Focus on Cardiovascular Disease

Addressing the Quality Gap in Cardiovascular Care

As described in the previous section, cardiovascular risk factors such as dyslipidemia, hypertension, and diabetes are still largely uncontrolled.^[1],[2]To close this gap in quality cardiovascular disease (CVD) management, barriers to preventive care must be identified; interventions must be developed, implemented, and fine-tuned; and finally, results must be measured. Although each plan will have its own unique barriers to quality care, research has demonstrated that the following obstacles often stand in the way of quality cardiovascular care:^[3]

• Systems are not in place for reminders, case management, and quality improvement initiatives
• Physicians may not have the requisite knowledge, attitude, and motivation to incorporate preventive services into their practice
• Patients may not have the motivation and willingness to change their behavior, comply with therapy, and follow up with their physicians

Interventions that can be used by health plans to address some of these common barriers to quality cardiovascular care include, but are not limited to:

• Behavioral change programs directed at clinicians and patients that focus on use of clinically relevant material from consensus statements and/or clinical guidelines
• Performance measurement with feedback and benchmarking
• Disease and case management programs^[4]
• Reimbursement for effective preventive care

Effective interventions must be tailored to address the plan’s unique barriers, meet the needs of the plan’s clinicians and members, and must be supported by the plan’s resources (funding, staffing, and systems). Results should be assessed with meaningful and reproducible measures that, again, are supportable and sustainable by the plan’s infrastructure.

Improving the quality of cardiovascular care is a worthwhile investment. According to the Centers for Disease Control and Prevention and the National Center for Health Statistics, life expectancy will rise by almost seven years if all major forms of CVD are eliminated.^[5] And the World Health Organization asserts that deaths and disability caused by heart disease and stroke could be cut in half by reducing major risk factors such as hypertension, dyslipidemia, obesity, and smoking.^[6] The claim is, in fact, supported by a recent study which concluded that the risk of cardiovascular events could be reduced by about 50% in patients with type 2 diabetes and microalbuminuria by applying a multifactorial intervention that targeted hypertension, dyslipidemia, hyperglycemia, and microalbuminuria (and used aspirin therapy for secondary prevention of CVD).^[7]

Financial benefits to total cardiovascular risk management exist as well. Effective cardiovascular risk management has the potential to reduce the huge economic burden that is borne by health plans, employers, patients, and society. Although the cost effectiveness of a comprehensive approach to risk factor assessment and management has not yet been determined, the following findings on the assessment and management of individual risk factors suggest that such an approach should prove to be associated with enhanced efficiencies:

• Screening for the presence of hypertension is highly cost effective^[8]
• Treatment for hypertension is generally cost effective for both men and women of all ages^[8]
• Treatment of dyslipidemia with hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors appears to be cost effective in coronary heart disease (CHD)^[9]
• The cost effectiveness of various HMC-CoA reductase inhibitors varies widely^[9]
• Secondary prevention of CVD through intensive management of lipid abnormalities is particularly cost effective among diabetics^[10]
• Primary prevention with HMG-CoA reductase inhibitors in diabetic patients may be associated with substantial benefits and attractive cost-effectiveness ratios^[10]

The most immediate and significant benefit associated with improved cardiovascular care is the ability to reallocate resources once used for expensive procedures such as coronary artery bypass surgery. These resources are better applied to preventive care, which has additional collateral benefits. These include more satisfied and healthier members, a competitive advantage with employers over plans without improved cardiovascular management, the use of cardiovascular initiatives for accreditation, the opportunity to collaborate with clinicians, and pay for performance through programs such as the Heart Stroke Recognition Program (HSRP), which was recently launched by National Committee for Quality Assurance (NCQA) and the American Heart Association/American Stroke Association (AHA/ASA), and supported in part by a grant from Pfizer. Modeled after the American Diabetes Association/NCQA Diabetes Physician Recognition Program (DPRP), the HSRP aims to stimulate improvement in the quality of cardiovascular and stroke care by creating incentives for physicians to increase screening and control of the major CVD risk factors. If the HSRP can achieve the same kind of results as were achieved through the DPRP - thousands of lives can be spared each year.

[1] - Data on file, Pfizer Inc, New York, NY.

[2] - National Diabetes Education Program. The link between diabetes and cardiovascular disease. Available at: www.ndep.nih.gov/control/CVD.htm Accessed June 6, 2003.

[3] - Keevil JG, Stein JH, McBride PE. Cardiovascular disease prevention. Prim Care Clin Office Pract. 2002;29:667-696.

[4] - Pearson TA, McBride PE, Miller NH, Smith Stephen Covey Jr. 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 8. Organization of preventive cardiology service. J Am Coll Cardiol. 1996;27:1039-1047.

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

[6] - World Health Organization. Cardiovascular death and disability can be reduced more than 50 percent [press release]. October 17, 2002. Available at: www.who.int/mediacentre/releases/pr83/en/print.html. Accessed June 19, 2003. . Accessed July 24, 2003.

[7] - Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003;348:383-393.

[8] - Goldman L, Garber AM, Grover SA, Hlatky MA. 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task force 6. Cost effectiveness of assessment and management of risk factors. J Am Coll Cardiol. 1996;27:964-1047.

[9] - Elliott WJ, Weir DR. Comparative cost-effectiveness of HMG-CoA reductase inhibitors in secondary prevention of acute myocardial infarction. Am J Health Syst Pharm. 1999;56:1726-1732.

[10] - Grover SA, Coupal L, Zowell H, Dorais M. Cost-effectiveness of treating hyperlipidemia in the presence of diabetes: who should be treated? Circulation. 2000;102:722-727.

[11] - Physician Consortium for Performance Improvement. Clinical performance measures: chronic stable coronary artery disease. American Medical Association. Available at: www.americanheart.org/downloadable/heart/1055798504173CADMiniSetR030158_final.pdf. Accessed August 23, 2003.

[12] - Tipton ML, Fleming M. Stroke prevention in managed care: a five-dimensional health improvement model. In: Gorelick PB, After M, eds. The Prevention of Stroke. New York, NY: The Parthenon Publishing Group; 2002:123-130.

[13] - National Cholesterol Education Program. Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Bethesda, MD: National Heart, Lung, and Blood Institute; 2002. NIH publication 02-5215.

[14] - 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.