Spotlight on Cardiovascular Disease

February 2021

Introduction

Cardiovascular disease (CVD) is the leading cause of hospitalizations in the VA health care system, often accompanied by comorbidities such as diabetes, PTSD, and spinal cord injuries¹. Although CVD also refers to heart rhythm, valve, and muscular function problems, the most common form of CVD is coronary artery disease (CAD). In CAD a buildup of cholesterol plaque inside the artery walls partially blocks arteries and the resulting decrease in blood flow starves the heart of oxygen².

Almost from its inception VA was at the forefront of CVD research, establishing its first research unit in 1935. Through World War II and the 1950’s VA continued to lead studies into hypertension treatment.  A VA study conducted in the 1960’s generated the first definitive evidence that treating high blood pressure through drugs helps prevent and delay heart, artery, and kidney disease as well as stroke. VA pioneered the Pacemaker³ and led the SPRINT⁴ and COURAGE⁵ trials. A 2016 trial found that older men treated within the VA health care system for heart attack are less likely to die within 30 days after the event than Medicare beneficiaries treated at other hospitals⁵.

VA funded studies continue to address many aspects of care for Veterans across the VA health care system, including gender and racial differences in risk and treatment, CVD telemedicine, and operating costs⁷. Following are several examples of HSR&D investigators adding to VA’s history of research to improve CVD care for Veterans.

• Delaying Cardiovascular Procedures to Curb the Spread of COVID-19 among Veterans: Variation in VHA Practice Patterns and Outcomes
• Race/Ethnic Differences in Guideline Recommended Hypertension Medications in VHA
• Appropriate Use of Cardiovascular Procedures to Optimize Healthcare Value
• Peer Support for Cardiovascular Risk Reduction in Female Veterans

Delaying Cardiovascular Procedures to Curb the Spread of COVID-19 among Veterans: Variation in VHA Practice Patterns and Outcomes

Implications:

This work will directly translate into actionable outcomes by informing the optimal triage of cardiovascular procedures under severely resource constrained settings, identify any inequitable distribution of limited resources to vulnerable populations within VA, and serve as an early warning if current practices are negatively impacting Veteran health outcomes. These findings will extend to routine prioritization of procedures as this pandemic resolves.

In 2020, the rapid spread of coronavirus worldwide forced VA hospitals across the country to start triaging the delivery of medical procedures, in efforts to flatten the curve of COVID-19 growth and its associated high mortality. On March 17, 2020, with a shelter-in-place order first deployed across a 6-county region of Northern California, then soon after across the state of California and other regions across the country, VA hospitals started postponing all elective cardiovascular procedures, permitting only urgent, life-threatening ones. Days later, professional societies published guidelines recommending similar rationing at scale, both to conserve resources and to prevent elderly, at-risk patients from unnecessary exposure to the highly contagious virus.

There are important reasons why this approach warrants rapid evaluation: (1) COVID-19 has produced an unprecedented natural experiment to demonstrate the comparative effectiveness of a vast number of high cost procedures to guide future treatment decisions on usefulness of therapies or de-implementation, which traditional randomized controlled trials will likely never accomplish, (2) evaluation of this approach will inform how to best manage healthcare rationing responses in disaster situations, pandemics, workforce disruptions, and abrupt changes in operational capacity or funding, (3) it must be determined whether vulnerable populations are disproportionately impacted by this approach to ensure that VA is delivering equitable care to Veterans at highest risk of adverse health outcomes.

This study, funded through April 2021, has three corresponding specific aims:

1. To describe the impact of the COVID-19 pandemic on cardiovascular procedural volumes across VA nationally.
2. To assess whether there were differences in procedural treatment among vulnerable populations within VA comparing the pre- to post-COVID-19 period.
3. To compare downstream outcomes in Veterans before and after the COVID-19 pandemic and to determine if inpatient procedure use mediates those outcomes.

Study Update:

• Identification of total numbers of cardiovascular procedures across the spectrum of interventional cardiology, structural heart, electrophysiology and cardiac imaging from December 2018 to November 2020 with weekly changes has been completed.
• Assessment of inpatient outcomes and comparison across demographic characteristics is in progress.

