Real World Health Care Blog

Tag Archives: heart attack

Three Ways You Can Reduce the Impact of Cardiovascular Disease this American Heart Month

Most of the readers of this blog know that cardiovascular disease (CVD) is the number one killer of men and women in this country. According to the Centers For Disease Control and Prevention, CVD is a leading cause of disability, preventing Americans from working and enjoying family activities. Out-of-hospital cardiac arrests cause the deaths of an estimated 250,000 Americans each year. CVD costs the United States over $300 billion each year.

Joel Zive

Joel Zive

There are many small but significant actions we can take. Here is what you can do to make a difference: empower or continue to empower patients to take care of themselves.

1. Address the cost of heart medication

If the cost of your medicine is an issue, talk to your doctor or contact a patient assistance program that may be able to help with prescription co-pays.

2. Encourage healthy behaviors

Want people to eat better? Give them coupons for healthy food. Exercise? Give them coupons for short-term memberships to health clubs.

The stakes are higher in our country’s current health care landscape. With more people on health insurance than ever before, we need to do everything we can to empower people to seek help before an emergency and talk to their doctor about what they can do to take better care of themselves. This will have a direct effect on deaths from heart disease.

3. Ask your employer about Automatic External Defibrillators

There are instances in which individuals are dealt devastating genetic hands of cards. Recently, the Philadelphia Inquirer highlighted the plight of a Philadelphia family that had a genetic link to hypertrophic cardiomyopathy, a disease of the heart muscle.

For those who do experience heart issues, or even have a major event such as cardiac arrest, Automatic External Defibrillator (AED) devices can significantly increase the likelihood of survival. AEDs have been available for over 20 years, but in recent years, device makers have reduced the size and cost and increased usability of defibrillators, making public access defibrillation viable. “We believe ease of use is one of the most important qualities in an AED because the potential user may not be well-trained in resuscitating a victim of sudden cardiac arrest,” said Bob Peterhans, General Manager for Emergency Care and Resuscitation at Philips Healthcare. “This is consistent with the American Heart Association’s criteria for choosing an AED.”

While risk factors for CVD are often genetic, the majority of CVD is triggered by factors that are controllable: smoking, diet, and exercise. And this is where individual efforts need to be focused.

For more information on preventing CVD, check out the American Heart Association’s guidelines for taking care of your heart, which are broken down by age. The Centers for Disease Control and Prevention also offer an American Heart Month guide to controlling risk factors for cardiovascular disease. You may also want to check out The Heart Truth, a campaign from the National Institutes of Health to make women more aware of the danger of heart disease.

Read more Real World Health Care heart health-related posts:

Are you taking steps to prevent cardiovascular disease? If you, a family member, or a friend has CVD, what is working for treatment? Share your experiences and insights in the comments section.

It’s Not Over Yet: Addressing Part Two of the Door-to-Balloon Time Initiative’s Success

ReillyJohn

John P. Reilly, M.D., FSCAI

From the very first sign of a heart attack, the clock starts ticking in the race to save a patient’s heart muscle and even his or her life.

Thanks to technology and finely tuned systems of heart attack care that are now available in communities throughout the United States, we are getting faster all the time.

But sometimes we still lose the race.

During a heart attack, the heart is deprived of oxygen. The longer the heart goes with too little oxygen, the more muscle is lost, often irreversibly. This is what doctors mean when we say, “Time is muscle.” How quickly a patient receives treatment once heart attack symptoms appear often determines if he or she will make a full recovery, suffer heart muscle damage, or die.

Door to Balloon Signaled Success, or Did It?

This is why, a decade ago, healthcare professionals across the country set out to reduce the time it takes to treat heart attack patients once they arrive at the hospital. Since stopping a heart attack often involves balloon angioplasty to reopen the blocked artery, the effort was called the Door-to-Balloon (D2B) Initiative. This effort has prevented or limited heart damage for countless patients.

The D2B initiative involved making the healthcare system more efficient, more responsive and more effective, starting from the moment a heart attack patient comes to the attention of an emergency medical responder (EMR) answering a 9-1-1 call or presenting in the emergency department.  When D2B began, it often took more than two hours from the time a heart attack patient arrived at the hospital until he or she received life-saving treatment to reopen a blocked artery.

