High Burden, Great Opportunity: Preventing Heart Attacks and Strokes

Coordinator:
Good afternoon and thank you for standing by. As a reminder, all lines have been placed on a listen-only mode until the question and answer segment of today's conference call. Today's call is being recorded, if you have any objections, you may disconnect at this time.

I would now like to turn today's call over to Ms. Loretta Jackson-Brown. Thank you, you may begin.

Dr. Loretta Jackson-Brown:
Thank you, Michelle. Good afternoon. I'm Loretta Jackson-Brown and I'm representing the Clinician Outreach and Communication Activity, COCA, with the Emergency Risk Communication Branch at the Center for Disease Control and Prevention.

I'm delighted to welcome you to today's COCA call, high burdens, great opportunities preventing heart attacks and stroke. You may participate in today's presentation by audio only, via Webinar, or you may download the slides if you are unable to access the Webinar.

The PowerPoint slide set and the Webinar link can be found on our COCA Web page at emergency.cdc.gov/coca. Click on February 23rd COCA Call. The slide set is located under Call Materials.

Free continuing education is offered for this COCA call. Instructions on how to earn continuing education will be provided at the end of the call. CDC, our planners, presenters and their spouses' partners wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, supplies of commercial services, or commercial support.

Planners have reviewed content to ensure there is no bias. This presentation will not include any discussion of the unlabeled use of a product or products under investigational use.

At the end of this presentation, you will have the opportunity to ask the presenters questions. On the phone, dialing Star 1 will put you in the queue for questions. You may submit questions through the Webinar system at any time during the presentation by selecting the Q & A tab at the top of the Webinar screen and typing in your question.

At the conclusion of today's session, the participant will be able to describe the key components of Million Hearts and the targets that must be met to prevent one million heart attacks and strokes. Discussed accomplishments of Million Hearts, state how evidence-based strategies can help identify and address the needs of those at greatest risk for heart attack and stroke, and discuss the use of standardized treatment approaches to improve outcomes for patients at risk for heart attack and stroke.

Today's presenter is Dr. Janet Wright. Dr. Wright is a Board-certified cardiologist with over 20 years of experience in interventional and clinical practice. As a former Senior Vice President for Science and Quality at the American College of Cardiology, Dr. Wright oversaw the development of guidelines, performance measures and appropriate use criteria to include the National Cardiovascular Data Registry.

Dr. Wright has served as Executive Director of Million Hearts since its launch in 2011. In this capacity, she has worked across federal and private partners to execute evidence-based strategies to prevent cardiovascular diseases and improve health.

At this time, please welcome Dr. Wright.

Dr. Janet Wright: 
Thank you so much, Dr. Jackson-Brown. I want to thank you and the entire COCA team for the opportunity to represent Million Hearts on the Webinar today. I look forward to a robust question and answer period and let's just get started.

In fact, with the foundation of these COCA calls in emergency preparedness and response, I'd like to make the case today that hypertension in the country is approaching, if not an emergency, at least an urgency. When you combine the impact on the families and individuals and communities of uncontrolled high blood pressure and the cost-the wasted costs that we are spending on the events that could be prevented, I think we're getting pretty closely into the category of at least a national urgency.

So today's agenda is on this slide. I'm going to give you a quick overview of Million Hearts, the Initiative, a bit of a progress report on where we are now as we begin our fifth-five years. What we've learned and what we understand to be the effective strategies and interventions to prevent a million events. And along the way, I hope to sprinkle every one of you with resources to assist you that are available with you in your work.

Million Hearts, as Dr. Jackson-Brown mentioned, is a national initiative. It was launched by the Department of Health and Human Services and is co-led by CDC and CMS. It has an explicit goal to prevent a million heart attacks and strokes and other cardiovascular events in a five-year time stretch between January 1 of 2012 and December 31st of 2016.

Obviously, the reason we would try to tackle a government and a set of private partners and individuals, a single condition, is because cardiovascular disease remains the number one killer, the cause of over a million and a half events each year and eight hundred thousand deaths.

It also is the cause of major disparities in outcomes, that is cardiovascular disease, for the African American, for example, lose 14 months of life to cardiovascular disease.

So let me move to our next slide which shows you the basic construct of Million Hearts. Mirroring the co-lead of CDC and CMS, you will see public health actions and those related to clinical care. So let's start over on the right side and these interventions and strategies that were chosen were actually the product of a series of predictive modeling exercises, as well as review of the literature and interviews with subject matter experts.

