"Let's Meet the Challenge" by Samuel C. Waters, M.D.

Let's Meet the Challenge!

By Samuel C. Waters, M.D.

Cardiovascular disease has been the leading cause of death in Texas since 1950. Immense opportunities exist to save lives of Texans and improve the quality of their lives by addressing and monitoring risk factor reduction and by appropriate long term medical management. When we review the cardiovascular facts, the magnitude of the problem is awesome.

Cardiovascular facts

Leading causes of death in Texas

Cardiovascular disease 42,330

Cancer 31,959

Stroke 9,845

Accidents 7,217

Lung disease 6,370

Cardiovascular disease in Texas

Cardiovascular disease (CVD) has been the leading cause of death in Texas since 1950.

30% of CVD deaths occur in people under age 65.

The estimated total costs of CVD is $9 billion (1994).

The average cost of coronary artery bypass totals $44,200.

Heart attack is the first symptom of CVD in one third of cases.

Medicare paid more than $1 billion for CVD-related hospital stays (1995).

The average cost of stroke is $15,000 per patient.

Cardiovascular disease in women

CVD claims twice as many women’s lives as do all forms of cancer.

In 63% of women who died suddenly of CVD, no previous evidence of the disease existed.

Stroke kills twice as many American women annually as breast cancer.

The death rate from CVD in African American women is 71% higher than white women.

Reprinted with permission from Texas Medicine. Sources: Texas Department of Health, American Heart Association, Centers for Disease Control and Prevention, Health Care Financing Administration, and National Stroke Association

We as Texas physicians must develop a system which consistently monitors risk factor reduction and monitors appropriateness of care in every patient. Numerous studies have demonstrated inadequate follow-up and treatment in even the most aggressive practices.

Heart Care Partnership offers a platform from which such a system can be launched. Without true commitment to a locally developed, explicit protocol, and the systems to ensure coordination of care, many high risk patients are missed by even the most aggressive treatment advocates. The following questions must be assessed in all ischemic heart disease patients.

Are they receiving

Aspirin?

Beta-blocker therapy?

Statins?

Has every patient received

Adequate counseling with regard to proper diet?

Adequate counseling with regard to cessation of smoking?

Adequate counseling with regard to the proper quality and quantity of exercise?

Some patients have special needs

Are all diabetic patients’ blood sugars appropriately controlled?

Are all patients with left ventricular dysfunction on an ace inhibitor or an angiotensin II receptor blocker?

Are all patients with hypertension treated to a maximum effect?

Are all patients’ lipid profiles being monitored and consistently addressed?

Are all postmenopausal women receiving appropriate hormone replacement therapy?

Heart Care Partnership utilizes the effectiveness of the American Heart Association, the Texas Medical Association, and others to develop local programs which work to achieve these goals. Local physicians in active practice are clearly in the best position to improve care in their community. Achieving a practical, viable system depends upon:
Coming to consensus on what constitutes good clinical practice.
Identifying barriers to good clinical practice and making changes to remove those barriers.
Continuing comparison of actual performance versus optimal standard of care.
Commitment to continuous improvement through shared learning.

In our own local institution, we have begun the process. Our cardiovascular case manager, Linda Chandler, R.N., and Dr. David M. Pogue represented us in the Heart Care Partnership seminar. Subsequently, we developed our risk factor assessment and reduction strategy. The following diagnoses were chosen as the target group: myocardial infarction, angina, and those patients undergoing coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, or cardiac catheterization and coronary arteriography for coronary heart disease. The following information was to be collected.

CARDIOVASCULAR RISK DOCUMENTATION FORM
Admitting Diagnosis:

_____Acute MI
_____Angina/Ischemia
_____PTCA
_____CABG

_____CHF
_____arrhythmia
_____Other CV disease
_____PVD

_____CVA
_____TIA
_____Diabetes Mellitus
_____Carotid Stenosis

Clinical Assessment:

NYHA CHF Class_____ Ejection Fraction_____
Risk Factors:

_____Male >45 years, or Female >55 years or premature menopause w/o HRT

_____Family History of premature CHD(father, brother, or son who has had MI or sudden death before age 55) or mother, sister, or daughter before age 65.
_____Cigarette Smoker _____Current _____Number packs/day _____Number of years

_____Former _____Second Hand Exposure

_____Hypertension Most recent BP _______________mmHg
_____Hyperlipidemia Most recent lipid profile on _____________

T Chol________ TG___________
HDL _________ LDL__________
_____Diabetes Mellitus Most recent FBS______ HbA 1c________
_____Obesity Ht________ Wt______
_____Sedentary Lifestyle
Discharge Treatments Regimen:

Medications: _____ASA _____Beta Blocker _____Ace Inhibitor
_____Other antihypertensives _____Anticoagulant
_____Nitrate _____HRT _____Lipid Lowering agent
Referrals _____Cardiac Rehab

_____Coumadin Clinic
_____Lipid Clinic
Counseling Received:
_____General patient education
_____Smoking Cessation
_____Dietary Modification
_____Activity Recommendations
_____Stress Reduction

Our review of 30 random patient records revealed some strong points and some glaring inadequacies of treatment. We do well with aspirin therapy. 93% of patients receive aspirin unless contraindicated. We do very poorly with appropriate lipid reduction therapy. Only 9% of patients were on any therapy. We then set our goals and compared them to actual performance.

CHD PATIENT CHART REVIEW:

OPPORTUNITY ASSESSMENT

Target Group: MI, Angina, CABG/PTCA/Catheterization Diagnostic for CHD

Steps to complete this form:

1. Agree on risk interventions to be taken for all CV patients by the time of discharge and enter into Column A below.

2. Enter data from individual patient charts onto the other side of this form (e.g.,, the next 30 consecutive coronary heart disease patients, or the last 30 patients; use the most recent values from a patient’s chart).

3. Tabulate the results from Step 2 and enter into Column B below.

4. A difference between Column A (goal) and Column B (actual) indicates an opportunity to improve care.

	Column A	Column B
RISK INTERVENTION	GOAL AT DISCHARGE (% of patients)	ACTUAL FROM CHART REVIEW (% of patients)
Example: Aspirin/other antiplatelet therapy	95%	70%
If smoker, counseling provided	85%	72%
Lipid Management:
Fasting LDL cholesterol in chart	90%	40%
Total cholesterol in chart	90%	69%
Statin if LDL cholesterol > 130mg/dL	90%	20%
Other lipid-lowering therapy	25%	9%
Diabetes:
Fasting blood glucose in chart	95%
Diabetes medication if fasting blood glucose >120mg/dL	95%

Aspirin/other antiplatelet therapy	95%	93%
ACE Inhibitor	80%	57%
Beta Blocker	85%	50%
Blood pressure controlled (diastolic <90mmHg)	90%

It is our plan to continue to monitor actual performance data and to compare it to our goals on a regular basis. With this system in place, I have no doubt that we will clearly improve care to patients. The Heart Care Partnership gives a tool to maximize performance for risk factor reduction and monitor appropriateness of care to optimize patient management.

editor@medmag.org