Thank You Janet
ABCS of Heart Disease and
Stroke Prevention
Our Challenge
Our Partners
Jacquie Halladay MD MPH, UNC-CH
Lindsay Beavers, CCME
ABCS of Heart Disease and Stroke
Prevention

Aspirin: Increase low dose aspirin therapy according
to recognized prevention guidelines.

Blood pressure: Prevent and control high blood
pressure; reduce sodium intake.

Cholesterol: Prevent and control high blood
cholesterol.

Smoking: Increase the number of smokers
counseled to quit and referred to State quit lines;
increase availability of no or low-cost cessation
products.
http://www.cdc.gov/DHDSP/programs/nhdsp_prog
ram/docs/ABCs_Guide.pdf
National Heart Disease and Stroke
Prevention (NHDSP) Program
Anchored in the Socio-ecological Model.
Use strategies that..
Are evidenced based.
 Have broad “reach and impact” to general
and priority populations.

National Heart Disease and Stroke Prevention Program Strategies for States to Address the “ABCS”
Linked to “Policy and Systems
Change” outcome measures
Objectives: to understand….
•
•
•
The components of the ABCS.
Partners in NC.
How are we are addressing the ABCS at
various levels of the Socio-ecological Model
in NC.
Plan
Review ABCS Media materials and evaluation
plans (CCME)
 “Next Steps” Heart Healthy Lenoir Project
 Discuss “coaching” as a self management
support resource (State Health Plan and CCNC
Medical Home)
 Briefly discuss the Community Transformation
Grant (CTG) activities (NC DPH)

HDSP- CCME - Heart Lessons
The ABCS of Heart Disease
and Stroke Prevention
Janet Reaves Memorial Conference
February 3, 2012
Television Education Campaign
•
Target audience: Adults, 45 years of age and older, who
have an annual household income below $100,000
•
The commercial will focus on the ABCS, which is a
national CDC campaign.
•
The new commercial will air for 4 weeks in February 2012
on cable and network television across the state, covering
media markets in Greenville, Raleigh, Greensboro,
Charlotte, and Asheville.
 Estimated potential impressions: 5,429,818
•
The media buy was based on Nielsen Ratings.
Television Education Campaign, cont.
• Storyboard Focus Groups
 Three focus groups tested three different concepts for
the commercial. The spot entitled “Heart Lessons” was
chosen.
• Participants:
 At least 12 participants per group
 Equal number of ethnic majority and minority
participants, male and female
 45 years or older
 Household incomes below $40,000
 All were residents in counties east of I-95, where the
highest burden of heart disease and stroke exists
2012 Television Education Campaign
Evaluations
•
•
Measurement

600 pre- and post-campaign surveys will be
conducted.

This process was designed to specifically determine
the impact of the TV advertising campaign in the
eastern counties of NC.
Methodology

Surveys will be conducted through telephone
interviews.

Surveys will measure impact of public awareness on
ABCS, prevention measures, and advertisement.
SWYH Banner Ads
•
SWYH banner page on the SWYH website
www.startwithyourheart.com
Home > Health Professionals > SWYH Banners
Educational Material, cont.
• Other materials:
• 8,000 blood pressure index cards
• 5,000 consumer ABCS flyers
• 7,500 stroke magnets
Educational Material
• Brochures on stroke, blood pressure, and
cholesterol have been printed and provided to
health coordinators.
Media Outreach
• Sodium op-ed was published in the N&O on
December 23, 2011.
 http://www.newsobserver.com/2011/12/23/17285
02/cut-the-salt-and-help-your-health.html
 Circulation/distribution total: 144,075
• High blood pressure and Cholesterol op-eds in
progress
• SWYH promotional messages distributed via the
CCME QP Online newsletter, Facebook and Twitter
pages, and the CCME website.
Community Outreach Activities
• Conduct outreach activities in 2012, predominantly
in eastern North Carolina
 February 2012
o Provide ABCS flyers to be distributed at a
Go Red Gala in Greenville on Feb. 5
o Provide an ABCS insert for church bulletins
to 35 churches in eastern NC through
Cornerstone Ministries
 May 2012
o Send ABCS flyers to 21 Wal-Mart pharmacies
in eastern NC to distribute to their patients
Questions?
100 Regency Forest Drive, Suite 200, Cary, NC 27518
800.682.2650 • www.thecarolinascenter.org
Heart-Healthy Lenoir
Blood Pressure Control Project:
ECU / UNC-Chapel Hill
PI’s: Alice Ammerman, Darren DeWalt, Cam Patterson
HTN office intervention team
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Darren A. DeWalt, MD,
MPH - PI
Skip Cummings,
PharmD
Katrina Donahue, MD,
MPH
Beverly Garcia, MPH
Jacquie Halladay, MD,
MPH
Alan Hinderliter, MD
Cassie Miller, MPH
Crystal Wiley-Cene,
MD, MPH
Goals for the Hypertension Control Project
Reduce blood pressure levels among
patients with poorly controlled
hypertension.
 Reduce disparities in blood pressure by
race and by literacy.
 Create systems that can sustain these
improvements within current primary
care practice.

