Focus on Cardiovascular Disease

A Look to the Future

For prevention to become the primary approach to disease management, the way cardiovascular medicine is practiced must change.[1] The cornerstone of this new standard of care will be the modification and control of multiple risk factors.[2],[3] With their unmatched access to population-based data and ability to communicate with key health care stakeholders (eg, clinicians, members, employers), plans can be instrumental in driving this paradigm change by investing in prevention.

As was illustrated in the two quality improvement activities (QIAs) profiled in the previous chapter, many plans use disease management programs that utilize both lifestyle changes and aggressive management of treatable risk factors. Because hypertension, dyslipidemia, and diabetes tend to cluster in cardiovascular disease (CVD), plans utilizing disease management interventions should be prepared to:

• Search for two other major cardiovascular risk factors if one is discovered (eg, look for dyslipidemia and diabetes in patients with hypertension)[4]
• Assess and manage three major cardiovascular risk factors[4]
• Treat to goal using evidence-based guidelines that specifically consider the intersection of modifiable risk factors in an individual patients[2],[3][5]-[7]
• Encourage both the patient and the practitioner to embrace the concept of overall cardiovascular risk, managing risk factors through lifestyle changes and, if necessary, aggressive treatment
• Address and engage the patient in lifestyle changes (weight control, physical activity, and smoking cessation) to move the care paradigm toward prevention
• Commit to long-term management of the patient

Although many plans educate practitioners and members about several cardiovascular risk factors as part of their disease management programs, few measure overall cardiovascular risk. The plan highlighted in the following example did pursue a multiple risk factor intervention strategy. This plan not only recognized that CVD was multifactorial, it also realized that measuring the simultaneous management of multiple modifiable cardiovascular risk factors was an important way to improve the quality of CVD care provided to its members. In the future, it is likely that more plans will begin to incorporate into CVD QIAs measures like the comprehensive coronary artery disease (CAD) clinical indicator described in this profile.

Assessing the Quality of Comprehensive CAD Care

As early as 1994, the plan began efforts to reduce coronary events in its members by implementing initiatives on aspirin use, weight management, exercise, hypertension control, and tobacco use.[8] Low-density lipoprotein (LDL) cholesterol monitoring and management were added as focuses in 1996, and two Health Plan Employer Data and Information Set (HEDIS®) measures (LDL screening in CAD patients and LDL control in screened CAD patients) were chosen to measure the impact of interventions (see Interventions, 1996 to 2001) in a CAD initiative.

After gaining experience in the implementation of CAD quality improvement (QI) initiatives, the plan decided the multiple modifiable risk factors should be measured simultaneously in individual patients to truly assess the quality of their CAD care. By using a comprehensive measure, the plan felt it could emphasize the importance of completing all services for a patient rather than focusing on individual service rates.

The plan created a composite measure of several major modifiable risk factors, the comprehensive CAD clinical indicator, which looked at the percentage of patients whose risk factors for CAD were optimally managed. This measure was based on guidelines developed by a local coalition that brings together different physician groups and practitioners to establish best practices. To be considered “optimally managed,” patients had to have their LDL levels managed appropriately (screened, treated if eligible, and controlled to <130 mg/dL); use aspirin therapy (if eligible); have their blood pressure controlled to goal (<140/90 mm Hg for patients <60 years of age; <160/90 mm Hg for patients >60 years of age); be assessed for exercise, nutrition, and tobacco use; and receive advice on smoking cessation. See appendix 17 for an example of the telephonic screening and assessment questionnaire.

Using administrative data (for LDL screening and prescription of lipid-lowering medication) and medical records (for all other components), the plan collected data on a stratified random sample of 66 patients per medical group. All patients had been diagnosed with CAD and were between 18 and 75 years of age. This sampling strategy provided medical group estimates with 95% confidence intervals of +12% (at worst for medical groups) and health plan estimate confidence intervals within +6%.

Baseline

Baseline performance, based on data collected on 1,205 CAD patients between January 1999 and December 1999, showed a comprehensive CAD clinical indicator rate of 21.3% (Table 1). Rates associated with the individual components ranged from a low 56.5% for LDL control to a high of 90.7% for assessment of smoking status. The striking difference between the rate of the composite measure (21.3%) compared with the rates of the individual components (56.5% to 90.7%) illustrates the difficulty in managing all of a patient’s cardiovascular risk factors.

