Right Care Happy Birthday---and a Challenge---from Million Hearts Right Care Initiative. April 5, 2018

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1 Right Care 2028 Happy Birthday---and a Challenge---from Million Hearts 2022 Right Care Initiative April 5, 2018 Janet Wright MD, FACC Executive Director, Million Hearts

2 Disclaimer/Disclosure The opinions expressed by the speaker do not necessarily reflect the opinions of the US Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the Center for Medicare and Medicaid Services. Dr. Wright has no conflicts to disclose.

3 Million Hearts What Happened? Improvements in Aspirin, BP control, Cholesterol; progress in artificial trans-fat and sodium policies Target likely achieved for tobacco prevalence Millions covered by systems reporting on the ABCS By 2014, ~115,000 CV events were prevented We estimate that up to half a million events total will have been prevented when final data are in Million Hearts = 120 official partners, 20 federal agencies, all 50 states, and the District of Columbia

4 Heart Disease and Stroke Mortality Trends, Heart Disease and Stroke Mortality Trends, Heart Disease All Cardiovascular Disease Stroke THE CVD HEADWIND Source: Mensah GA, et al. Decline in Cardiovascular Mortality Possible Causes and Implications. Circ Res. 2017;120:

5 Heart Disease Mortality Rates County-level percent change in heart disease death rates, Ages 35-64, Over 50% of counties had increases in heart disease mortality from Source: Adam Vaughan, PhD, MPH ( communication, December 11, 2017); Vaughan et al. Widespread recent increases in county-level heart disease mortality across age groups. Annals of Epidemiology. 2017;27:

6 Simulation Modeling for Million Hearts Planning Original Million Hearts Initiative First 5-year Period Second 5-year Period Prevention Impacts Simulation Model (PRISM) CVD Policy Model Three Models HealthPartners ModelHealth TM : CVD Microsimulation Model Risk Factors Assessed Aspirin use for secondary CVD prevention Blood pressure control Cholesterol management Smoking prevalence Secondhand smoke exposure Mean daily sodium intake reduction Obesity prevalence Diabetes incidence Diabetes management Particulate matter Poor fruit and vegetable diet Excess junk food Inadequate physical activity 63

7 Relative Contributions to the Million 600,000 Estimated events prevented during , , , , ,000 0 Aspirin When Appropriate Blood Pressure Control Cholesterol Management Smoking Cessation Physical Inactivity Sodium Reduction Cardiac Rehab Notes: Describes the estimated number of events prevented if Million Hearts objectives are gradually achieved during The events included closely aligns with those outlined in Ritchey et al. JAHA. 2017;6(5). The total no. of expected events prevented does not equal the sum of events prevented by risk factor type as those totals are not mutually exclusive. The aspirin when appropriate intervention reflects aspirin use for secondary prevention only. Data sources: 1 Reflects preliminary findings from simulation modeling conducted using the CVD Policy Model, ModelHealth:CVD, and PRISM (unpublished). Baseline risk factor data were determined for: aspirin when appropriate using NHANES; BP control and cholesterol management using NHANES; smoking cessation and physical inactivity using 2015 NHIS; and sodium reduction using NHANES. 2 Cardiac rehab estimates from: Ades P, et al. Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaboration. Mayo Clin Proc. 2017;92(2):

8 Million Hearts 2022 Aim: Prevent 1 Million Heart Attacks and Strokes in 5 Years Keeping People Healthy Optimizing Care COMMUNITY Priority Populations

9 Million Hearts 2022 Objectives and Goals Keeping People Healthy Reduce Sodium Intake Decrease Tobacco Use Increase Physical Activity Optimizing Care Improve ABCS* Increase Use of Cardiac Rehab Engage Patients in Heart-healthy Behaviors Improving Outcomes for Priority Populations Blacks/African Americans with Hypertension 35- to 64-year-olds due to rising event rates People who have had a heart attack or stroke People with mental and/or substance use disorders who smoke *Aspirin use when appropriate, Blood pressure control, Cholesterol management, Smoking cessation

