Transcript The Consortium for Southeastern Hypertension Control (COSEHC)

THE CONSORTIUM FOR SOUTHEASTERN
HYPERTENSION CONTROL (COSEHC)
Who we are….
What we are doing…
Where we are going…
JaNae Joyner, Ph.D.
Hypertension Center RiP Meeting
March 9, 2011
www.cosehc.org
Heart Disease Trends in US regions
340
320
300
280
Rate
South Atlantic US
East South Central US
260
West South Central US
Total US
240
220
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
200
JoynerJ, Simmons DR, Moore MA, Ferrario, CM. The Impact of Changing ICD Code on Hypertension-Related Mortality in the Southeastern United States from
1994-2005. . The Journal of Clinical Hypertension. 2010;12(3):213-222.
www.cosehc.org
who we are….
COSEHC Establishment
Non-profit 501 (c) (3) volunteer organization
 Established in 1994 at Wake Forest University
 Co-founded by Drs. Carlos Ferrario and
Michael Moore
 Initial expert thought leaders from academic
institutions throughout the Southeast and from
the NIH

www.cosehc.org
COSEHC Officers and Staff

Officers
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
Michael A. Moore, MD, President
Carlos M. Ferrario, MD Vice Pres of Development
Daniel Wise, MD, Vice Pres of Administration
Richard Schuster, MD, MMM, Secretary
Paul Farrell, MD, Treasurer
Staff



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
Debra Simmons, MS, Executive Director
JaNae Joyner, PhD, Research Associate
Jeff Atwell, IT Manager
Janie Marshall, IT Programmer
Susie Pollock, Program Coordinator
www.cosehc.org
Vision and Mission


Vision: To eradicate vascular disease in all
people
Mission: To empower health care
professionals, patients, and the public with
better knowledge, tools, and competencies
through continuous quality improvement to
secure vascular health for all people
www.cosehc.org
COSEHC Cardiovascular (CV) Centers of ExcellenceTM
 Currently, a collaborative network of 33 Centers
 Works together to reduce excess CV disease in
the Southeast
 Provides database driven best practices,
professional and consumer education, research, and
quality improvement evidenced-based strategies.
Jamaica
Barbados
Benefits of Joining COSEHC
Database Benchmarking
Networking
Access to Best Practices
Quality Improvement Initiatives
Continuing Medical Education Opportunities
Access to Clinical Trials
www.cosehc.org
Expectations of COSEHC CV Centers TM
Identify a COSHEC CV Center director
Ongoing participation in the COSEHC clinical
database
Ongoing professional outreach/education
Defined business/program/project plan
Completion of the COSEHC CV Center annual
report
Attendance at COSEHC meeting by the
Center director
www.cosehc.org
COSEHC Continuing Medical Education (CME)
Continuing Professional Education
Annual
Scientific
Sessions
Joint
Sponsorships
With CV
Centers
ASH, SMA,
ADA, Health
Dept
Regional
Lectures and
Symposia
TriState
Program
International
Presence
(IASH)
Quality Improvement
Programs
ATGOAL
ATGOAL-LA
COSEHC is accredited by the Accreditation Council for Continuing Medical
Education (ACCME) to provide continuing medical education for physicians.
what we are doing…
Current Activities/Projects

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

COSEHC Annual Scientific Sessions
Novartis TriState (Regional Meetings)
ATGOAL (Quality Improvement)
ATGOAL-LA (Quality Improvement)
COSMIC (Quality Improvement)
COSEHC Risk Tool/Database (CV Centers)
Patient Inertia (Patient behavior)
COSEHC Annual Scientific Sessions



Has held 16 annual scientific sessions
Held an international meeting in 2007 with the
Inter-American Society of Hypertension (IASH)
Planning underway for 2011 Scientific Sessions to
be held in Charlotte, NC (November 3-6, 2011)
The Novartis TriState Project
Addressing Cardiometabolic Neuronal-Hormonal Pathophysiology to
Reduce the Risk of the Cardiometabolic Syndrome
Funded by a continuing medical education grant
from Novartis Pharmaceutical Corporation
Learning objectives:


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Describe the neuro-hormonal pathophysiology of the cardiometabolic syndrome;
Define the pathological interrelationship of the RAS that underlies the cardiometabolic
syndrome;
Diagnose the cardiometabolic syndrome;
Demonstrate competency in prescribing evidenced based treatment with focus on
reducing the activity of the RAS to reach the recommended treatment goals
Methodology