Stanford-USFC EBPC
 Performed
a systematic
reviews of interventions
aimed at reducing BP’s
among people with HTN.
Methods: Stanford-UCSF EBPC

Search the literature from 1980 to 2003
regarding QI and BP reductions strategies

Restrict to interventions targeting provider
behavior*/organizational change.

* separate review performed on “patient only” interventions
Classification of Interventions
classifications
examples
Provider Education
Materials/instructions given to
providers regarding appropriate care
Provider Reminders
Prompts to providers to perform
specific care tasks
Provider Audit and Feedback
Clinical performance reports
Facilitated relay of clinical data to
providers
Patient clinical data transmitted from
home BP cuffs etc.
Patient Education
Materials/instructions regarding HTN
Patient Reminders
Appointments , adherence
Promotion of self management
Access to resources/devices
Team Change
Additions of role changes
Financial Incentives
Reimbursement structure changes
Classification of Interventions
classifications
examples
Provider Education
Materials/instructions given to
providers regarding appropriate care
Provider Reminders
Prompts to providers to perform
specific care tasks
Provider Audit and Feedback
Clinical performance reports
Facilitated relay of clinical data to
providers
Patient clinical data transmitted from
home BP cuffs etc.
Patient Education
Materials/instructions regarding HTN
Patient Reminders
Appointments , adherence
Promotion of self management
Access to resources/devices
Team Change
Additions of role changes
Financial Incentives
Reimbursement structure changes
For instance…..
Patient Interviews:
 HTN awareness (seriousness, “know their # s”)
 Barriers to taking medication.
 Ideas on home BP monitoring method (HBPM).
 Perceived healthcare disparities
(race/ethnicity/literacy level/SES).
 Ideas
on phone or office selfmanagement support
“coaching” program.
Current work:
Develop and implement the phone
coaching program.
Evidence regarding effectiveness
 NC programs

Evidence for phone coaching
Hutchison et al. 2011
 >1000 studies (Randomized controlled
trials)
 41 trials - 34 phone coaching services.
 Wide variety of coaching models on several
different diseases.
 Overall the evidence supports that phone
coaching is an effective intervention
especially for chronic cardiovascular
conditions and diabetes…..with the most
notable benefits including…..

Phone Coaching
Improved patient compliance with self
care regimens.
 Increased patient confidence towards
disease management.
 Reduced hospital readmissions
 Improved mental health

Coaching activities
…..Adjunct to provider care, not a replacement
Medication review (purpose, side effects)
Involve family members and friends as support
Assist with empowerment (role play)
Augment problem solving skills
Discuss food labels, low sodium options
Provide follow-up post hospitalization to ensure
understanding of medication regimen and to see that
a follow-up provider visit is scheduled
 Goal setting
 Smoking cessation/behavioral counseling
 Many more…..
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NC Health Smart
www.shpnc.org
http://www.shpnc.org/ncHealthSmart/faq-nchs-healthcoach.aspx
NC Health Smart
Coaching from the NC from the
State Health Plan!

Weight control
◦ “Ya’ll calling and know that you're going to call
is really motivating for me.
 Lost 22 pounds

Improved diabetes control
◦ A1c from 10.7 to 7.0%

Control of BP.
◦ Medication adherence and with resulting BP’s
from 177/92 to 124/70!
Coaching from the NC from the
State Health Plan!

Assistance with understanding symptoms
of an acute MI.
◦ Connected with patient post hospitalization
and started working with her on how to
manage her medications and laboratory
testing post MI.

The Graduate.
◦ Fasting BG’s from 160 to 70mg/dl.
Phone coaching : Duke team(s)
Hayden Bosworth, PhD
 Nurse lead phone coaching programs in
NC.

 Center for Health Services Research in Primary
Care,Veterans Affairs Medical Center, Center for
Aging and Human Development, Duke
Hypertension Center, and Duke Clinical Research
Institute.
Bosworth et al. - Improved BP
control
475 patients from 32 zip codes around
Duke, 2 year intervention.
 Strategy: phone coaching targeting HTN
behaviors +/- home BP monitoring.
 Bottom line: Improved BP control at
minimal costs (~ $400 dollars per year
including BP monitors and bi-monthly
coaching calls).

Bosworth and CCNC - Adherence.
QI approach in 3 CCNC networks.
 Measured pharmacy fill rates for HTN meds
“MPR”.
 6 month intervention for 558 patients.
 Called every 3 weeks for a max of 10 calls.
 Encounters included “core” modules addressed each time (adherence and
medication tolerance.
 AND additional modules activated at specific
times (diet, HTN knowledge, social support).

