Imagine if there was an emerging epidemic of slow cyclists. It wasn’t always like this. Despite their lack of feather-light bikes, carbon-soled shoes, wind-cheating lycra, people used to go really fast on their bikes.
Are you still imagining?
Imagine if people spent more money on “things†that might make them faster: they buy better equipment, monitor their meager outputs, and report them to a provider coach. They even have strategy sessions online with teams of their peers and coach.
But yet they pedal fewer watts.
What gives?
The problem, of course, is that going faster on the bike comes from making the personal commitment to ride. Your bike doesn’t ride itself; your watt meter doesn’t generate watts; and your coach can’t pedal for you.
Herein lies my problem with our government’s new initiative to reduce the expanding burden of heart disease.
The Million Hearts Initiative is the catchy name given to the program aimed at preventing a million heart attacks and strokes over the next five years. The leaders of the CDC and CMS, Dr Frieden and Dr Berwick introduce the highly progressive program in this grandiose essay in the NEJM.
Now to be fair, before launching into a pessimistic and endothelial-unfriendly rant, let me lay out the positives. (Always look for the positive first—that’s heart-healthy.)
- The goals of the program are spot-on. Of course we need to address the onslaught of heart disease. No one can argue that the burden is expanding—both in human costs, as well as in dollars.
- To increase public awareness of heart disease is a beneficial side-effect. Though many argue there’s enough public information available for anyone to know what’s healthy and what’s not, I say keep the information flowing.
- Promoting “Community-based†prevention strategies sounds encouraging. Does this mean more bike lanes, walk paths and more accessible health facilities? Government support of human-powered transportation would surely make cyclists feel less unwell on April 15th.
- And I was delighted that Mrs Obama’s quest to fight childhood obesity, the “Let’s Move†campaign, got an early mention.
That’s the good stuff. Good intentions, good goals, and exercising kids. Beautiful.
Now for the glaring problems. It’s the idea that someone else is in charge of our health. Let me go over a few of their lofty principles:
Their first principle is to focus. But they do not mean focus on taking care of oneself; rather they mean doctors should focus on reporting better data to Medicare. Translation: we should get better at filling out forms. Cycling simile: Recording data alone, does not make you fast.
Secondly, they recommend “providers†(Gosh I hate that word) use computers to make people healthier. Yeah, right. That will work. Listen to their words: (they are not bloggers)
HIT (Health Information Technology) enables providers and facilities to improve cardiovascular care and target intervention to patients in need of intensified care through registries and EHR functions used at the point of care.
Yep, these guys keep it simple. Cycling simile: Buying complicated training software doesn’t make you faster.
Thirdly, they recommend clinical innovation. What they are getting at here is the notion that team-based care, which they call, the patient-centered medical home, holds promise in getting more to take their aspirin, blood pressure and cholesterol medicines and to stop smoking. Maybe they are right, but there is no data that I know of to suggest that medical teams function more effectively than individuals. Cycling simile: your bike team doesn’t pedal your bike for you.
Finally, the idea that government will regulate, mandate, and control our salt and trans-fat intake bothers me. Should government–or doctors–be our mothers? Is it really government’s role to make our Chinese take-out less salty, or our French Fries less toxic? Who is forcing us to eat that high-fat, high salt, highly processed pizza? What’s more, who is forcing us to eat the entire pizza?
Summary:
Not once in the Millions Heart essay is the word “exercise†used. In the many hundreds of very large words, only “physical activity†gets a couple token mentions. Want to engineer something? Engineer a culture that holds exercise as the wonder pill. Start in the schools–by making gym class a daily affair. Change the upcoming generation. Get people thinking this: for preventing heart disease, a lifetime of regular (non-excessive) exercise tramples pills.
Never once is the notion that preventing heart disease stems from individuals making good (and simple) decisions. Things like not munching potato chips all night in front of the TV, or that one would have to run for thirty minutes to burn off that double mocha latte. Tell people the truth; it’s not mean.
The essence of the Million Hearts campaign espouses that government, doctors and computers hold the answer to better heart health.
Really?
Do they really think this?
JMM
P.S. For another, slightly less progressive take on the Million Hearts campaign, I would recommend this post by my EP colleague, Dr Wes Fisher.
4 replies on “CW: Can Government Prevent a Million Heart Attacks?”
I am uncomfortable with the proposed quality targets for LDL-lowering. The problem I have is that it is possible to have high LDL as defined in the CDC press release and still be very low risk. Let’s say I am a 25-year-old woman with LDL 175 and no other risk factors. My risk of a heart attack in the next 10 years is extremely small. Should my doctor be pushing me to take a statin to get my LDL below 160? Should that be a quality standard for my doctor?
It’s not that you won’t prevent some heart attacks by treating all the low risk people. It’s just that you have to treat a lot of people for each event prevented.
MM,
Thanks for commenting. I agree strongly with your thesis. I’ve written about my notions on cholesterol before. The story is much more than just the numbers. We can measure numbers; we can’t yet measure the effects of chronic inflammation on the blood vessels of our vital organs.
I’m not a public health doc or epidemiologist, but I think an exercising person eating nutritious food, getting good sleep who smiles frequently that has an LDL of 175 is at less risk than the typically inflamed, overweight, over-scheduled medication-induced sedentary American with an LDL< 100,
Put me in the inflammation camp–this I believe holds the key to the treasure, not numbers.
I agree with your assessment except in a single point: the focus of the initiative may be a little skewed but the idea is good. As a blogger you know “that which is tracked is improved.” We need to believe this could work. What I would change is the fact that it is reported to Medicare. The paperwork alone will delay care for another million patients who didn’t have a high heart attack risk.
That being said it would be interesting how this program unfolds. You are correct when you complain about not making exercise the pillar that keeps it standing. It’s like the government lost that battle with adults. They are trying to help the kids but there’s nothing we can do for you if you are 30. Would like to see which changes, if any, do they make as they implement it.
Inflammation in cardiovascular disease is a fascinating topic, although it gets complicated because high LDL seems to be associated with inflammation and its hard to separate the effects of LDL from the effects of inflammation, if you catch my drift. James K. Liao and colleagues have done some interesting work on this. For instance, in the current issue of ATVB they have published the following study:
http://atvb.ahajournals.org/content/31/10/2353.full
Soga et al., Rho-Associated Kinase Activity, Endothelial Function, and Cardiovascular Risk Factors. Arteriosclerosis, Thrombosis, and Vascular Biology. 2011; 31: 2353-2359.
The study measured Rho-associated kinase (ROCK) activity and endothelial function and found that they correlate with cardiovascular risk factors.
By the way, statins inhibit ROCK activity and it is thought that some of the benefit of statins comes from inhibition of ROCKs.
Mainly what I was trying to get at in my comment though is that the Million Hearts Initiative is aimed partly at low risk people and the number needed to treat to prevent each heart attack in people at low risk is high. Plenty of people who are low risk have heart attacks, though, so if you put a bunch of low risk people on statins you will prevent some heart attacks. But from the point of view of each of those people, the potential benefit is very small. I’m a big fan of shared decision making. Each person should be told what their baseline risk is (there are online risk calculators that calculate this) and how much it can be lowered with a statin. They should then ask themselves whether it is worth it to them in terms of cost, bother, and potential side effects to take a pill every day. It’s a personal decision, not one a government bureaucrat should be making for anyone. That’s just my opinion, fwiw.