Current Quality of Cardiovascular
Prevention for Million Hearts™
An Analysis of 147,038 Outpatients from The
Guideline Advantage ™
Zubin J. Eapen, MD, MHS; Li Liang, PhD; Vincent J.
Bufalino, MD; Eric D. Peterson MD, MPH; Adrian F.
Hernandez, MD, MHS
Duke Clinical Research Institute (Durham, NC) and Midwest Heart
Specialists (Naperville, IN)
Presenter Disclosure Information
ZJ Eapen: none
Li Liang: none
VJ Bufalino: none
ED Peterson: research funding from Eli Lilly & Company, Janssen
Pharmaceuticals, Society of Thoracic Surgeons, American Heart
Association, American College of Cardiology (significant); consulting for
Boehringer Ingelheim, Janssen Pharmaceuticals Inc. (modest).
DISCLOSURE INFORMATION:
AF Hernandez: research funding from Amylin Inc., Johnson & Johnson,
Portola Pharmaceuticals; consulting for AstraZeneca, Johnson &
Johnson, Ortho-McNeil-Janssen Pharmaceuticals, Inc., Corthera
(modest).
Background
• Million Hearts™ is a national initiative to
prevent 1 million heart attacks and strokes over
5 years by improving cardiovascular prevention.
• The quality of outpatient cardiovascular
prevention has not been fully described.
Goals of Million Hearts
A
• Aspirin for high-risk patients
B
• Blood pressure control
C
• Cholesterol management
S
• Smoking cessation
Mechanism for contributing data
Mapping document
Mapping document
Mapping document
Site
Site
Site
Mechanism for contributing data
Continuity of care record
Continuity of care record
Continuity of care record
Site
Site
Site
Denominators
A
B
C
S
•Patients aged 18 and older with:
•a diagnosis of ischemic vascular
disease or acute myocardial
infarction
Denominators
A
B
C
S
•Patients aged 18 through 85 years who:
•have a diagnosis of hypertension
•whose blood pressure was
adequately controlled (<140/90
mmHg) during the most recent
outpatient visit
Denominators
A
B
C
S
•Patients aged 18 through 75 years with:
•a diagnosis of diabetes mellitus
•whose most recent LDL-C level was
less than 100 mg/dL during the 12
months prior to the most recent visit
Denominators
A
B
C
S
•Patients aged 18 years and older who:
•were screened for tobacco use at
least once during the 24 months prior
to the most recent visit and
•received a tobacco cessation
intervention if identified as a tobacco
user
Baseline characteristics
Characteristics
Age, median (25th, 75th) year
Female sex, %
Frequency (n = 147,038)
62 (49,73)
49.6
Race
White
73.4
Black or African American
5.4
Hispanic
1.5
Asian
0.9
Other
5.4
Unable to determine
13.4
Baseline characteristics
Characteristics
History of, %
Chronic pulmonary disease
Diabetes mellitus
Heart failure
Hyperlipidemia
Hypertension
Peripheral arterial disease
Coronary artery disease
Prior myocardial infarction
Long-term dialysis
Stroke or transient ischemic attack
Tobacco abuse
Frequency (n = 147,038)
7,760 (5.3)
8,815 (6.0)
10,195 (6.9)
67,826 (46.1)
65,212 (44.4)
4,345 (3.0)
22,717 (15.5)
5,164 (3.5)
412 (0.3)
3,073 (2.1)
10,443 (7.1)
Compliance with Million Hearts
Denominator
Numerator
Compliance
Rate
Antiplatelet use in IVD
28044
16777
59.8
Blood pressure control
57449
39927
69.5
Cholesterol control in diabetes
16296
12900
79.2
Smoking cessation
115737
86565
74.8
Clinical Quality Measure
Site-level variation in compliance
B
No. of sites
15
10
5
0
10
20
30
40
50
60
70
80
90
8
6
C
4
2
0
10
20
30
40
50
60
70
80
90
10
20
30
40
50
60
70
80
90
8
6
S
4
2
0
% of patients
Factors associated with compliance
Antiplatelet therapy for ischemic vascular disease
Variable
Age (per 10 years)
Female gender (vs. male)
Black race (vs. white)
Other race (vs. white)
