Million Hearts

Preventing 1 million heart attacks and strokes in 5 years

What is Million Hearts?

• Goal: Prevent 1 million heart attacks and strokes over the next 5 years

• Engage public and private sector partners in a coordinated approach to:– Reduce the number of people who need treatment– Improve the quality of treatment for those who need it– Maximize current investments in cardiovascular

health

Heart disease and strokes are leading killers in the U.S.

• Cause 1 of every 3 deaths• More than 2 million heart attacks and strokes

occur every year; 800,000 die– Leading cause of preventable death among people

<65

• Treatment accounts for about $1 of every $6 spent on health care

• Accounts for the largest single portion of racial disparities in life expectancy

Status of the ABCS

Aspirin People at increased risk of cardiovascular disease who are taking aspirin

47%

Blood pressure

People with hypertension who have adequately controlled blood pressure

46%

Cholesterol People with high cholesterol who have adequately controlled hyperlipidemia

33%

Smoking People trying to quit smoking who get help 23%

Source: MMWR: Million Hearts: Strategies to Reduce the Prevalence of Leading Cardiovascular Disease Risk Factors --- United States, 2011, Early Release, Vol. 60

Key components of Million Hearts

• Clinical Prevention – improving care of the ABCS through:– Focus – simplify and align quality measures; emphasize

importance of improved care of the ABCS– Health IT – use electronic health records to improve care

and enable quality improvement through clinical decision support, patient reminders, registries, and technical assistance

– Care innovations – team-based care, interventions to promote medication adherence

• Community prevention – reducing the need for treatment through:– Prevention of tobacco use– Improved nutrition – decrease sodium and artificial

trans fat consumption

Community preventionTobacco control

• Tobacco is leading preventable agent of death

• Strengthen tobacco control and reduce smoking by discouraging smoking initiation and encouraging cessation– Warn people about harms of tobacco use through

package labeling, mass media, and other measures

– Create smoke-free public places and workplaces

• Comprehensive tobacco control programs are most effective– Synergies between individual program elements

Reasons for hope: Reduced smoking in New York City

18.9%

11%

% o

f N

ew Y

ork

Cit

y S

mo

kers

8

10

12

14

16

18

20

22

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

18.3%17.5%

• 350,000 fewer adult smokers• >100,000 fewer smoking-related deaths

in future years

15%

19.2%

21.5%

18%

2008

8.5%

16.9%

15.8%

Community preventionReducing sodium intake

• Most Americans consume far too much sodium, which increases risks of hypertension and cardiovascular disease

• Most (~80%) sodium comes from processed/restaurant foods, which makes it difficult for Americans to limit sodium consumption

• Federal procurement guidelines and school food standards include a focus on sodium reduction

• FDA/USDA have issued a request for information on sodium reduction

• CDC is increasing public and professional education about sodium

• NHANES will begin collecting information on sodium consumption

Community preventionEliminating artificial trans fat

• Trans fat increases LDL cholesterol, decreases HDL cholesterol, increases risk of heart attacks– IOM: reduce intake to as close to zero as possible

• Replacing artificial trans fat with heart-healthy oils is feasible and does not increase the cost or change the flavor or texture of foods

• Since FDA began requiring listing of trans fat content on food labels, the food industry has voluntarily reformulated foods– Americans’ trans fat consumption has decreased

by at least half

What can be doneIn the community

• Retailers – Offer blood pressure monitoring and educational resources;

focus on improving ABCS care in retail clinics

• Government – Support community and systems transformation to reduce

tobacco use and improve nutrition, including smoke-free policies and food procurement standards; provide data for action; expand coverage for the uninsured

• Foundations – Support consumer and provider outreach and education

• Advocacy groups – Monitor progress toward goal and promote actions

that prevent heart attacks and strokes

New CDC Community Supports

• Community Transformation Grants (CTG)– >$100 M in prevention grants– ~60 Communities– All communities will address tobacco, physical

activity, nutrition, clinical preventive services – specifically to control HTN, HBC

– Look for announcement of communities next week.

National Dissemination and Support for CTG’s

• Dissemination Networks• APHA• Asian Pacific Partners for Empowerment and Advocacy• Community Anti-Drug Coalition• National Farm to School Network at Occidental College

• Acceleration Networks– American Lung Association– National REACH coalition– YMCA of the USA

Pharmacy Outreach Program

• Objectives– Grow and strengthen community of orgs

focusing on HTN– ↑ awareness that poor adherence to HTN

meds is weak link in CVD risk reduction– ↑ # of pharmacists actively engaging in

counseling pts on adherence– ↑ # of pts who are discussing HTN meds with

their pharmacist.

Million Hearts Leadership

• Co-led by CDC and CMS• Quarterly reporting to HHS• All of HHS• Executive Director

– Janet Wright MD FACC– CDC Medical Officer housed at CMS

Innovations Center

Operating Values

How we shall work together and with others?

• Boundarilessness• Speed and Agility• Unconditional Teamwork• Valuing Innovation• Customer Focus

The Three Part Aim

Better Health forthe Population

Better Carefor Individuals

Lower CostThrough

Improvement

Reasons for hope

• HRSA Health Centers Collaborative Study increased daily aspirin intake from 53% to 67% after intervention

• KP Colorado high Blood Pressure and Cholesterol Management Program improved from having 26% of patients with cholesterol under control to having 73% of patients with cholesterol under control

• Rhode Island Cardiovascular Chronic Care Collaborative saw an increase in blood pressure control among participants from 20% to 60%

• Work by Medicaid Massachusetts yielded a drop from a smoking rate of over 38% to a smoking rate of 28% in 2.5 years

The question is not whether superb performance and sustainability is possible,

the question is whether it is possible at scale.