10 Keeping People Healthy Goals Reduce Sodium Intake Target: 20% Effective Public Health Strategies Enhance consumers options for lower sodium foods Institute healthy food procurement and nutrition policies Decrease Tobacco Use Target: 20% Enact smoke-free space policies that include e-cigarettes Use pricing approaches Conduct mass media campaigns Increase Physical Activity Target: 20% (Reduction of inactivity) Create or enhance access to places for physical activity Design communities and streets that support physical activity Develop and promote peer support programs

11 Optimizing Care Goals Improve ABCS* Targets: 80% Increase Use of Cardiac Rehab Target: 70% Engage Patients in Heart-healthy Behaviors Targets: TBD Effective Health Care Strategies High Performers Excel in the Use of Teams including pharmacists, nurses, community health workers, and cardiac rehab professionals Technology decision support, patient portals, e- and default referrals, registries, and algorithms to find gaps in care Processes treatment protocols; daily huddles; ABCS scorecards; proactive outreach; finding those with undiagnosed high BP or cholesterol, tobacco use, particulate matter exposure Patient and Family Supports training in home blood pressure monitoring; problem-solving in medication adherence; counseling on nutrition, physical activity, tobacco use, risks of particulate matter; referral to community-based physical activity programs and cardiac rehab *Aspirin use when appropriate, BP control, Cholesterol management, Smoking cessation

12 Improving Outcomes for Priority Populations Disparate outcome Effective interventions Well-positioned partners Priority Population Objectives Strategies Blacks/African Americans year olds People who have had a heart attack or stroke People with mental and/or substance abuse disorders who smoke Improving hypertension control Improving HTN control and statin use Decreasing physical inactivity Increasing cardiac rehab referral and participation Avoiding exposure to particulates Reducing tobacco use Deliver guideline-congruent treatment Problem-solve in med adherence Advance practice of out-of-readings Increase access to and participation in community-based activity programs Implement treatment protocols Increase access to and participation in community-based activity programs Use opt-out referral and CR liaison visits at discharge; ensure timely enrollment Increase use of Air Quality Index Integrate tobacco cessation into behavioral health treatment Institute tobacco-free policy at treatment facilities Tailored quitline protocols

13 Million Hearts Cardiac Rehab Collaborative Amer Assoc of Cardiac and Pulm Rehab Amer Association of Nurse Practitioners American Academy of Family Practice American College of Cardiology American College of Physicians American College of Sports Medicine American Council on Exercise America s Essential Hospitals American Heart Association American Hospital Association/HRET Blue Cross Blue Shield Assoc Christiana Care Cleveland Clinic Clinical Exercise Physiology Assoc CR Participants & Caregivers Emory University George Washington University School of Public Health and Health Services Heart Failure Society of America HHQI Hospital of the University of PA Howard University Johns Hopkins Mended Hearts MedStar Health System National Medical Association Ohio State University PCORI Preventive CV Nurses Assoc Relevate Health Group Rush University Medical Center Seton Hall University Sutter Health University Hospitals UC Davis UCLA U of Pennsylvania U of Pittsburg U of Vermont Health Network Vanderbilt University Visiting Nurse Service of NY WomenHeart

14 Million Hearts CR Collaborative Action Plan Objectives Increase awareness of the value of CR among health systems, clinicians, patients and families, employers, payers Increase use of best practices for referral, enrollment, and participation; address knowledge gaps. Built equity in CR referral, participation, and program staffing Increase sustainability of CR programs through innovations in program design, delivery, and payment Measure, monitor, and report progress toward the CRC aim

15 increasing CR participation from 20% to 70% would save 25,000 lives and prevent 180,000 hospitalizations annually in the US

16 NIH-Funded Opportunities to Boost CR Participation Increasing Use of Cardiovascular and Pulmonary Rehabilitation in Traditional and Community Settings (R61/R33) Tailoring Cardiac Rehabilitation to Enhance Participation of Older Adults (R01)

