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NOVEMBER / DECEMBER 2012 :: 73(6)
Heart Disease and Stroke

This issue focuses on heart disease and stroke, leading causes of death in North Carolina. Commentaries explore collaborations, state-of-the-art treatment, and various efforts to reduce mortality due to these conditions, including the national Million Hearts initiative. Authors also discuss contributions of groups within the state such as the Justus-Warren Heart Disease and Stroke Prevention Task Force and the Eastern North Carolina Stroke Network. Original articles examine heart disease and stroke awareness among women and the public’s valuation of tobacco control policies.


It Takes a Community: The North Carolina Division of Public Health and the North Carolina Area Health Education Center Program Partner to Reduce Strokes and Heart Attacks

Samuel Cykert, Ruth Petersen, Ann Lefebvre

N C Med J. 2012;73(6):469-475.PDF | TABLE OF CONTENTS

The North Carolina Division of Public Health is leading a statewide project using a combination of approaches to address cardiovascular risk factors including obesity, hypertension, diabetes, and cigarette smoking. The objectives are to decrease tobacco use, increase physical activity, improve nutrition, and increase access to evidence-based clinical preventive services targeting hypertension, hypercholestrolemia, tobacco use, and weight management.

The burden of cardiovascular disease in North Carolina remains large. In 2011, the cardiovascular death rate was 275 per 100,000 population [1]. Cardiovascular diseases accounted for almost one third of deaths in the state [2]. In 2011, North Carolina was ranked 31st in the nation for cardiovascular deaths (meaning that the rate was lower in 30 other states) [1]. The annual cost of hospitalization attributable to cardiovascular causes in North Carolina is more than $4.6 billion, a figure that does not include the cost of outpatient care, loss of work, rehabilitation, and home health services [2].

Why is cardiovascular morbidity so great a problem in North Carolina? Disease progression is largely determined by risk factors including diabetes, hypertension, serum cholesterol levels, and tobacco use. All of the risk factors except tobacco use are intertwined with dietary habits, exercise, and obesity. Yang and colleagues [3] recently assessed cardiovascular risk factors in individuals 20 years of age or older who had participated in the National Health and Nutrition Examination Survey (NHANES) and found that the effects of the risk factors were cumulative. Meeting a greater number of American Heart Association cardiovascular health metrics—being a non-smoker, being physically active, eating a healthy diet, having a healthy weight, having normal blood pressure, as well as normal levels of blood glucose and total cholesterol—was associated with a lower risk of mortality [3]. People who met at least 6 of the 7 metrics were half as likely to die of any cause and one fourth as likely to die of cardiovascular disease as were those who met only 1 or none of the metrics [3]. People who do poorly on these measures are not uncommon in North Carolina: 65% of adults in the state are overweight or obese (30% are obese), 32% have hypertension, nearly 10% have diabetes, 20% smoke, and 54% fail to meet physical activity targets [4]. In addition, 27% of people with diabetes are unaware of their diagnosis because they have no regular source of medical care, and 13% of those who have been diagnosed with diabetes have poor control of their glucose levels (ie, their glycosylated hemoglobin level is greater than 9%) [5, 6]. Only half of patients treated for hypertension currently have their blood pressure under control [7], and only half of patients aged 40 to 64 with elevated serum cholesterol levels have been treated sufficiently to lower their cholesterol to recommended levels [8]. Best practice care can help mitigate the burden of cardiovascular disease and premature death that is prevalent today in North Carolina. Yang’s age threshold highlights the urgency of risk-factor modification, not just in the middle-aged individuals that we usually think of as needing help, but in adolescents and young adults as well. Healthier lifestyles and more comprehensive primary care will be the key to improving outcomes.

Several factors contribute to disappointing population results. On the clinical side, most medical practices lack data systems that would allow them to readily identify patients whose chronic illnesses are out of control outside the confines of a particular office visit [9]. As a result, care intensification is often delayed, because the health care system depends on the patient to initiate sporadic appointments. What is needed is a persistent, systematic monitoring and intervention plan triggered by an electronic, real-time, chronic disease registry that identifies high-risk patients whether they are present in the office or not. On the community side, because of limited health literacy or lack of education in self-management, many individuals have a poor understanding of their chronic illnesses, the consequences of poor control, and the significant impact that lifestyle and medication adherence can exert in attenuating what are often asymptomatic conditions with insidious long-term sequelae [10-12].

