Focus on Cardiovascular Disease

Where is Health Care Quality in 2003?

Each week, an estimated 1,000 Americans die because they haven’t received the care that medical science can offer (Table 1).[1] This gap in the quality of health care is readily apparent in the management of cardiovascular disease (CVD):

• Only 27% of patients with hypertension are controlled on medication; the remaining 73% either are unaware of their condition, aren’t on medication even though they have been diagnosed, or are not controlled with medication.[2]


• Almost 49 million people smoke tobacco.[2]


• Despite the widespread availability of cholesterol screening and effective lipid-lowering agents, 105 million people still have total cholesterol levels of 200 mg/dL or higher; 42 million have total cholesterol levels of 240 mg/dL or higher.[2]

Yet, if we use the level of performance already being achieved by the top 10% of health plans as a proxy for the care that all Americans might reasonably expect to receive, many deaths from CVD would be avoided.[1]

There are five Health Plan Employer Data and Information Sets (HEDIS^®) measures that quantify the quality of CVD management:

• Controlling High Blood Pressure


• Cholesterol Management After a Heart Attack — Screening


• Cholesterol Management After a Heart Attack — Control


• Beta-Blocker Treatment After a Heart Attack


• Advising Smokers to Quit

Figure 1. Controlling High Blood Pressure-- Commercial Rates: 1999-2002[1] The Controlling High Blood Pressure measure estimates whether blood pressure was controlled in adults 46-85 years of age with diagnosed hypertension. Adequate control was defined as a blood pressure of 150/90 mm Hg or lower. Both systolic and diastolic pressure must have been under these thresholds in order for the person's blood pressure to be considered controlled.

Additionally, there are two measures from the Comprehensive Diabetes Care relating to CVD management:

• Comprehensive Diabetes Care LDL-C — Screening


• Comprehensive Diabetes Care LDL-C — Control
  

Of these, only one—Beta-Blocker Treatment After a Heart Attack—has average performance rates higher than 90%. Thus, HEDIS® data indicate that, although steady progress is being made, health plans and clinicians should continue to perform, enhance, and augment quality improvement (QI) efforts in order to move toward optimal cardiovascular patient care. Health plans, in particular, can use QI initiatives to help ensure that risk factors are managed not only after, but also before, a first cardiovascular event.

Among commercial plans, the average rate for the HEDIS Controlling High Blood Pressure measure rose three percentage points between 2001 and 2002 (Figure 1).[1] Although commercial plans have improved how they help clinicians control hypertension among their members -- as evidenced by an almost 20 percentage-point increase in performance rates over the last four years -- there is still room for improvement. On average across all commercial health plans, the blood pressure of about 42% of members with high blood pressure was not controlled in 2002. The figure is even lower outside the health plan sector. Even the top-performing commercial plans were able to demonstrate blood pressure control in only slightly more than two thirds of their members with high blood pressure.[1]

The average rates among commercial plans for both cholesterol screening and cholesterol control were two percentage points higher in 2002 than they were in 2001 (Figures 2 and 3).[1] However, on average, about 20% of commercial health plan members were still not screened for low-density lipoprotein (LDL) levels, and 39% were not controlled to <130 mg/dL, despite being highly vulnerable to another heart attack. There was also wide variability in the performance of plans, with the top 10th of plans scoring 45 percentage points higher than the bottom 10th of plans.[1]

From 1999 to 2002, the average rates for cholesterol screening among commercial plans rose about 10 percentage points (Figure 2), while the rates for cholesterol control rose 16.2 percentage points (Figure 3.)

Figure 2. Cholesterol Screening--Commercial Rates: 1999-2002[1] The Cholesterol Management-Screening measure estimates the percentage of health plan members aged 18-75 years who had evidence of an acute cardiovascular event and whole LDL-C was screened in the year following the event.

Figure 3. Cholesterol Control--Commercial Rates: 1999-2002[1] The Cholesterol Management-Control measure estimates the percentage of health plan members aged 18-75 years who had evidence of an acute cardiovascular event and whose LDL-C was controlled to less than 130 mg/dL in the year following the event.

Although the HEDIS measure Comprehensive Diabetes Care LDL-C-Screening and Comprehensive Diabetes Care LDL-C-Controlled don’t measure the quality of CVD management in patients who already have CVD, they do assess the management of a risk equivalent for CVD (dyslipidemia) in diabetes patients who are already at increased risk for CVD. In fact, diabetes is now considered to be a risk equivalent to that of a first heart attack.3 The improvement in performance rates for these measures from 2001 to 2002 among commercial health plans reflects a growing appreciation of the importance of lipid management in patients with diabetes, with statistically significant increases in both screening and control (Figures 4 and 5).[1] Unfortunately, on average, the lipid levels for 45% of commercial plan members with diabetes were still not controlled in 2002.

