Recent Advances in the Treatment of Hypertension

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Levels of Prevention Primordial, Primary,
Secondary, or Does it Matter?
George A. Mensah
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Ill and unfit choice of words wonderfully
obstructs the understanding
- Bacon
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T Wilson. Universal Press Syndicate, 1986
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Objectives

• Emphasize why prevention levels matter
• Review current classification systems and the
  basis for confusing terminology
• Highlight the need for standardization
• Present the proposed CVH model
• Discuss CDC perspectives
• Identify challenges opportunities

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Background

• Current terminology definitions of CVD
  prevention strategies lack
• Precision
• Standardization of use
• Clarity

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Last. A Dictionary of Epidemiology, 4th Edition
2001

• Primordial Prevention minimize hazards to
  health
• 1o Prevention Reduce the incidence of disease
• 2o PreventionReduce the prevalence of disease
• 3o Prevention Reduce the impact of complications

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Confusing Terminology Imprecise Definitions

• Primordial Prevention Protoprophylaxis
• 1o Prevention Reduction in incidence of disease
  in a susceptible population screening and
  treatment of HTN

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Confusing Terminology Imprecise Definitions

• 2o Prevention Reduction in the prevalence or
  consequence of disease
• 3o Prevention Reduction in disability or
  complications in those who already have disease
  Treatment of high lipids in people who already
  have an MI

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Confusing Terminology Imprecise Definitions

• 4o Prevention Rehabilitation or restoration of
  function heart transplantation

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American College of Cardiology website
www.acc.org
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Main Objective

• To propose a model that addresses the limitations
  in current terminology for prevention strategies
  in order to

• Facilitate cross-sectoral communication and
  prevention research
• Provide examples of public health roles using
  this model
• Discuss impact on future partnerships

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The Model

• Health Promotion
• Primary Prevention
• Secondary Prevention

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Levels of Prevention
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Basic Principle Underlying the Proposed Model

• The prevention level is determined by the
  characteristics of the population served and not
  by the nature of the intervention.

Level 2
Level 1
Level 0
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(No Transcript)
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Level 0Health Promotion

• Target Population
• Entire population, regardless of risk factor or
  disease status

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Health Promotion
"The process of enabling people to increase
control over and improve their health. It
involves the population as a whole in the context
of their everyday lives rather than focusing on
people at risk for specific diseases, and is
directed toward action on the determinants or
causes of health.
Last. A Dictionary of Epidemiology, 4th Edition
2001
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Level 1Primary Prevention

• Target Population
• Persons free of heart disease or stroke but who
  have one or more cardiovascular risk factors

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Level 2Secondary Prevention

• Target Population
• Survivors of a heart attack, stroke persons who
  have any other established heart or vascular
  disease

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(No Transcript)
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Prevention and Control of Heart Disease and
StrokeA Summary Scheme and Characteristics of
Prevention Levels
Level of Prevention
Target Population
Goals of Prevention
Published Guides
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Characteristics of the Levels of Prevention

• Well-defined target population
• Well-defined objectives and goals
• Consistent with AHA/ACC definitions and
  guidelines for primary secondary prevention

• Consistent with Healthy People 2010 goals and
  objectives for heart disease and stroke focus area

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Levels of Prevention and theCore Functions of
Public Health
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Public Health Roles in Comprehensive CVD
Prevention
www.health.gov/phfunctions/public.htm
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Coordination of Activities Within CDCs National
Center for Chronic Disease Prevention Health
Promotion
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Prevention and Control of Heart Disease and
Stroke Spectrum of Levels, Strategies and Core
Public Health Functions
A Consensus Statement for Public Health Practice
from the Centers for Disease Control and
Prevention
Mensah GA, Bales VS, Collins J, Dietz WH, Henson
R, Labarthe D, Kolbe L, Vinicor F, Marks
JS. National Center for Chronic Disease
Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia
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Summary

• A comprehensive program for a heart-healthy and
  strokefree living uses all 3 levels of
  preventive strategies
• Coordination within chronic disease
  organizational units is crucial, especially, at
  the Health Promotion and Primary Prevention
  levels
• Secondary prevention represents a niche area for
  CVH programs and deserves special attention

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Event Reduction Associated With a 12-13 mmHg
Average Systolic BP Reduction in Randomized
Controlled Trials
Coronary Heart Disease
Total Cardiovascular Mortality
All-Cause Mortality
Stroke
Percent Reduction
He Whelton. Am Heart J 1999 138211-219
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Secondary Preventionof Heart Disease and Stroke
Survivors of a first non-fatal CVD event
Patients with recurrent non-fatal CVD events
Mensah, 2001
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Receipt of Physician Advice on Lifestyle Changes,
1997 Behavioral Risk Factor Surveillance System
Advice to eat fewer high-fat and high-cholesterol
foods
Advice to exercise more
Greenlund, Giles, Keenan, Croft, Mensah. Stroke
200233565-571
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The Gap Between Science and Practice

• Poor hypertension treatment and control rates
• Suboptimal adherence to guidelines for post-MI
  care
• Poor adherence to evidence-based management of
  congestive heart failure

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Utilization of Risk Reduction Measures in MI
Survivors, USA, 1996

• Referral to cardiac rehabilitation lt10
• Smoking cessation 20
• Estrogen replacement (women) 20
• Cholesterol-lowering diet 20
• Cholesterol-lowering drug 30
• b-blocker therapy 40
• ACE inhibitor therapy 60
• Aspirin therapy 70

From Vogel RA. Coronary Artery Disease 1995
6466471.
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Quality Indicators in Post-MI ManagementThe
Cooperative Cardiovascular Project

• Percent

N 186,800 Medicare Patients, 2/94-7/95
OConnor et al. JAMA 1999281627-633
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Quality of Care and Mortalityfor Medicare
Patients With Acute MI
HOSPITAL TEACHING STATUS
Plt0.001 for all 3 groups
Allison et al. JAMA 2000 2841256-1262
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Why is CHF Important?

