Author + information
- Michael Mansour, MD, FACC, Immediate Past Chair, ACC Board of Governors and
- Robert Shor, MD, FACC, Chair, ACC Board of Governors∗ ()
- ↵∗Address correspondence to:
Dr. Robert Shor, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
The American College of Cardiology (ACC) and cardiovascular specialists around the world have long focused on secondary prevention. However, with the burden of cardiovascular disease set to increase 57% worldwide by 2020 and noncommunicable diseases (NCDs) such as hypertension, diabetes, and obesity reaching epidemic proportions, there is a need to look closely at primary prevention, health equity, and social determinants of health (1).
The ACC’s new Population Health Policy and Health Promotion Committee, chaired by Gerard R. Martin, MD, FACC, recently convened a group of ACC members and prevention experts from across the spectrum of academia, government, and the private sector to discuss these very issues and begin to chart a path forward. Coming out of the meeting, it was clear that population health along with primary and secondary prevention of cardiovascular disease must be tackled by health care providers and society as a whole.
Given the United States’ ranking of 33rd in life expectancy (79 years) despite its health care sophistication, as well as rising health care costs across the country, population health is not just an issue for poor countries or poor regions of this country, but rather for the entire nation. ACC chapters, as the grassroots arm of the College, can play a critical role in helping to get this work done (2–4).
Encouraging state support for the United Nations and the World Health Organization’s goal of a 25% reduction in NCDs among persons between the ages of 30 and 70 years by 2025 is one way ACC chapters can make a real difference (5). This 25 × 25 initiative, supported by the ACC and others in the NCD Alliance, may 1 day be seen as the most important contribution to world health in the 21st century. To be successful, partnerships will be critical not only among health care providers and professional societies, but also across the spectrum of governmental agencies and policymakers.
Navigating the current and anticipated changes in the U.S. health care delivery system, including payment reform, is another area of importance. These changes will require cardiologists to work more closely with primary care physicians and other providers to benefit both patients and practices. As health care delivery system reform takes shape, reduced regulatory burden will be an integral factor in the process to increase transparency, accountability, and linkage of payment to long-term outcomes as well as measurable short-term endpoints. ACC chapters can play leading roles in supporting ways to address population health in a manner that improves health and lowers the cost of health care delivery.
Already, the College has endorsed Million Hearts’ new Cardiovascular Risk Reduction Model—the first of its kind from the Centers for Medicare and Medicaid Services—that uses a data-driven, predictive modeling approach and gives each participant an individualized 10-year risk score. The score can then be leveraged by both providers and the patient to explore various treatment options, such as lowering blood pressure, ending a smoking habit, or implementing a statin/aspirin regimen. Practices will be required to restratify the patient’s risk regularly and follow it over time. In terms of payment, the model’s value-based payment design will reward statistical reduction in predicted risk of heart attack and stroke, rather than specific blood pressure or cholesterol numbers. Participating doctors will be paid on the basis of actual reduction of the absolute risk of their entire panel, increasing incentives to manage high-risk patients. Practice enrollment began in June.
Finding ways to use data registries, like those that fall under the ACC’s National Cardiovascular Data Registry suite of hospital and outpatient registries, for population health and screening is another opportunity. Using these registries to identify at-risk populations for timely intervention before overt disease occurs could be revolutionary. Recognizing wide variances in patient populations and coupling this data with cost data can help determine best practices and bend the cost curve for health care.
State-level policies can also have major effects on early screening for cardiovascular disease, smoking, healthy eating, and more. To date, the total number of states with screening programs for congenital heart disease in newborns with use of pulse oximetry is 47, with only Wyoming, Idaho, and Kansas lagging behind. Many effective policies are already in place around smoke-free environments, marketing restrictions, taxes on unhealthy food, improved school lunches, and physical and nutrition education programs. Other policies continue to be championed at the level of state legislatures and local municipalities. Opportunities to continue these positive trends abound. Six states—Illinois, Hawaii, Massachusetts, Mississippi, New York, and Vermont—require gym classes to be provided at every grade level. Imagine the gains we could make if other states joined this effort.
The assistance of the U.S. Department of Agriculture, which currently focuses on hunger and obesity through 15 federal nutrition programs, could be another potential opportunity—especially with targeted cultural and health literacy programs, which have been found to be especially important with children and adolescents and changing long-term behavior. Speaking at the ACC’s population health retreat, keynote speaker Valentin Fuster, MD, MACC, noted the need for disease prevention and treatment to span across the stages of life, with the biggest potential effect for prevention to come from efforts aimed at children. Habits related to diet, physical activity, and smoking are established early in life.
Moving forward, it will be important to continue to work with partners both new and old to build a population health agenda encompassing a holistic view of health promotion. This agenda will need to encompass specific goals and targets related to diet, nutrition, and exercise as well as efforts in tobacco control, smoking prevention, and limited alcohol use. Our ability to meet these goals and successfully improve cardiovascular health outcomes and the cost of health care delivery is dependent on successfully changing the environment that our patients exist in and creating a culture of primary prevention beginning early in life. These are big, audacious goals, but they are achievable and necessary if we hope to improve health disparities and health equity, lower the cost of health care delivery, and stem the global epidemic of NCDs.
- American College of Cardiology Foundation
- Fuster V.,
- Kelly B.B.,
- Vedanthan R.
- Institute of Medicine (IOM)
- O’Gara P.T.