Now, 90 percent of patients who enter hospital doors receive treatment in less than 90 minutes and many are treated within 60, 30, even 15 minutes. [1]

D2B is one of healthcare’s greatest success stories. But, according to a new study [2], reducing D2B times has not been enough to significantly reduce mortality rates among heart attack patients.

What Happens Before the Hospital Door?

There are two sides to the time equation. Unfortunately, the part of the equation that has not improved enough is how long it takes patients to get to the hospital once heart attack symptoms start. Most patients wait two or more hours after heart attack symptoms appear to seek medical help. [3] Many patients are taking too long to call 9-1-1, placing themselves at risk of suffering irreversible heart damage or death.

We must do for Symptom-to-Door (S2D) Time what we have done so successfully for D2B. Revamping a system of care outside the hospital, however, is much different and perhaps more difficult than revamping a system of care within the hospital.

There have been myriad heart attack awareness programs, including online public education programs like SecondsCount.org, for which I am an editor, aimed at helping people understand the risks of heart attack, how to recognize the symptoms and why responding promptly is essential.

We have made progress. An increasing number of people know that chest pain, shortness of breath, nausea, fatigue, dizziness, and pain in the jaw, back or arm are often the first signs of heart attack. While I see more people who identified their symptoms early on, there are also many who remain unaware, are in denial or are just confused. Every day, I see patients who thought their symptoms “weren’t that bad” or explain them away as indigestion or a virus. I also see the toll that lost time takes in hearts damaged and lives lost.

Only 60 percent of patients contact emergency medical responders when experiencing symptoms. About 40 percent arrive at our hospitals on their own. [4] That’s dangerous, whether the patient is driving him- or herself. Or, even if a friend or relative is driving, it still represents a lost opportunity for treatment to begin in the ambulance, or to alert the doctors in the emergency room that a heart attack patient is on the way in.

Let’s Save More Hearts and Lives

To get started, here are a few thoughts on how we might reduce S2D:

  • We need a concerted national effort to reduce S2D time that establishes consistent messages rather than myriad programs offering incomplete or inconsistent information.
  • We must improve regional and statewide systems of care to coordinate heart attack care to ensure everyone gets the most expeditious care.
  • We need to better inform the people who are most at risk for heart attack or other heart issues about what symptoms to look for and what to do if they develop.
  • And, of course, we must continue our educational efforts, helping everyone to understand that if they are concerned they may be having a heart attack, then they should call 9-1-1 without delay and without concern about looking foolish if their symptoms turn out to be something other than a heart attack.  The alternative – sitting at home while having a heart attack, with heart muscle dying as the minutes tick by – would be far worse.

We’ve had remarkable success in reducing D2B times. But it’s not enough. To save hearts and lives, we must take on the other side of the heart attack challenge.

We’ve done it once. We can do it again.

1. Bates ER, Jacobs AK. Time to Treatment in Patients with STEMI. N Engl J Med 2013;369:889-892.
2. Menees DS, Peterson ED, Wang Y, et al. Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med 2013;369:901-9.
3.  Life After a Heart Attack. National Heart, Lung, and Blood Institute.
4.  http://nypress.com/forty-percent-do-not-call-911-survival-rates-show-every-minute-matters/, http://www.nejm.org/doi/full/10.1056/NEJMp1308772

Kaiser Permanente Gives Providers Evidence-Based Tools to Increase Adherence

At an industry conference years ago, I met an HIV-positive patient. We spoke about her treatment as well as her adherence program. “Who takes care of you?” I asked. “Kaiser Permanente,” she responded. Afterward, I did a little research and discovered this was one of the first HMOs created in the United States that takes care of millions of patients. Based in Oakland, California, their goal is “supporting preventative medicine and attempting to educate its members about maintaining their own health.”

Joel L. Zive

Joel L. Zive

Adherence remains a capstone in caring for patients after medications are dispensed and is an especially important issue for indigent populations. But now with implementation of health care reform fast approaching, patients will be required to take even more responsibility for their health, including adherence to medication regimens. Although no integrated health care structure is perfect, Kaiser’s integrative model fascinates me and allows its health care teams to implement successful adherence strategies.

