Assessing the impact of the heart of New Ulm Project on cardiovascular disease risk factors: A population-based program to reduce cardiovascular disease

Tailoring remote patient management in cardiovascular risk management for healthcare professionals using panel management: a qualitative study

BACKGROUND

While remote patient management (RPM) has the potential to assist in achieving treatment targets for cardiovascular risk factors in primary care, its effectiveness may vary among different patient subgroups. Panel management, which involves proactive care for specific patient risk groups, could offer a promising approach to tailor RPM to these groups. This study aims to (i) assess the perception of healthcare professionals and other stakeholders regarding the adoption and (ii) identify the barriers and facilitators for successfully implementing such a panel management approach.

METHODS

In total, nineteen semi-structured interviews and two focus groups were conducted in the Netherlands. Three authors reviewed the audited transcripts. The Consolidated Framework for Implementation Strategies (CFIR) domains were used for the thematic analysis.

RESULTS

A total of 24 participants (GPs, nurses, health insurers, project managers, and IT consultants) participated. Overall, a panel management approach to RPM in primary care was considered valuable by various stakeholders. Implementation barriers encompassed concerns about missing necessary risk factors for patient stratification, additional clinical and technical tasks for nurses, and reimbursement agreements. Facilitators included tailoring consultation frequency and early detection of at-risk patients, an implementation manager accountable for supervising project procedures and establishing agreements on assessing implementation metrics, and ambassador roles.

CONCLUSION

Panel management could enhance proactive care and accurately identify which patients could benefit most from RPM to mitigate CVD risk. For successful implementation, we recommend having clear agreements on technical support, financial infrastructure and the criteria for measuring evaluation outcomes.

Population health interventions for cardiometabolic diseases in primary care: a scoping review and RE-AIM evaluation of current practices

Introduction

Cardiometabolic diseases (CMD) are the leading cause of death in high-income countries and are largely attributable to modifiable risk factors. Population health management (PHM) can effectively identify patient subgroups at high risk of CMD and address missed opportunities for preventive disease management. Guided by the Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM) framework, this scoping review of PHM interventions targeting patients in primary care at increased risk of CMD aims to describe the reported aspects for successful implementation.

Methods

A comprehensive search was conducted across 14 databases to identify papers published between 2000 and 2023, using Arksey and O'Malley's framework for conducting scoping reviews. The RE-AIM framework was used to assess the implementation, documentation, and the population health impact score of the PHM interventions.

Results

A total of 26 out of 1,100 studies were included, representing 21 unique PHM interventions. This review found insufficient reporting of most RE-AIM components. The RE-AIM evaluation showed that the included interventions could potentially reach a large audience and achieve their intended goals, but information on adoption and maintenance was often lacking. A population health impact score was calculated for six interventions ranging from 28 to 62%.

Discussion

This review showed the promise of PHM interventions that could reaching a substantial number of participants and reducing CMD risk factors. However, to better assess the generalizability and scalability of these interventions there is a need for an improved assessment of adoption, implementation processes, and sustainability.

Pop-up screening nested within routine community activities unmasks an addressed cardiovascular risk: A pilot study (Gippsland Healthy Heart Study)

OBJECTIVE

To evaluate the benefits of a pop-up health screening for cardiovascular risk factors (CVRF) in the Gippsland region, and to assess the acceptability of the screening and to determine whether such a process results in attendance at a general practitioner (GP).

PARTICIPANTS

Overall, 454 participants over the age of 18 who were residents of the Gippsland region were enrolled.

METHODS

This is a community-based, observational, prospective cohort study using pop-up screening sites at six retail locations or workplaces, where participants' blood pressure, body weight and lipid profile were measured. The primary outcome was to assess the proportion of participants with at least one unaddressed CVRF (hypertension [blood pressure >140/90 mmHg], overweight and obesity [body mass index >25 kg/m2 ] or hypercholesterolaemia [low-density lipoprotein cholesterol >2.5 mmol/L]). Email surveys were performed after 4 weeks of follow-up.

RESULTS

Overall, 85.8% (95% confidence interval [CI], 82.1%-88.8%) of participants had at least one unaddressed CVRF. Among the 54 participants who responded to the email survey, 50 participants (92.6% [95% CI, 81.3%-97.6%]) found the screening approach acceptable, and 31 (57.4% [95% CI, 43.3%-70.5%]) considered a discussion with the GP.