Bosworth and CCNC - Adherence
Those with at least one call improved
their medication adherence scores.
 And had higher fill rates than nonparticipants.
Medication Possession Ratios:

 “very poor” if the ratio is < 0.6
 “poor” if 0.6-0.8
 “good” if ≥ 0.8
Average Medication Adherence Overtime:
(a) intervention group vs. (b) usual care
a
Participants - MPR:
to 77%
59%
Intervention Start
NON-participants - MPR:
60% to 64%
b
Adherence compared to themselves
Very Poor
Intervention Start
Poor
Good
More coaching partners..

People like Dr. Jonathan Rubens from
ActiveHealth management.
Health Plans, Hospitals, Health
Systems
44
Employers
UPS
IUOE
TVA
Westinghouse
4
5
Socio-ecological Model
First of its kind in Brunswick Co.
North Carolina
Community
Transformation
Grant
Strategic Directions

Tobacco–Free Living

Active Living and Healthy Eating

High Impact Quality Clinical and Other
Preventive Services (HTN and
Cholesterol)
Policy, Environment, Programmatic, and
Infrastructure Change

Policy – Educate the public and stakeholders about policy
interventions to improve population health

Environment – create social and physical environments
that support healthy living

Programmatic – Increase access to prevention programs
to support healthy living

Infrastructure – Change systems, procedures, and
protocols within communities and institutions that
support healthy behavior
Core Principles
Maximize health impact through prevention
Advance health equity and reduce disparities
Use and expand the evidence base
North Carolina Strategies
Tobacco–Free Living
 Increase smoke-free regulations of local government
buildings and of indoor public places.
 Increase tobacco-free regulations for government
grounds, including parks and recreational areas.
 Increase smoke-free housing policies in affordable multiunit housing and other private sector market-based
housing.
 Increase the number of 100% tobacco-free policies on
community colleges campuses and state and private
university/college campuses.
North Carolina Strategies
Active Living
 Increase the number of convenience stores that
increase the availability of fresh produce and decrease
the availability of sugar-sweetened beverages.
 Increase the number of communities that support
farmers’ markets, mobile markets, and farm stands.
Healthy Eating
 Increase the number of communities that implement
comprehensive plans for land use and transportation.
 Increase the number of community organizations that
promote joint use/community use of facilities.
North Carolina Strategies
High Impact Quality Clinical and Other
Preventive Services (High Blood Pressure and
Cholesterol)
 Increase the number of health care providers’
quality improvement systems for clinical practice
management of high blood pressure and high
cholesterol, weight management and tobacco
cessation.
 Increase the number of healthcare organizations
that support tobacco use screening and referral to
cessation services.
North Carolina Strategies

Increase the number of community
supports for individuals identified with
high blood pressure/cholesterol and
tobacco use (e.g. Chronic Disease SelfManagement Programs, (CDSMP) weight
management programs, tobacco cessation
programs).
CTG Regions
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Heart Healthy Lenoir Project P-50
Goals:
Understand factors that lead to worse health
in Lenoir County.
Understand factors that lead to disparities
within Lenoir County.
R01- Patterson: Study genetic footprints that affect treatment
success.
R01- Ammerman/Keyserling: Test a sustainable program to
improve nutrition/physical activity and support weight loss.
R01- DeWalt: Test a system to improve blood pressure control
through primary care practices.
Control of High Blood Pressure and
High Blood Cholesterol-Strategies
Strategies- Primary Care Health Systems
 Promote systems to support selfmanagement (e.g., telephonic follow-up,
linkages to home monitoring, selfmanagement programs).
 Promote system changes that integrate
and sustain use of community health
workers and other healthcare extenders
within healthcare settings.

Timeline
Get to know patients and practices
Enroll 600
Implement/Test New Strategies
Track Outcomes
Analyze results
Yr 1
Yr 2
Yr 3
Yr 4
Yr 5
5/10-4/11
5/11-4/12
5/12-4/13
5/13-4/14
5/14-4/15
Role of Hypertension in CVD
HTN accounts for 27% of total CVD
events in women and 37% in men
 60% of those with known HTN are on
medical therapy
 50% of those on therapy are at their goal
BP
 Controlling BP reduces the risk of stroke
(35-40%), myocardial infarction (20-25%),
and heart failure (50%)

Chobanian et al. JAMA. 2003; 289:2560-2572.
Jajjar and Kotchen. JAMA. 2003; 290:199-20.
HTN, It is important….
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WHO: “credits” HTN with 1 in every 8
deaths
It is the 3rd leading cause of death worldwide
“The most important public health problem in
developed countries”.
 Agency for Healthcare Research and Quality. Technical Review 9.
January 2005.

“Controlling hypertension is the single most
effective clinical service for reducing
mortality”
 Farley TA Am J Prev Med 2010