Although preclinical, community-based, primary prevention is the ultimate goal, the incremental impact of achievable small improvements in clinically important care measures for people with diabetes and cardiovascular disease cannot be overlooked in the short term. For instance, in a trial in which patients newly diagnosed with diabetes were randomized to receive either conventional or intensive treatment with either sulfonylurea insulin or metformin, mean glycosylated hemoglobin level in intensive treatment groups was 0.5 to 0.6 percentage points lower than in the conventional treatment groups [13]. And a decade later, risk of death in the intensively treated groups was significantly lower than in the conventionally treated groups (absolute risk of death from any cause in the metformin-treated patients was 25.9% in the intensively treated group, compared with 33.1% in the conventionally treated group), as was the risk of potentially debilitating complications of diabetes [13]. Treatment for hypertension also reduces risk. A systematic review of the effectiveness of lowering blood pressure in patients with a history of stroke or transient ischemic attack showed that in comparison with those who did not receive antihypertensive therapy, those who were treated were 24% less likely to have a stroke, 21% less likely to have a myocardial infarction, and 21% less likely to have any kind of vascular event [14]. Finally, antiplatelet therapy with daily aspirin for individuals who have experienced a vascular event leads to the prevention of 36 serious vascular events for every 1,000 patients treated for 2 years [15].

The North Carolina Community Transformation Grant (CTG) program, funded through the Centers for Disease Control and Prevention (CDC), is a unique opportunity to combine improved clinical care with community interventions to promote healthier lifestyles. With its CTG award, the North Carolina Division of Public Health will work with state and local partners, including local health directors, AHEC, and Community Care of North Carolina, over a period of 5 years to help communities make it easier to live healthily in North Carolina. The objectives of the North Carolina project are to decrease tobacco use, increase physical activity levels, improve nutrition, and increase access to evidence-based clinical preventive services targeting hypertension, hypercholesterolemia, tobacco use, and weight management. The North Carolina CTG has 10 multicounty collaboratives, each with 1 local health department that has assumed responsibility for coordinating efforts. AHEC quality improvement coordinators will be working with the multicounty areas to address health care practices that implement quality improvement systems regarding prevention, screening, treatment, and referral for hypertension, hypercholesterolemia, tobacco use, and overweight or obesity. CTG staff in each of the multicounty areas will work in a strategic manner, taking into account health needs and disparities, to create environmental changes such as smoke-free local government buildings, smoke-free housing, and increased access to healthy foods and places for physical activity. Together, this partnership promotes clinical interventions that will lead to immediate cardiovascular health benefits and emphasizes community awareness, practices, and environmental constructs that will achieve the dream of neighborhood-based primary prevention. This article provides a summary of the approaches embraced by this important initiative dedicated to protecting the hearts of North Carolinians.

Enhanced Practice-Based Support
In 2007, the North Carolina Improving Performance in Practice (IPIP) program was developed to help make quality improvement tools and techniques available to primary care practices across the state. IPIP was developed in collaboration with Community Care of North Carolina, the North Carolina Division of Public Health, the North Carolina Academy of Family Physicians, the North Carolina Pediatric Society, the Carolinas Center for Medical Excellence, Area Health Education Centers (AHEC) program, and other partner organizations. The AHEC Program in 2 distinct areas of the state hired 2 quality improvement consultants to deliver an educational model of specific changes structured to improve the delivery of care for diabetes and asthma patients in practices that volunteered for this service. AHEC was involved in this initiative because of its mission to meet the state’s health and health workforce needs by providing educational programs in partnership with academic institutions, health care agencies, and other organizations committed to improving the health of the people of North Carolina.

Eighteen practices participated in the pilot program, and after 1 year of intervention, improvement was found in almost every clinical indicator for the 2 disease states included in the program [16]. In 2010, under the auspices of a federal grant that created the North Carolina Regional Extension Center for Health Information Technology, AHEC’s consulting services expanded to include on-site guidance regarding the adoption, implementation, and meaningful use of electronic health records (EHRs) in an effort to provide practices with the tools necessary to improve care. Nearly 1,100 practices across North Carolina are currently receiving practice-based consulting services to help them to select and use EHR systems, to implement necessary changes in their delivery of care, and to improve vital clinical indicators for patients with chronic diseases.

The recent development of the North Carolina CTG program creates an additional opportunity for the North Carolina Division of Public Health to again partner with AHEC to focus on clinical prevention strategies. These strategies include blood glucose control, blood pressure control, tobacco cessation, cholesterol reduction, and aspirin use after ischemic vascular events—all of which have all been shown to reduce the incidence of coronary disease, strokes, and other disabling cardiovascular events. Building on the experience of improving care in other chronic disease states, the AHEC Program will apply these tried and true methods to assist practices with improvements to their care delivery systems that initially will improve control of these risk factors and ultimately will reduce the burden of heart attack and stroke in the state.

The proven method of high-level, systems-based changes used throughout the AHEC practice-support program was developed by the AHEC Program together with the national Improving Performance in Practice Program through the American Board of Medical Specialties. It is based on the Chronic Care Model developed by Edward H. Wagner and others at the MacColl Center for Health Care Innovation [17]. Wagner and his colleagues have shown that care is often compromised by inattention to robust care coordination, failure to follow evidence-based practice guidelines, and insufficient patient teaching of self-management techniques, because of lack of data, lack of team organization, and lack of electronic tools in traditional medical practices. There is evidence that adherence to these concepts results in better clinical outcomes [18].