CONCLUSIONS

This study supported the feasibility and effectiveness of pop-up screening to detect CVRF in rural communities.

Estimated versus observed 10-year atherosclerotic cardiovascular event rates in a rural population-based health initiative: The Heart of New Ulm Project

Objective

Assess discrepancy between estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk and observed 10-year event rates in a rural population participating in cardiovascular health initiative.

Methods

The study included a rural sample of individuals participating in the Heart of New Ulm (HONU), a population-based health initiative aimed at reducing ASCVD risk in a rural community. HONU conducted over 100 baseline screening events with 5221 individuals participating in 2009. For this analysis, we included participants who were aged 40-79 years, free of ASCVD at baseline, and had adequate data to calculate 10-year ASCVD risk. Electronic health record data and state death records were used to determine rates of non-fatal myocardial infarction and stroke, and ASCVD death from 2010-2019. ASCVD event rates were compared to estimated 10-year risks calculated using the Pooled Cohort Equations, stratified by sex and clinically relevant risk categories.

Results

The sample (n = 2819, mean ± SD age 56.1 ± 9.9 years, 59.6% female) had a low prevalence of tobacco use (8.1% current smokers) and diabetes (6.5%) and a high prevalence of hypertension (44.4%) and hyperlipidemia (56.6%). The median estimated 10-year ASCVD risk for the entire sample was 5.7% (IQR 2.3-13.5%) with an observed 10-year ASCVD event rate of 3.4%. The largest gap between observed and estimated risk was in those at intermediate/high (≥7.5%) ASCVD risk (median 10-year risk 15.8% [IQR 10.4-29.0], observed ASCVD event rate 6.4%).

Conclusio

In a sample of rural participants exposed to a multifaceted ASCVD prevention initiative, observed rates of ASCVD were substantially lower compared to estimated ASCVD risk. The potential for significantly lower than predicted ASCVD event rates in certain populations should be included in the clinician-patient risk discussion.

Reduction in medical costs for cardiovascular diseases through innovative health awareness projects in a rural area in Japan

To promote health awareness and improve life expectancy in Hirosaki, a Japanese rural area, the Center of Healthy Aging Program (CHAP) was founded in 2013. The most important characteristic of CHAP is a personalized interview just after the checkup to discuss individual results. We evaluated the clinical and economic effects of CHAP by analyzing the cohort data of voluntary participants from annual health checkups since 2005 in the Iwaki district of Hirosaki. We calculated 10-year incidence risk scores for coronary heart diseases (CHDs) and stroke, and compared the risk-score trend before and after the start of CHAP by adjusting other risk factors using multivariate generalized linear regression analyses. We also predicted the 10-year incidences of CHDs and stroke based on the risk scores, for future scenarios of the two conditions, with and without CHAP, and compared them to their treatment costs between scenarios. The number of participants ranged between 808 and 1,167, from 2008 to 2016. The mean age (55 years) and proportion of women (60%) did not significantly change throughout the period. After adjusting for sex, age, outside temperature on the checkup date, the preparation effect of CHAP in 2012, and risk scores in the previous year, the annual increases in risk scores of CHDs and stroke were significant even after CHAP (+0.413, p <0.001; +0.169, p <0.001, respectively), but slightly less compared to before CHAP (+2.638, p <0.001; +1.155, p <0.001, respectively). Assuming the trend continued until 2021, the 10-year incidences of CHDs and stroke have decreases by 22,486 and 9,603, respectively, and treatment costs decreased by JPY 21,973 and 16,056 million, respectively. CHAP contributes to a significant decrease in the incidences of CHDs and stroke, and reduces economic burden on the local government.

Beyond patient care: a qualitative study of rural hospitals' role in improving community health

OBJECTIVES

Rural population face more health disadvantages than those living in urban and suburban areas. In rural communities, hospitals are frequently the primary organisation with the resources and capabilities to address health issues. This characteristic highlights their potential to be a partner and leader for community health initiatives. This study aims to understand rural hospitals' motivations to engage in community health improvement efforts and examine their strategies to address community health issues.

DESIGN

Eleven semistructured interviews were conducted with key leaders from four rural hospitals in a US Midwestern state. On-site and telephone interviews were audio-recorded and transcribed. The combination of inductive and deductive qualitative analysis was applied to identify common themes and categories.

SETTINGS

Participating hospitals are located in US rural counties that have demonstrated progress in creating healthier communities.

