Spotlight on Cardiovascular Health
VA has pioneered several cardiac care innovations, perhaps most notably the first pacemaker, which was implanted into the first patient, a 77-year-old man, in 1960. Nine other patients received pacemakers that year, several of whom survived more than 20 years.
As far back as 1935, VA had established a cardiovascular research unit in Washington, DC. Soon after World War II, findings that Veterans who had suffered heart attacks during service still had high blood pressure led to the development of several hypertension drugs in the 1950’s. In 1970, the Journal of the American Medical Association (JAMA) published results of a VA study conclusively showing that treating moderate hypertension prevented or delayed heart failure and stroke. In fact, the drugs were so effective that the study was stopped early, and all Veterans in the study were given the drugs.
More recently, the 2015 Systolic Blood Pressure Intervention Trial (SPRINT) found that significantly lowered blood pressure in people over 65 reduced not only heart disease and stroke, but kidney diseases and age-related declines. Another study found that anxiety and depression, often symptoms of trauma experienced during combat deployment, were linked to heart disease. Other recent studies have found that effectively treating diabetes also reduces the risk of heart disease.
Following are examples of VA’s continued effort to improve cardiovascular health in Veterans. As hypertension drug therapy is now standard care, innovations are now in the areas of the pursuit of best practices and support for adherence.
Impact: An in-hospital cardiac arrest (IHCA) occurs when a patient's heart stops beating effectively, either due to electrical or muscular problems. IHCA is a medical emergency; VA devotes great resources to responding to IHCAs. In the ResCU-1 study, investigators discovered that important improvements could be made to the care of many Veterans who suffer IHCA. This study identified remaining inadequate documentation and barriers and facilitators to improving IHCA care via better documentation. Additionally, better practice and better post-IHCA debriefing methods were examined, and interventions designed to improve their use. But ResCU-1 also showed that a few Veterans go on from IHCA to become super-survivors, showing remarkable recovery after their cardiac arrest, thus this study also identified practices that lead to super-survivorship.
Improving in-hospital cardiac arrest (IHCA) care is an important VA priority. For example, at the individual level, vast amounts of VA clinician time are devoted to having every clinician recertify their Basic or Advanced Cardiac Life Support training every two years to improve the care of IHCA. The previous ResCU project identified critical gaps in VA care of IHCA:
- Documentation of key IHCA factors that help systems drive quality improvement, and that help clinicians determine prognosis and treatment after IHCA were often unavailable.
- Approximately 30 to 60 percent of of VA hospitals underutilized other best practices in IHCA care such as mock codes and post-IHCA debriefing.
- Some Veterans had remarkable recovery from IHCA, becoming “super-survivors”—but findings were not clear as to how the care of super-survivors differed from those who did not achieve this status.
Building on the first ResCU study’s foundations, and in partnership with the VA Resuscitation Education Initiative (REdI) this study sought to:
- Assess implementation of a new documentation template as a model for quality efforts.
- Develop and pilot new interventions to improve IHCA care, focusing on post-code debriefing, mock code simulation training, and code documentation, through identification of barriers and facilitators and operational partnerships.
- Identify IHCA super-survivors and best practices associated with their care, through qualitative interviews.
Principal Investigator: Theodore Iwashyna MD, PhD, is a research scientist with the Center for Clinical Management Research (CCMR) at the VA Ann Arbor Healthcare System.
Coe AB, Vincent BM, Iwashyna TJ. Statin discontinuation and new antipsychotic use after an acute hospital stay vary by hospital. PLoS ONE. 2020 May 8; 15(5):e0232707.
Impact: Integrating peer health coaches into primary care may improve VA's ability to provide community outreach to Veterans. Cardiovascular disease risk reduction provides an ideal target for intervention given the prevalence of modifiable risks among Veterans. The study will increase understanding of the utilization of peer support within Patient Aligned Care Teams (PACT). If findings confirm the main hypothesis this evidence-based support model could be tested more widely among Veterans with other chronic conditions to improve health outcomes.