Getting to Scale

“I think when people look back at our time, they will be amazed at one thing more than any other.

It is this – that we do know more about ourselves now than people did in the past, but that very little of this knowledge has been put into effect.”

Doris Lessing

Getting to Scale

Eleven Lessons from the Best

1. They have shared, crisp, public aims, owned by leadership, and they’re rabid about them.

2. They welcome everyone. (Unleash)

3. They get to the field. (It’s not a web site.)

4. Their work is rooted in actions and transactions. (Rhythm)

5. They are “brutally opportunistic.” (Jazz)

6. They play well with levers.

7. They tend to affection. (Value)

8. They have a shared story and they use the language of creation (not avoidance).

9. They go broad and deep.

10. They examine and revise their rules base.

11. The patient is in the room…always.

Eleven Lessons from the Best

1. They have shared, crisp, public aims, owned by leadership, and they’re rabid about them.

2. They welcome everyone. (Unleash)3. They get to the field. (It’s not a web site.)

4. Their work is rooted in actions and transactions. (Rhythm)

5. They are “brutally opportunistic.” (Jazz)

6. They play well with levers.7. They tend to affection. (Value)

8. They have a shared story and they use the language of creation (not avoidance).

9. They go broad and deep.

10. They examine and revise their rules base.

11. The patient is in the room…always.

Clinical preventionFocus on ABCS

• Improving management of ABCS can prevent more deaths than other clinical preventive services

• Increasing utilization of these simple interventions could save more than 100,000 lives a year– Patients reduce risk of heart attack or stroke by taking

aspirin as appropriate– Treating high blood pressure and high cholesterol

substantially and quickly reduces mortality among high-risk patients

– Even brief smoking cessation advice from clinicians doubles likelihood of successful quit attempt – use of cessation medications increases quit rates further

Improved cardiovascular care could save 100,000 lives/year in U.S.

Source: Farley TA, et al. Am J Prev Med 2010;38:600-9.

Smoking cessation

Blood Pressure control

Cholesterol control

Aspirin prophylaxis

Clinical preventionIncreasing focus

• Improving ABCS is top priority • Aligning incentives, communication, clinical

measurement, and reporting by physicians, health care facilities, and health care systems

• Simple, consistent ABCS indicators into:– Physician Quality Reporting System, – EHR meaningful use criteria, community clinic

measures, and guidelines from private-sector organizations

– Medicare Part D & MA/PD Plan Ratings– Quality Improvement Organizations

•

Clinical preventionInformation technology

• HIT will enable health care providers and facilities to improve cardiovascular care and target intervention to patients in need of intensified care– Registries, EHR functions used at point of care

• Include clinical quality measures for hypertension and cholesterol control in Meaningful Use criteria– Can include routine assessment of cardiac risk;

use of patient recall, reminders, decision support, order sets; and monitoring of medication adherence

Clinical preventionTeam-based approaches to care

• Team-based care can provide higher quality at lower cost– Allied health workers can provide support to

physician-directed efforts

• Increasing use of effective ABCS care practices through support, evaluation, and rapid dissemination of innovations including– Team-based care

– Patient-centered medical homes

– Interventions to promote adherence

Pharmacists can be key partners in CVD prevention

CVD Risk Factor ReductionSystolic/diastolic blood pressure –8.1/–3.8 mm Hg

Total cholesterol –17.4 mg/L

LDL cholesterol –13.4 mg/L

Smoking 23% reduction

Care from pharmacists* is associated with significant reductions in cardiovascular disease risk

* Interventions exclusively conducted by a pharmacist or implemented in collaboration with physicians or nurses; may include patient educational interventions, patient reminder systems, measurement of CVD risk factors, medication management and feedback to physician, and/or educational intervention to health care professionals.

Source: Santschi V, et al. Arch Intern Med 2011;171:1441-53.

What can be doneIn the medical system

• Health care providers – Focus on prevention of heart disease and stroke; improve

care of ABCS; use health IT, including decision supports and registries, to drive quality improvements

• Pharmacists– Monitor medication refill patterns; engage doctors and

patients in managing health

• Insurers – Include ABCS in performance measures; collect and share

data for quality improvement; empower consumers

• Individuals – Take aspirin, if appropriate; take blood

pressure and cholesterol medications as prescribed; if you smoke, quit

How will you help?

Monitoring progress of Million Hearts

Population Metric Baseline 2017

Aspirin for those at high risk1 ~50% 65%

Blood pressure control2 ~50% 65%

Cholesterol control2 ~33% 65%

Smoking prevalence3 ~19% 17%

Average sodium intake2 ~3.5g/day 20% reduction

Artificial trans fat intake2 ~ 1% of calories 50% reduction

1As measured in NAMCS2As measured in NHANES3As measured in NHIS

Note: Population-wide indicators – clinical performance goals higher

Public sector support

• Administration on Aging• Agency for Healthcare Research and Quality• Centers for Disease Control and Prevention • Centers for Medicare & Medicaid Services• Food and Drug Administration• Health Resources and Services Administration• Indian Health Service• Substance Abuse and Mental Health Services

Administration• National Institutes of Health, National Heart Lung and

Blood Institute• National Prevention Strategy• National Quality Strategy

Private sector support• American Heart Association • America’s Health Insurance Plans • American Medical Association• American Nurses Association• American Pharmacists’ Association and the American Pharmacists’

Association Foundation • Kaiser Permanente• The National Alliance of State Pharmacy Associations and the Alliance

for Patient Medication Safety• The National Community Pharmacists Association • UnitedHealthcare• Walgreens • The Y

http://millionhearts.hhs.gov

Million Hearts Publications

For More Information:

www.millionhearts.hhs.gov