Cardiovascular Risk Reduction at UnitedHealthcare of North Carolina

CARDIOVASCULAR RISK REDUCTION
Cardiovascular Risk Reduction at UnitedHealthcare
of North Carolina: The First 12 Months
Darryl Landis, MD, Archelle Georgiou, MD, Joanna Apple, MPH, RN, and Jennifer Durand, RN
D
espite a remarkable 27% decline in age-adjusted cardiovascular mortality between 1986 and 1996, cardiovascular disease (CVD) remains the leading
cause of death among adults in the United States [1]. Approximately 5 million persons are evaluated in the emergency department for chest pain each year, and of those admitted to a cardiac care unit, about 30% are subsequently
discharged with a diagnosis of acute myocardial infarction [2].
Of the nearly 1 million persons who survive a myocardial
infarction each year, 18% of men and 35% of women will
have a recurrent heart attack within 6 years [1]. The typical
health plan with 100,000 commercial members averages more
than 1.9 cardiovascular hospital admissions per 1000 members per year at an annual cost of almost $5 million. The economic burden of CVD and stroke in this country is substantial; this year, it will account for 18 cents of every health care
dollar spent, or $160 billion [1].
Efforts to improve the health status of patients with CVD
are hampered by several obstacles. Fragmented health care
delivery systems fail to provide a comprehensive, coordinated approach to care. Access to care may be limited, especially in rural areas. Physicians’ time constraints may hinder
their ability to develop and implement a comprehensive
treatment plan. In addition, less than one third of patients
who experience a cardiac event participate in rehabilitation
programs, and most patients are unsuccessful in making
long-term lifestyle changes.
For UnitedHealthcare of North Carolina (UHC-NC), heart
disease is the number one diagnosis based on cost. Licensed
in all 100 counties, UHC-NC is an open-access HMO with
more than 300,000 members, 11,000 physicians, and 100 hospitals statewide. UHC-NC is a part of UnitedHealthcare
Corporation, a large, for-profit health care management services company. Believing that there was significant potential
for improved clinical management of their CVD patients,
UHC-NC partnered with CorSolutions (formerly Cardiac
Solutions), a national provider of disease management services, to implement a care management system for members
who have suffered an acute cardiovascular event. This paper
reports on the cardiovascular risk reduction (CVRR) program
that was introduced on 1 April 1997.
40 JCOM April 2000
Methods
Intervention
The CVRR program is a telephone-based care management
program for patients who have experienced an acute myocardial infarction, coronary artery bypass grafting procedure
(CABG), percutaneous transluminal coronary angioplasty
(PTCA), or admission for unstable angina. The goals of the
CVRR program are threefold: (1) to slow the rate of disease
progression through smoking cessation, dietary changes,
medication management, and exercise interventions; (2) to
promote treatment plan compliance by providing education
and counseling support; and (3) to reduce emergency room
visits and hospital admissions for repeat events. Patients are
identified and referred to the program by their case manager or physician. The program uses MULTIFIT, a care delivery
methodology developed by Stanford University and exclusively licensed to CorSolutions [3]. MULTIFIT is a wellresearched, highly structured approach to providing health
care to patients with chronic illness, who require ongoing
rather than episodic assistance. Among the resources incorporated into the MULTIFIT system are clinical guidelines,
proprietary patient management tools, surveys, and educational materials.
Upon enrollment, an experienced cardiac nurse works with
the patient and his or her physician to establish an individualized treatment plan. The nurse has regular telephone contact
with patients to educate, monitor changes in condition, identify symptoms, and evaluate treatment plan adherence. The
CVRR program focuses on behavior modification for all identified modifiable risk factors associated with CVD. A variety of
topics are addressed during both initial and reinforcement
teaching sessions, including disease process, smoking cessation, medications (antiplatelet, β-blocker, and antilipemic therapy), the National Cholesterol Education Program Step II diet
Darryl Landis, MD, Medical Director, UnitedHealthcare of North
Carolina, Greensboro, NC; Archelle Georgiou, MD, Chief Medical
Officer, UnitedHealthcare Corporation, Minneapolis, MN; Joanna
Apple, MPH, RN, Director of Product Development, CorSolutions,
Buffalo Grove, IL; and Jennifer Durand, RN, Manager of Cardiac
Programs, UnitedHealthcare Corporation.
Vol. 7, No. 4
OUTCOMES IN PRACTICE
and weight reduction, exercise, stress management techniques,
and early symptom identification [4].