17 Particle Pollution PM 2.5 refers to particulate matter of 2.5 micrometers or less in diameter Exposure is linked to an increase in risk of heart attacks, strokes, and rhythm disorders Particle pollution info on Million Hearts website Image source: EPA, Office of Research and Development

18 Populations At-Risk Are Known Susceptible populations include Populations with pre-existing respiratory disease Populations with pre-existing cardiovascular disease Adults 65 years of age and older Populations with lower socio-economic status Children & the developing fetus Populations suspected to be at greater risk Populations with chronic inflammatory diseases (e.g., diabetes, obesity) Populations with specific genetic polymorphisms (e.g., GSTM1) mediate physiologic response to air pollution 18

19 Effects of particulate matter (PM2.5) on the cardiovascular system. Hanan Qasim et al. J Am Heart Assoc 2017;6:e006353

20 Million Hearts PM 2.5 Priority Actions Raise awareness of mitigation behaviors among those at-risk, their families, and the clinicians who care for them Encourage health professionals to take EPA s web-based course: Particle Pollution and Your Patients' Health Incorporate air quality messages into cardiac rehab program curricula Encourage hospitals, employers, health systems, and others to adopt of EPA s Air Quality Flag Program Disseminate particulate info via Million Hearts channels

21 2017 Guidelines SMBP Recommendations

22 SMBP Implementation Challenges Lack of a standard definition, protocol Clinicians often don t trust readings from outside Health IT limitations Patient-generated data are not used in quality metrics Coverage for monitors Reimbursement for clinician time to Train patients and families Validate monitors Interpret home readings and provide timely advice

23 Characteristics of an Ideal System Generates a pattern of readings that is actionable Supports timely and well-timed interactions Convenient, efficient, affordable for both parties Adaptable and scalable across diverse settings Meets high standards of satisfaction for both parties Leads to rapid, safe, and sustained BP control

24 Path to the Ideal System Compelling case for accuracy and OOO readings Billing codes and/or value-based contracting Performance measure(s) that consider OOO readings EZ, smart connection between patients and clinicians Exemplars and implementation guidance Activation of people with HTN to own their BPs

25 Progress to the Ideal System? Compelling case for accuracy and OOO readings Billing codes or value-based contracting Performance measure(s) that consider OOO readings EZ, smart connection between patients and clinicians Exemplars and implementation guidance Activation of people with HTN to own their BPs

26 National SMBP Strategy Long-term vision: SMBP will be accessible to everyone for diagnosis and management of hypertension National experts--researchers, clinicians, public health experts, community organizations have convened to advance this practice

27 What is THIS?

28 What is JUUL? Electronic vaporizer that uses nicotine salts Promoted as a satisfying alternative to cigarettes By accommodating cigarette-like nicotine levels, JUUL provides satisfaction to meet the standards of smokers looking to switch from smoking cigarettes. Available in tobacco, fruit, mint and other flavors Every JUUL flavored pod contains nicotine

29 JUUL Nicotine Delivery 59 mg/ml

30 JUUL Market Growth In January, 2018, JUUL represented 49.6% dollar share of the e-cig market. Source: Nielsen Total US xaoc/convenience Database and Wells Fargo Securities, LLC

31 Opportunities in U.S. Adults to Prevent Cardiovascular Disease Blood Pressure 34 M Cholesterol 35M/42M Sodium 215M Physical Activity 124 M Tobacco Use 36.5 M Uncontrolled Unmanaged Overconsume Underexert Smoke We Know What Works

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34 Million Hearts Hypertension Challenge California Champions LifeLong Medical Care Downtown Oakland Health Center Sharp Rees-Stealy Medical Groups Petaluma Health Center Family Health Centers of San Diego Kaiser Permanente, Southern California Kaiser Permanente, Northern California

35 Deepest Gratitude to Generous Teachers, Powerful Change Agents Tony DeMaria, MD Kathleen Tong, MD Hattie Hanley MPP Joel Handler, MD Jerry Penso, MD, MBA