The AHEC Program provides participating practices with on-site, skilled consultants to help providers address these key areas. The work begins with using EHR systems to produce clinical data that can be used as the basis for measuring improvements in care. In conjunction with data reporting, the EHR system can be programmed to complement real-time clinical care by triggering alerts and reminders that address issues such as screening, drug allergies, and application of evidence-based interventions. The EHR can also provide educational materials for patients related to diagnoses, prescribed medications, and local resources. As sophisticated as EHR technologies are, they are of limited value unless they are integrated into normal practice patterns and daily workflows by the physician provider and the entire medical practice team. It is the melding of technology, teams, teaching, and patient access that establishes true patient-centered medical homes. So far, this approach has been extremely effective in the realms of diabetes and asthma. The CTG will extend this methodology to measures of cardiovascular care, so that primary care practices can specifically mitigate the risk factors that perpetuate devastating cardiovascular events in our state.

Addressing Environmental Influences on Cardiovascular Risk
North Carolina needs high-quality, accessible clinical systems to effectively address cardiovascular disease. However, even the best and most accessible clinical network cannot eliminate cardiovascular disease in isolation [19]. North Carolinians are at risk for heart disease and stroke due to a multitude of factors in their communities and environments. Choices that individuals make, such as whether they use tobacco, maintain appropriate weight, and are physically active, do influence their risk for heart disease and stroke. However, these individual choices are influenced by complex social and physical surroundings. If a physician advises a patient with heart disease to quit smoking, yet that patient is continuously exposed to tobacco or to encouragement to continue smoking, he or she is not likely to be successful at implementing the physician’s advice. Likewise, if patients with hypertension and heart disease are asked to increase their level of physical activity to address weight management, they will fail to make these individual behavior changes if their environment does not provide safe, attractive, accessible places to be physically active. Unfortunately, populations with the greatest health disparities regarding cardiovascular disease are the ones most likely to reside in areas characterized by a high concentration of establishments that sell tobacco, and a low concentration of places that sell healthy foods or have safe venues for physical activity [20-23].

Understanding the effect that one’s environment has on one’s risk of cardiovascular disease, the CDC is using CTGs to support states in making environmental changes to reduce the incidence of chronic diseases, promote healthier lifestyles, reduce health disparities, and control health care spending.

Environmental approaches to disease prevention have been found to be more cost-effective than clinical interventions or nonclinical, person-directed interventions [19, 24]. A recent example showing that environmental change can reduce cardiovascular risk in North Carolina is that the number of emergency department visits for acute myocardial infarction was found to have dropped 21% after the implementation on January 1, 2010, of legislation that banned smoking in bars and restaurants in the state [25]. Continued environmental interventions on the part of the North Carolina CTG will be critical if similar successes are to be obtained.

In conclusion, although systematic clinical intervention remains important for those with current cardiovascular compromise or risk, a combined course that also includes environmental tactics that address cardiovascular disability and death represents the only approach that positions North Carolina to effectively reduce health disparities, improve health status, and lower health care costs.

Potential conflicts of interest. All authors have no relevant conflicts of interest.

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22. Zenk SN, Schulz AJ, Israel BA, James SA, Bao S, Wilson ML. Neighborhood racial composition, neighborhood poverty, and the spatial accessibility of supermarkets in metropolitan Detroit. Am J Public Health. 2005;95(4):660–667.

23. Diez Roux AV, Evenson KR, McGinn AP, et al. Availability of recreational resources and physical activity in adults. Am. J. Public Health 2007;97(3):493–499.

24. Chokshi DA, Farley TA. The cost-effectiveness of environmental approaches to disease prevention. N Engl J Med. 2012;367(4):295-297.

25. North Carolina Tobacco Prevention and Control Branch Epidemiology and Evaluation Unit. The North Carolina Smoke Free Restaurant and Bars Law and Emergency Department Admissions for Myocardial Infarction: A Report to the North Carolina State Health Director. Raleigh, NC: North Carolina Department of Health and Human Services; 2011. Accessed August 1, 2012.

Samuel Cykert, MD associate director for medical education and clinical director, North Carolina Regional Extension Center for Health Information Technology, North Carolina Area Health Education Centers Program, professor of medicine, Division of General Internal Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Ruth Petersen, MD, MPH section chief, Chronic Disease and Injury Section, Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina.
Ann Lefebvre, MSW, CPHQ associate director for quality and executive director for the North Carolina Regional Extension Center for Health Information Technology, North Carolina Area Health Education Centers Program, adjunct assistant professor, Division of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Address correspondence to Dr. Samuel Cykert, NC AHEC Program Office, 145 N Medical Dr, CB# 7165, Chapel Hill, NC 27599 (