As part of ongoing communication with the patient’s
personal physician, a written report is produced after the initial evaluation of the patient and periodically thereafter unless otherwise specified by the physician. The cardiac nurse
also consults the physician as necessary to discuss specific
clinical situations. Member and physician participation in
the program is voluntary and offered at no additional cost to
the participant. Specific outcomes tracked include modification of lifestyle behaviors, compliance with therapy, and
inpatient and emergency room utilization.
Program Implementation
Senior leadership of UHC-NC was actively involved in program implementation. In addition to allocating sufficient
staffing and financial resources to launch and evaluate the
pilot program, they championed the program to customers
and providers. As the program was the first comprehensive
disease management program offered by any North Carolina
health plan, physician awareness and support were deemed
essential to program success. Preparing the physician network for the program and ensuring their cooperation was the
most time-consuming component of the implementation
process. Practice managers and physicians in key physician
groups were oriented to the program by a health plan disease
management specialist with medical director support. In addition, each cardiology practice in the network was contacted
by CorSolutions and by health plan staff to review the purpose and operational processes of the program.
Program Evaluation
To assess program effectiveness, we examined the claims of
patients who were enrolled in the CVRR program during the
first 6 months of implementation. Enrollees were patients
who had suffered a recent cardiac event (acute myocardial
infaction, inpatient admission for unstable angina or suspected coronary ischemia) and agreed to participate after
being referred to the program by a case manager. Age- and
sex-matched controls were identified retrospectively from
inpatient admission claims that contained an ICD-9 code for
acute myocardial infarction, unstable angina, or suspected
coronary ischemia or a CPT code for CABG or PTCA during
the 6 months immediately preceding program implementation. After tracking both groups for 12 months and allowing
for a 4-month claims run-out, a claims-paid comparison of
inpatient, emergency room, and pharmacy utilization and
costs was performed for both groups. Self-reported measures of compliance with antiplatelet, β-blocker, and lipidlowering therapy, dietary intake measured by a Food Frequency Questionnaire, smoking cessation, functional status
measured by the Duke Activity Status Index, and satisfacVol. 7, No. 4
Table 1. Utilization and Costs for Program Enrollees
Compared with Controls
Period studied
Program Group
Control Group
4/1/97 to 3/31/98
10/1/96 to 9/30/97
1131
0.028
0.008
$771
$341
$95
1297
0.047
0.030
$970
$543
$121
Member months
Inpatient admissions*
ED visits*
Total costs*
Inpatient costs*
Pharmacy costs*
ED=emergency department.
*Per member per month.
tion were reported for the program cohort and compared
with their baseline status. Claims paid for members in the
program group between their program enrollment date and
the end of the 12-month reporting period were included for
analysis. For members assigned to the control cohort, claims
with dates of service between the discharge date of the eligible cardiac event and the end of the 12-month reporting period or the date of their enrollment in the CVRR program were
included in the analysis.
Results
During the first 6 months of implementation, 185 patients
were referred to the program and 148 (80%) agreed to participate. There were 143 control patients. The average age of
program enrollees was 54 years (controls, 55 years) and 72%
were male (controls, 73%). A total of 1131 member months
were observed in the intervention cohort compared with
1297 member months in the control cohort.
Compared with the control cohort, the program group
experienced significant reductions in hospital admissions,
emergency department visits, and total costs. Overall inpatient admission rates for all diagnoses were reduced by 40%,
and emergency department visits dropped by 73% on a permember per-month basis. For patients enrolled in the program, total costs were 21% lower and inpatient costs were 37%
lower than for control group members, after CVRR program
costs were accounted for. Although compliance with medication regimens improved in the program group, pharmacy
costs were 21% lower for program group members (Table 1).
Compared with baseline status, members in the CVRR
program reported a 36% increase in β blocker usage and a 52%
increase in lipid-lowering therapy at 12 months. Antiplatelet
therapy for patients enrolled in the program was 97% (Table 2).
Dietary intake among enrollees showed 28% improvement as
measured by the Food Frequency Questionnaire. Total cholesterol levels dropped 15% from 221 mg/dL to 187 mg/dL, LDL
JCOM April 2000 41
CARDIOVASCULAR RISK REDUCTION
Table 2. Medication Compliance in Patients Enrolled in Cardiovascular Risk Reduction Program
Medication
β Blocker
Antiplatelet
Antilipemic
Program Patients Eligible
for Medication
(n = 148)
112 (76%)
145 (98%)
26 (18%)
levels 14% from 132 mg/dL to 113 mg/dL, and triglycerides
30% from 253 mg/dL to 177 mg/dL. Exercise levels increased
as measured by the Duke Activity Status Index, and 47% of
the smokers enrolled in the CVRR program stopped smoking.