Principal Investigator: Celina M. Yong, MD, MBA, MSc, is a CDA awardee, interventional cardiologist, and Director of Interventional Cardiology at the Center for Innovation to Implementation (Ci2i) at the VA Palo Alto Healthcare System, Palo Alto CA.

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Race/Ethnic Differences in Guideline Recommended Hypertension Medications in VHA

Implications:

This ongoing study will identify the causes of blood pressure related disparities and will develop an informatics strategy to support high quality, equitable healthcare for all Veterans. Findings will inform the clinical decision support strategy which, aligned with current blood pressure management guidelines, will be developed to support the PACT workflow.

About the Study:

Hypertension is the most common chronic condition among Veterans, affecting 37% of those treated by VA. Hypertension can lead to stroke, myocardial infarction, chronic kidney disease, and heart failure. Among US Blacks as compared to Whites, hypertension tends to occur earlier in life, is more common and severe, and is less likely to be controlled. Blood pressure control among Veterans has improved significantly - from 46% in 2000 to 76% in 2010. However, disparities in blood pressure control persist and reasons for these disparities are not well understood. Recently, the Systolic Blood Pressure Intervention Trial (SPRINT) led to changes in hypertension management guidelines. SPRINT investigators reported that reducing systolic blood pressure to <120 mmHg (versus <140 mmHg) lowered risk of cardiovascular events and mortality in 3 years of follow-up. The extent to which this target is achieved overall and by race/ethnicity in VA remains unknown, however.

This study seeks to identify patient-, provider-, and facility-level predictors of use of guideline-recommended medications and blood pressure control among Veterans with newly diagnosed hypertension and to describe how the effect of these predictors vary by race. Investigators then will develop and pilot test a provider/team focused informatics strategy to facilitate hypertension control tailored to reduce minority race disparities.

Study investigators are conducting a national longitudinal cohort study of approximately 60,000 Black and 428,000 White Veterans who received VA primary care including a first occurrence of at least two high blood pressure readings within 90 days between 2007 and 2012. Assessment of patient predictors such as demographic, clinical, and military characteristics for achieving blood pressure control at 1-year follow-up by race is ongoing. Quantitative analysis methods are being used to identify provider- and facility- level predictors such as number of visits and urban vs rural localities. Review of 300 charts, and semi-structured interviews with Patient Aligned Care Team (PACT) providers will identify reasons for lack of guideline-concordant blood pressure management and prescribing.

Preliminary Findings:

• Among Veterans who had at least 2 outpatient visits at VA from January 1,2007-December 31, 2012, 7.0% (N=531,709) had a new occurrence of high blood pressure and were not previously diagnosed with or treated for hypertension.
• Initial analyses suggest Black (vs White) Veterans were more likely to be female, younger, have a history of homelessness, and were less likely to have a history of diabetes, heart failure, myocardial infarction, or stroke.

Principal Investigator: April Mohanty, MPH, PhD, is a Research Health Scientist at HSR&D’s Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS) at the VA Salt Lake City Health Care System, Salt Lake City, UT.

Publications:

Mohanty AF, Levitan EB, Dodson JA, et al. Characteristics and Healthcare Utilization Among Veterans Treated for Heart Failure With Reduced Ejection Fraction Who Switched to Sacubitril/Valsartan. Circ Heart Fail. 2019 Nov;12(11):e005691. doi: 10.1161/CIRCHEARTFAILURE.118.005691. Epub 2019 Nov 13.

Mohanty AF, McAndrew LM, Helmer D, et al. Chronic Multisymptom Illness Among Iraq/Afghanistan-Deployed US Veterans and Their Healthcare Utilization Within the Veterans Health Administration. J Gen Intern Med. 2018 Sep;33(9):1419-1422. doi: 10.1007/s11606-018-4479-6. PMID: 29797218;

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Appropriate Use of Cardiovascular Procedures to Optimize Healthcare Value

Implications:

This study has the potential to inform approaches to reducing inappropriate and low-value care, thus improving the quality of cardiovascular care for Veterans. Findings may lead to as much as $20 million annual savings for the VA Healthcare System, by eliminating unnecessary percutaneous coronary interventions and stress testing in Veterans without significant ischemic or coronary disease burden.