Chronic pulmonary disease
Diabetes mellitus
Heart failure
Dyslipidemia
Hypertension
OR (95% CI)
0.98 (0.98, 0.99)
0.63 (0.59, 0.67)
0.78 (0.63, 0.95)
1.01 (1.01, 1.01)
0.94 (0.94, 0.94)
1.12 (0.92, 1.36)
0.83 (0.79, 0.87)
1.69 (1.65, 1.74)
1.00 (0.98, 1.01)
Peripheral arterial disease
Dialysis
Stroke/TIA
Tobacco abuse
Systolic blood pressure (per 10 mmHg)
1.18 (1.11, 1.26)
0.56 (0.43, 0.74)
0.69 (0.55, 0.87)
0.98 (0.88, 1.09)
1.04 (1.03, 1.05)
Factors associated with compliance
Blood pressure control
Variable
Age (per 10 years)
Female gender (vs. male)
Black race (vs. white)
Other race (vs. white)
Chronic pulmonary disease
Diabetes mellitus
Heart failure
Dyslipidemia
Peripheral arterial disease
Coronary artery disease
Prior myocardial infarction
Dialysis
Stroke/TIA
Tobacco abuse
OR (95% CI)
1.00 (0.99, 1.00)
0.93 (0.81, 1.06)
0.72 (0.67, 0.77)
0.96 (0.91, 1.01)
1.02 (0.99, 1.05)
0.93 (0.91, 0.94)
1.29 (1.21, 1.38)
1.24 (1.15, 1.33)
0.96 (0.92, 0.99)
1.14 (1.09, 1.19)
1.00 (0.96, 1.03)
1.00 (1.00, 1.00)
0.99 (0.91, 1.08)
0.96 (0.89, 1.03)
Factors associated with compliance
Cholesterol control in diabetes
Variable
Age (per 10 years)
Female gender (vs. male)
Black race (vs. white)
Other race (vs. white)
Chronic pulmonary disease
Heart failure
Hypertension
Peripheral arterial disease
Coronary artery disease
Prior myocardial infarction
Dialysis
Stroke/TIA
Tobacco abuse
Systolic BP (per 10 mmHg)
OR (95% CI)
1.01 (1.00, 1.03)
0.71 (0.65, 0.76)
0.63 (0.47, 0.85)
0.87 (0.67, 1.14)
1.03 (0.92, 1.16)
0.92 (0.65, 1.30)
0.93 (0.86, 1.01)
1.15 (1.02, 1.29)
1.30 (1.17, 1.45)
0.91 (0.86, 0.96)
2.60 (1.95, 3.47)
0.92 (0.78, 1.08)
0.80 (0.75, 0.85)
0.96 (0.92, 1.00)
Factors associated with compliance
Smoking cessation
Variable
Age (per 10 years)
Female gender (vs. male)
Black race (vs. white)
Other race (vs. white)
Chronic pulmonary disease
Diabetes mellitus
Heart failure
Dyslipidemia
Hypertension
Peripheral arterial disease
Coronary artery disease
Prior myocardial infarction
Dialysis
Stroke/TIA
Systolic BP (per 10 mmHg)
OR (95% CI)
1.01 (1.00, 1.02)
1.08 (1.03, 1.12)
1.24 (1.18, 1.30)
0.88 (0.72, 1.07)
0.81 (0.75, 0.86)
1.21 (1.10, 1.34)
1.23 (1.07, 1.40)
1.41 (1.19, 1.65)
1.21 (1.06, 1.39)
1.06 (0.96, 1.18)
0.92 (0.90, 0.95)
1.06 (1.01, 1.11)
0.85 (0.77, 0.93)
1.02 (0.98, 1.06)
0.96 (0.95, 0.97)
Limitations
• Quality of care may be different among practices
motivated to participate in this quality improvement
initiative.
• A significant proportion of the failure to prescribe may
be due to undocumented and confounding physician
impressions.
• Currently, there are significant challenges in
standardizing EHR data for national quality
improvement initiatives.
Conclusions
• Evaluating quality of ambulatory care across multiple
practices is possible via The Guideline Advantage™, a
national quality improvement program.
• Compliance with clinical quality measures for the Million
Hearts™ initiative varies widely across outpatient practices.
• There are gender and racial disparities in the quality of
outpatient care.
• Our findings identify multiple opportunities to improve the
quality of outpatient care for cardiovascular prevention.
Acknowledgments
• This project was supported by the American Heart
Association in partnership with the American
Cancer Society and the American Diabetes
Association
• This project was supported in part by grant number
U19HS021092 from the Agency for Healthcare
Research and Quality. The content is solely the
responsibility of the authors and does not represent
the official views of the Agency for Healthcare
Research and Quality.