Evaluation 1

Although the change from baseline to the first remeasurement period (January 2000 to December 2000) in the rate for the composite comprehensive CAD clinical indicator (21.3% vs 25.5%, respectively) was not statistically significant, most comprehensive CAD components trended in a positive direction (Table 2). In fact, the improvement in the percentage of patients whose LDL was controlled (56.5% vs 66.3%, respectively) was statistically significant (P=.028).

Evaluation 2

For the next remeasurement period (January 2001 to December 2001), the plan decided to make some changes. One change was to increase the sample size to 92 (80 + 15% over-sample) per medical group. The other was to adjust the individual components that made up the comprehensive CAD clinical indicator. First, they dropped two components, exercise and nutrition assessment, which were very difficult to quantify objectively. Second, to be considered optimally managed, the plan decided that members with CAD must not use tobacco.

Figure. Comprehensive Risk Factor Management: Baseline to Remeasurement 2

To allow comparison between remeasurements, the composite measure for 2000 was recalculated based on the abbreviated list of components. The comprehensive CAD rate in 2000 rose from 25.5% to 35.8% as a result of this recalculation. Using the new composite measure, there was a 3% increase in optimally managed CAD patients - an additional 4,500 patients from remeasurement 1 to remeasurement 2 (Table 3). Rates associated with the individual components ranged from a low of 65.2% for LDL control to a high of 86.0% for prescription of lipid-lowering medications.

Moving Along the Quality Continuum

The comprehensive CAD clinical indicator described above (now called Optimal Coronary Artery Disease Care) required development and fine-tuning, which took time, resources, and planning. Why did the plan go the extra mile? Because it recognized the value of comprehensive measures that reflect whether individual patients are getting quality care, thus placing its members at the center of the health care equation. This progressive approach is an excellent example of how plans can play a leading role in moving cardiovascular care along the continuum toward quality of secondary prevention through the application of overall cardiovascular risk management.

Note: The components of this measure are evaluated on an annual basis to ensure alignment with the most current clinical practice guidelines. The plan’s 2002 results will include an additional composite measure based on new LDL and blood pressure targets.

For over a decade, the health care system in our country has been in a state of flux.[9] Two phenomena will be largely responsible for reshaping the health care system of the 21st century: growth of technology and the evolving need for chronic health care.[9] As the health care system is reshaped by these forces, so too will be the delivery of cardiovascular care.

Information Technology

Information technology (IT) has enormous potential to improve quality of care.[9] With IT playing a central role in the automation of clinical, financial, and administrative transactions, quality can be improved, errors prevented, consumer confidence in the health system enhanced, and efficiency increased. Specifically, IT can contribute to an improved health care delivery system by:

• Providing practitioners and patients with better access to the medical knowledge base through the Internet or other media
• Facilitating the consistent application of evidence-based medicine to patient care through computer-aided decision support systems
• Improving coordination of care across practitioners and settings through automated clinical data collection and sharing the creation of disease-specific registries
• Reducing medical errors through standardization and automation of decision-making systems and identification of potential errors before their occurrence
• Enhancing the relationship between patients and practitioners through, for example, the use of the Internet for communications (permitting continuous monitoring of chronic conditions), access to test results, and participation in interactive care management services and support groups[9]

Electronic Medical Records

Electronic medical records (EMRs) can improve quality, recordkeeping, and efficiency by enabling practitioners to:

• Collect, track, and analyze data on all the patients in their practice
• Compare their performance against evidence-based guidelines
• Track outcomes across a broad patient population
• Identify patients for research or QI activities
• Implement disease management programs for chronic conditions[10]

The data warehouse used to improve the management of CAD in the QIA profiled earlier (see Addressing the Quality Gap in Cardiovascular Care, Improving the Management of Risk Factors for CVD, Improving CAD Management) is an excellent example of how EMRs can be used to improve the quality of cardiovascular care. This system featured daily downloads of clinical data from various sources, daily updates, and a “drill-down” report that identified patients in need of services.