About the Study:

Proper patient selection for diagnostic and therapeutic procedures is central to providing the right care for the right patient at the right time. The importance of proper patient selection is reflected in the efforts of the Choosing Wisely campaign and Appropriate Use Criteria that seek to reduce the use of medical tests and procedures that may be inappropriate (i.e. provide no patient benefit despite procedural risk). Few contemporary data exist on whether invasive and expensive diagnostic and therapeutic procedures are used inappropriately in VA. In the care of Veterans with coronary artery disease (CAD), more than 10,000 percutaneous coronary interventions (PCI) and 50,000 stress tests are performed annually. Use of these procedures in certain patients with stable coronary disease is rarely appropriate and results in unnecessary procedural risks. Additionally, these procedures contribute more than $200 million in healthcare expenditures annually to VA.  The prevalence, patient risks, and expense of these procedures demand further investigation to understand whether they are being used for the appropriate patient populations in VA. Furthermore, in an era where VA is increasingly asked to do more with less, it is critical to determine if inappropriate use of these procedures is a significant contributor to unnecessary costs in low-value care.

This study seeks to assess the rate of PCI and stress tests performed in Veterans rarely classified as appropriate by the Appropriate Use Criteria across the VA healthcare system and identify patient, provider, and environmental factors associated with inappropriate use. Additionally, investigators will determine the extent of variation in healthcare value that is attributable to inappropriate use of PCI and stress tests in patients with stable coronary artery disease and identify best-practices for appropriate procedural use and high-value healthcare.

The study cohort includes more than 2,611 patients with stable CAD diagnosed by coronary angiography performed at one of 56 VA cardiac catheterization labs between November 1, 2013, and October 31, 2015. Using data from the Clinical Assessment Reporting and Tracking (CART) Program enhanced by chart review, investigators determined the proportion of these PCI that were classified as appropriate, may be appropriate, or rarely appropriate by Appropriate Use Criteria. Among CAD patients who undergo stress tests after PCI, investigators have completed chart review to determine procedural appropriateness while concurrently developing methods to allow prospective appropriateness measurement. They have also assessed the relationship between appropriateness and clinical outcomes of mortality and readmission.  Overall costs of care and factors underlying both PCI appropriateness and costs will be included in the determination of healthcare value following PCI.  Analyses related to stress testing after PCI are also ongoing.

Initial Findings:

• Between November 1, 2013, and October 31, 2015, most PCIs for stable coronary artery disease were classified as appropriate or may be appropriate.
• However, 1 in 10 PCIs were classified as rarely appropriate, with variation across hospitals.
• There was no relationship between PCI appropriateness and clinical outcomes such as mortality and readmission, suggesting that each metric alone does not fully characterize PCI quality.

Investigators: Paul Hess, MD, MHS and P. Michael Ho MD, PhD are cardiologists and investigators at the Seattle-Denver Center of Innovation for Veteran-Centered and Value Driven Care at the Rocky Mountain Regional VA Medical Center, Aurora, CO.

Publications:

Kini V, Hess PL, Liu W, et al. Association Between Elective Percutaneous Coronary Intervention Appropriateness and Publicly Reported Outcomes. Circ Cardiovasc Qual Outcomes. 2021 Jan;14(1):e007421. doi: 10.1161/CIRCOUTCOMES.120.007421. Epub 2020 Nov 9.

Hess PL, Kini V, Liu W, et al. Appropriateness of Percutaneous Coronary Interventions in Patients With Stable Coronary Artery Disease in US Department of Veterans Affairs Hospitals From 2013 to 2015. JAMA Netw Open. 2020 Apr 1;3(4):e203144. doi: 10.1001/jamanetworkopen.2020.3144.

