Narrator:
Welcome to ReachMD. You are listening to Lipid Luminations, produced in partnership with the National Lipid Association and supported by an educational grant from AstraZeneca. Your host is Dr. Alan Brown, Director of the Division of Cardiology at Advocate Lutheran General Hospital and Director of Midwest Heart Disease Prevention Center at Midwest Heart Specialists at Advocate Health Care.
Dr. Brown:
Heart disease and stroke are two of the leading causes of death in the United States. The Department of Health and Human Services with several key partners launched the Million Hearts Program, a national public and private initiative. Million Hearts aims to prevent 1 million heart attacks and strokes over 5 years through behavioral changes as well as clinical interventions.
I'm your host, Dr. Alan Brown, and with me today is Dr. Janet Wright, cardiologist and Executive Director of Million Hearts in Washington, DC. Janet, thanks very much for taking the time to talk to us today.
Dr. Wright:
Pleasure to join you, Alan.
Dr. Brown:
So, tell me a little bit about what the Million Hearts Program entails and how it got started and what our listeners need to know about it?
Dr. Wright:
Million Hearts was birthed by really about three folks who looked across the medical, clinical and public health landscape for action that we could take over a fairly short period of time and have a major impact on outcomes and on health; and of course, cardiovascular disease quickly came to the top of that list. The idea was to bring the experts in public health together with those in healthcare and target specific evidence-based strategies, working together with these complementary assets of public health and healthcare tackle a big goal. That was really the original thinking around Million Hearts. And predicted models were undertaken to find out what actual activities could contribute to prevention in a short period of time, like 5 years, and that's really how the design elements of Million Hearts came together.
Dr. Brown:
So, 5 years to reduce a million cardiovascular events is a pretty bold strategy. Can you tell our listeners what the key components of the Million Hearts is and how you intend to make this a reality?
Dr. Wright:
Right. So, it's a very focused initiative based really on those predictive models. What was spat out of the models on the public health side were big levers like reducing sodium intake across the entire population. The second one was eliminating artificial trans fat in the food supply, and the third is increasing our exposure to smoke-free space. So, really instituting policies across the landscape that help us avoid secondhand smoke dangers. So, over on the public health side of Million Hearts is reducing sodium, eliminating trans fat and improving air quality. On the clinical side, we're really focused on what we call the ABCS, so aspirin for secondary prevention, blood pressure control is the B, the C is for cholesterol management, optimal cholesterol management, and the S, of course, is for smoking cessation.
Dr. Brown:
So, did you find partway through the program that the thought about aspirin kind of shifted, and was it originally part of a general preventative strategy and then switched to secondary prevention?
Dr. Wright:
A good question. Primary and secondary were both fed into these predictive models, and it was the secondary prevention that looked like it would have the biggest return. There was also concern about the lack of clarity around primary prevention at the time. This was back in 2010 and early 2011.
Dr. Brown:
So, I think that's important. I think some of our listeners may not be aware that aspirin, as a primary prevention tool, has been sort of moved to the back burner because of the risk of side effects and bleeding being greater than the benefit in those patients, but certainly not in those people who have high risk, correct?
Dr. Wright:
Absolutely right, absolutely right. Yes, that evidence is rock solid. But to your point, Alan, about measures, we knew about aspirin and we knew enough at the time to pick secondary prevention; but during the course of Million Hearts, of course, there's been much discussion about the appropriate targets for blood pressure control. And we know that with new guidelines for optimal management of lipids, there is new conversation going on about LDL targets. So, within the course of Million Hearts, two of our measures, two of our ABCS measures, have undergone a lot of tire kicking.
Dr. Brown:
Yes, and that's a topic for another show. It's been an ongoing discussion and, of course, the data keeps coming, so both of those areas are going to be maturing.
So, from a public health perspective, what types of things are being done to reach these goals, and how are you measuring success?