Current
progress
Six regional ½ day live educational activities in the
states of Alabama, Mississippi, and Louisiana by
COSEHC faculty members


One webinar-inter-reactive educational activity


Pre-test and post-test via an audience response system
An announcement will be sent via e-mail blast to 10,000
individuals including those in the COSEHC contact
database and purchased e-mail lists
One enduring CME Newsletter using educational
content developed for the live programs
Regional Meetings
179 total participants across 6 workshops
1
2
3
3
5
4
2
4
6 1
5
6
Mobile, Alabama
July 17, 2010
13 participants
Birmingham, Alabama
August 7, 2010
44 participants
Jackson, Mississippi
August 28, 2010
28 participants
Metairie, Louisiana
October 2, 2010
36 participants
Baton Rouge, Louisiana
December 4, 2010
23 participants
Hattiesburg, Mississippi
January 8, 2011
35 participants
Test of Immediate Retention –
Difference in Percent


A pre/post test was given to physicians at each
regional meeting using an audience response system
On average, there was a 21% increase in physician
knowledge after participation in the COSEHC TriState
½ day regional meeting.
Location
Difference in Percent of Knowledge
Mobile, AL
+15%
Birmingham, AL
+28%
Jackson, MS
+9%
Metairie, LA
+17%
Baton Rouge, LA
+14%
Hattiesburg, MS
+40%
AVERAGE
+21%
Difference in Percent = (% correct post test – % correct pre test)
30 day web-based post-test

Objective:
 Designed
with clinical scenarios to evaluate
physician competency in managing cardiovascular
patients

Results:
 72%
return rate
 The top two areas stated where new knowledge or
skills were obtained was:
 Current
goals for treatment of hypertension,
hyperlipidemia, and diabetes
 Management of hypertension
30 day post-test responses
Changes made in Care
Less use of beta blockers for
hypertension
Use of HgA1c as
diagnostic
criteria
More Aggressive
Treatment
Medication Protocols
Assessment of
waist
circumference
Different strategies for
rather than BMI
management of diabetic
Increase patient
patients
awareness of
Early use of
consequences of health
Metformin; using
Valturna more
Optimizing BP control using more
frequently for
than one medicine
uncontrolled BP
30 day post-test responses
Physician Perceived Barriers to Implementing Change



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




Medication costs
Social issues/lifestyles
Time constraints
Insurance restrictions (drugs & tests)
Insurance formulary changes
Patient compliance
Patient finances
Patient lack of motivation
Poor patient education
Too much paperwork
The ATGOAL Project
AGGRESSIVELY TREATING GLOBAL CARDIOMETABOLIC RISK
FACTORS TO REDUCE CARDIOVASCULAR EVENTS (ATGOAL)
Funded by a continuing medical education grant
From Pfizer, Inc.
Learning objectives:
•Improved concordance to guidelines by physicians in targeted practices.
•Assess cardiovascular risk by understanding cardiometabolic risk factors and the
importance of early assessment of these risk factors.
•Prescribe treatment for aggressively treating the global cardiometabolic risk factors to
therapeutic target goals as described by JNC-7, ATP-III, and ADA guidelines.
Abstract presented/submitted
Presented:
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

The American Society of Hypertension (ASH). May, 2010 (New York, NY)
The International Society of Hypertension in Blacks (ISHIB). July, 2010
(Washington, DC)
The Consortium for Southeastern Hypertension Control (COSEHC) annual
scientific sessions. October, 2010 (Charleston, SC)
Submitted:


The American Society of Hypertension (ASH). May, 2011 (New York, NY)
The American Heart Association (AHA) Quality of Care and Outcomes in
Cardiovascular Disease and Stroke. May, 2011 (Washington DC)
National Control Rates
ALL PATIENTS
 50.1% = Hypertension Control Rate


To levels < 140/90 mm Hg
33.2% = LDL Cholesterol Control Rate

To levels < 100 mg/dL
DIABETIC PATIENTS
 45.2% = Diabetic Hypertension Control Rate