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Peer Support for Cardiovascular Risk Reduction in Female Veterans

Impact:

Women Veterans are at significant risk for cardiovascular disease. Since the majority of women Veterans receive care in the community, this study’s findings related to cardiovascular disease (CVD) risk reduction are relevant to both VA-based providers and those outside VA. Findings related to needing help with accountability and low underlying social support suggest that peer support models can be a powerful facilitator in cardiovascular risk reduction among females, both in the Veteran and general populations. For a successful peer support program to support CVD risk reduction, women Veterans stated that common goals and establishment of trust would be important.

Cardiovascular disease (CVD) is the leading cause of death among women in the United States. Due to elevated rates of cardiovascular disease risk factors and inadequate awareness of CVD risk, the growing female Veteran population is at significant risk for developing CVD related morbidity and mortality. Compared with non-Veteran women, high rates of mental health disease and low levels of social support create unique challenges for traditional models of health behavior interventions for Veteran women. Growing evidence supports the use of peer support to deliver health related content for chronic disease management, including in the male Veteran population.

This study’s aim 1 sought to estimate the prevalence of comorbidities, health behaviors, and preferences among women Veterans at risk, not at risk, and diagnosed with CVD. In aim 2, investigators assessed how a peer support intervention could best support CVD risk reduction among women. Aim 3 developed and then aim 4 piloted a novel peer support intervention combining the strengths of reciprocal peer support (RPS) and peer coach models. In parallel, a fifth aim examined gender-based differences in experiences with a telephone based intervention for patients with poorly controlled hypertension and/or hyperlipidemia.

Study investigators used multiple methodologies including a descriptive analysis of National Survey of Women Veterans data, qualitative primary data collection of perceived barriers and facilitators, as well as uses of peer support, proof-of-concept pilot study, and semi-structured interviews regarding Veterans’ experiences in a randomized trial.

Findings:

• Greater than 50% of women Veteran have risk factors for CVD.
• Female Veterans who prefer gender-specific care settings, and those with current PTSD symptoms have greater odds of being at risk for CVD.
• Women Veterans placed importance on sharing a common behavior change goal with a peer partner and felt that peer support would be helpful for accountability. However, they also expressed a need to establish trust with a peer partner, often starting face-to-face.
• Both male and female Veterans appreciate the ease and convenience of phone-based support and prefer proactive outreach around cardiovascular risk control.
• A hybrid reciprocal peer support and peer coaching model is feasible and acceptable to both male and female Veterans.

Principal Investigator: Karen Goldstein, MD, MSPH, is a core investigator with HSR&D’s Center of Innovation to Accelerate Discovery and Practice Transformation, Co-Director of the Durham Evidence Synthesis Program (ESP), co-site lead for the VA Women's Health Practice Based Research Network (PBRN) and co-lead for the Women's Health Research Network strategic priority area on primary care and prevention at the Durham VA Medical Center, Durham NC. She is also co-Director of the Durham VA Quality Scholars Program.

Publications:

Goldstein KM, Zullig LL, Bastian LA, Bosworth HB. Statin Adherence: Does Gender Matter? Curr Atheroscler Rep. 2016;18(11):63.

Goldstein KM, Stechuchak KM, Zullig LL, et al. . Impact of Gender on Satisfaction and Confidence in Cholesterol Control Among Veterans at Risk for Cardiovascular Disease. Journal of Women’s Health (Larchmt). 2017;26(7):806-14.

Goldstein KM, Oddone EZ, Bastian LA, et al. . Characteristics and Health Care Preferences Associated with Cardiovascular Disease Risk among Women Veterans. Women’s Health Issues. 2017;27(6):700-6.

Goldstein KM, Zullig LL, Oddone EZ,et al. . Understanding women veterans' preferences for peer support interventions to promote heart healthy behaviors: A qualitative study. Prev Med Rep. 2018;10:353-8.

Goldstein KM, Zullig LL, Dedert EA, et al. . Telehealth Interventions Designed for Women: an Evidence Map. Journal of General Internal Medicine. 2018;33(12):2191-200.

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