Edisto Fork United Methodist Church Orangeburg, South Carolina - - PowerPoint PPT Presentation

Edisto Fork United Methodist Church Orangeburg, South Carolina February 11, 2016

Brent Egan, MD ISHIB

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Tri-County Health Network & ISHIB Present:

Cardiometabolic Health Equity: Improving Outcomes through Patient-Centered Best Practices Brent M. Egan, MD

President, International Society on Hypertension in Blacks (ISHIB) Professor of Medicine, USCSOM–Greenville Chief Science Officer, Care Coordination Institute

Cardiometabolic (CM) Health Equity: Improving Outcomes through Patient-Centered Best Practices

Symposium Objectives – Bi(Multi)-directional learning:

• Identify and discuss medical and social factors contributing to

cardiometabolic (CM) health disparities

• Identify and discuss Patient-Centered Outcomes Research

(PCOR) opportunities to improve CM health equity

• Apply lessons learned from this Symposium & focus groups to

develop and fund an intervention that can be sustained locally and replicated in other communities with CM disparities

(Cardio)Metabolic Syndrome

3 or more of:

• 1. Waist 35+” women, 40+” men)
• 2. High fasting blood sugar (≥100)
• 3. High fasting triglycerides (≥150)
• 4. Low HDL-cholesterol

(<50 women, <40 men)

• 5. Hypertension or BP 130+/85+

Ford, et al: JAMA. 2002;287:356.

Complications of Cardiometabolic Syndrome

1. Heart Attack 2. Heart Failure 3. Stroke 4. Kidney Disease and Failure (dialysis) 5. Peripheral Vascular Disease (Amputation) 6. Memory Loss (Dementia) 7. Blindness (especially from diabetes) 8. Poor Quality of Life 9. Early Death

Population Health Perspective

Kindig, DA. Improving population health. http://www.improvingpopulation health.org/blog/what-is-population-health.html

20%; ~90% 80%; ~10%

Variance in Health; Spending

Modern Life Has Its Conveniences and Costs

“ACCESS TO EXCESS” calories, sugar, fat, salt, labor saving devices and passive entertainment . . . A KEY DRIVER OF CHRONIC DISEASE

Lambert, Craig And Bing, Christopher. The Way We Eat Now. Harvard Magazine; May-June, 2004; Page 50.

Tri-County Health Network Strategic Plan – Three Year Goals

Tri-County Health Network will use a collective approach to support systems change to:

• Increase the percentage of adults and children

participating in physical activity.

• Increase the percentage of adults and children who

eat more fruits and vegetables daily.

• Sustain a community-wide partnership that focuses
• n healthy lifestyles

Healthy People in Healthy Communities . . .

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Effect of optimal control of BP and LDL-C in men Currently:

Optimal BP control: Optimal BP and LDL-C control

1,500,000 CHD Events 1,078,500 CHD Events 385,500 CHD Events

Wong ND, et al. Am J Cardiol. 2003;91:1421-1426.

Potential Benefit of Combined Blood Pressure and Lipid Control in Men

Cardiometabolic (CM) Health Equity: Improving Outcomes through Patient-Centered Best Practices

Symposium Objectives – Bi(Multi)-directional learning:

• Identify and discuss medical and social factors contributing to

cardiometabolic (CM) health disparities

• Identify and discuss Patient-Centered Outcomes Research

(PCOR) opportunities to improve CM health equity

• Apply lessons learned form this Symposium & focus groups to

develop and fund an intervention that can be sustained locally and replicated in other communities with CM disparities

Cardiometabolic Health Interactive Workshop: Good Health Made Simple[r]

Brent M. Egan, MD

President, International Society on Hypertension in Blacks (ISHIB) Professor of Medicine, USCSOM–Greenville Chief Science Officer, Care Coordination Institute

Cardiometabolic (CM) Health Interactive Workshop: Good Health Made Simple[r]

Outline:

• 1. Working definition
• 2. Key factors determining good CM health
• a. Non-modifiable (can’t change)
• b. Modifiable (can change)
• 3. What you can do to enhance your CM health

without losing sleep or breaking the bank

Good (Cardio)Metabolic Syndrome

Absence or control of: :

• 1. Waist 35+” women, 40+” men)
• 2. High fasting blood sugar (≥100)
• 3. High fasting triglycerides (≥150)
• 4. HDL-Chol <50 women or <40 men
• 5. Hypertension or BP 130+/85+

And: Good physical and mental endurance which allow you to participate fully in life-stage appropriate activities

Ford, et al: JAMA. 2002;287:356.