RESULTS

Three types of motivation drive rural hospitals' community health improvement efforts: internal values, economic conditions and social responsibilities. Three categories of strategies to address community health issues were identified: building capacity, building relationships and building programmes.

CONCLUSIONS

Despite the challenges, rural hospitals can successfully conduct community-oriented programmes. The finds extend the literature on how rural hospitals may strategise to improve rural health by engaging their communities and conduct activities beyond patient care.

Community and Social Context: An Important Social Determinant of Cardiovascular Disease

Disease prevention frameworks and clinical practice guidelines in the United States (US) have traditionally ignored upstream social determinants of health (SDOH), which are critical for reducing disparities in cardiovascular disease (CVD)-the leading cause of death in the US. Existing evidence demonstrates a protective effect of social support, social cohesion, and community engagement on overall health and wellbeing. Increasing community and social support is a major objective of the Healthy People 2030 initiative, with special provisions for vulnerable populations. However, to date, existing evidence of the association between community and social context (CSC)-an integral SDOH domain-and CVD has not been reviewed extensively. In particular, the individual and cumulative impact of CSC on CVD risk and the pathways linking CSC to cardiovascular outcomes are not well understood. In this review, we critically appraise current knowledge of the association between CSC and CVD, describe potential pathways linking CSC to CVD, and identify opportunities for evidence-based policy and practice interventions to improve CVD outcomes.

The impact of a population-based prevention program on cardiovascular events: Findings from the heart of new Ulm project

BACKGROUND

Cardiovascular disease (CVD) and its associated risk factors are the principal drivers of mortality and healthcare costs in the United States with rural residents experiencing higher CVD death rates than their urban counterparts.

METHODS

The purpose of this study was to examine incidence of major CVD events over 9 years of implementation of the Heart of New Ulm (HONU) Project, a rural population-based CVD prevention initiative. HONU interventions were delivered at individual, organizational, and community levels addressing clinical risk factors, lifestyle behaviors and environmental changes. The sample included 4,056 residents of New Ulm matched with 4,056 residents from a different community served by the same health system. The primary outcome was a composite of major CVD events (myocardial infarction, ischemic stroke, percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), and CVD-related death). Secondary outcomes were the individual CVD events and procedures.

RESULTS

The proportion of residents in New Ulm with a major CVD event (7.79%) was not significantly different than the comparison community (8.43%, P = .290). However, the total number of events did differ by community with fewer events in New Ulm than the comparison community (447 vs 530, P = .005), with 48 fewer strokes (84 vs 132, P = .001) and 42 fewer PCI procedures (147 vs 189, P = 0.019) in New Ulm. Incidence of ischemic stroke was lower in the New Ulm community (1.85 vs 2.61, P = .020) than in the comparison community. Other specific CVD events did not have significantly different incidence or frequencies between the 2 communities.

CONCLUSION

In HONU, the proportion of residents experiencing a CVD event was not significantly lower than a match comparison community. However, there was a significant reduction in the total number of CVD events in New Ulm, driven primarily by lower stroke, PCI, and CABG events in the intervention community.

Pharmacist-led cardiovascular risk prevention in Western Canada: a qualitative study

OBJECTIVES

Preventing cardiovascular diseases (CVD) is a public health and policy priority, including for employers. A novel CVD risk management programme that included medication management was delivered by pharmacists to employees of a Canadian university. This qualitative study describes the experiences and perceptions of participants who received individual health consultations in this programme.

METHODS

A qualitative study design using free-text responses was adopted. Data (5658 words) came from evaluation surveys completed by 119 programme participants were iteratively coded and thematically analysed.

KEY FINDINGS

We identified four themes characterising participant experiences of pharmacist-led CVD prevention. Theme one was labelled self-efficacy because personalised health information and advice on CVD risk factor management empowered participants to make improvements for their health. Participants expressed a range of positive responses about the longer consultations, supportive communication and safe setting of their pharmacist-led encounters; hence, Theme two is labelled pharmacists' interpersonal skills. The wider context of the programme included a number of enabling factors (Theme three) that either supported or limited participant engagement in the programme. A number of changes to behaviour and health measures were identified and participant suggestions to expand and continue the programme further contributed to perceptions of positive programme impact (Theme four).

CONCLUSIONS

This study raises questions about how external resources and broader determinants might enable, or hinder, future programme success and sustainability. It also highlights the need for greater understanding and communication of the importance of primary prevention and the role of pharmacists in CVD risk reduction and workplace health promotion.

