A managed care organization's use of integrated health management to improve secondary prevention of coronary artery disease.

Abstract

To evaluate the effect of a managed care organization's multifactorial intervention program in optimizing secondary prevention of coronary artery disease (CAD).
Retrospective observational analysis of claims-based data of health plan members with CAD receiving 1 or more prescriptions per year of any of the following classes of medications used for secondary prevention of CAD: lipid-lowering agents, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs) and beta-blockers.
Claims-based data of members from 2000 to 2004 were analyzed to discover trends in the use of medications for secondary prevention of CAD. chi(2) Test of proportion was used to determine whether the changes in the annual medication use rates were statistically significant.
The annual medication use rates improved consistently throughout each year of the study period. From 2000 to 2004, the medication use rates increased for lipid-lowering agents (from 55% to 71%), ACE inhibitors or ARBs (from 44% to 55%), and beta-blockers (from 36% to 47%). Changes in all 3 indicators were statistically significant at P < .001.
An integrated multifactorial approach is essential in addressing the underutilization of therapies available for secondary prevention of CAD. Managed care organizations are in a unique position to optimize the use of evidence-based pharmacological and behavioral therapies to effectively prevent and treat the underlying pathophysiology of CAD in member populations.

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I MANAGERIAL I
T
heart disease is the single largest killer of American men and women and
causes 1 of every 5 deaths in the United States. An American will expe-
rience a coronary event approximately every 26 seconds, and someone
will die of it about every minute. Coronary heart disease exerts a signifi-
cant burden on the economy, costing an estimated $142 billion in direct
and indirect expenditures in 2005. In 2002, an estimated 6.8 million
inpatient cardiovascular operations and procedures were performed in the
United States. The American Heart Association predicts that the epi-
demic of CVDs will continue for years to come because of the alarm-
ing increase in unattended risk factors in younger generations. Despite
the magnitude of this problem, efforts to prevent or treat CVDs remain
inadequate.
he American Heart Association has estimated that 71.3 mil-
lion Americans (approximately 1 in 4 persons) have at least
1 form of cardiovascular disease (CVD) and that 13.2 million
of those with CVD have coronary heart disease.1Coronary
BACKGROUND
To prevent a first occurrence and recurrent episodes of ischemic coro-
nary events, pharmacological therapies play an important role. Individual
medications such as antiplatelet agents, statins, β-blockers, angiotensin-
converting enzyme (ACE) inhibitors, and angiotensin receptor blockers
(ARBs) are proven to be effective in secondary prevention of coronary
artery disease (CAD).2-7When coprescribed, many of these agents
demonstrate an additive effect, and the benefits increase significantly.8,9
Despite the strong beneficial effect of these agents, secondary preventive
therapies continue to be underused. Several articles in the literature point
out that healthcare providers are missing valuable opportunities in
secondary prevention of CAD with regard to the prescription of
statins, β-blockers, and ACE inhibitors.10-15The evidence for underuti-
lization of life-saving medications in secondary prevention of CAD is fur-
ther supported by analyses using administrative data sets. A medical
record audit of 16 of 58 890 outpatients
who had CAD or congestive heart fail-
ure showed that among 16 603 patients
with congestive heart failure only 50%
were taking an ACE inhibitor and only
A Managed Care Organization’s Use of
Integrated Health Management to Improve
Secondary Prevention of Coronary Artery Disease
John T. Berthiaume, MD; Jim Davis, PhD; Deborah A. Taira, ScD; and Ko Ko Thein, MBBS
Objective:To evaluate the effect of a managed
care organization’s multifactorial intervention pro-
gram in optimizing secondary prevention of coro-
nary artery disease (CAD).
Study Design: Retrospective observational analy-
sis of claims-based data of health plan members
with CAD receiving 1 or more prescriptions per
year of any of the following classes of medica-
tions used for secondary prevention of CAD:
lipid-lowering agents, angiotensin-converting
enzyme (ACE) inhibitors, or angiotensin receptor
blockers (ARBs) and β-blockers.
Methods: Claims-based data of members from
2000 to 2004 were analyzed to discover trends in
the use of medications for secondary prevention of
CAD. χ2Test of proportion was used to determine
whether the changes in the annual medication
use rates were statistically significant.
Results:The annual medication use rates improved
consistently throughout each year of the study
period. From 2000 to 2004, the medication use
rates increased for lipid-lowering agents (from
55% to 71%), ACE inhibitors or ARBs (from 44%
to 55%), and β-blockers (from 36% to 47%).
Changes in all 3 indicators were statistically sig-
nificant at P < .001.
Conclusions: An integrated multifactorial
approach is essential in addressing the underuti-
lization of therapies available for secondary pre-
vention of CAD. Managed care organizations
are in a unique position to optimize the use of