For example, a Kaiser physician at the South San Francisco Medical Center conducted a hypertension study (“Improved Blood Pressure Control Associated With a Large-Scale Hypertension Program”) that compared their program’s results to those at the state and national level. The outcomes are startling:

  • The Kaiser Hypertension control rate nearly doubled, skyrocketing from 43.6 percent in 2001 to 80.4 percent in 2009.  
  • In contrast, the national mean of hypertensive control went from 55.4 to only 64.1 percent during the same time period.

One aspect of this program included using single pill combination therapy, which has been shown to boost adherence. In a slightly different approach to adherence in hypertension, Kaiser Permanente Northern California and UC San Francisco were recently awarded an $11 million grant to fund a stroke prevention program by targeting and treating hypertension among African Americans and young adults.

By Googling “Kaiser Permanente adherence” the Kaiser Permanente Division of Research appears. Their published research draws from Kaiser Permanente units throughout their network, collaborations with academic institutions nationwide, and the HMO Research Network – a consortium of 18 health care delivery organizations with both defined patient populations and formal, recognized research capabilities. These resources provide clinicians and pharmacists with a plethora of study designs and disease states from which to choose and evaluate.

In the study “Determination of optimized multidisciplinary care team for maximal antiretroviral therapy adherence,” for example, a multidisciplinary care team was assigned to patients with new antiretroviral drug regimens. Because this model translated to improved adherence rates, clinical teams around the country now use some variation of a multidisciplinary approach, enabling each discipline’s area of expertise to benefit the patient.

Another article from Kaiser — “Health Literacy and Antidepressant Medication Adherence Among Adults with Diabetes: The Diabetes Study of Northern California (DISTANCE)” – demonstrates that adherence is multifactorial.  This study’s conclusions underscore the importance of health care literacy components, simplifying health communications for treatment options, executing an enhanced public relations campaign around depression and monitoring refill rates.

In my experience, if someone with mental health issues does not take his or her medications, then regardless of disease state, the patient’s treatment falls off the track. I approach these difficult situations by drawing on the conclusions of the above studies:

  • First, is there a different message I could give the patient? Or am I reaching the patient at a level of health care literacy he could understand? For example, I had a deaf patient who found it tiresome writing messages back and forth to me. When I realized he “speaks” to people via a teletype machine, I began communicating with him via word processing software. This made our communications less cumbersome. And this improved adherence to his regime because he was less frustrated.
  • Next, the multidisciplinary approach is quite powerful. When I served HIV-positive patients in the South Bronx, if anything occurred that affected adherence, the prescriber, nurse, social worker or case manager immediately were made aware. Sometimes we would discontinue the regimen and other times we would tweak the regimen and get the patient back on treatment.

The real adherence tragedy for indigent patients is not whether they receive medication, but whether they have access to the tools, education and knowledge they need to take their meds as prescribed. Leveraging articles from resources like Kaiser’s Division of Research may be the solution to reversing the trend of low adherence.

Now we want to hear from you. If you’re a patient, has your doctor or pharmacist worked with you to improve med adherence? If you’re a provider, what resources have you found to be useful when helping patients understand why they should take meds as prescribed? Share your stories in the comments.

Categories: Access to Care

More Patients DASH to New Solution to Reduce High Blood Pressure: Part I

Shawn_J_Green

Shawn J. Green

What’s the solution to reversing the tide of hypertension, the most commonly diagnosed condition in the United States?  More evidence indicates that the answer begins with the food choices we make every day.

An underlying cause of heart attacks, strokes and kidney disease, one in three American adults now experiences high blood pressure – the single-largest contributor to death worldwide. It is also becoming more resistant to the pharmaceutical drugs used to lower it. In fact, blood pressure remains elevated in nearly one-third of all treated hypertensive patients on pharmaceutical drugs.

Instead of relying on prescriptions, more patients are turning to a healthier eating approach: Keeping sodium intake low and making consumption of nitric oxide-rich vegetables and leafy greens high. This cardio-protective daily diet, known as the DASH (Dietary Approach to Stop Hypertension) Eating Plan, is emerging as an effective way to delay or prevent high blood pressure altogether.