Good Cardiometabolic Health Prevents Complications or Delays Them to Late in Life

1. Heart Attack 2. Heart Failure 3. Stroke 4. Kidney Disease and Failure (dialysis) 5. Peripheral Vascular Disease (Amputation) 6. Memory Loss (Dementia) 7. Blindness (especially from diabetes) 8. Poor Quality of Life 9. Early Death

Keys to Good Cardiometabolic Health

• 1. Healthy lifestyles
• a. Balanced nutrition
• b. Minimize Sedentary Activity
• c. Low and Moderate Intensity Physical Activity
• 2. Good Medical Care – Access to, use of, and

adherence with evidence-based guidelines for:

• a. Risk factor screening
• b. Risk factor treatment and control
• 3. HOPE; I’m connected to caring people and

believe my life has purpose (makes a difference)

Healthy Food Doesn’t Taste Good & Costs More – Myth Buster!

It Costs Too Much To Eat Healthy: The Revis Family of North Carolina Spends $342 Weekly on Food.

The Aboubakar Family in Breidjing Camp (Chad; refugees from Darfur, Sudan). Food costs for 1 Week $1.23.

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A year supply of wheat, rice, oats, and beans weighs 400 pounds (ten 6-gallon pails) and provides ~1800 Calories / day for 1 person for 1 yr. If these items provided half of daily calories or ~900 Calories/day, then the cost is $0.69 / day. $490 + $12 shipping ($502) from Emergency Essentials http://beprepared.com

Cost of Basic Healthy Food in the U.S.

Walking is a Great Exercise with Major Health Benefits

Many Americans Spend Most Waking Hours Sitting: It’s Killing Us: Stand, Stretch and Bend.

Consider a Standing Desk at Work, Home & School!

Have ‘Standing’ Conversations !!!

The Sedentary Life is Killing US !!

“ACCESS TO EXCESS” calories, sugar, fat, salt, labor saving devices and passive entertainment . . . A KEY DRIVER OF CHRONIC DISEASE

Lambert, Craig And Bing, Christopher. The Way We Eat Now. Harvard Magazine; May-June, 2004; Page 50.

Do you know your BMI?

5'4"

Height Weight (lbs)

5'2" 5'0" 5'10" 5'8" 5'6" 6'0" 6'2"

120 130 150 160 170 180 190 200 210 220 230 240 250 140 260 270 280 290 300

6'4"

Control Blood Pressure and Treat Cholesterol to Reduce Heart Disease and Stroke by More than Half !!!

Effect of optimal control of BP and LDL-C in men Currently: Optimal BP control: Optimal BP & LDL-C control:

1,500,000 CHD Events 1,078,500 CHD Events 385,500 CHD Events Wong ND, et al. Am J Cardiol. 2003; 91:1421-1426.

Screening of Risk Factors for Heart Disease & Stroke

• Have your BP checked
• 1. at least every two years if <120/<80
• 2. At least every year if 120–139/80–89 (pre-hypertension)
• 3. At least every month if more than 140/90
• Have your cholesterol checked at least every 5 years

know your risk for heart disease and stroke and whether you are a candidate for statin treatment – your risk for heart disease and stroke fall at least 20% for every 40 point fall in bad (LDL) cholesterol

• Screen every 3 years for diabetes if last test is normal

(fasting glucose <100, HbA1c less than 5.7%

• Check BMI at least yearly and take action to reduce

weight by 5% or more if overweight or obese

Hypertension Treatment Algorithm: Based on ISHIB Guideline and Discount Medications

Regimen-1 (3 pills; 3 meds) Regimen- 2 (2 pills; 3 meds) Lisinopril 40 (Free) Benazepril / Amlodipine 40/10 ($4/Mo) Amlodipine 10 ($4/mo) Indapamide ($4/mo) HCTZ 25 ($4/mo) Total Cost: $8/month Total Cost: $8/month Regimen- 3 (3 pills; 3 meds) Regimen- 4 (2 pills; 3 meds) Losartan 100 ($4/mo) Valsartan / HCT 320/25 ($10/mo) Amlodipine 10 ($4/mo) Amlodipine 10 ($4/mo) HCTZ 25 ($4/mo) Total Cost: $12/month Total Cost: $14/month

Pharmacological Treatment algorithm (should control 80%–90% of hypertensives to <140/<90). Note: If patients have compelling indications for specific medication classes, then begin with those. For information on inexpensive medications for use in delivery of the CCI Treatment Algorithms, visit CCIHealth.org.