To levels < 130/80 mm Hg
46.6% = Diabetic LDL Cholesterol Control Rate

To levels < 100 mg/dL
Egan et al, JAMA. 2010; 303(20): 2043-2050.
CDC. Centers for Disease Control and Prevention MMWR. 2011; 60(4): 109-114
Bernard et al, Ther American Journal of Medicine. 2009; 122: 443-453.
NHANES Data: Hypertension Prevalence,
Awareness, Treatment and Control
Prevalence
Awareness
Treatment
Egan, B. M. et al. JAMA 2010;303:2043-2050
Control
Physician quality improvement
initiatives
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Considerable gaps persist in physician knowledge
and application of therapeutic and lifestyle guideline
recommendations for cardiovascular risk reduction.
Only 47% of the 96% of subjects qualifying for lipid
therapy received any treatment
35-85% of patients with hypertension,
hyperlipidemia, and diabetes were not reaching
therapeutic target goals
Steinberg et al, American Heart Journal, 2009; Schrott et al, JAMA, 1997
Objective

To determine if customized
performance/process improvement continuing
medical education (PI-CME) can improve
concordance to guidelines by physicians in
targeted practices as demonstrated by an
increase in the number of patients at
recommended cardiovascular disease target
goals from that recorded at baseline
evaluation.
PI-CME

Performance Improvement CME is when:
1) an educational need is determined through a
measure of a physician’s performance in practice,
 2) a physician engages in educational experiences to
meet the need.
 3) The physician integrates learning into patient care
 4) The physician’s performance is re-evaluated.

ATGOAL INTERVENTION MAP
Baseline data
collected and
analyzed
2nd quarter data
collected and
analyzed
CME education
program by
COSEHC faculty
Webinar (Joyner &
Simmons) notes recorded
and provided to faculty
Feedback
notes recorded
2nd quarter webinar
(includes COSEHC faculty who provided
CME program). Focus on review of action
plan progress and additional interventions
to improve performance.
Intervention Plan
1st quarter
webinar to
practice (Joyner
& Simmons)
3rd quarter data
collection and
analysis
90 days after
education, data
collected and
analyzed
4th quarter data
report and
annual report
Data Abstraction Process and
Limitations
Data Abstraction Process
Limitations
Practice sites create a list of patients
seen within past 18 months for ICD
codes 272, 250, and/or 401
Charts randomized from patient list
to obtain n=300
Manual or electronic data
abstraction
Collected data analyzed and
benchmark reports developed
Clinical data
divided by
subgroups does
not always reflect
the total sample
size of that group
Lab date is not
always the same as
the visit date. Most
recent lab values
used -- may have
missed some values
as a result.
Missing data may
be the results of
not finding the
data in the chart
during manual
abstraction
Ethnicity
determined from
the chart (if
available) or by
consultation with
the
physician/office
staff
COSEHC PI-CME
Baseline
Patient
Outcomes
Assessment
Plan
Identify
Professional
Gaps in
Patient
Outcomes
Do
CME
Intervention
ACT
Check
3 Month
Clinical Data
Assessment
Summary Status
27 Enrolled Practices/ 9 sites in Discussion
Baseline Data
Collection
(27)
Baseline Data
Webinar
(23)
CME Completed
(21)
Quarter 1 Data
Collection and
Webinar
(21)
Quarter 2 Data
Collection and
Webinar
(14)
Quarter 3 Data
Collection and
Webinar
(4)
Quarter 4 Data
Collection and
Webinar (2)
Pending Signature
of Consents
(4)
Sites in Discussion
(5)
As of February 23, 2010
Locations
27 Enrolled Practices / 9 in Discussion
2
4
3
2
4
1
5
6
4
5
Current ATGOAL sites
Pending sites
Systolic blood pressure control rates among
COSEHC ATGOAL practices in the Southeast US
100
70
89
69
81
75
68 71
58
60
78
69
79 82
86
85
76
70 72 70
69
72
77
68 7171
69
73
61
53
50
40
30
20
10
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
AVERAGE
Percent (%)
90 83
80
Key:
National Hypertension Control Rate = 50.1%
Average of all ATGOAL practices
Individual ATGOAL practices
LDL cholesterol control rates among COSEHC
ATGOAL practices in the Southeast US
70
60
64
63
58
49
46
43
48
45
48
41
41
49
49 49
46
41
44
39 39
40
32
30
20
10
Average of all ATGOAL practices
Individual ATGOAL practices
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
National LDL cholesterol control Rate = 33.2%
AVERAGE
Key:
9
8
7
6
5
4
3
2
0
1
Percent (%)
50
58
56
55
54
53 53
51
62
HDL cholesterol control rates among COSEHC
ATGOAL practices in the Southeast US
69
74
75 78
83
72 70
Key:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
AVERAGE
Percent (%)
100
90
90
90
82
78
78
76
80
74
71
70
69 70 6767 70
70
58
57
55 57
60
51
50
44
40
30
20
10
0
Average of all ATGOAL practices
Individual ATGOAL practices
Percent of patients achieving therapeutic target goals
among 20 ATGOAL practices at baseline
All
Diabetic
African
American
> 65
Years
Female
SBP
< 140 mm Hg
< 130 mm Hg
(diabetic)
74% 47%
73%
73%
73%
LDL
< 100 mg/dL
48% 63%
45%
55%
44%
HDL
> 40 mg/dL
66% 60%
72%
69%
77%
www.cosehc.org
Changes in average CVD risk factors between
baseline and three months after the initial CME
Changes in Cardiovascular Risk Factor Mean Values between Baseline and 3
Month Follow-up.
patient
3 month
record
Baseline
follow-up
sample size
Systolic blood pressure (mm
Hg)
131.2 + 17.4
129.2 + 15.6 *
1958
LDL Cholesterol (mg/dL)
99.7 + 34.9
98.9 + 33.4
986
HDL Cholesterol (mg/dL)
46.7 + 15.7
48.2 + 22.4 *
1008
* p< 0.05; values expressed as mean + standard deviation. Patients had to have
both a baseline and follow-up value to be included in this paired t-test.
Data from 20 ATGOAL practices
Improvements at 3 months




