Improving Healthcare for Veterans with Heart Disease
February is American Heart Month. The term heart disease is used to describe an array of conditions that can affect the heart, including coronary artery disease, heart rhythm problems, and birth defects that may affect how the heart functions. Heart disease also may be referred to as cardiovascular disease. The American Heart Association defines cardiovascular disease (CVD) as conditions that arise from problems of blood flow to the heart muscle, many of which are related to atherosclerosis–a condition that develops when plaques (i.e., fats, cholesterol, calcium, and other substances) build up in the artery walls, which can restrict blood flow and lead to heart attack or stroke. Approximately 610,000 people die of heart disease in the United States every year (1 in every 4 deaths), and it’s the leading cause of death among both men and women.1 Moreover, cardiovascular disease is the leading cause of death among Veterans enrolled in the VA healthcare system.2
Studies funded by VA's Health Services Research & Development Service (HSR&D) address many aspects of care for Veterans with heart disease, including: gender differences and cardiovascular disease risk; remote support via telemedicine for rural Veterans managing CVD risk factors; and the impact of heart disease on VA operating costs. The following studies represent just a few of the completed and ongoing HSR&D-funded investigations into heart disease.
EMPOWER QUERI: Improving Cardiovascular Health and Care for Women Veterans
HSR&D’s Quality Enhancement Research Initiative (QUERI) focuses on implementing optimal evidence-based practice into care for Veterans across the VA healthcare system. As a part of QUERI’s national program network, the Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) Program is designed to improve women Veterans' engagement and retention in evidence-based care for three high-priority health conditions: cardiovascular health, diabetes, and depression and anxiety.
The implementation phase of the EMPOWER project, "Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans” (CV toolkit), began in April 2017 in two of VA’s Women’s Health Practice-Based Research Network sites. Study aims include:
- Increasing the identification of cardiovascular disease risk among women Veterans;
- Enhancing patient/provider communication and shared decision-making about CV risk; and
- Providing a supportive, coordinated health coaching intervention to facilitate women Veterans’ engagement and retention in appropriate health services.
Overall, the CV toolkit components encourage women Veterans to become more active participants in their healthcare by improving communication and interactions between healthcare providers and Veterans – and by giving women choices as to how to achieve their health goals. Nationally, CV risks are pervasive with persistent differences by gender; eliminating these disparities and reducing overall risks is a priority for VA.
Remarkable advances during the past 50 years in technology to prevent, diagnose, and treat cardiovascular disease have contributed to marked declines in mortality related to cardiovascular disease. However, these gains have been accompanied by substantial growth in healthcare costs. The VA healthcare system faces pressure like never before to more fully optimize the value of its cardiovascular care. Therefore, this mixed-methods study compared the outcomes and costs of care for two widely prevalent and high-cost cardiovascular conditions – ischemic heart disease (IHD) and chronic heart failure (CHF) – across VA medical centers from fiscal years 2010 to 2014.
Findings: Investigators completed their analyses of cardiovascular outcomes for CHF (n=348,015) and IHD (n=930,079) at 138 VA hospitals and their affiliated outpatient clinics. Statistically significant variation in the mortality rates for Veterans with these diseases was observed across hospitals. Results show:
- For IHD, VA hospitals’ risk-standardized mortality varied from 6% to 9%.
- For CHF, VA hospitals’ risk-standardized mortality varied from 12% to 18%.
- Hospitals’ mortality rates among their IHD/CHF populations were only loosely correlated to hospitals’ 30-day mortality rates for myocardial infarction or hospitalized heart failure (don’t think anyone would know what this is).
Investigators are currently finalizing an analysis of the costs of care for Veterans with CHF and/or IHD, and are collecting data via interviews of cardiovascular caregivers at high- and low-performing VA hospitals.
Implications: Results to date indicate that risk-standardized mortality rates for IHD and CHF varied widely across VA hospitals, and this variation was not well explained by differences in demographics or comorbidities. This variation may signal substantial differences in the quality of cardiovascular care across the VA healthcare system. Via ongoing interviews with high- and low-performing hospitals, this project will identify the key institutional, programmatic, and leadership factors associated with high-value IHD and CHF care, thereby providing a critical blueprint to VA clinical and operations leaders seeking to improve cardiovascular care throughout the VA healthcare system. Findings will be communicated to key policy and clinical leaders in VA cardiology, who are partnering with the project's research team as co-investigators in the design and administration of this study.
Home telehealth (HT) programs are increasingly used to improve heart failure self-management, effectively monitor disease exacerbations, improve health outcomes, and decrease inappropriate health services use. Patient adherence to the use of home telehealth devices in chronic disease management impacts both care efficiency and effectiveness. Home telehealth can connect a Veteran to a VA hospital from home using regular telephone lines, cellular modem, and cell phones (using an interactive voice response system). However, the factors that impact adherence to HT, as well as associations between adherence and health services outcomes, remain to be fully explored.