The Internet

The Internet is reshaping health care delivery by empowering the patient.[9] Many patients now use the Internet to gather information on specific diseases or treatments, manage chronic health problems, take part in discussion groups, evaluate health risks, assess health plans and clinicians, and buy health care products.[9] Physicians use Web-based technologies to check prescriptions against formularies, evaluate potential drug interactions, and send their prescriptions to a pharmacy.[11] In the future, the dropping cost of, and easier access to, Internet services will help to foster health-related communications between patients and their clinicians and between physicians.[9], [12]

Remote Disease Monitoring

IT also enables remote disease monitoring, which is especially useful in conditions that require frequent monitoring. By making possible the remote capture, reporting, and analysis of patients’ health data between office visits, IT can help physicians and patients to play an active role in the management of chronic conditions.[11] An excellent example of the use of a remote disease monitoring system is the sophisticated technology used to improve the management of congestive heart failure in the QIA profiled earlier (see page 29).

Coordination of Care

With the help of increasingly sophisticated information systems, it is hoped that in the future the delivery of health care services will be coordinated across settings, practices, and patient health conditions over time. Care processes will be redesigned to more effectively address the needs of the patient population (eg, patients with CVD) for integrated, seamless care.[11] In this type of “systems-minded” care, processes and patient care will flow smoothly without waiting periods, obstacles, or failures of coordination.[13] This is especially relevant in the management of CVD.

Patient-Centered Care

In the ideal health care system of the 21st century, health care will be patient centered, with the patient and his/her family as integral members of the care team, empowering the patient. Through shared decision making and personal investment in their own care, patients will have access to as much information as they want and will be able to control their care as long as their preferences are medically sound.[9][13]

The Challenge

Moving from today’s highly decentralized system to one that can provide quality preventive, acute, and chronic care will be challenging for everyone involved in the delivery and use of health care.[9]

This challenge can be met, however, with a strong commitment to organizing services around patient needs, designing patient-focused care processes, and appropriately using IT. The keys to these dramatic system-wide changes include:

• Investment in technology and systems that support evidence-based care
• Increased collaboration between health care professionals
• Payment systems that reward excellence
• Increased consumer engagement in clinician selection and health care decisions
• Easier access to information that enables consumers and others to see and compare quality information1[4]

[1] -Smith Stephen Covey Jr. Need for a paradigm shift: the importance of risk factor reduction therapy in treating patients with cardiovascular disease. AM J Cardiol. 1998;82:10T-13T.

[2] - Pearson TA, Blair SN, Daniels SR, et al. AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update. Circulation. 2002;106:388-391.

[3] - Smith Stephen Covey Jr, Blair SN, Bonow RO, et al. AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update. Circulation. 2001;104:1577-1579.

[4] - Selby JV, Peng T, Karter AJ, et al. High rates of co-occurrence of hypertension, elevated LDL-cholesterol, and diabetes mellitus in a large managed care population. Am J Manag Care. In press.

[5] - Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Bethesda, Md: National Institutes of Health; 2001. NIH publication 01-3670.

[6] - Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA. 2003;289:2560-2572.

[7] - American Diabetes Association. Position statement. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2003; 26(suppl 1):S33-S50.

[8] - National Committee for Quality Assurance. Quality Profiles™: In Pursuit of Excellence in Managed Care. National Committee for Quality Assurance; 2001.

[9] - The Institute of Medicine Committee on Quality of Health Care In America. Crossing the quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

[10] - Reece RL. EMR helps improve quality. Available at: www.premierhealthcare.com/cgi-bin/article.cgi?article_id=1430. Accessed September 17, 2003.

[11] - Sipkoff M. Internet use rising, report says. Available at: www.premierhealthcare.com/cgi-bin/article.cgi?article_id=1452. Accessed September 17, 2003.

[12] - Sipkoff M. Systems aid rural health deliver. Available at: . Accessed September 18, 2003..

[13] - Reece RL. Momentum is building, but much work remains, says quality expert. Available at: www.premierhealthcare.com/cgi-bin/article.cgi?article_id=927. Accessed September 4, 2003..

[14] - The National Committee for Quality Assurance. The State of Healthcare Quality: 2003. Washington, DC: The National Committee for Quality Assurance; 2003

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