The value of nitric oxide was spotlighted when the Nobel Prize was awarded in 1998 for discovery of this naturally produced cardio-protective factor. A string of clinical studies underscored that vegetables (like red beet roots) and leafy greens (such as spinach and arugula) are replete with nitric oxide.

Diets known for promoting heart health and lowering rates of diabetes and obesity – like Japanese diets, Mediterranean diets and plant-based diets, such as DASH, among others including TLC, Ornish, and Pritikin – incorporate these natural whole foods. The need to consume more nitric oxide-potent vegetables and leafy greens becomes even more critical as we age because our bodies are less able to synthesize this natural hypertensive-fighting factor.

Reducing hypertension would not only improve health outcomes for individual patients, but would also benefit the health system as a whole. Although the percentage of resistance to antihypertensive drugs is relatively lower in the U.S., elevated blood pressure among a rapidly growing number of baby boomers will mean more challenges for health care in the long run unless we identify tools that work and make them as accessible and user-friendly to the public as possible.

DASH holds great promise to fuel compliance – a critical driver to prevent elevated blood pressure – among those living with hypertension. But a healthful eating strategy alone will not mean better outcomes for patients without a model to help them break bad habits and support dietary changes on a personal level, one day at a time.

So how do we get there?

Join us here next Thursday for the second post in our two-part series. Discover what innovative tools can empower patients to make the DASH Diet a part of their arsenal in the fight against hypertension.

Meditation Found to Cut Risk in Half of Death, Heart Attack, or Stroke in African Americans

Here’s an idea that every person alive can do, costs nothing, and takes as little as 20 minutes a day: Meditate.

A recent peer reviewed, published study shows why:

“Meditation is usually thought of as a practice of healthy, well-off white people and Asians. But newly published research suggests it can produce hugely significant health benefits in a very different demographic group: African Americans with heart disease.

“A study that followed 201 African Americans for an average of five years found those who meditated regularly were far more likely to avoid three extremely unwelcome outcomes. Compared to peers participating in a health-education program, meditators were, in that period, 48 percent less likely to die, have a heart attack, or suffer a stroke.

Read more about the research here, and to access information regarding the technique of Transcendental Meditation as well as evidence-based benefits, you can visit this website.

What are ways we can encourage more people to meditate? We’d love to hear more about what works, what doesn’t when it comes to meditation to improve health outcomes.  Please share links to any evidence-based findings!

Why Aren’t Patients Taking Their Medication?

It’s a question with which many in the health care community grapple. In some cases, it’s a matter of affordability, as the high cost of certain therapies makes it difficult to pay for needed drugs AND to pay for essentials like rent or the mortgage, utilities and food. Even with medical insurance, the copays for these expensive therapies put them well out of reach for many Americans.

In other cases, it’s a matter of easy access to refills – a problem being solved, in part, by mail-order pharmacies. This was especially the case among 44,000 hypertension patients recently studied by Kaiser Permanente. Research found that making prescription refills more affordable and easier to access might reduce disparities in medicine-taking behaviors among racial and ethnic groups.

The study authors noted that as early as the first refill, some patients are forgoing their hypertension medication. The result? According to the CDC, hypertension can lead to heart attacks, strokes and deaths related to cardiovascular disease. The impact is devastating to communities of color, particularly among African Americans, where males have the highest hypertension death rates of any other racial, ethnic or gender group.

The research found that both mail-order pharmacy enrollment and lower copayments were associated with a significantly lower likelihood of being non-adherent.

Said the study authors, “Our findings suggest that while racial and ethnic differences in medication adherence persist – even in settings with high-quality care – interventions such as targeted copay reductions and mail order pharmacy incentives have the potential to reduce disparities in blood pressure.”

If you’re in the health care field, what ideas have you seen put in action that work to improve treatment compliance? As a patient, have you ever stopped taking your medication due to high cost or hassles getting refills? And have you turned to mail-order pharmacies or copay assistance programs for help?

Categories: Cost-Savings