And what the models and the other types of investigation spat out are getting excellence in what we call the ABCS. That is aspirin for secondary prevention, blood pressure control, optimal cholesterol management, and smoking cessation as the most powerful things that those in healthcare careers can contribute to preventing a million events in a five-year timeframe.

I apologize for my slide, but the content over on the left side are the major, very powerful public health levers that can be pulled and that contribute mightily to prevent an event. The first one, although you can't see it, is smoke-free space, so improving our ability to avoid exposure to secondhand smoke. The second is gradually lowering the intake of sodium by each one of us. And the third is eliminating artificial trans fats, something that we believe FDA's final determination last June will effectuate over a period of several years.

Going back over on the clinical side, because this is a - we hope that they're a group of dedicated clinicians on the phone today. Obviously, in order to get experts (unintelligible) in the ABCS, you need a scheme and we know that new models of care support the same delivery.

So getting dieticians and pharmacists and community health workers and peer support groups involved in managing these risk factors for heart disease is part of the pathway to success, as is the deployment of health information technology. And we'll hit a couple of highlights of how - what that looks like.

But I'll say before I leave this slide, central to all the work in Million Hearts, from the beginning to focus on populations with the greatest burden and at the greatest risk. So you will see references to health disparities and the actions that we think will contribute to elimination of those disparities along the way today.

Here, I will give you -- start to give you a bit of a progress reports. So as I mentioned, we are a five-year initiative and we are beginning the fifth year. And I'll give you a bit of an update on each of the categories shown on this slide. When it comes to engagement and activation, there are a Million Hearts' actions and factors throughout all 50 states. There are many regional and state coalitions. There are subscribers to any update that comes out every other month, and I think we've talked about 65,000 subscribers.

I'd ask each of you if you're not receiving the newsletter, to go to any page on our Website and at the bottom of that page you can sign up to receive the newsletter. It does give us a chance to highlight work going on around the country by a (unintelligible), by communities and by clinical settings. It also is a place for us to share the breaking science and any new resources that we have either (unintelligible) or discussed.

(Unintelligible) of 100 Congregations for Million Hearts that really was built upon learning that many state-based organizations had health ministries, but were struggling implement the evidence-based strategies. They needed some assistance in understanding what would make the most difference, as many are not awash in resources, and it's true for all of our settings.

All of us want to use our minutes and our other resources for the maximum impact. We blew by 100 Congregations some time ago and I think now we're up to about 260. More information about 100 Congregations is on the Website.

When it comes to clinical quality measure alignment, who would dream that in a four - in a five-year initiative, something as fundamental and non-controversial as blood pressure and cholesterol would actually become a hot topic?

My letters here signify that despite the challenges of changing guidance about blood pressure control measures, and cholesterol, perhaps LDL targets, we have managed to keep the blood pressure, cholesterol and smoking measures , as well as the aspirin one embedded in the initiative and quality reporting programs, both in the federal government and in the private sector. As the evidence evolves and guidelines change, we will again make sure that we can contribute as much as possible to alignment.

The purpose of that alignment is for – twofold. or the benefits about alignment. First is that it reduces the reporting burden for busy practitioners who might be participating in these reporting programs. And on the other side, it actually makes the measures that are reported on much more robust because they refle – (unintelligible) measuring the same thing the same way, so we can understand performance much better.

So speaking of understanding what works where and why, this has been one of the most exciting parts of Million Hearts,  to recognize high performers around the country, sit with them and understand why they made performance, and for example, blood pressure control, their priority,  what they learned from that and how they achieved such levels of high performance.

We're leaning many examples of this high performance from the quality improvement works and quality improvement organizations funded by CMS. But also through CDC's Champion's program which recognizes practices and systems that achieve a control rate of 70% or greater for their hypertensive patients. A tremendous wealth of knowledge, very practical knowledge that can be applied in other places.

We have tried to provide resources that we found missing in the environment and I think more importantly we've been able to collect and then disseminate resources that are truly road-tested. You'll find these on our Website and we're happy to also take advice about something that you would find helpful, but you do not find available. I'll reference a couple of these items a little bit later in the talk.

And then finally in terms of progress, we have seen just breathtaking support for prevention. First of all, CMS now considers itself an agency focused on prevention, which is an extraordinary development. Posted below here, you'll find some other programs that are now out in –out in the fields, really from ARC through BiCore and the National Institute of Health.