Beta-blocker treatment rates have risen a dramatic 30 percentage points since 1996, indicating that sustained attention and effective initiatives can improve care (Figure 6).[1] Because of the high performance rates already being achieved for this measure, QI initiatives for Beta-Blocker Treatment After a Heart Attack have not been presented in this issue of Quality Profiles: The Leadership Series.

In 2002, 100% of patients in top-performing commercial plans received a prescription for a beta-blocker after hospitalization for a heart attack.[1]  Unlike the other measures, across all commercial health plans, very few members (only 6.5%) did not receive beta-blockers after a heart attack.

In 2002, an average of 67.7% of self-identified smokers reported that a physician had advised them to quit smoking (Figure 7)[1]. This means that 32% of smokers did not receive such advice.

Figure 4. Comprehensive Diabetes Care LDL-C--Screening, Commercial Rates:1999-2002[1] The Comprehensive Diabetes Care LDL-C-Screening measure estimates the percentage of health plan members with type 1 and type 2 diabetes aged 18-75 years who had a serum LDL-C screening during the measurement year.

Figure 5. Comprehensive Diabetes Care LDL-C--Controlled, Commercial Rates: 1999-2002[1] The Comprehensive Diabetes Care LDL-C-Controlled measure estimates the percentage of health plan members with type 1 and type 2 diabetes aged 18-75 years who had their serum LDL-C controlled to less than 130 me/dL during the measurement year.

Figure 6. Beta-Blocker Treatment After a Heart Attack Commercial Rates:1999-2002[1] The Beta-Blocker Treatment After a Heart Attack measure estimates the percentage of members aged 35 years and older who were hospitalized and discharged from the hospital after surviving a heart attack and who received a prescription for a beta-blocker.

Figure 7. Cholesterol Control--Commercial Rates:1999-2002[1] The Cholesterol Management-Control measure estimates the percentage of health plan members aged 18-75 years who had evidence of an acute cardiovascular event and whose LDL-C was controlled to less than 130 mg/dL in the year following the event.

Although HEDIS measures have driven improvement of the management of CVD by identifying patients at high risk and measuring the quality of their care, there is still much work to be done. Health plans continue to be well positioned to improve both the secondary and primary prevention of CVD through QI initiatives that use the HEDIS measures discussed previously to assess the impact of their efforts. Plans in collaboration with their clinicians and hospitals should also assume a leadership role in improving the quality of cardiovascular care, taking advantage of opportunities to structure QI activities around the timely detection of coprevalent risk factors (e.g., high blood pressure, diabetes, and dyslipidemia) and improving the diagnosis and treatment of CVD.

Plans face many challenges when attempting to improve the quality of cardiovascular care. In addition to the standard challenges of changing patient and clinician behavior, patient identification may be difficult, as miscoding can occur when patients are being evaluated for a diagnosis that is not subsequently confirmed. If HEDIS measures are not available, the identification of valid, reliable measures is a major barrier. And, physicians and patients may object to disease management programs.

Until recently, some physicians believed that disease and care management programs were just another way for health plans to control costs by limiting their autonomy, and some still express concern about the lack of time for patient education.[4] Patients, on the other hand, sometimes feel that these programs will interfere with the patient-doctor relationship. The following profile of a congestive heart failure (CHF) QI initiative provides insight into some of the challenges and solutions associated with the secondary management of CVD. Additional profiles can be found in the next section: Managing the Overall Risk of Cardiovascular Disease.

[1] - The National Committee for Quality Assurance. The State of Health Care Quality: 2003. Washington, DC: The National Committee for Quality Assurance; 2003.

[2] - American Heart Association. Heart Disease and Stroke Statistics - 2003 Update. Dallas, Tex: American Heart Association; 2002.

[3] - American Heart Association. Risk factors and coronary heart disease: AHA scientific position. Available at: www.americanheart.org/presenter.jhtml?identifier+4726 Accessed August 21, 2003.

[4] - . Sipkoff M. Once shunned, disease management programs are now winning favor. Available at: www.premierhealthcare.com/cgi-bin/article.cgi?article_id=869. Accessed September 4, 2003.

[5] - Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. Circulation. 2001;104:2996-3007.

[6] - Rich MW. Heart failure disease management: a critical review. J Card Fail. 1999;5:64-75.

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