60% (12 of 20 clinics) improved the percentage of
total patients at systolic BP goals at 3 months
55% (11 of 20 clinics) improved the percentage of
total patients at LDL cholesterol goals at 3 months
70% (14 of 20 clinics) improved the percentage of
total patients at HDL cholesterol goals at 3 months
The greatest improvement was among the female
subpopulation.
Preliminary Conclusions

Scope of practice designed process
improvement continuing medical education
(PI-CME) can improve therapeutic target
goal rates for CVD risk factors through a
continuous quality improvement (CQI)
process.
The ATGOAL-LA Project
Aggressively Treating Global Cardiometabolic Risk Factors in Louisiana to Reduce
Cardiovascular Events, Improve Patient Outcome, and Reduce Healthcare Costs
Funded a grant
From Blue Cross Blue Shield of Louisiana
Learning objectives:
•Engage early and aggressive management of patients with cardiometabolic risk factors by improving the
clinical competency and performance of providers
•Educate Louisiana providers in the use of a quality improvement process
•Promote the appropriate use of cost-effective medications to assist in the achievement of treatment goals
•Evaluate best methods for providing physician education to improve patient cardiovascular disease
outcomes
Project Overview
Collect cardiovascular
(“CV”) clinical data
Establish steering
committee
Enroll the 10
primary care practices
Collect additional NCQA
Diabetes Recognition
Program (DRP) required
clinical data
Produce baseline reports to
illustrate CV risk factor
control professional
practice gaps
Deliver a customized
Category 1 practicespecific education program
intervention onsite
Collect and analyze 4
quarterly post data
collections after initial
education to measure
changes in performance
Provide quarterly practice
performance trend and
benchmark reports to
enrolled practices by
webinar.
Provide 20 Category 1
AMA or AAFP CME Credits
for Physicians
• Analyze to determine baseline level of
performance in achieving CV risk
factor control
NCQA Diabetes Recognition Program


National Committee on Quality Assurance (NCQA) is an independent not
for profit organization that evaluates managed care organizations with a
mission of improving health care quality.
Diabetes Recognition Program (DRP):



Outcomes measures

HbA1c > 9%; < 8%; <7%

Blood Pressure > 140/90 mm Hg; < 130/80 mm Hg

LDL > 130 mg/dL; < 100 mg/dL
Process measures

Eye Exam

Foot Exam

Nephropathy Assessment

Smoking Status and Cessation Advice/Treatment
Need overall score of 75 to receive DRP Recognition and receive
financial incentives from insurers (in this project – Blue Cross Blue Shield)
Project information