Dr. Wright:
Yes, so on the public health side, the great bulk of work there is being done with, and at, FDA, CDC, and particularly, when it comes to sodium, with the food industry and the restaurant industry. The major push is to make more choices, more lower sodium choices available to people, to label so that it's easier for people to understand the sodium content, and the choice then will allow them to gradually reduce their sodium intake, and then a lot of education, because what we know -- and I frankly didn't really absorb this as a practicing doc -- but most of the sodium in our diets is already in the food when we eat it. What we add in the kitchen and at the table is really a fraction of our sodium intake, the combination of either eat out or buys out and eats in, and so the processed foods already have a fairly high sodium content. So, the work in sodium, as I said, mostly with the food and restaurant industry in a voluntary way to help increase choice for folks.
With the trans fat, as you know, artificial trans fat or partially hydrogenated oils are in the food. They have been reduced over the last 4 or 5 years, but they're still present. FDA has requested comment on a tentative determination that those substances are not safe, and we are looking to them to issue a final determination, very hopeful that that will come before the end of the year, and that kind of determination will actually, in effect, eliminate that substance from the food supply. And the impact on lives and on heart attacks is really dramatic when it comes to trans fats.
Dr. Brown:
That's very encouraging. Now, I've known you over a lot of years, Jan, and I remember when you were a member of the Board of Trustees at the American College of Cardiology; you've served on many committees. What brought you to get involved with Million Hearts, and how did you become the executive director? And tell us a little bit about your level of enthusiasm for this.
Dr. Wright:
Well, it remains high, and I very much loved the work that I was allowed to do with the College. I was on the staff at the ACC at the time Million Hearts came across the radar screen, and I really thought that my job would be understanding how the ACC members could contribute specifically. Clearly, they are contributing daily in the work that they do, but how the College might contribute to reducing heart attack and stroke. But my interest in the initiative led to interviews, and then I ended up on the list of folks being considered for this position, and so, right around the time of the launch in September 2011, I became -- I went into federal service as they say, and it's been quite an experience getting to know the various agencies. We have 19 federal partners and something over 110 private sector partners all at work in actions to prevent heart attack and stroke.
Dr. Brown:
And do you feel like there is good coordination and enthusiasm across the agencies for reducing cardiovascular disease?
Dr. Wright:
The folks who came together to design this initiative believed that there was already enormous work going on across both federal and private sectors to prevent heart attack and stroke, but not all the work was focused on strategies that are likely to have the greatest impact, and there certainly was no hot timeline underneath the pot to cook the work, accelerate the work. And so, I think Million Hearts has served as a bit of a focusing factor, delivering -- where we can -- those evidence-based strategies, try to shine the light on high performers in order to acknowledge and reward them but also to inspire others. And then, we seem to serve as a dot connector, literally introducing folks to each other. They have worked together in the same community, but public health folks and healthcare folks have not had had much in common, but Million Hearts seems to be, I think about it as an emulsifier, bringing those two layers together into something that's very powerful.
Dr. Brown:
If you're just tuning in, you're listening to Lipid Luminations on ReachMD. I'm your host, Dr. Alan Brown, and I'm speaking with Dr. Janet Wright, the Executive Director of the Million Hearts initiative.
So, I'm going to ask you to give me some examples from a public health perspective of things you've been able to do that may have started an appropriate initiative in the public health arena or with partners that you brought together, and then the same on the clinical side with possibly medical organizations. Tell me what you're most proud of in terms of both the public health part and the clinical part of your initiative?
Dr. Wright:
Well, Alan, thank you, that's a great question, and I will preface it by saying because there was enormous work already in play before Million Hearts was ever on the scene, I want to be very careful to say that the results that are being achieved are not the results of Million Hearts. They are really the results of all the folks, their organizations, who were hard at work here. We've had a chance, as I said, to highlight some, or to glean lessons from some, and be able to spread them, but we are certainly not taking any credit for it. But, that said, I can tell you some of the most exciting things are understanding from communities and municipalities that have gone smoke-free. Within a very short period, a matter of months, they see their emergency room admissions dropping for heart attack in very short order, in addition to lung problems as well, so going smoke-free has very rapid results.