All of these models or funding opportunities are on the street. Many are focused on hypertension control, but all of them will also contribute to work for the redesigned, smoother connections between patients, communities and clinical settings.

So we'll move on now and we'll just show you two slides capturing a small subset of the accomplishments to date. Now I want to be very clear, this is not Million Hearts the small federal team. These accomplishments are the product of all of our federal and private sector partners.

What we know is that all working together between 2011 and 2014, almost four million smokers have quit. Stunning. We know of an arrangement between ARC large food supplier and the American Heart Association that will result in two billion meals per-year with a reduced sodium content. These are meals served in sports venues and other settings.

And then as I mentioned, FDA issued its final determination on trans fat elimination back in June and we know it will have a remarkable impact on heart attacks and stroke rate and also death from cardiovascular causes.

On the clinical side again, we know that now millions of Americans are covered by health systems that are being recognized and rewarded for performance in the ABCS through these value reporting - value-linked models.

And in just a couple of projects, over a half a million people have been identified with hypertension. They had not been diagnosed so it is the deployment of health IT tools that is helping identify those who are still at risk with undiagnosed hypertension. And as I mentioned, millions of dollars in both public and private funds are now leveraged to improve the ABCS measures.

So let's talk about what works to prevent a million. First of all, cardiovascular disease, as you all know, is a systemic condition. We tend to focus on it in one sort of bed like the heart or the brain, but we know it is throughout the body. That makes perfect sense then that we need a systems approach to treating it and to preventing it.

I'd like to try out this idea of focusing on what matters, finding people who are at high-risk and not yet optimally treated. And I did put fixed (unintelligible) because if fix covers the lot, each of us who has a chronic condition knows that most of that fixing comes from within, but certainly with assistance from our community and from our own personal team including our healthcare professionals.

So let's take a look at focusing on what matters. I would like to convince you that this has done a bit of work for you. I mentioned the predictive models and we know that if smoking prevalence decreases, sodium is reduced and trans fats are eliminated, there is an extraordinary contribution to preventing events.

You see on this slide the baseline estimates for prevalence reduc-sorry, sodium and trans fats and where we aim to be by 2017. On the clinical side, you will see the ABCS that we mentioned before, what these measures showed in terms of performance before Million Hearts was launched, and the clinical targets for 2017.

So we're asking practices in health systems to achieve at least 70% on these measures that will help bring up the population-wide goal to 65%, recognizing that the population-wide goal reflects people who are not yet connected to healthcare.

This -- the oval is around blood pressure control because we had focused a lot of our band width on blood pressure control for obvious reasons and I'll go over those in just a moment.

This slide is a bit dizzying, but about two years ago we recognized that we would need to ultra-focus on the actions that are most likely to contribute to a million prevented in a five-year period. So we still very much care about aspirin and trans fat and cholesterol management. But we know that if we can help 6.3 million fewer smokers quit over the duration of a Million Hearts and help 10 million more people control their uncontrolled blood pressure, while bringing the sodium intake down of adults by just 20%, that will result in a million fewer events.

The bullet points in each category are very specific interventions and strategies which have been undertaken by both federal and private sector partners. We know that some are doing things other than, you know, in addition to the things that are on this list, but these are the ones that we think will have the greatest impact.

And today, I'd like to focus on the ones that are in red. I will spend a little bit of time on each, but that is really for the purpose of our audience today and where I feel that you all can have the greatest impact, not to say that the other things are not just as important.

So let's talk about finding those at risk. Who is at risk? First of all, we have good tools for assessing risk and these are meant to start the conversation with patients, not to dictate treatment by any means, but just to get the conversation going about cardiovascular risk.

Clearly, people who've already had an event have marketed themselves as being high-risk for a second event. First thing to do of course is to check and make sure that their ABCS have been well addressed and if not, to do so.

The second, and I put it in capitals because we know that cardiac rehabilitation multi-disciplinary team approach to those who have had an event is extraordinarily powerful in saving lives and actually reducing hospitalization and yet is under-utilized, so that's why that's in all caps. I'm giving you a couple of examples. The (NIH) tool, the ACC (J1) and the Mayo Clinic Risk Estimator all are slightly different. Please explore these to find out which one works best or best in your setting.