We have 7 practices enrolled and will begin data
collection in March, 2010.
Working with the Baton Rouge Clinic (Dr. David
Carmouche), a COSEHC CV Center of Excellence,
as a primary partner for this project.
This project will evaluate best methods for providing
physician education to improve patient
cardiovascular disease outcomes
Determination of best methods for
providing physician education
10 Practices
Identified by
BCBS of
Louisiana
Baseline Intervention
Chart
Identification and
Abstraction by
Protocol
All practices Receive Their Data,
Comparison with ATGOAL Practices
or COSEHC Database + Standard
CME Discussion of BP, Lipid,
Diabetes Goals per COSEHCApproved Teaching Slides
Quarterly Chart
Abstraction for All
Practices
Interventions 1-5
Intervention 1:
Intervention 2:
Intervention 3:
Intervention 4:
Webinar with
COSEHC staff after
each quarter data
collection
Physician meeting
(webinar/site visit)
after Q2 data
analysis to address
gaps
CD-ROM set as
enduring
material/resource
Webinar with
COSEHC staff after
each quarter data
collection
Physician meeting
(webinar/site visit)
after Q2 data
analysis to address
gaps
Monthly enewsletter to
practitioners
Webinar with
COSEHC staff after
each quarter data
collection
Physician meeting
(webinar/site visit)
after Q2 data
analysis to address
gaps
Quarterly or
monthly
teleconference with
thought leaders
Webinar with
COSEHC staff after
each quarter data
collection
Physician meeting
(webinar/site visit)
after Q2 data
analysis to address
gaps
No step #3.
Intervention 5:
No baseline
intervention, no
educational
intervention, and no
benchmarking reports
until the end of the
year. This group will
serve as the control
group.
Value Driven Vascular Risk Factor Management: An
Evaluation of the COSEHC Customized Model of
Intervention and Care
Health Outcomes Contract from
Novartis Pharmaceutical Corporation
www.cosehc.org
Abstract presented/submitted
Presented:



The Consortium for Southeastern Hypertension Control (COSEHC) annual
scientific sessions. October, 2010 (Charleston, SC)
Wake Forest University Surgical Sciences Research Day. November, 2010
(Winston Salem, NC)
North Carolina Academy of Family Physicians (NCAFP) meeting. December,
2010 (Ashville, NC)
 This abstract was awarded the NCAFP physician poster award.
Submitted:


The American Society of Hypertension (ASH). May, 2011 (New York, NY)
The American Heart Association (AHA) Quality of Care and Outcomes in
Cardiovascular Disease and Stroke. May, 2011 (Washington DC)
Background – South Carolina
Mortality Rates

The South Carolina counties served by the large
South Carolina practice demonstrated higher 2005
cardiovascular associated mortality rates including
those for diabetes and cerebrovascular disease as
compared to the national average.
CDC Wonderbase 2005 Mortality Rates (per 100,000)
in counties served by the large SC Primary Care Practice
as compared to National Average
Large SC Practice
National Average
Diabetes
Diseases of the Heart
Cerebrovascular Disease
Data from the CDC Wonderbase
29
25
200
220
53
48
Objective


To evaluate the effectiveness of the COSEHC
CuStomized Model of Intervention and Care
(COSMIC) on the clinical management of
cardiometabolic disease patients within a large
primary care practice in South Carolina.
This primary care practice is a COSEHC CV Center
of ExcellenceTM.
COSMIC Model