On a 5-point satisfaction scale (1-very poor, 2-poor, 3-good, 4very good, 5-excellent), 100% of the patients rated the CVRR
program 3 or higher.
Discussion
The CVRR program implemented at UHC-NC resulted in
impressive improvements after just 12 months. Program results included increased medication compliance, improved
lifestyle behaviors, and fewer hospital admissions and emergency department visits. Several studies have shown that
aggressive risk factor reduction can reduce clinical events by
approximately 50% in the first year even though coronary
artery stenosis may only decrease by 1% to 10% annually [5].
These favorable effects of cardiovascular risk factor reduction may be mediated by improved endothelial function and
plaque stabilization [6] and may explain the results documented in our pilot study.
Several characteristics of the CVRR program distinguish
it from other disease management programs. To help build a
strong relationship, each patient is sent a picture of their cardiac nurse that includes a brief personal and professional
biography. Establishing a personal bond with the patient
facilitates communication and alleviates patient anxiety. This
may lead to fewer emergency or unplanned visits.
Another feature of the program critical to its success is the
ease of patient participation. Since the risk of death is greatest
during the first 6 weeks after a myocardial infarction and the
risk of a recurrent clinical event after PTCA does not decline
exponentially until after the first 6 months [5], prompt program enrollment could potentially reduce the risk of future
cardiac events. Patients receive advice and counseling over
the telephone in the privacy of their home at times that are
convenient to them. For patients with limited access to cardiac
rehabilitation programs due to work schedules or driving distance, the CVRR program can serve as an effective alternative.
The nurse works with the physician to design individualized treatment plans. To facilitate behavioral modification, it is essential that the patient receive consistent mes42 JCOM April 2000
Eligible Patients on
Medication at Baseline
65 (58%)
133 (92%)
6 (24%)
Eligible Patients on
Medication at 12 Months
105 (94%)
141 (97%)
20 (76%)
sages from caregivers. Disease management programs that
narrowly focus on only one aspect of clinical care and that
are not integrated with the physician’s treatment recommendations may confuse the patient and alienate the physician. Integrating care plans with the patient’s personal
physician is important in assuring a comprehensive
approach to care.
The CVRR program is tightly integrated with other quality and medical management programs at UHC-NC. Medical management leadership and the appropriate physician
committees approve all disease management programs. The
CVRR program was an integral part of NCQA quality
improvement standard QI 7 (“the managed care organization actively works to improve the health status of its members with chronic conditions”) when the plan underwent the
NCQA accreditation process in February 1998. This standard
was found to be in full compliance.
Although studies of other cardiac disease management
programs have documented similar favorable results [3,7],
measuring the impact of disease management programs and
their return on investment for health plans is fraught with
methodological pitfalls. Several limitations are inherent in
our pilot study design. Case-mix or severity-of-illness adjustment was not performed during the analysis. Since the
program cohort was identified by prospective case management referral and the control cohort was selected based on
retrospective claims review, membership of the 2 groups
may differ in their risk for future cardiac events and health
care utilization. Healthier members or those more motivated
to modify lifestyle behaviors may have been more willing to
participate in the CVRR program. Other psychosocial factors
not measured in the study may have also significantly impacted utilization experience. Examining the cardiac risk
profile and prevalence of comorbid conditions in both
groups and performing a claims-paid analysis during an
identical baseline and follow-up time period could mitigate
some of these limitations. Analysis of eligible members who
declined program enrollment or who voluntarily disenrolled
from the program before completion could determine
whether their risk profile and claims-paid experience differ
from the remainder of the program group. Evaluating the
distributions of cost and utilization data for each member
Vol. 7, No. 4
OUTCOMES IN PRACTICE
might identify outliers that may have unfavorably affected
the claims experience in the control group.
This pilot program suggests that a care coordination
approach to disease management can be successfully implemented in an open-access network-model health plan. There
are currently 475 patients enrolled in the CVRR program at
UHC-NC. UnitedHealthcare will be implementing the program in other health plans across the country to assess reproducibility of program impact; additional evaluation may serve
as a platform to implement programs targeting other clinical
conditions that impact the health and well-being of patients.
Author addresses: Dr. Landis: UnitedHealthcare of NC, 2307 West
Cone Blvd., Greensboro, NC 27408, e-mail [email protected].
Dr. Georgiou and Ms. Durand: 5901 Lincoln Dr., Edina, MN
55436. Ms. Apple: CorSolutions, 1371A Abbott Ct., Buffalo Grove,
IL 60089.
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Copyright 2000 by Turner White Communications Inc., Wayne, PA. All rights reserved.
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