Cumulative event rate

HR: 0.80 (0.72, 0.90)

Time to Primary Outcome(days)

ACEI / HCTZ CCB / ACEI 650 events 552 events

P <0.001

Jamerson K, et al. NEJM. 2008;359:2417–2428.

679 events 20% fewer heart problems and strokes with the CCE / ACEI than diuretic / ACEI

Slide Source: Lipids Online Slide Library www.lipidsonline.org

1 2 3 4

Cumulative Incidence (%) Years

ASCOT: Low dose statin reduces heart disease in hypertensive patients

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

Atorvastatin 10 mg Number of events 100 Placebo Number of events 154

36% reductio n

HR = 0.64 (0.50–0.83); p = 0.0005

Sever PS et al. Lancet 2003;361:1149–1158. Reprinted with permission from Elsevier Science.

Cost of Statins to Lower Bad (LDL) Cholesterol

Generic: Low-Dose1 High-Dose2 Cost3 Atorvastatin 10 – 20 mg 40 – 80 mg $6+ / mo Lovastatin 40 mg $4 / mo Pravastatin 40 – 80 mg $4 / mo Simvastatin 20 mg $4 / mo

Brand Name Rosuvastatin 5 – 10 mg 20 – 40 mg

1Low-Dose lowers LDL 30% – 45% 2High-Dose lowers LDL 48% – 63% 3Cost is out-of-pocket assuming no insurance; otherwise generic co-

pay if lower

Side Effects of Statins

Side Effect Frequency

• Muscle symptoms

1Common >10%

• Major muscle inflammation

2Uncommon (<0.1%)

• Liver enzymes 3 times normal

3~1% with high-dose

• Diabetes

4~1%

1Dose-related; reduced with every other day dosing; may be less

common with pravastatin; more common if underactive thyroid

2If marked muscle tenderness / weakness, then stop the statin and tell

your doctor immediately

3Routine monitoring of liver enzymes is no longer recommended; dose

related – caution with higher doses in elderly, smaller individuals, patients with liver disease or other liver ‘toxins’

4Dose-related and mostly in individuals at high-risk for diabetes; diabetes

develops a few weeks to months earlier with than without a statin

National Rankings and Improvement

SC Improvement in CV Mortality Rank

• vs. Other ‘Stroke Belt’ States: 1995 to 2009.

ST STROKE BE BELT 1995 Rank 2009 Rank  rank 31—Virginia 27—Virginia +4 34—North Carolina 32—N. Carolina +2 35—Indiana 34—S. Carolina +16 41—Arkansas 40—Georgia +4 43—Alabama 39—Indiana

• 4

44—Georgia 44—Kentucky +2 46—Kentucky 45—Tennessee +4 47—Louisiana 48—Louisiana

• 1

49—Tennessee 46—Arkansas

• 5

50—South Carolina 50—Alabama

• 7

51--Mississippi 51--Mississippi

Source: CDC WONDER

Centers for Disease Control and Prevention, National Center for Health

• Statistics. Compressed Mortality File 1979-
• 1998. CDC WONDER On-line Database,

compiled from Compressed Mortality File CMF 1979-1998, Series 20, No. 2E, 2003 and CMF 1999-2009 Series 20 No. 2O, 2012 and using 2009 population as a constant for all comparisons. Accessed at http://wonder.cdc.gov/cmf-icd10.html on Sep 28, 2012.

50th in US WORST (1995) 34th in US FIRST in Stroke Belt (2009)

Healthy People in Healthy Communities . . .

Keys to Good Cardiometabolic Health

• 1. Healthy lifestyles
• a. Balanced nutrition
• b. Minimize Sedentary Activity
• c. Low and Moderate Intensity Physical Activity
• 2. Good Medical Care – Access to, use of, and

adherence with evidence-based guidelines for:

• a. Risk factor screening
• b. Risk factor treatment and control
• 3. HOPE; I’m connected to caring people and

believe my life has purpose (makes a difference)

Cardiometabolic (CM) Health Interactive Workshop: Good Health Made Simple[r]

Outline:

• 1. Working definition
• 2. Key factors determining good CM health
• a. Non-modifiable (can’t change)
• b. Modifiable (can change)
• 3. What you can do to enhance your CM health

without losing sleep or breaking the bank

Brent Egan, MD ISHIB

167

Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree

13% 0% 0% 27% 60%

A.