Baseline performance data collection via the COSEHC database
Comparison of performance data to evidence-based therapeutic
target goals
Definition of professional gaps towards achieving optimal care
Education specific to defined gaps and physician perceived barriers
Academic detailing with education and evaluation of system
changes
Collection of quarterly performance data to determine
performance improvements
Continue PDCA (plan-do-check-act) cycle for practice sites not
achieving goals.
Methodology
A prospective nested cohort study using a staggered design will evaluate
the effectiveness of the intervention model called
COSEHC CuStomized Model of Intervention and Care (COSMIC).
A large Charleston, SC primary care practice (a COSEHC CV Center) was divided into six groups based
upon geographical location, practice and patient characteristics, and payor mix.
Each of the distinctive groups (A-F) was further divided
into two comparison cohorts by practice sites. Patients (n=200 per group per cohort) had to have an
ICD code of 401 and at least 2 blood pressure measures in the past year.
Cohort 1 within each Group received the COSMIC intervention first
starting at time zero (July, 2010) and ending 12 months later at time 12 months.
Cohort 2 will commence the COSMIC intervention at time 6 months (January, 2011)
and will finish 12 months later at time 18 months.
The rate of change in percentage and clinical parameters of
cardiometabolic disease patients meeting therapeutic target goals
will be compared between Cohort 1 and Cohort 2 at Baseline, 6, 12, and 18 months
Current
progress
Baseline Clinical Variables
Cohort 1 vs cohort 2
Clinical Information
Cohort 1
(n=1200)
Systolic blood pressure (mm Hg + SD)
131 + 15
135 + 17 *
Diastolic blood pressure (mm Hg + SD)
78 + 9
77 + 10 *
LDL cholesterol (mg/dL + SD)
103 + 33
103 + 34
HDL cholesterol (mg/dL + SD)
48 + 15
47 + 15
Total cholesterol (mg/dL + SD)
177 + 39
176 + 40
Triglycerides (mg/dL + SD)
132 + 68
130 + 68
A1c (% + SD)
7.0 + 1.2
6.8 + 1.2
Creatinine (mg/dL + SD)
0.95 + 0.27
Height (cm + SD)
66 + 5
Weight (lbs + SD)
200 + 48
BMI (kg/m2 + SD)
33 + 8
* p < 0.05, cohort 1 vs cohort 2. Values are represented as mean +SD.
Cohort 2
(n=1200)
0.97 + 0.35
67 + 4
202 + 52
33 + 8
Baseline Medication Use
Cohort 1 vs Cohort 2
cohort 1
10.4 per person
1.5 per person
cohort 2
9.8 per person
1.5 per person
Hypertension medications (% being administered by class)
ACE inhibitors
Renin inhibitors
Angiotensin Receptor Antagonists
Alpha Blockers
Beta Blockers
Calcium Channel Blocker
Diuretic
Vasodilator/Nitrates
42%
1%
32%
7%
28%
22%
17%
1%
42%
2%
39%
6%
22%
22%
12%
1%
Diabetes medications (% currently being administered by class)
Insulin
Metformin
Sulfonurea
TZD
4%
16%
6%
4%
3%
16%
7%
5%
Cholesterol medications (% currently being administered by class)
Statins
Cholesterol inhibitors
61%
8%
55%
9%
All medications (per person)
Hypertension medications (per person)
Cohort 1 – Percent of Patients at Therapeutic
Target Goals (Baseline vs 6 months)
Change in % of Patients at Therapeutic Target Goals
All
African
patients Diabetic
American Elderly Female
Systolic BP
(< 140 mm Hg non-diabetic;
< 130 mm Hg diabetic)
Baseline
6 months
Change
LDL Cholesterol
(< 100 mg/dL)
Baseline
6 months
Change
HDL Cholesterol (> 40 mg/dL) Baseline
6 months
Change
75%
77%
49%
46%
69%
74%
73%
72%
+2%
-3%
+5%
-1%
75%
75%
No
change
54%
56%
+2%
67%
74%
+7%
68%
66%
-2%
55%
71%
+16%
68%
45%
-23%
66%
82%
+16%
59%
60%
+1%
68%
74%
+6%
48%
51%
+3%
81%
85%
+4%
KEY:
Increase % of Patients ATGOAL
Decrease % of Patients ATGOAL
Apples to apples comparison = examining patients who had return visit
during 6 month follow-up period compared to those patient’s at baseline
6 month clinical comparisons
Cohort 1 vs Cohort 2
Cohort 1 has had the COSMIC intervention for 6 months.
Cohort 2 has yet to receive the COSMIC intervention.
A comparison of changes in cardiovascular disease (CVD) risk factors
between baseline and six months among cohort 1 and cohort 2.
Cohort 1
Systolic Blood Pressure (mm Hg)
-0.91 + 15.56
Cohort 2
-1.79 + 15.11
Diastolic Blood Pressure (mm Hg) -0.76 + 9.47 * -1.74 + 8.63
Total cholesterol (mg/dL)
0.92 + 22.79
1.57 + 22.39
LDL cholesterol (mg/dL)
-0.34 + 19.58
0.08 + 18.15
HDL cholesterol (mg/dL)
1.04 + 5.87
1.01 + 5.34
Triglycerides (mg/dL)
0.55 + 37.01
0.74 + 37.81
Hemoglobin A1c (%)
0.003 + 0.59
0.062 + 0.68
Creatinine
-0.03 + 0.16
-0.03 + 0.13
Body Mass Index (BMI)
0.07 + 2.12
0.08 + 1.69
* p < 0.05, cohort 1 vs cohort 2. Values are represented as mean +SD.
Significant change:
Cohort 2 had
significantly more
improvement in DBP
after 6 mo.
Tendency for change:
While TC, Triglycerides,
and HgA1c increased for
both groups, cohort 1
had small increases than
cohort 2.
LDL tended to improve
for cohort 1 but tended to
not improve for cohort 2.
6 month – return evaluation of CVD
risk variables (cohort 1 vs cohort 2)
The percent of patients possessing a valid value for each cardiovascular disease
(CVD) risk factors between baseline (BL) and 6 months.
cohort 1
cohort 2
Systolic blood pressure (SBP)
80%
75%
Diastolic blood pressure (DBP)
80%
75%
Total cholesterol (TC)
53%
48%
LDL cholesterol (LDL-C)
52%
47%
HDL cholesterol (HDL-C)
53%
48%
Triglycerides
53%
47%
Hemoglobin A1c (HgA1c, diabetic patients only)
99%
63%
Creatinine
72%
64%
Body mass index (BMI)
78%
69%
At 6 months, cohort 1 had a higher percentage of total patients
with return values for SBP, DBP, TC, LDL-C, HDL-C, triglycerides,
HgA1c, creatinine and BMI as compared to cohort 2.
Preliminary Conclusions


