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February 10, 2011 Volume VII, No. 31

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

This week's issue is focused on strokes and heart attacks. Learn how a woman's family history can dictate if she is at risk for heart attack or stroke, and how a patient with high blood pressure and cholesterol could be at risk for both conditions.

On the research front, read about a particular population that receives more aggressive stroke treatments and has a better stroke survival rate than other populations.

Your colleague in the business of healthcare,
Jessica Papay
Editor, Disease Management Update

This week's DM news:

Table of Contents

  1. Stroke & High BP, Cholesterol
  2. Maternal Stroke History
  3. Health Risk Assessments
  4. DM Case Loads
  5. Who's Using Telehealth for Remote Monitoring?
  6. Health Coaching in 2010
  7. Stroke Treatments for African Americans
  8. Accountable Care Organizations in 2011

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Please send comments, questions and replies to jpapay@hin.com.

Melanie Matthews, mmatthews@hin.com

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Most Americans with High Blood Pressure, High Cholesterol at Unnecessary Risk for Stroke and Heart Attack

Two out of three U.S. adults with high cholesterol and half of U.S. adults with high blood pressure are not being treated effectively, according to the latest Vital Signs report from the CDC. Although treatment of high blood pressure and high cholesterol is very effective and relatively low-cost, most people with these conditions remain at elevated risk for strokes, heart attacks and other problems. People who lack health insurance have the lowest rates of control. Among those whose blood pressure or cholesterol is not under control, more than 80 percent have private or public health insurance — showing that healthcare coverage is necessary but, for most people, not enough to control these leading killers. High blood pressure and cholesterol are two major risk factors for strokes, heart attacks and related vascular diseases, which kill more than 800,000 Americans each year — more than any other condition. Of these, 150,000 are younger than age 65.

Cardiovascular disease costs the nation an estimated $300 billion each year in direct medical costs and those costs are increasing rapidly. Treatment for this disease accounts for $1 in every $6 U.S. health dollars spent. The Vital Signs report examined data from the National Health and Nutrition Examination Survey (NHANES), an ongoing study that explores the health and nutritional status of about 5,000 participants every year. The report also noted that control rates for high blood pressure and high cholesterol are especially low among people in certain socioeconomic and ethnic groups. Those with the lowest rates of control had no health insurance, no usual source of medical care, had received care less than twice in the last year or had income below the poverty level. Rates of control were also low among young adults and Mexican Americans.

To improve blood pressure and cholesterol control levels among U.S. adults in every age group, a comprehensive approach that involves policy and systems changes to improve healthcare access, quality of preventive care and patient adherence to treatment is needed, according to the authors of the report. The Affordable Care Act provides coverage for blood pressure and cholesterol screenings with no cost sharing. Additional healthcare system improvements including EHRs with registry and reminder functions can improve follow up treatment and management. Allied health professionals (nurses, dietitians, health educators and pharmacists) can also help increase patient adherence to medications. The CDC is collaborating with other federal agencies to address cardiovascular disease by improving coordination of care, increasing attention to population health, supporting Healthy People 2020 cardiovascular health goals and objectives. In addition, the agency is complementing the Let's Move initiative and other public health efforts that help Americans make healthy lifestyle choices, such as staying active, eating well and maintaining a healthy weight.

It's important for individuals to understand healthy markers when it comes to cholesterol and blood pressure. LDL cholesterol (bad cholesterol) should be less than 160 for people without heart disease or diabetes; less than 130 for people without heart disease or diabetes but with two or more other risk factors for heart disease; and below 100 for people with heart disease or diabetes. Blood pressure should be less than 120 over 80 and requires management if it is higher than 140 over 90. Also, patient adoption of healthy behaviors is critical. Individuals can take steps to lower cholesterol and blood pressure and improve their heart health by consuming a diet that is low in sodium; low in total fat, saturated fat and cholesterol; rich in fruits and vegetables; and balanced with a healthy level of exercise. Making a healthy diet accessible and affordable for all Americans is an important part of the solution. Food producers and processors, restaurants and fast food businesses can help by reducing salt in our foods, according to the report.

To learn more about this research, please visit:

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Maternal Stroke History Tied to Women’s Heart Attack Risk

If a woman has a mother who had a stroke, that woman may be at risk of a heart attack in addition to a higher risk of stroke, according to new research on family history and heart disease published in the American Heart Association journal Circulation: Cardiovascular Genetics. In a study of more than 2,200 patients, female heart patients were more likely to have mothers who had suffered a stroke than fathers who did.

The Oxford Vascular Study included patients who had suffered a stroke or transient ischemic attack (TIA) or had experienced a heart attack or chest pain known as unstable angina. It’s the first study in which researchers investigated the link between a relative’s stroke and heart disease risk by sex of the patient and sex of the relative. In a previous study of the same group, researchers found that women face a higher risk of heart attack before age 65 if their mothers have also had a heart attack at an early age. Other research has linked a mother’s history of stroke to a daughter’s stroke risk. Understanding such gender-specific risk factors is important because women, despite their lower odds of suffering a heart attack, are more likely than men to die from one, said the researchers.