Population-Level Reach of Cardiovascular Disease Prevention Interventions in a Rural Community: Findings from the Heart of New Ulm Project

This study examines participation by residents of a rural community in programs implemented as part of The Heart of New Ulm (HONU) Project, a population-based cardiovascular disease (CVD) prevention initiative. The study compares participation rates for the various interventions to assess which were the most engaging in the priority community and identifies factors that differentiate participants vs. nonparticipants. Participation data were merged with electronic health record (EHR) data representing the larger community population to enable an analysis of participation in the context of the entire community. HONU individual-level interventions engaged 44% of adult residents in the community. Participation ranked as follows: (1) heart health screenings (37% of adult residents), (2) a year-long community weight loss intervention (12% of adult residents), (3) community health challenges (10% of adult residents), and (4) a phone coaching program for invited high CVD-risk residents (enrolled 6% of adult residents). Interventions that yielded the highest engagement were those that had significant staffing and recruited participants over several months, often with many opportunities to participate or register. Compared to nonparticipants, HONU participants were significantly older and a higher proportion were female, married, overweight or obese, and had high cholesterol. Participants also had a lower prevalence of smoking and diabetes than nonparticipants. Findings indicate community-based CVD prevention initiatives can be successful in engaging a high proportion of adult community members. Partnering with local health care systems can allow for use of EHR data to identify eligible participants and evaluate reach and engagement of the priority population.

Population-level changes in lifestyle risk factors for cardiovascular disease in the Heart of New Ulm Project

Lifestyle significantly influences development of cardiovascular disease (CVD), but limited data exists demonstrating lifestyle improvements in community-based interventions. This study aims to document how lifestyle risk factors changed at the population level in the context of Heart of New Ulm (HONU), a community-based CVD prevention initiative in Minnesota.

HONU intervened across worksites, healthcare and the community/environment to reduce CVD risk factors. HONU collected behavioral measures including smoking, physical activity, fruit/vegetable consumption, alcohol use and stress at heart health screenings from 2009 to 2014. All screenings were documented in the electronic health record (EHR). Changes at the community level for the target population (age 40–79) were estimated using weights created from EHR data and modeled using generalized estimating equation models.

Screening participants were similar to the larger patient population with regard to age, race, and marital status, but were slightly healthier in regards to BMI, LDL cholesterol, blood pressure, and less likely to smoke. Community-level improvements were significant for physical activity (62.8% to 70.5%, p < 0.001) and 5+ daily fruit/vegetable servings (16.9% to 28.1%, p < 0.001), with no significant change in smoking, stress, alcohol or BMI.

By leveraging local EHR data and integrating it with patient-reported outcomes, improvements in nutrition and physical activity were identified in the HONU population, but limited changes were noted for smoking, alcohol consumption and stress. Systematically documenting behaviors in the EHR will help healthcare systems impact the health of the communities they serve, both at the individual and population level.

Effect of Marine Microalga Chlorella pyrenoidosa Ethanol Extract on Lipid Metabolism and Gut Microbiota Composition in High-Fat Diet-Fed Rats

Effects of marine microalga Chlorella pyrenoidosa 55% ethanol extract (CPE55) on lipid metabolism, gut microbiota and regulation mechanism in high fat diet-fed induced hyperlipidaemia rats were investigated. Structure characterizations of major compounds in CPE55 were determined by ultra-performance liquid chromatography-quadrupole/time of flight mass spectrometry (UPLC-Q-TOF-MS/MS). The compositions of gut microbiota in rats were analyzed by high-throughput next-generation 16S rRNA gene sequencing. Oral administration with CPE55 markedly alleviated dyslipidemia through improving adverse blood lipid profile and inhibiting hepatic lipid accumulation and steatosis. CPE55 has downregulated the gene expression levels of acetyl CoA carboxylase, sterol regulatory element-binding transcription factor-1c, and 3-hydroxy-3-methyl glutaryl coenzyme A reductase and upregulated adenosine 5'-monophosphate-activated protein kinase-α. It has also improved the abundance of bacteria Alistipes, Prevotella, Alloprevotella, and Ruminococcus1 and decreased the abundances of Turicibacter and Lachnospira. Turicibacter and Lachnospira were both positive correlations of metabolic phenotypes. The findings above illustrated that CPE55 might be developed as food ingredients to ameliorate lipid metabolic disorders and hyperlipidaemia.