This project reveals the modest improvements that
can be seen through simple continuous quality
improvement (CQI) programming lasting only 6
months in a real-world setting including small
differences in clinical variables and higher patient
return.
Continuation of this and other COSEHC CQI
programming will determine the impact that
customized CQI can have on improving
cardiovascular disease (CVD) risk in the Southeast
United States.
The COSEHC Database/Risk Score
Funded a grant
From Daiichi Sankyo
Ferrario et al. COSEHC global vascular risk management quality
improvement program: Rationale and design. Vascular Health and Risk
Management. 2010 6:1-11.
Purpose:
1) Define baseline cohort
2) Demonstrated that the modified COSEHC-11 risk calculation has correlation with
the original COSEHC-17 risk score.
• The COSEHC 11 eliminated height, serum creatinine, homocysteine, prior
MI, prior stroke, and diabetic status based upon fasting glucose
Patient Inertia (def) = temporary disabling and absence of
motivation to actively engage in self-protective behaviors
that would reduce, delay, and/or eliminate problematic selfmanagement behaviors.
Patient Inertia
Awareness/
Knowledge/
Cognition
Psychological
Distress/
Self-efficacy/
Coping
In collaboration with:
Dr. David Cline; Dr. David Mount
Patient
Inertia
Environment/
Socioeconomic
Factors
Resources/
Access
I will have complications from high blood
pressure no matter my actions
45%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
40%
30%
27%
20%
13%
9%
9%
6%
0%
S.A
SW.A
Church
N
SW.D
S.D
Emergency Department
There was a significant difference (Fisher’s exact test; p=0.0348) in hopelessness surrounding blood pressure control
between the two groups. The church had a higher response of strongly disagree while the emergency department patients
had a higher response of somewhat agree. Strongly agree (S.A), somewhat agree (SW.A), neutral (N), somewhat
disagree (SW.D), strongly disagree (S.D).
Where we are going…
Future Directions







Complete the projects discussed today
Expand the ATGOAL initiative to other states
 State Health Departments of South Carolina, Georgia,
and Mississippi and private entities are interested
Tease out best practices
Physician inertia and Patient Inertia
Childhood obesity and cardiovascular risk
The impact of formulary changes on cardiovascular
disease
Cardiovascular Disease Journey pathways
Questions?

Acknowledgements:
 The
COSEHC home office team
 Debbie,
Jeff, Janie, and Susie
 COSEHC
Officers
 COSEHC Board Members
 Funding Support
 Novartis
 Pfizer
 Daiichi
Sankyo
 Blue Cross Blue Shield of Louisiana
 State Health Departments
Hypertension prevalence and control rates in 2003-2004 by age and race/ethnicity in men
and women
Ong, K. L. et al. Hypertension 2007;49:69-75
Copyright ©2007 American Heart Association
LDL Control Rates among Aging
Patients


For individuals aged 40-64, there was a 33.8% LDL
cholesterol control rate (years 2005-2008)
For individuals aged > 65, there was 44.7% LDL
cholesterol control rate (years 2005-2008).
Centers for Disease Control and Prevention MMWR Report, Vol 60, No. 4, February 4, 2011.