The study also found that:

  • About 24 percent of the heart attack and angina patients, and roughly the same percentage of the stroke patients, had at least one first-degree relative who had a history of stroke. This indicates that stroke history in these relatives — which included siblings and parents — is as important to a person’s risk of heart attack or angina as it is to risk of stroke, said the researchers.
  • The female patients who had heart attacks or unstable angina, conditions known collectively as acute coronary syndromes, were more likely to have had any female relative than any male first-degree relatives with stroke history. Male patients were the opposite.
  • Parents’ stroke history didn’t help predict where patients’ heart disease showed up on coronary angiography or whether disease was present in multiple blood vessels. This suggests that whatever family influence is occurring doesn’t directly affect the heart’s anatomy or dictate where dangerous plaques build up in the coronary arteries. Instead, family history might influence a more general tendency toward thrombosis or clot production.
The new findings can’t be attributed to genetics alone because shared environmental factors such as relatives’ wealth or poverty can also influence disease risk, said the researchers.

To learn more about this research, please visit:

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Health Risk Assessments — Administration, Delivery and Completion Benchmarks

Who's using health risk assessments (HRAs), and how are they administered? What are the top incentives driving HRA completion, and what are the top three uses for HRA data? What completion rates can be expected? In this month's healthcare benchmarks podcast, Healthcare Intelligence Network executive VP and COO Melanie Matthews shares the latest market research on HRA use. This month's metrics are derived from HIN's June 2010 survey on HRAs, with commentary from Dr. Marcia Wade, Aetna Medicare’s senior medical director.

To listen to this complimentary HIN podcast, please visit:

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DM Case Loads

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's expert is Marcus Barnes, director of the Richland Care Medical Home Network for Palmetto Health.

Question: How did you deploy DM? Do you use case managers or extenders? How many cases per full-time employee?

Response: We have our nurse case manager. She is a registered nurse (RN) and she has one other employee — a licensed practical nurse (LPN) — who serves as a community health coordinator. Their case loads fluctuate, but they can have anywhere from 20 to 30 participants. Some are visited weekly, some are visited every two or three weeks — it depends on the situation. They follow these patients even when they’re not visiting them. We also have a step down program. Once the participant reaches a certain level where they’re maintaining their hypertension or diabetes at a fairly safe level, then we transition them out to a less intensive DM program. That is where we have employees that call them on a monthly basis just to check in, see how they’re doing, see if they need anything and to see if there’s a need for them to renter our intense DM program.

For more information on DM and the medical home, please visit:

We want to hear from you! Submit your question for Disease Management Q&A to info@hin.com.

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Who's Using Telehealth for Remote Monitoring?

With an increase in telehealth use to expand healthcare access and curb costs, we wanted to see how many organizations are using telehealth for remote monitoring of patients or members.

Click here to view the chart.

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Health Coaching in 2010 — Telephone Still Top Coaching Delivery Method

This white paper captures the ways in which 161 organizations are implementing health coaching in 2010 — including the top three areas targeted by health coaching — as well as the financial and clinical outcomes that result from this health improvement strategy. These benchmarks are based on organizations' responses to the Healthcare Intelligence Network August 2010 e-survey on health coaching.

To download this complimentary white paper, please visit:

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African Americans Receive More Aggressive Stroke Treatments Than Whites, Gain Better Survival Rate

African Americans have a better survival rate compared to whites after being hospitalized for a stroke, according to a study from the University of Rochester Medical Center. This conclusion is one piece in a growing body of evidence that points to the important role that patients — and the decision they and their families make in terms of treatment — may play on mortality rates. The study used data from the New York State Statewide Planning and Research Cooperative System, a reporting system that collects detailed information on every hospital and emergency department admission in the state. They compiled information for all non-Hispanic blacks and non-Hispanic whites age 18 and older who were admitted to a hospital with a diagnosis of acute ischemic stroke in 2005 and 2006.

The researchers used a novel statistical approach to minimize the difference between two pools of black and white patients in terms of demographic profiles, co-morbidities, and the type of hospital where they received their care. They then looked at mortality rates for several incremental periods beginning at seven days and up to a year after the stroke and what life-sustaining interventions the patients received during their hospitalization. The authors found that over the course of the year African American patients had a statistically lower rate of mortality and at the same time were more likely to receive aggressive life-sustaining treatments. For example, at 30 days post-hospitalization, African Americans were 30 percent less likely to die after a stroke than whites. After a year, the disparity in survival rates narrows but remains significant.

The study also found that — after adjusting data for variables such as age, socioeconomic status and risk factors — African Americans who were hospitalized for acute ischemic stroke had a significantly lower mortality rate than whites. The survival advantage was most pronounced early after the stroke but persisted for up to one year. The study found that African Americans were also more likely during their hospitalization to have received more aggressive treatment measures, such as kidney dialysis, a tracheostomy or cardiopulmonary resuscitation. They were also less likely to use hospice care.

While the data used for the study does not illustrate the role of patient preference — either expressed intent or in the form of do not resuscitate orders, healthcare proxies or living wills — or the decisions made by family member on their behalf, the authors believe the evidence indicates that there might be a link between the treatment decisions made by patients and their families when seriously ill with stroke and survival rates. According to the researchers, “These results show that black patients with strokes have worse outcomes. Even though we do not know the exact reasons for these differences, these data highlight the potential importance of treatment intensity, and the expression of patient preference for different treatments on survival and mortality.” Researchers also added that, "African Americans are more likely to be treated aggressively and this may have an impact on their mortality outcomes.”

To learn more about this research, please visit:

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Accountable Care Organizations in 2011

Accountable care organizations (ACOs) create integrated delivery systems that encourage teams of physicians, hospitals and other providers to collaboratively coordinate care for ACO members. To learn more about this emerging trend, complete HIN's survey on accountable care organizations and get a FREE executive summary of the compiled results. More than 65 healthcare organizations have already responded!

To participate in this survey and receive its results, please visit:

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