36 Thank you More information about Million Hearts 2022 at Reach me at

37 Resources

38 New Resources Million Hearts 2022 web content Particle Pollution Physical Activity Tobacco Use Partner Opportunities Cardiac Rehabilitation EPA s citizen science mobile app: Smoke Sense

39 Million Hearts for Clinicians Microsite Makes an evergreen link to Million Hearts content on your website Features Million Hearts protocols, action guides, and other QI tools Uses a small amount of HTML code customizable by color and responsive to layouts and screen sizes Content is free and continuously maintained by CDC Available at

40 Million Hearts Clinical Resources and Tools Action Guides Hypertension Control: Change Package for Clinicians Self-Measured Blood Pressure Monitoring: Action Steps for Clinicians Identifying and Treating Patients Who Use Tobacco: Action Steps for Clinicians Team Protocols for treating Hypertension, Tobacco use, Cholesterol Undiagnosed Hypertension Finding Patients Hiding in Plain Sight change package Prevalence Estimator Tool Making the Most of Health IT Million Hearts EHR Optimization Guides-how to find and use data on the ABCS Clinical Quality Measures Million Hearts ABCS Million Hearts Dashboard quality reporting on the ABCS measures by state Other Tools ASCVD Risk Estimator Hypertension Control Champion Success Stories Million Hearts for Clinicians Microsite at 40

41 Million Hearts Community Resources and Tools Action Guides Self-Measured Blood Pressure Monitoring: Action Steps for Public Health Medication Adherence: Action Steps for Public Health Practitioners Medication Adherence: Action Steps for Health Benefit Managers Cardiovascular Health: Action Steps for Employers CDC State Heart Disease and Stroke Prevention Programs State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health (1305) Coverdell National Acute Stroke Program WISEWOMAN Sodium Reduction in Communities Building GIS Capacity for Chronic Disease Surveillance Million Hearts Cardiac Rehab Collaborative Healthy Is Strong 100 Congregations for Million Hearts 41

42 Million Hearts Consumer Resources and Tools Heart Age Predictor My Life Check High Blood Pressure: How to Make Control Your Goal Visit Checklist Supporting Your Loved One with High Blood Pressure Blood Pressure Wallet Card Smoke Free (SF) Million Hearts Videos (on YouTube) Million Hearts E-Cards & Shareables Mind Your Risks Tips from Former Smokers 42

43 Wildfire Smoke Guide 2018 To be Released before Next Wildfire Season Updated look Smoke vs urban particles Addition of ozone Add sections - PM web course - Sensors - Ash clean-up Stand-alone fact sheets - Children - Older adults - Pets/livestock - Older adults - Respirator use - Ash clean-up - Preseason preparedness - Exposure reduction - Know when to evacuate 43

44 Wildfire Smoke Guide 2018 Example of Draft Fact Sheets 44

45 An individual can be advised to: Stay indoors Reduce outdoor physical activity Respirators (e.g., N-95) can help in the short-term Public Health Recommendations Exposure Reduction Measures Activate asthma/copd action plans Use a home clean air shelter A community can be advised to: Cancel outdoor events Provide community clean air shelters Increase air filtration in institutions Evacuate 45

46 Key Actions to Protect Your Health From Air Pollution Know who is at risk Youth and older individuals Those with cardiovascular or respiratory disorders Check to know when and where particle pollution levels may be unhealthy o Busy roads o Rush hour traffic o Smoke from fires Track the Air Quality Index for forecasts of daily air quality Adapt activities to mitigate exposure Reduce overall risk of heart disease or stroke

47 Interactive Atlas of Heart Disease and Stroke High quality local level data and maps Mortality & Hospitalization Data Behavioral Risk Factors Social and Economic Data Health Care Delivery & Insurance Air Pollution Blood Pressure Medication Adherence Cost Data Overlay Features (includes hospitals with cardiac rehabilitation services) Download data Share maps Identify clusters Produce reports Compare data