Cardiovascular disease is one of the most common chronic conditions that primary care doctors treat, yet improving patient outcomes can be challenging for a variety of reasons. Treatment often requires a combination of prescription drugs and lifestyle changes, and patients need to adhere to all treatment recommendations to get better.
“There is the medical treatment side and the behaviors side, and the reality for many patients is that they struggle with both,” says Eugene Yang, M.D., FACC, University of Washington School of Medicine and chair-elect of the American College of Cardiology Prevention Section and Leadership Council. “It is across-the-board difficult to have a patient adhere to guidelines for their medications and also adhere to specific lifestyle recommendations that are based on clinical studies.”
As physician income becomes increasingly tied to patient outcomes through the CMS Quality Payment Program and value-based care contracts with private payers, these struggles can affect a practice’s bottom line.
“We are all increasingly being paid based on performance, and everyone is moving toward having a higher percentage of that type of payment model,” says Yang. “If you manage things well, you can reduce the rates of patients coming in with strokes and heart attacks.”
So what can physicians do to improve the cardiovascular health of their patient population? Experts say it starts with a firm understanding of each patient’s unique circumstances and adapting treatment plans to fit each individual patient.
Recognize, address social determinants
One of the most common reasons a patient fails to follow a doctor’s treatment plan or fails to take prescribed medicine is social determinants of health. A patient who is urged to exercise may not have a street that is safe to walk on, limiting their options. The lack of a readily accessible grocery store can also present challenges for patients who need to eat a healthier diet.
For some patients, the signs of a lack of food or safe housing may be obvious, but for others, physicians may not even realize social determinants are a factor.
“There are absolutely unseen barriers that, even for care teams with long-term cognitive patients, can go totally missed,” says Aaron George, D.O., FAAFP, director of medical education for Meritus Health in Hagerstown, Maryland. “Sometimes it’s obvious when you have a patient with challenges you have to work through, but there are often socio-economic, family and community barriers that the patients face that we lack the ability to see upfront.”
George says to be careful about placing patients into categories and to be aware that bias cuts both ways. A patient who has a low literacy level and is struggling with social determinants may have a tremendous desire to be healthy and be willing to do anything to achieve that goal. Conversely, a patient who appears affluent with a high education level and no financial issues may have little dedication toward living a healthier lifestyle.
“One approach to solving this is to have a standardized initial process for trying to understand where a patient is,” says George, noting that tools are available from many professional societies that help a physician identify how a patient lives and their barriers to care. “Implement one of those tools for every patient at the outset, perhaps at their first visit, before they even step in with the physician. You will start with a firm … understanding where they are coming from, as opposed to having information trickle out over the course of months or years of care.”
Ada Stewart, M.D., FAAFP, president-elect of the American Academy of Family Physicians, says that understanding the patient’s specific challenges and building a solid relationship are key to keeping patients on track with their treatment plan — and that includes assessing their mental health. “Make sure you are looking at mental health issues, such as depression or other stressors like alcohol use, as those are really important to be able to find out why folks are not adherent.”
Set shared goals
Patients need goals to be successful but, according to experts, they also need to be part of the decision-making process when setting those goals. Patients need to understand their risks, what they can do to lower them and the importance of regular check-ins to chart progress or address challenges.
“Make patients accountable for their own health,” says Yang. “The way to do that is to increase the frequency of check-ins with patients. The more frequent check-ins, the better chance they feel they can achieve a certain goal.”
More frequent check-ins can also help identify what is working and what isn’t, says Yang. For example, a yearly checkup for cholesterol level won’t offer any insight into what the patient is doing that’s helping, but a more frequent one can help pinpoint behavior that is having an effect one way or another.
The pandemic’s boost to telemedicine may help doctors manage patients with cardiovascular disease better than before, says Yang. “With the increase in telemedicine, we are seeing more and more virtual visits, and that may allow us to increase the frequency of checking in,” he says. “The higher the frequency of checking in, the greater the benefits of achieving goals and maintaining adherence because the patient feels a stronger connection to the physician.”
When Stewart checks in with patients, she uses motivational interviewing techniques to see where they are in their treatment. For example, with high blood pressure, she’ll ask: “How is the medication working for you?” or “Are you able to take your medication every day?”
“If they say that they’re not taking their blood pressure medication, I try to make sure they understand the consequences of not taking it and emphasize the importance of the medicine, diet and exercise,” says Stewart. “Then I’ll address any barriers they have and let them know that I understand their challenges. You want to make sure that they recognize they are a partner in their health.”
She says for some patients, focusing on one key goal may be the best strategy. “We fail a lot of times as physicians in making sure our regimens are simplified,” says Stewart. Maybe a patient won’t walk a mile a day, but maybe they are willing to walk down their street or to the mailbox and back. “We have to talk about what their goals are and what they see themselves doing to get there.”
Experts say to be wary of overwhelming patients with too many goals and guidelines, or the patient may not achieve any of them.
“A lot of times you throw a whole bunch of things at them and you think they are listening, but when they come back for a follow-up, they didn’t do any of them because they didn’t understand,” says Stewart. “When they don’t hear you, we end up having increased hospitalizations and increased deaths, especially when we are talking about heart disease. If you put too much on them, then a lot of times they will just give up and say, ‘Forget it.’ ”
Set goals with the patient that they believe they can meet and keep making progress on, even if it’s in small increments. Other patients may be able to handle bigger steps. There’s no one-size-fits-all plan. “Every patient is not the same,” says Stewart. “You have to look at who your patient is, where they are, and what barriers they may have and what we can do to help them.”
Yang says that some population health initiatives are helping to identify high-risk patients by assigning them risk scores based on hospital utilization. A team of caregivers is then assigned to help the patient better manage their blood pressure and keep track of how they are progressing toward their heart health goals. He adds that physicians should use nurses, advanced care providers and other staff as needed to help keep patients on track.
Stewart only has one care coordinator for her patient panel, and that person will reach out to patients that Stewart has identified as high risk for nonadherence. The care coordinator will follow up about two weeks after an appointment to make sure the person is taking their medication and isn’t experiencing side effects and to answer any questions.
But even without the benefit of a full care team or computer-generated risk scores, George says there is one warning sign of increased cardiovascular risk that often goes unnoticed by physicians.
“I think the biggest warning sign that we ignore nationally is the subtle creep of weight gain,” says George. “I rarely find a patient that puts on 60 pounds in six months; it’s 3 pounds one year, 4 pounds the next year and six pounds the next year. Somehow, I think we all tolerate it and accept it as an almost unfortunate norm.”
Because the weight gain is minimal, physicians tend to ignore it and the patient is willing to accept it, says George. “I’m really quick to show patients the trend of their weight gain over the last eight years or 10 years, and how it’s gone up just a couple of pounds each year. I tell them, ‘Imagine where you’re going to be 10 years from now or five years from now.’ ”
Paying attention to patient trends is an important part of monitoring cardiovascular health. The more patient contact, the better.
“I can tell you that without a doubt, almost all my patients in the days leading up to their visit will take their medications because they want their blood pressure to look good, or they won’t eat bad foods for a couple days before they are having their lipid tests done,” says George. “But we don’t live life like that. For the majority of patients, the more frequent touch points that are brief and done by nonphysician team members are going to be increasingly important.”
– Todd Shryock, Medical Economics