I would say on the clinical side, but really one of the most exciting things is beginning, as I said, to see public health and healthcare folks work together. The Association of State and Territorial Health Officials was funded by CDC to work with clinical partners across a subset of states on hypertension control, and what happened -- and I'm over simplifying this grossly -- but people with public health expertise, epidemiology, surveillance, and people who could bore through data, public health data, came together with clinical partners, meaning federally qualified health centers, clinical practices, in some cases commercial payers, looked at data together; they meshed the clinical and public health data to understand the population, understand the prevalence, and to tackle blood pressure control using electronic health records and other techniques, and they began to see in very short cycles of improvement dramatic increases in blood pressure control rates. So, although it is tempting to say some of this is all public health and some of this is healthcare, the really exciting stuff is when these people are around the same table working together.
Dr. Brown:
So, Janet, you mentioned briefly that you saw rapid decreases in emergency room admissions for patients with coronary disease after towns became smoke-free. Any other metrics that show that the Million Hearts initiative is reducing the numbers of people with cardiovascular disease?
Dr. Wright:
Well, I would love to be able to tell you -- we often think of the McDonald's ticker and how many cheeseburgers have been consumed. We would love to have a similar ticker to indicate how many heart attacks and strokes have been prevented. As you know, that is data hallucination. Those data just aren't available. But what we do see on our short-term indicators, we're seeing greater adoption of electronic health records. We're seeing other short-term indicators begin to look very promising, the number of healthcare professionals that are choosing to report on the ABCS measures in the quality reporting programs across the country. We are certainly seeing in pockets very high performance on blood pressure control. We have for the last 3 years executed a Champions Program where we recognize systems and clinics around the country that have achieved blood pressure control rates of over 70%, and the number we've been able to recognize has gone up dramatically. I think a total of 41 places have been recognized for high performance. We know that in order to drop that heart attack and stroke rate, blood pressure control has to occur, and of course, cholesterol after we manage the aspirin and the smoking as well. So, part of the delay in seeing the heart attack and strokes fall will be getting excellence in those ABCS measures.
Dr. Brown:
Yes, that makes sense. It seems to me 5 years was a lofty goal to be able to measure a million cardiovascular events being reduced. How do you think you're doing along that timeline?
Dr. Wright:
Right, so we know, as I said, that there are pockets of progress, but there is so much work left to do. And now, looking at about 20 more months of work, we are in a frenzy to plant as many seeds as possible into fertile soil -- it's a spring analogy, I guess -- so that long after we have folded the Million Hearts tent we'll continue to see a return. Part of that work is across the Centers for Medicare and Medicaid Services to make sure that the ABCS measures get into the quality reporting programs, into the registries that are developed and developing around the country, and where we get the incentives aligned so that all the team members who are so powerful in helping people reach these goals are, that the team members are supported in these new models. So, again, I wish I could give you today's count on the number prevented, but I can tell you that we are working, as my mother would say, like cranberry merchants, to get as many policy and systems changes made as possible before Million Hearts ends.
Dr. Brown:
Unfortunately, we've run out of time. I would love to have you back to get some final metrics when the program wraps up and find out not only what great things we all know you've accomplished but what other strategies we can employ to measure our efforts going forward.
Dr. Wright:
Thank you so much.
Dr. Brown:
I'm your host, Dr. Alan Brown, and you've been listening to Lipid Luminations. Thank you very much for joining us.
Narrator:
You've been listening to Lipid Luminations, produced in partnership with the National Lipid Association and supported by an educational grant from AstraZeneca. To download this program and others in this series, please visit Reachmd.com/lipids. That's Reachmd.com/lipids.