Strongly disagree

B.

Disagree

C.

Neither agree nor disagree

D.

Agree

E.

Strongly agree Please rate your level of agreement or disagreement with the following statement: This program met my expectations for information.

168

Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree

9% 0% 6% 29% 56%

A.

Strongly disagree

B.

Disagree

C.

Neither agree nor disagree

D.

Agree

E.

Strongly agree Please rate your level of agreement or disagreement with the following statement: The approach (presentations, breakout discussions) was appropriate to facilitate my learning experience.

169

Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree N/A

6% 3% 0% 18% 74% 0%

Please rate your level of agreement or disagreement with the following statement: The topics in the presentations and breakout sessions were relevant to me.

A.

Strongly disagree

B.

Disagree

C.

Neither agree nor disagree

D.

Agree

E.

Strongly agree

F.

N/A

170

Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree

9% 0% 9% 19% 63%

Please rate your level of agreement or disagreement with the following statement: My input was heard and discussed.

A.

Strongly disagree

B.

Disagree

C.

Neither agree nor disagree

D.

Agree

E.

Strongly agree

171

Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree N/A

3% 3% 9% 28% 50% 6%

Please rate your level of agreement or disagreement with the following statement: This program prepared me to participate in a focus group to inform a patient-centered outcomes research (PCOR) study on CM health.

A.

Strongly disagree

B.

Disagree

C.

Neither agree nor disagree

D.

Agree

E.

Strongly agree

F.

N/A

172

Yes No 87% 13%

A.

Yes

B.

No

173

Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree

9% 0% 3% 26% 63%

Please rate your level of agreement or disagreement with the following statement: I am willing to attend another program similar to this

• ne.

A.

Strongly disagree

B.

Disagree

C.

Neither agree nor disagree

D.

Agree

E.

Strongly agree

174

Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree

8% 0% 3% 33% 56%

Please rate your level of agreement or disagreement with the following statement: I am likely to recommend that others attend a program similar to this one.

A.

Strongly disagree

B.

Disagree

C.

Neither agree nor disagree

D.

Agree

E.

Strongly agree

175

Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree

6% 0% 3% 34% 57%

Please rate your level of agreement or disagreement with the following statement: Today’s program and the plan discussed will lead to better cardiometabolic health within the next one to five years.

A.

Strongly disagree

B.

Disagree

C.

Neither agree nor disagree

D.

Agree

E.

Strongly agree

176

Brent Egan, MD Brenda Williams

177

Cardiometabolic (CM) Health Equity: Improving Outcomes through Patient-Centered Best Practices

Symposium Objectives – Bi(Multi)-directional learning:

• Identify and discuss medical and social factors contributing to

cardiometabolic (CM) health disparities

• Identify and discuss Patient-Centered Outcomes Research

(PCOR) opportunities to improve CM health equity

• Apply lessons learned form this Symposium & focus groups to

develop and fund an intervention that can be sustained locally and replicated in other communities with CM disparities

Keys to Good Cardiometabolic Health

• 1. Healthy lifestyles (TCHN GOALS)
• a. Balanced nutrition
• b. Minimize Sedentary Activity
• c. Low and Moderate Intensity Physical Activity
• 2. Good Medical Care – PCORI EAIN Collaboration

Access to, use of, and adherence with evidence-based guidelines for:

a. Risk factor screening and prevention b. Risk factor treatment and control

• 3. HOPE; I’m connected to caring people and believe my

life has purpose (makes a difference)

TCHN & ISHIB: Partnership for Health

Please rate your level of agreement or disagreement with the following statement: This program prepared me to participate in a focus group to inform a patient-centered outcomes research (PCOR) study on CM health.

199 0% 20% 40% 60% 80% 100% Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree N/A 3.13% 3.13% 9.38% 28.13% 50.00% 6.25%

Please rate your level of agreement or disagreement with the following statement: Today’s program and the plan discussed will lead to better cardiometabolic health within the next one to five years.

203 0% 20% 40% 60% 80% 100% Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 5.71% 0.00% 2.86% 34.29% 57.14%