health plans willing to share their accomplishments and challenges, the series is the product of a partnership between two organizations deeply committed to advancing quality in health care: NCQA and Pfizer Inc. NCQA has worked for over a decade toward improving the quality of health care delivered to people everywhere, through its accreditation programs and the ongoing development of HEDIS® measures, which measure improvement in the health status of health plan enrollees. Equally committed to the delivery of quality health care, Pfizer has worked with health plans, medical groups, and other health care organizations to facilitate the achievement of clinical and service excellence. In addition, Pfizer has sponsored NCQA’s electronic and print publication of successful QI efforts, which serve as prototypes for health plans faced with similar health care improvement issues.

We would like to thank the following people and organizations, whose dedication to the delivery of quality health care has made this edition of Quality Profiles: The Leadership Series possible:

Contributing Health Care Organizations

Quality Profiles Peer Reviewers

Mark Bloomberg, MD
Erick Davis, MD
Lucia Hatch
Marie Howson
Patricia Mayer

NCQA Staff Members

Kathleen C. Mudd, MBA, RN
Vice President for Product Delivery

L. Gregory Pawlson, MD, MPH
Executive Vice President

Barry A. Scholl
Vice President for Communications and Marketing

Elizabeth Usher
Director, Customer Relations

Pfizer Staff Members

Benjamin Eng, MD

Jeff Henderson

Lindsay S. Rosen

David Schaaf, MD

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