Cardiovascular disease (CVD) is the leading cause of mortality among Veterans, and poor risk factor control is a significant cause for the continued prevalence of CVD. Despite clinic-based programming that includes nurse care management, pharmacy support, telephone care programs, and intensive quality improvement efforts, CVD risk factors remain sub-optimally controlled among Veterans. Given the high prevalence and cost within VA, cost-effective programs are needed to assist Veterans in better managing prevalent CVD risk factors. Veteran peer health coaches may be one such option. Previous studies of peer support in non-VA populations report significant improvement in hypertension control and CVD risk reduction. However, limited data of this model with VA primary care currently exists.
This study seeks to test the effectiveness of a peer health coaching intervention to reduce CVD risk and promote health behavior change among Veterans with multiple CVD risk factors. To target a high-risk population, approximately 270 Veterans with poorly controlled hypertension and at least one other CVD risk factor were randomized to receive either treatment as usual, or the peer health coach intervention - consisting of home visits, telephone support, and linkages to community-based and clinic resources. The primary outcome was a reduction in systolic blood pressure from baseline to follow-up at 1 year. Secondary outcomes include a reduction in Framingham Cardiovascular risk score and individual cardiovascular risks, as well as increases in health-related quality of life and health care utilization. Additionally, qualitative interviews were conducted with a subsection of Veteran participants, peer health coaches, and PACT primary care staff to assess satisfaction with, and barriers and facilitators to adoption of the intervention.
- Role play sessions conducted by the health coaches with a standardized patient actor increased observed behavior change in hypertension, smoking cessation and medication adherence counseling by 18 points on the Behavior Change Counseling Index.
- The peer health coach model can be modified to remote telehealth intervention delivery (due to COVID-19).
Principal Investigator: Karin M. Nelson, MD, MSHS, is the Director of the Primary Care Analytics Team (PCAT) at VA’s Office of Primary Care, and a core investigator at the VA Seattle-Denver Center of Innovation (COIN),.
Nelson K, Fennell T, Gray KE, Williams JL, Lutton MC, Silverman J, Jain K, Augustine MR, Kopf W, Taylor L, Sayre G, Vanderwarker C. Veteran peer Coaches Optimizing and Advancing Cardiac Health (Vet-COACH); design and rationale for a randomized controlled trial of peer support among Veterans with poorly controlled hypertension and other CVD risks. Contemporary clinical trials. 2018 Oct 1; 73:61-67.
Impact: This project attempts to balance geriatric outcomes, such as falls and fall injury, with traditional cardiovascular outcomes. It will support the use of individual patient data to inform decisions about net benefit (or harm) of various treatment strategies. This research fits clearly with VHA priorities to reduce use of inappropriate and harmful treatments and to enhance patient-centered care. The research has the possibility of informing future performance measures and decision support tools to help minimize both cardiovascular and fall injury, and appropriately individualize care for older adults with hypertension.
VA has been highly successful at improving blood pressure (BP) control, exceeding performance on existing BP measures by 79% versus only 62% in Medicare. Older individuals stand to benefit from good BP control, especially in stroke and heart attack reduction. However, older individuals are at risk of falls due to multiple medical conditions and polypharmacy. One concern is that existing dichotomous BP targets result in inadvertently low BPs, especially as aging Veterans develop geriatric conditions such as fall risk. Whether or not VA providers should consider de-intensifying BP care in older Veterans has not been well-studied.
This study sought to define Aggressive Hypertension Care (AHC), measure inter-facility variation in characteristics that predict AHC, and develop a performance measure to support appropriate hypertension care. The presence of AHC was defined as BP < 130/65 in combination with continuing 3+ or escalating 1+ BP medications in primary care Veterans 65 and older with a diagnosis of hypertension. Facility characteristics that predict AHC were identified and the factors associated with wide variations were measured. Researchers also explored whether AHC is linked with increased risk of fall injury requiring medical attention (including office visits, emergency room care, and hospitalization), and if so, whether the risks exceed the cardiovascular benefits (avoidance of acute strokes and myocardial infarction). Lastly, researchers plan to develop a performance measure to support appropriate hypertension care and identify barriers and facilitators to implementation.
