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Value Based CVD Care / CMS - The Million Hearts Initiative:
Preventing 1 Million Heart Attacks and Strokes
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"In support of Million Hearts, the Center for Medicare & Medicaid Innovation (CMMI) of the CMS recently announced its plans to perform a large cluster randomized payment model test of value-based payment designed to determine whether financially rewarding reductions in 10-year predicted risk for ASCVD across a physician's patient population is an effective model to reduce the burden of heart attack and stroke.5 This Cardiovascular Risk Reduction Model will represent the largest test of value-based prevention payment conducted by CMS."
Conclusions and Implications
The Million Hearts initiative is designed to reduce the burden of ASCVD in the United States and aims to prevent 1 million heart attacks and strokes by 2017. A key focus of this initiative is implementation of the ABCS in appropriate individuals at elevated risk. Substantial observational data support the current paradigm in primary prevention of ASCVD that the intensity of prevention efforts should match the absolute risk of the patient, with drug therapy reserved for those at higher predicted risk, in whom net clinical benefit will be greater.
In concert with Million Hearts, CMMI aims to assess whether incentivizing physicians to reduce ASCVD risk among Medicare beneficiaries at high predicted risk will result in lower rates of heart attacks and strokes. To support the proposed Million Hearts Cardiovascular Risk Reduction Model testing this hypothesis, we have developed the Longitudinal ASCVD Risk Assessment Tool. The tool provides a baseline 10-year ASCVD risk estimate for black and non-Hispanic white men and women. The tool also provides projected values of risk reduction that would be associated with institution of ABCS therapies alone or in combination; these estimates are based on the best available evidence from formal, high-quality systematic reviews and meta-analyses. The projected risk reductions that are presented by the tool are based on average responses to the therapies, and are intended to guide decision-making around what preventive therapies to pursue (in the context of therapeutic lifestyle change) while considering net clinical benefit in the course of the guideline-recommended, patient-clinician discussion. Finally, the tool also provides updated 10-year ASCVD risk estimate, to be calculated at a follow-up visit, which represents a more personalized updated risk estimate that reflects the actual response of a given patient, incorporating their individual changes in risk factor levels. This approach to personalized estimation of benefits from risk-reducing therapies may represent the next wave in clinical practice to help target therapies to those in whom they will provide the greatest benefit.
The Million Hearts Tool has been developed to assist clinicians and patients to understand risk, to monitor patients' risks over time, and to quantify potential benefits of preventive therapies based on high-quality evidence. It can also assist CMMI and clinical practices in monitoring risk in patient cohorts over time. Whereas it requires further assessment and validation in diverse clinical populations and scenarios, its implementation in the Million Hearts Cardiovascular Risk Reduction Model proposed by CMMI for high-risk Medicare patients will be an important scientific investigation of the current paradigm for ASCVD prevention.
Circulation March 2017
The Million Hearts Initiative: Preventing 1 Million Heart Attacks and Strokes
In 2012, the US Department of Health and Human Services initiated Million Hearts, a national public-private initiative with an ambitious goal of preventing 1 million heart attacks and strokes by 2017.3 The Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services (CMS) co-lead the initiative on behalf of the US Department of Health and Human Services. The American Heart Association (AHA) and American College of Cardiology (ACC) have enthusiastically supported the program.
Million Hearts aims to prevent heart attacks and strokes by pursuing a number of public health and healthcare strategies, outlined in Table 1.4 Central to the implementation of these strategies is management of the "ABCS"Ņaspirin therapy in appropriate patients, blood pressure control, cholesterol management, and smoking cessation. Identification of individuals at high risk for ASCVD, in whom application of these evidence-based therapies would have the greatest benefit, and improving adherence to these therapies once prescribed are essential for achieving these goals.
In support of Million Hearts, the Center for Medicare & Medicaid Innovation (CMMI) of the CMS recently announced its plans to perform a large cluster randomized payment model test of value-based payment designed to determine whether financially rewarding reductions in 10-year predicted risk for ASCVD across a physician's patient population is an effective model to reduce the burden of heart attack and stroke.5 This Cardiovascular Risk Reduction Model will represent the largest test of value-based prevention payment conducted by CMS.
As described by Sanghavi and Conway:
Medicare beneficiaries will be encouraged to "know [their] numbers," share decision making with their physicians, and choose from a menu of options (for example, controlling blood pressure..., taking daily aspirin, or eliminating tobacco use) tailored to the patient's readiness. The model's value-based payment design will reward not specific blood pressure values or cholesterol target numbers but rather reduction in predicted risk of myocardial infarction and stroke. On the payment side, clinicians will be rewarded on a sliding scale tiered by absolute risk reduction across their entire high-risk patient panel, which increases incentives for health management of entire cohorts of patients. An additional benefit is that overtreatment of individuals at low risk could be minimized because overtreatment is not rewarded significantly.5
To conduct the test of the Cardiovascular Risk Reduction Model, CMS solicited the creation of the Million Hearts Longitudinal ASCVD Risk Assessment Tool, an innovative tool that predicts baseline 10-year ASCVD risk, projects changes in ASCVD risk that would be expected with initiation of and adherence to evidence-based therapies, and incorporates individual patient responses to these therapies over time to allow for dynamic, longitudinal ASCVD risk prediction. The model was developed by CMMI in collaboration with a research and development team from the CMS Alliance to Modernize Healthcare (CAMH), a federally funded research and development center (FFRDC) operated by The MITRE Corporation for the US Department of Health and Human Services. In this special report, we describe the development of the Longitudinal ASCVD Risk Estimator that was designed to support the overarching Million Hearts Cardiovascular Risk Reduction Model to be tested, and its application in clinical practice.
The "2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults"22 identified 4 groups of patients for whom net clinical benefit of statin therapy has been demonstrated in randomized clinical trials: (1) patients with clinical ASCVD; (2) individuals with low-density lipoprotein (LDL)-cholesterol ≥190 mg/dL not attributable to secondary causes; (3) patients aged 40 to 75 years with diabetes mellitus and LDL-cholesterol 70 to 189 mg/dL; and (4) patients aged 40 to 75 years with estimated 10-year risk for ASCVD ≥7.5%. The last group represents those patients who need primary prevention of ASCVD as a result of elevated risk attributable to combinations of risk factors in the context of age, sex, and race/ethnicity. Despite the demonstrated benefits of pharmacological interventions (the ABCS), these therapies are often underutilized in populations with existing ASCVD23,24 as well as among higher-risk individuals eligible for primary prevention of ASCVD events.8
The Million Hearts Longitudinal ASCVD Risk Assessment Tool
Effects of Risk-Reducing Therapies
The results of the systematic reviews, which were performed to inform the tool, have been previously published.6 Briefly, from 1967 identified reports, 35 systematic reviews of randomized clinical trials were identified, including 15 reviews of aspirin, 4 of blood pressure-lowering therapy, 12 of statins, and 4 of tobacco cessation drugs. Methodological quality varied, but 30 were judged to be of sufficient quality based on AMSTAR ratings. Using the highest quality evidence, the effects of aspirin, blood pressure-lowering therapy, statins, and smoking cessation on ASCVD risk are summarized in Table 2.
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