Purpose: Coronary heart disease (CHD) is the leading cause of morbidity and mortality in the United States and worldwide. While public health programs have substantially reduced CHD mortality rates since the 1970s, recent policy changes promoting accountable care organizations (ACOs) and integrated healthcare systems afford new opportunities to potentially improve population health through clinic- or hospital-based point-of-care interventions. To quantify the potential impact of these programs on population health, we identified gaps in preventive practices for CHD and projected health outcomes associated with adoption of point-of-care interventions addressing these gaps.
Method: We analyzed national data from 3.3 million patients who completed Life Line Screening health questionnaires between 2003-2008. We examined the prevalence of unhealthy behaviors (smoking, sedentary lifestyle, poor diet) and clinical risk factors (systolic blood pressure>140mmHg, overweight or obese BMI, absence of statin use in CHD) and projected four-year risk of onset or progression of CHD (defined as angina, myocardial infarction, or cardiac death) using Framingham Heart Study models and meta-analyses of randomized trials. We linked participants' residential addresses to U.S. Census data at the zip code-level to adjust for community income, education, and racial/ethnic diversity.
Result: Median age was 64 years (interquartile range, 56-71), 64% were women, 10% had diabetes, 25% smoked, and 9% had a history of CHD or stroke. Full adherence to preventive behaviors and practices was present in <2% of patients. Using ordinal logistic regression, we found that poorer adherence was associated with age>65 years (aOR 1.3, 95% CI 1.2-1.3), male gender (aOR 1.3, 1.2-1.3), black race (aOR 1.3, 1.3-1.4), and diabetes (aOR 1.4, 1.4-1.5). Adjusting for patient compliance and uptake, clinic- or hospital-based distribution of free high-dose nicotine patches to smokers, free statins to patients with CHD, free pedometers to all patients, and promotion of a Mediterranean diet high in nuts would prevent at least 92, 110, 490, and 480 new or recurrent incidents of CHD per-100,000 adults over four years. In comparison, a 50% reduction in salt consumption--a recommendation widely endorsed by public health organizations--would prevent at least 380 incidents.
Conclusion: Adherence to recommendations for the prevention or progression of CHD is poor. In light of growing integration of healthcare systems and ACOs, selective adoption of clinic- or hospital-based point-of-care programs may further reduce the population burden of CHD.