The last one - the first three that I showed are really tools for healthcare professionals, experts. The last tool, Heart Age, is actually one that's directed at consumers. It helps translate statistics into personal risk.

On this slide you'll see, and there are links here to Heart Age, but it is basically a way of estimating, based on risk factors, how old someone's heart is and whether or not it is the same age as that person. It's - I will tell you that when the vital signs showing - this tool was launched last September, it shut down the servers because it was such an engaging concept and easy to understand.

What the data show, and this won't surprise you all, is that in the Southeast our beloved stroke belt, hearts are older than the people who own those hearts. A very dramatic setting here, and it does give a way to personalize and make those statistics jump off the page.

Let's talk a little bit more about who is at risk. I mentioned one in three of us has high blood pressure, and as it turns out, the likelihood of being under control is about a coin flip. It's about a 54% chance that if you have high blood pressure in this country, that your blood pressure is safely controlled.

This slide also points out that 13 million people (unintelligible) have uncontrolled high blood pressure but are not aware that they have high blood pressure at all. Now when I first heard this number, I assumed that these people were not under medical care and that they were perhaps not even insured. And yet in this slide, you will see, and these are pre-a- extended coverage data.

You see that almost 90% of the people with uncontrolled high blood pressure, those 35 million, have a usual source of care, and 85% are insured, including 14 million who are covered by Medicare. A really, staggering statistic is that 3/4 of the people who have uncontrolled high blood pressure have seen their regular provider twice or more in the previous 12 months. These people are literally in the system, but below the radar.

So I will- I will share this slide, it is a bit busy, but it is a synopsis of an article, the reference is in the lower-right corner, of what big systems and smaller practices can do to find people who are in their system with undiagnosed hypertension. It really is an opportunity for the entire team to come together and make sure that they are identifying, appropriately diagnosing and then appropriately controlling folks who have high blood pressure.

We have provided some resources for you. These will soon be posted on the Million Hearts Website. But first, a - an entertaining short video that outlines the steps that I mentioned to find those who test blood pressure, but are not yet diagnosed.

The prevalence estimator tool that will help practices and systems understand their own local prevalence make sure that it is consistent with that (unintelligible) neighborhood. And then finally, they a - undiagnosed hypertension change package available. Now these are road-tested materials that can be used in federally-qualified health centers. (Unintelligible).

I want to move from hypertension to cholesterol. The data on this file comes from – (unintelligible) 2010 (unintelligible) and what the investigators did was overlay the 2013 cholesterol management guidelines looking to find out of that population (unintelligible) any change from that 2005 to 2012 period. How many people would be either on or eligible for cholesterol treatment based on the 2013 guidelines? Number of people, 78 million people are reported for treatment based on those guidelines. And those people from that - in that time period, only a little more than half were actually taking medication, cholesterol-lowering treatment. And under 50% percent were modifying their lifestyle in any way.

Now down below, you see targets, LDL (unintelligible). And the only thing I'd left out here in the box to the far right. Now we know that people who have extremely elevated LDL are at very high risk for heart attack and stroke.

They're a small percentage of the population and yet you can see in this data analysis only 22% of these extremely high-risk people were on medication and still fewer than half were modifying their lifestyle. So we are concerned that we're not identifying those at risk of - with high cholesterol in an efficient and systemic way.

Another subset here I will show you are those who have a condition perhaps familiar to all of you called Familial Hypercholesterolemia or FH. And I draw your attention to this because identification of people with FH is a chance to change the life of an entire family. FH is a genetic abnormality, results in a very high LDL and untreated, a twenty-fold increased risk of coronary heart disease.

Estimates in the US, that it affects at least 16 (unintelligible).

Dr. Loretta Jackson-Brown:
Dr. Wright, are you still with us?

Coordinator:
She is connected.

Dr. Loretta Jackson-Brown:
Okay. Please stand by.

Dr. Wright, go ahead.

Dr. Janet Wright:     
Thank you all. On the Familial Hypercholesterolemia slide, and yet I'm not seeing that one on my set. But let me finish that off by saying these individuals are a very high risk and only about 10% have been identified. So remarkable opportunity to get them on optimal treatment, which is usually a generic-based Statin and reduce their risk to that of the general population.

This slide is a very busy one, but it is about cardiac rehab, as I mentioned earlier. And the only point I will make, you can look at the factors that are - make a person less likely to get a referral for cardiac rehab on the left and more likely on the right. There are some gender differences, age differences, and geography differences.