• The leading principal diagnosis for
  hospitalization among older adults
• Total costs exceed 21 billion /yr
• Nearly 5 million people affected
• 550,000 new cases annually
• Average 5-year survival is 50
• Nearly 50 of severe CHF patients die within a
  year of diagnosis.
• Adverse US demographic trends

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Why is CHF Unique?

• Prevalence likely to increase as a result of
  advances in CVD care
• It is the only CVD for which the incidence,
  prevalence, and morbidity have continued to
  increase
• Although in-hospital case-fatality has decreased,
  the overall death rate remains very high
• Unlike all other CVD, death rates have failed to
  decline appreciably.

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Public Health Roles in 2o Prevention

• Generate surveillance data on disease burden
• Prevalence incidence mortality disability
  trends
• Monitor the gap between prevention guidelines and
  preventive care delivered
• Provide feedback to practitioners on compliance
  with preventive guidelines
• Form partnerships for continued education
• For patients families and health professional
• Support systems change informatics support

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Public Health Roles inSecondary Prevention of
CVD - 1

• Develop and implement
• Environmental and policy changes (tobacco,
  nutrition, physical activity, access to care,
  etc) for stroke and heart disease patients
• Skill-based professional education for care
  providers, patients, families
• Incentives for guidelines compliance

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Public Health Roles inSecondary Prevention of
CVD - 2

• Simplify disseminate guidelines
• Develop monitor health care process outcome
  measures
• Provide feedback to providers
• Develop and nurture partnerships with providers,
  purchasers, health plans and quality improvement
  organizations

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Examples of 2o Prevention Activities in the
State-Based CVH Programs - 1

• ACE Program in North Carolina
• Managed care setting Feedback to MDs
• ? CHF hospitalizations via ?ACE inhibitor Rx
• HEART Program North Carolina
• Pre-post design claims database
• Statin Rx for high cholesterol MD feedback
• CABBAGE Program in New York
• Mortality rates post bypass surgery
• Publication of report cards

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Examples of 2o Prevention Activities in Public
Health Service - 2

• Cardiovascular Collaborative
• CDC partnership with HRSA
• CHF and post-MI management
• Process outcome measures tracked
• CVH Council-AHA-Industry Project
• AHA Pharmaceutical Roundtable
• 100,000 awarded in grants to State Health
  Departments

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Examples of 2o Prevention Activities Within State
Health Departments - 1

• ACE Program in North Carolina
• Managed care setting Feedback to MDs
• ? CHF hospitalizations via ?ACE inhibitor Rx
• HEART Program North Carolina
• Pre-post design claims database
• Statin Rx for high cholesterol MD feedback
• CABBAGE Program in New York
• Mortality rates post bypass surgery
• Publication of report cards

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Examples of 2o Prevention Activities Within State
Health Departments - 2

• Cardiovascular Collaborative
• CDC partnership with HRSA
• CHF and post-MI management
• Process outcome measures tracked
• CVH Council-AHA-Industry Project
• AHA Pharmaceutical Roundtable
• 100,000 grant to be awarded in grants to State
  Health Departments

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Wisconsin CVH State ProgramSecondary Prevention
Efforts

• Collaborative Diabetes Quality Improvement
  Project
• Partnership with Diabetes Control Program, 17
  HMOs, 1 tribal council, 1 health care provider
• Improving quality of care through utilization of
  HEDIS data
• CVD included in 2000
• Development of State Lipid Guidelines beginning
  June 2002

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Oklahoma CVH State ProgramSecondary Prevention
Efforts

• Development of Stroke Protocols
• Partnership with
• Local Health Departments, hospitals, and
  emergency first responders
• AHA, QIO, and Hospital Association
• Address stroke response from emergency call
  through rehabilitation
• Tailoring AHA/ASA and NSA guidelines to fit State
  needs

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Ohio CVH State ProgramSecondary Prevention
Efforts

• Data Partnership
• Ohio Department of Public Safety - active member
  of Ohio Alliance for Cardiovascular Health
• Emergency Medical Services Incidence Reporting
  System
• Data source for secondary prevention objectives
  and planning future interventions

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Conclusions - 1

• Secondary prevention is a key component of the
  comprehensive strategies for CVD prevention
• Significant gaps exist between the guidelines and
  services provided
• Public health has important roles in bridging
  this gap and in all aspects of secondary
  prevention

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Conclusions - 2

• Key public health roles include
• Convene strategic partners,especially within the
  health care setting
• Help disseminate best practices
• Assess risk factors and process outcome
  measures in preventive care
• Provide data feedback to providers
• Partner for continuing professional and patient
  education