MedicalResearch.com Interview with:
Michael D. Miedema, MD, MPH
Minneapolis Heart Institute Foundation
Abbott Northwestern Hospital
MedicalResearch.com: What is the background for this study?
Dr. Miedema: Heart disease is the leading cause of death in the United States. With increasing risk factors like obesity and diabetes more population level prevention efforts are needed. Heart of New Um Project (HONU) was created as a demonstration project to test prevention of cardiovascular disease by reducing modifiable risk factors across the entire community. HONU interventions focus on improving health by reaching individuals in health care, worksites, and the community settings but also creating healthier environment and a social movement around being healthy to enable individuals to make healthier choices. Example interventions in health care, worksite, and the broader community include:
- Health care: Comprehensive free heart health screening held every few years to identify risks (results shared with providers and follow up was done in clinics to address medication needs). We also used the electronic health record to apply some algorithms to calculate risk of heart disease and were able to offer health coaching to people who did not yet have heart disease or diabetes but who were at high risk.
- Worksites: we developed and partnered with over 40 worksites in the community to conduct health screenings of employees, to identify ways companies could improve their wellness policies, and offering onsite behavior change programs.
- Community: work with restaurants to improve healthy options, increasing farmers market participation by farmers and by consumers, creating run/walk events, community wide health challenges, and creating a social movement through social marketing and community organizing.
MedicalResearch.com: What are the main findings?
Dr. Miedema: Since there is one medical provider in the community, New Ulm Medical Center, our study was able to use de-identified electronic health record data to monitor how trends in risk factors for cardiovascular disease are changing over time – from the start of HONU through the first 5 years (2009-2013). The study included data for about 6000 people which represents about 80% of the residents of the area in the 40-79 age range. We believe this means our study is accurately capturing how risks are changing in the entire community.
We saw major improvements in blood pressure, cholesterol, and glucose levels. The percent of people who had normal blood pressure increased from 79% to 86%. Similarly, the percent of residents with total cholesterol < 200 increased from 59% to 64%. We compared changes in New Ulm to national trends and found that risk factors were improving in New Ulm while they were staying the same or getting worse in the national comparison population.
This study provides the first comprehensive scientific evidence that the Heart of New Ulm program is effective at lowering heart disease risk factors at a population level. Given that the improvements we see in the community are not happening in a similar national comparison population, this provides an indication that the results we are seeing in New Ulm are due to the community interventions and not due to other trends. We know that small decreases at a population level can have a large effect on heart disease development so we are optimistic that the improvements here in the first 5 years of the program decreasing heart disease risk factors will translate into a reduction in heart attacks in the longer term.
MedicalResearch.com: What should clinicians and patients take away from your report?
Dr. Miedema: Some innovative clinical intervention components of the Heart of New Ulm program may be of interest to health systems and clinicians. First, we used data from the electronic health record to calculate the risk of heart disease, for people who did not currently have diabetes or heart disease. By identifying those most at risk of getting heart disease, we were able to reach out to this high risk group and be more proactive with prevention efforts. These included improved use of preventive medications as well as offering a phone coaching program. Additionally heart health screenings offered to the community were an opportunity for risks to be identified in people who hadn’t been to the doctor in a while. In cases where risks were identified, there was a direct clinical follow up and data was shared with providers.
A key message of our program is about addressing prevention throughout the community. People need support outside the clinic walls – having programs in worksites, and broadly in the community help support healthy behaviors will make it easier for patients to adhere to the advice their doctors are giving them.
Findings from our study may be more relevant to the broader health systems and communities in which individual providers and patients live and work. More community initiatives are getting started nationally and HONU provides an example of how health care organizations can partner with the broader community to help improve health from many angles. We know that access to high quality health care is an important factor in determining health outcomes but we also know it only contributes about 20% there are so many other factors outside the clinic that influence the health of individuals – things like healthy food, exercise, stress, social ties, and the environment you live in. HONU is an example of how health care and many other organizations in a community can partner to impact all those other determinants of health. Providers and individuals could support such initiatives to engage in prevention from a broad perspective.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Dr. Miedema: A next step for us is to continue to research the association HONU interventions have with health improvement. Using data from a comparison population served by the same health system we will examine how these trends in heart disease risk factors as well as heart attacks and health care utilization have changed in New Ulm compared to a matched comparison population. We are also working with the state health department to examine changes in preventable heart attacks and heart disease related deaths.
From a broader perspective, improved integration of behavioral lifestyle risk factors and social determinants of health into the electronic health record would help enable population based research to examine non-medical determinants of health in combination with health things that are more traditionally measured in a clinical setting.
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Abbey C. Sidebottom, Arthur Sillah, Michael D. Miedema, David M. Vock, Raquel Pereira, Gretchen Benson, Jackie L. Boucher, Thomas Knickelbine, Rebecca Lindberg, Jeffrey J. VanWormer. Changes in cardiovascular risk factors after 5 years of implementation of a population-based program to reduce cardiovascular disease: The Heart of New Ulm Project. American Heart Journal, 2016; 175: 66 DOI: 10.1016/j.ahj.2016.02.006
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Michael D. Miedema, MD, MPH (2016). Population Based Program Improved Cardiovascular Health Across Community MedicalResearch.com