But the take-home point is that four people with heart failure currently only 10% are actually getting referred. And a person (unintelligible) can't participate in this life saving (unintelligible) service if they are not referred. Finding people at risk is a great opportunity here for us to improve.

So we will move quickly to fixing those at risk. But first I would - pathway there is standardized treatment approaches. This may seem counterintuitive as we all move to precision medicine and personalized care. But what standardized treatments allow us to do is to provide a floor below which no one falls so that everyone gets standard advice, evidence-based care and we can identify outliers that don't respond to those standardized approaches much quicker and get them the personalized care that they need.

So we recommend if you're in a practice or a system to land on the advice that you and your team members will give so that the patients and family hear very consistent guidance. Secondly, when it comes to hypertension, we advocate the use of treatment protocols, picking a protocol that is based on guidelines that make sense for your population. And also helping individuals manage and monitor their blood pressure.

So just a word about protocols. The - what you see on the right side of this slide is a screenshot of the protocol that you can download from our Website. There are active cells that you can put your practice or systems' preferred drugs in the drop-down menu and really personalize the care for your entire population of folks who have high blood pressure.

What we've learned from practices that adopt a standardized approach is that it expands the number of team members that can assist in achieving control. Secondly, it does standardize the content and the delivery of the lifestyle advice. So again, the patient continues to hear the same message from every team member.

It allows you to pick the drugs that you found most effective for the population that you care for. And one of my favorite parts to the protocol is it specifies – it specifies the intervals and the processes for patient follow-up. So people are not lost between visits and allowed to remain uncontrolled.

A couple of other ideas on this slide, I'll only bring up one. You see screenshots there of the other protocols that you can find on our Website from places that have been using these for years, Kaiser, New York City Health & Hospital, the VA and ICKSE in Minnesota.

But one of the things I love about a protocol, and I learned from busy practices, is that although a treatment protocol is a treatment device, it is about treating those with high blood pressure. What it does is actually raise the radar among patients and among team members about hypertension.

It almost creates a game-like attitude in the practice where all of the team members are looking for people whose blood pressure is not under perfect control and they go after them. When you talk to, or listen to patients in these practices, they uniformly comment on how much the team members care about blood pressure, and how they feel that they are tackling this problem very much together.

What I will share with you is that this is an example from Kaiser, Southern California where between 2004 and 2010 more people had high blood pressure - the population of those cared for increased, but the control rate increased dramatically over fairly short period of time.

They take a systems' approach at Kaiser, but they attribute at least part of this success to a single guideline and standard protocol. That by itself is exciting, but my- my- my most enthusiasm and excitement is on this slide, the source of enthusiasm and excitement. And that is the Kaiser setting in California was able to eliminate the disparity gap across races and ethnicity due to hypertension.

Although the numbers around the parameter of this pie chart look a little bit different, there is no statistical difference between the blood pressure control rates by race and ethnicity. They raised the bar for everyone. And again, they attribute a great deal of this success to the use of a standardized approach.

Last year, at Million Hearts, we asked all of our federal partners to make blood pressure control - blood pressure treatment protocols a priority. And as a result, they really answered the call and you see examples on this slide of places that the federal government can touch that without a mandate or a law or a rule have begun to implement the standardized protocols for hypertension. I will add at the end that when you talk to the people who were involved in the Sprint trial, they attribute a great deal of their success in control rates to the use of a standard protocol.

There's some slides here that are meant to help assist a busy practice in getting started with a protocol. I won't dwell on the bullet points, but those slides are available and these are just some sample questions that we find most team members address as they discuss which protocol they'll use and how they will implement the protocol.

I think it is time for a polling question. I'll turn it back over to Loretta.

Dr. Loretta Jackson-Brown:
Please select one of the answers for the poll by clicking in the small circle next to the colored dot. We'll keep the poll open for about five more seconds. Dr. Wright? You can continue Dr. Wright.

Coordinator:       
Her line is connected.

Dr. Loretta Jackson-Brown:
Please stand by, we're having some technical difficulties.

Please stand by while we're waiting for Dr. Wright to rejoin the Webinar.

Please stand by we're experiencing some technical difficulty with our audio connection with Dr. Wright. The Webinar will continue momentarily.

Coordinator:       
And Dr. Wright has joined us.