This study in Veterans with heart failure newly enrolled in the VA Home Telehealth Program will:
- Describe patient adherence to the use of HT devices in the first year;
- Examine the relationship between patient adherence to the use of HT devices at 1, 3, 6, and 12 months after enrollment, and health services use at 6 and 12 months; and
- Identify patient characteristics that influence adherence to the use of HT devices.
Using VA data, investigators identified all Veterans with heart failure who enrolled in the VA HT Program between 1/1/14 and 6/30/14. Patient adherence was examined via weekly reports of home telehealth device use, which were adjusted if the patient was in the hospital during the week. Investigators also examined patients’ use of health services, including emergency room and clinic visits, hospital admissions and/or readmissions.
Findings: A total of 3,503 Veterans met the inclusion criteria for the study. Other than the first month after enrollment, most average monthly adherence to the use of home telehealth devices among this cohort ranged from 66% to 69%. Average adherence for the first month was lowest because there were several weekly reports of “0” adherence, which may signify the learning curve of being in the program and daily use of the device. Preliminary findings regarding potential predictors of average adherence at 1, 3, 6, and 12 months found that those who might benefit from more support to improve their average adherence to the use of home telehealth devices include:
- Veterans with prior hospital admissions or low ejection fraction,
- Black Veterans as compared to White Veterans,
- Veterans who do not routinely use online tools (i.e., My HealtheVet), or
- Veterans with a mental health diagnosis.
Additional analyses (e.g., time to drop-off, sub-analysis of having a mental health diagnosis, and determining outcomes of adherence) are underway to further clarify the importance of adherence to the use of home telehealth devices in program efficiency and effectiveness.
Implications: Findings from this study will guide future research on the modifiable patient factors and organizational contexts associated with patient adherence to the use of home telehealth devices. Findings also may guide practice by providing guidance on the selection of patients that will most likely use HT devices for heart failure management.
Antiplatelet medications have contributed to the decline of deaths related to coronary heart disease. Despite this, medication adherence in patients with coronary heart disease is closely linked to adverse clinical outcomes such as re-hospitalization and mortality. This ongoing study (2016-2020) seeks to determine whether mobile health technology in the form of text messaging or a mobile application – compared with a general education website control - will improve medication adherence among Veterans with coronary heart disease.
Focus groups are being used to assess preferences for content and frequency of text messaging to promote medication adherence. Made up of Veterans with a history of coronary heart disease, focus groups also will help investigators determine the most patient-centered mobile app to promote medication adherence. In addition, study participants will explore different apps related to medication adherence and will discuss any facilitators and/or barriers related to using mobile apps. A sample of non-Veteran female participants has been enrolled from one medical center to allow for a representative sample of both sexes.
Findings: Thus far, focus group feedback about medication adherence shows:
- Veterans understand that medication use is critical to their health.
- They had overall confidence in taking medications, although afternoon doses were difficult to remember and sometimes skipped.
- Depression is a common condition among study participants, but it is not known whether or not depression significantly impairs medication adherence.
- Veterans have a deep appreciation for VA healthcare and its providers.
Focus group feedback about text messaging shows:
- Veterans prefer shorter positive messages, though their receptiveness decreased when the messages appeared to be designed to “persuade” or “motivate,” as opposed to direct reminders or tips.
- Veterans were receptive to receiving short reminders and educational tips about exercise and healthy eating.
- Veterans were less receptive to messages under the topic of social support.
Implications: Improving medication adherence through mobile apps may significantly lower morbidity and mortality among Veterans with heart disease. Study findings also may be applicable to non-Veterans with heart disease and other patients who require long-term medication use.
Studies have found patient self-care behaviors in heart failure (i.e., medication/dietary non-compliance) and health system factors (i.e., limited access, lack of education in patients and caregivers) played an important role in patients’ health status and hospitalization risk – to the extent that 50% of readmissions were judged to be preventable. One potential solution is to use shared medical appointments (SMA), in which a multi-disciplinary team of providers manage the patient’s heart failure in a group setting – in addition to regular physician visits. This ongoing trial (2016-2019) seeks to determine whether heart failure (HF) patients in HF-SMA, as compared to patients who receive usual care, experience better cardiac and overall health status.
Investigators enrolled patients within 12 weeks of discharge from an HF hospitalization at VA hospitals in Providence, RI, Cleveland, OH, and Phoenix, AZ. Veterans (n=375) were then randomized to receive either the SMA intervention every other week for 8 weeks or usual care for heart failure. The SMA team consists of a nutritionist, nurse, health psychologist, and a clinical pharmacist or nurse practitioner, but not a physician (cardiologist will be available on call). Preliminary findings are forthcoming.
Implications: Study results may be used in healthcare management and system redesign to provide better quality and patient-centered care for Veterans with heart failure that incorporates a multi-disciplinary team approach in a group setting.
- Heart Disease Facts. Centers for Diseases Control and Prevention (CDC). December 11, 2017.
- Costs and Outcomes of Chronic Heart Disease Care in the VHA. HSR&D study, Principal Investigator: Peter Groeneveld, MD, MS.