- Patients with more intensive blood pressure medication treatment and lower systolic blood pressure below 130 mmHg and greater than 140 mmHg have greater fall injury and negative cardiovascular outcomes than patients with an ideal SBP of 130-140 mmHg.
Principal Investigator: Lillian Chiang Min, MD, MSHS is an investigator with the Geriatric Research Education and Clinical Center (GRECC) and HSR&D’s Center for Clinical Management Research at the VA Ann Arbor Healthcare System.
Min L, Ha JK, Hofer TP, et al. Validation of a Health System Measure to Capture Intensive Medication Treatment of Hypertension in the Veterans Health Administration. JAMA Network Open. 2020 Jul 1; 3(7):e205417.
Min L, Tinetti M, Langa KM, Ha J, Alexander N, Hoffman GJ. Measurement of Fall Injury With Health Care System Data and Assessment of Inclusiveness and Validity of Measurement Models. JAMA Network Open. 2019 Aug 2; 2(8):e199679.
Impact: Findings from this study may be used in health care management and systems redesign to provide better quality and patient-centered care for Veterans with heart failure (HF). The long-term goal is to use a multi-disciplinary team approach in a group setting to manage HF and support physician visits in a peer support environment, all of which are necessary to provide patient-centered care and improve outcomes.
Heart failure is a complex chronic illness where comprehensive patient-centered care is difficult and resource intensive. Studies have found that patient self-care behaviors (medication and dietary non-compliance) and health system factors such as care discoordination, limited access, and lack of educational support played an important role in patients’ health status and hospitalization risk to the extent that 50% of readmissions were judged to be likely preventable. One potential solution to address patient and system factors based on the Chronic Care Model is to use shared medical appointments (SMA), where a multi-disciplinary team of providers with expertise in nutrition, nursing, behavior, and medication management join to manage HF in addition to and in support of, the patient's regular physician visits, in a group setting. SMA's can be a good solution to provide patient self-management support while also performing disease monitoring and medication management in an environment of peer support.
This project sought to improve the health status and decrease hospitalization and death for patients discharged with heart failure via education to patients, disease monitoring, and medication titration through shared medical appointments (SMAs). Veterans within 12 weeks of discharge from a HF hospitalization were randomized to receive either SMA intervention every other week for 8 weeks or usual care for HF. Specific aims were to determine whether HF patients who participate in HF-SMA, as compared to patients who receive usual care:
- Experience better cardiac health status and overall health status.
- Have fewer hospitalizations or death.
- Experience improvement in intermediate outcomes: a) increase in HF self-care behavior, and b) decrease in B-type natriuretic peptides (BNP) leading to lower blood pressure.
Additionally, for Veterans who participated in HF-SMA, investigators sought to determine perceived benefits, areas in need of improvement, potential obstacles of implementation, and fidelity of the intervention across sites, by conducting face-to face interviews with Veterans and telephone interviews with physicians and administrators.
- Veteran experienced better overall health.
- Results trend toward fewer hospitalizations.
- Veterans reported improvement in HF self-care behavior.
Principal Investigator: Wen-Chih Hank Wu MD, is Chief of Cardiology and Research Health Science at the Providence VA Medical Center, and part of HSR&D’s Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, Providence RI.
Wu WC, Parent M, Dev S, Hearns R, Taveira TH, Cohen L, Shell-Boyd J, Jewett-Tennant J, Marshall V, Gee J, Schaub K, LaForest S, Ball S. Group medical visits after heart failure hospitalization: Study protocol for a randomized-controlled trial. Contemporary clinical trials. 2018 Aug 1; 71:140-145.
Cohen LB, Parent M, Taveira TH, Dev S, Wu WC. A Description of Patient and Provider Experience and Clinical Outcomes After Heart Failure Shared Medical Appointment. Journal of patient experience. 2017 Dec 1; 4(4):169-176.