Dr. Loretta Jackson-Brown: 
Okay.

Dr. Janet Wright:     
Okay. I'm back and I see that we have slides and we're onto self-measured blood pressure monitoring. So we have a lovely accumulation of evidence that blood pressure clinical settings are actually a more accurate assessment of someone's real blood pressure. So we have become advocates for health-monitoring.

You see on this slide, available for downloading on the Website that does address many of the issues, some barriers and some facilitators for the use of SMBP or Self-Measured Blood Pressure monitoring at home. So I think we are ready for our second polling question.

Dr. Loretta Jackson-Brown:
Yes, we will put up the next polling question. "Do you teach patients to self-monitor their blood pressure?" Again, please select by clicking on the small circle next to the colored square. And five more seconds and the poll will come down.

Dr. Wright, continue.

Dr. Janet Wright: 
Thank you. Anne's been doing self-monitoring with the - your patients for a long time. This is not necessarily easy, maybe you have gotten the bugs out and we'll look forward to hearing in the question and answer how you've done that.

Here, you see a slide and a screenshot of hypertension control change packet -- it's available downloaded from our Website. It is brief, concise, pithy, practical and the - all of the interventions and strategies here are road-tested. So I hope this will be of value to you.

Getting on with our standardized treatment approaches, similar to our work in hypertension we recommend the use of a - an algorithm. There actually is one based on the guidelines and on this slide you see the recommendations for Statin therapy. In individuals with the conditions listed on the slide, clearly the guidelines from 2013 recommended healthy lifestyle modifications for everyone with elevated lipids and Statins for a subset.

The picture of part of the algorithm that's included in those guidelines is shown here, the second part here. And if this doesn't particularly apply to your patient population, I wanted to make sure I shared the one that's just being used with the VA and the DOD.

I know that the print is too small for you to make practical use of this one, but the reference is there if you would like to investigate that one further. But the same principles apply, of course, when it comes to standardized approaches.

And then finally here with standardized treatment, we'll talk about smoking cessation protocols. This is a draft of a protocol we'll have available on our Website in the second quarter of this year. What we've learned is that many busy practices are doing a great job of identifying people who want to stop smoking. The meaningful use measure actually helped with that we think.

So smokers are being identified, smokers that want to quit. But we are not, as we would like, delivering the ASSIST steps. I know the print's too small to read there, but it's the ASSIST step is what smokers need. They need their healthcare professionals providing the counseling, or access to the counseling, as well as to the medication.

We know that the combination of counseling and medication can help smokers quit. So we do hope that this protocol implemented across busy practices will help more smokers achieve that quit status. There are many protocols out there. This one is unique in that it does update the 2008 Public Health Service Guideline protocol.

It incorporates advice about the electronic cigarettes and the other changes that you see on this slide. We will be publishing an Action Steps Guide also. Again, short, brief, pithy and practical. And we're ready for our third question.

Dr. Loretta Jackson-Brown: 
And our third poll question is, "Do you refer people to a quit line?"

And it looks like most of the audience, I see you're saying, "Yes" or "Not applicable." The poll will be open for about three more seconds. You can continue, Dr.

Dr. Janet Wright:     
I will make my own confession. Thank you, Loretta. I practiced for 23 years in the same place, and to a quit line. I am embarrassed to admit that. I have learned more since then. So I'll close with just a comment about cardiac rehab. As I mentioned, it is life-saving, it actually reduces the risk of a re-hospitalization or hospitalization, and is vastly under-utilized.

This is part of an infographic that describes the benefits of cardiac rehab and really what it is. The coverage for cardiac rehab by both federal and private sector insurers is quite broad and appropriate, and very much based on the evidence.

So people who have had a heart attack, an angioplasty or stent, those who have systolic heart failure, those who've had a valve replacement or transplant, either lung or heart and lung, and those who've had bypass surgery or have chronic stable angina.

So a large number of people are eligible and yet participation rates remain low for a variety of reasons. Some of the problems are that folks are not being referred and those folks tend to be more women, more people of color, those with co-morbid conditions and those with low socio economic status, all people who carry a heavier burden of heart attack and stroke risk.

Fascinating here that black women are actually 60% less likely to be referred and enroll in rehab programs compared to whites. There is an enormous opportunity for improvement here. And when it comes to participation, one of the most, the greatest predictor of participation is strength of the physician's recommendation.

And as we know, the - our care patterns have changed dramatically over the last several years. Used to be if you got sick, your doctor admitted you to the hospital, saw you while you were there, discharged you and saw you in follow-up. And that very rarely, if ever, happens anymore. And so the chain of opportunities to reinforce the value of participation in cardiac rehab is fragmented beyond compare. And people who, from being hospitalized and getting many, many pieces of advice, are not hearing a clear signal about its value.

So the good news is there is a collaborative coming - has come together of some 30-plus organizations, all private sector. They've formulated an action plan to help address all barriers that exist in cardiac rehab and this collaborative cardiac rehab - cardiac rehab collaborative welcomes any of you and your organizations to join as you are able to exert some action.

The dates of their quarterly check-in calls are listed here and if you want to join, or you have further questions, you can send an email to millionhearts@cms.hhs.gov.

On this slide, you see a number of resources, I encourage you to visit the Website. We are updating our resources and content all the time. And if you know of things that you need that you don't find there and would find helpful, please let us know.

Just in by - thanking you for the work that you are doing now to prevent heart attack and stroke and other cardiovascular events. You absolutely can play such a strong role in helping us create a nation full of those with health hearts and healthy brains.

Thank you so much and Loretta, I'll turn it back over to you.

Dr. Loretta Jackson-Brown:
Wonderful. Thank you, Dr. Wright for providing our COCA audience with such a wealth of information. We will now open up the lines for the question and answer session. When asking a question, please state your organization. Also remember, you can submit questions through the Webinar system as well.

Coordinator:       
Thank you. At - at this time, if you do have any questions or comments, please press Star followed by the number 1. Please state your first and last name when prompted. If you'd like to withdraw your question, you may press Star 2.

Dr. Loretta Jackson-Brown: 
And Dr. Wright, while we're waiting for this first question from the audience, can you tell me how did Million Hearts select the ABCS, is that it - am I saying that right, ABCS - sodium - it has the best way to prevent events?

Dr. Janet Wright:     
Yes. Loretta, I can address that. And I'm - I may have mentioned that there were predictive modeling exercises prior - well before the launch that fed into the design of Million Hearts. And something I'll point out that was not obvious to me when I came on board at the time of the launch is that part of the magic of this question was what - what interventions would prevent events in a five-year timeframe? And as it turned out, the models consistently showed that aspirin, blood pressure control, cholesterol management, smoking cessation would have the greatest impact on the healthcare side. And improvements in sodium intake, smoke-free prevalence, smoke-free space, and trans fat elimination would be the greatest contributors on the public health side.

I personally would lay awake at night when I first heard about Million Hearts and questioned the A, that aspirin really was so - to have a bigger impact than A1C or physical activity, very hard for me to wrap my head around that. But once I looked at those models and understood from the experts you had participated in that, we were not able - the design team was able to identify specific interventions in physical activity that would return a million events in five years.

And in regard to diabetes, as it turns out for people with diabetes, those who have great blood pressure, well-controlled cholesterol, don't smoke and if they have to take aspirin and know risk, they actually do extremely well without significant regard to the A1C level.

So - and we know that diabetics actually die or have complications of vascular causes. So the attention in diabetics should be placed on ABC and S. That's probably a long-winded answer, but there you go.

Coordinator:       
And once again if you do have any questions, please press Star followed by the number 1. Again, that is Star 1 if you do have any questions.

Dr. Loretta Jackson-Brown: 
So while we're waiting for the audience to talk about their experience, can you, Dr. Wright, go into a little bit more detail about which blood pressure measures Million Hearts suggests and why?

Dr. Janet Wright:     
Yes. As you – as you all well know, there were some recommendations published by those who had been convened to write what would have been J&C8 the next National Guidelines.

They were - they got started on that process some years ago and during their tour of duty, the National Institute and Health - or National Heart, Lung and Blood Institute decided it was really not well-positioned to generate National Guidelines, that that should be done by physician organizations, but that NHLBI would provide systematic reviews.

Then the panel members decided to, based on their assessment of the evidence, produce some recommendations. Those recommendations were immediately followed by a dissenting opinion from panelists on that same writing group. And so there was, as you know, controversy about measures.

Subsequently, of course, we have the Sprint trial that has been published which really is (unintelligible) in guidance that lower is better and lower is not unsafe. So the take-away from all of that is that Million Hearts and CMS are sticking with blood pressure control measure of less than 140 on the top and less than 90 on the bottom. Always acknowledging that the appropriate blood pressure for a single person is based on that person's tolerance preference and should be a decision that the provider, or the professional and the patient make together. So patient/physician judgment reign supreme.

I will say too, as many of you know, there is a multi-stakeholder group convened now to generate hypertension true, hypertension guidelines, national guidelines, not just the subset of recommendations, but national guidelines. We anticipate that those will be available later this year coming from ACCAHA and a number of other organizations and their experts.

We are looking forward to seeing what those show and I know that the group that is convened is also trying to come out with performance measures quickly after the generation of the guidelines so that we can then get those measures embedded in programs around the country.

Dr. Loretta Jackson-Brown: 
Thank you, Coordinator, do we have any questions from the phone?

Coordinator:       
At this time, I am showing no questions. Again, that is Star 1 if you would like to ask a question.

Dr. Loretta Jackson-Brown:
Dr. Wright, we have a question from the Webinar and that is, "What is the role of community health workers with helping to implement the guidelines?"

Dr. Janet Wright:     
You know, we've been so impressed with the impact of community health workers in supporting individuals in their healthy lifestyle and also with their medication use because it's so hard to stay on a medication daily, particularly for conditions that don't cause any symptoms, like elevated cholesterol and hypertension.

So I think particularly in those two roles it is being that individual's, almost personal advisor, and support system. We the community health workers can help people see the value or translate the cardiac rehab and overcome the obstacles that are present to allow them to participate.

Dr. Loretta Jackson-Brown: 
And another question we have is, "You mentioned that the program is a five-year program. What happens when the program ends?"

Dr. Janet Wright:     
Another great question. I will tell you that there is a modeling exercise going on right now at CDC to look at the factors, take a fresh look at the factors that will continue to help prevent cardiovascular disease and improve cardiovascular health.

That information will be very valuable in crafting the agenda for future work of the CDC and I think of other agencies and private sector partners as well. There may be some after-life or other version of a national public/private initiative like Million Hearts, but my personal feeling is that it's very important for us to stick to sort of who (unintelligible) and that is a five-year focused initiative to deliver a million. And so this version will end in December of 2016. Because of the delays in our national surveillance system, we will not be able to give definitive data on the impact of a Million Hearts' partners on heart attack and stroke until probably 2018 with the delay.

So - and we also know of a number of national activities and funded work going on around the country that has either a (unintelligible), so we feel like there are roots and stalks growing out there after this five-year initiative folds the tent.

Dr. Loretta Jackson-Brown: 
Thank you. Coordinator, do we have anyone on the phone?

Coordinator:       
At this time, I am showing no questions.

Dr. Loretta Jackson-Brown:
Dr. Wright, do you have any closing remarks?

Dr. Janet Wright:     
Well, I just wanted to share from, even our early days, and that is I'd be so curious to know if this is the experience of our - today's participants. But there is a general feeling, I think, in the public that heart attack and stroke are natural events, that they're a natural part of aging. And that there is no - we can't fight back. And so we have tried to hit and to be very specific over these last four years that heart - most heart attacks and most strokes are preventable.

It takes good habits and good care and I would appreciate it if – if you all agree with that in your experience, that you continue to deliver on a daily basis the message that people can prevent heart attacks and strokes. They can rewrite their family's history. They do not have to follow the lineage that might have preceded them. And it is absolutely within our grasp to knock heart attack and stroke off as the country's number one killer. So Loretta, before I turn it back to you, let me thank those of you who joined today, and all of your continued efforts on vanquishing the number one killer.

Dr. Loretta Jackson-Brown: 
Thank you again, Dr. Wright. So on behalf of COCA, I would like to thank everyone for joining us today, with a special thank you to our presenter, Dr. Wright.

We invite you to continue the discussion after the Webinar. If you have additional questions for today's presenter, please email us at coca@cdc.gov. Click February 23rd COCA Call in the Subject line of your email and we will ensure that your question is forwarded to the presenter for a response. Again, that email address is coca@cdc.gov. The recording of this call and the transcript will be posted to the COCA Website at emergency.cdc.gov/coca within the next few days.

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Thank you again for being a part of today's COCA Webinar. Have a great day.

Coordinator:       
Thank you and you may go ahead and disconnect at this time. This does conclude today's conference call.