evidence-based pharmacological and behavioral
therapies to effectively prevent and treat the
underlying pathophysiology of CAD in member
populations.
(Am J Manag Care. 2007;13:142-147)
For author information and disclosures,
see end of text.
In this issue
Take-away Points / p146
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26% of those achieved the recommended target dosage.16A
subgroup analysis that examined 48 586 medical records of
patients with CAD demonstrated that only 44% of patients
had documented low-density lipoprotein cholesterol testing
in the previous year, 39% were receiving lipid-lowering
agents, and 25% had reached low-density lipoprotein choles-
terol goals.
Addressing the shortcomings in secondary prevention of
CAD can produce significant clinical outcomes among
patients. The Scandinavian Simvastatin Survival Study17
showed that secondary prevention for patients with CAD by
means of lipid-lowering therapy using 20 to 40 mg/day of
simvastatin resulted in improved clinical outcomes. During a
median follow-up period of 5.4 years, there were 189 coronary
deaths (8.5%) in the placebo group and 111 coronary deaths
(5%) in the simvastatin group, while 622 patients (28%) in
the placebo group and 431 patients (19%) in the simvastatin
group had 1 or more major coronary events. These represent
42% and 32% reductions in the relative risks of coronary
deaths and major coronary events, respectively. In addition to
the benefits in coronary risk reduction, the Scandinavian
Simvastatin Survival Study18showed that simvastatin therapy
in patients with CAD reduced hospital admissions for acute
CVD (including revascularization procedures) by 26%, the
mean length of hospital stay by 10%, and the number of hos-
pital days by 34% compared with the placebo group.
Multifactorial Approach
Managed care organizations (MCOs) have an important
ethical obligation to improve the quality of care that their
members receive. Increasingly, MCOs have initiated quality
improvement programs to enhance the quality of care provid-
ed to members with chronic diseases. Among 6 commercial
health plans in the state of Hawaii, the Hawaii Medical
Service Association (HMSA) is the largest MCO and is an
independent licensee of the BlueCross BlueShield
Association. It has a membership of more than 700 000, rep-
resenting more than half of the state’s population.
In an effort to improve the quality of care and health out-
comes in members with CAD, the HMSA has put into place
a multifactorial approach that optimizes members’ and
providers’ adherence to guidelines for secondary prevention of
CAD. One of the primary objectives of this approach is to
maximize the use of pharmacological therapy in secondary
prevention for members with CAD. The main components of
the HMSA’s multifactorial intervention program are its dis-
ease management programs, practitioner and hospital per-
formance incentive system, CAD-specific clinical practice
guidelines, and value-added services for healthcare providers.
The specific programs intended for members with CAD and
their healthcare providers are described herein:
Disease Management Programs. The HMSA operates 6
disease management programs, collectively known as Care
Connection, to help members with chronic diseases lead
healthy and productive lives. These programs are run in col-
laboration with Healthways, a leading provider of comprehen-
sive health and care support programs and services. Among
these disease management programs, Cardiac Care
Connection targets members with CAD and congestive heart
failure. It was initiated in 2000, and more than 10 000 mem-
bers with CAD are under active management. Cardiac Care
Connection is a comprehensive program that addresses all
levels of care, including prevention, self-care, and outpatient
services, along with extensive collaboration and coordination
with members’ healthcare providers. Members receive regular
health educational mailings, telephone reminders, and sup-
port from clinicians. These clinicians help members under-
stand their laboratory test results, medications, and effect of
lifestyle choices on their disease progression and symptoms.
The program also serves physicians by providing them with
educational information such as newsletters, medication
reports, and guidelines for care flowsheets. In addition,
provider services managers, nurses, and dieticians visit the
physicians and their office staff to provide information about
the program, offer physician practice support, and collaborate
on care coordination for members. Case managers also follow
up with members when they are hospitalized to provide sup-
port, assist with care coordination, and ensure that they are
followed up closely when discharged from the hospital.
Performance Incentive System. The HMSA was one of
the first health plans in the nation to initiate a pay-for-per-
formance program in a preferred provider organization setting.
The performance incentive system rewards the participating
practitioners and hospitals that maintain a high level of
patient care and service according to evidence-based practice
guidelines.
The Practitioner Quality and Service Recognition pro-
gram was developed in collaboration with Health
Benchmarks, Inc, and initiated in 1998 to reward Hawaii’s
healthcare practitioners for the quality medical care they pro-
vide to their patients. As a pay-for-performance program, the
Practitioner Quality and Service Recognition initiative trans-
lates accepted industry practices into standards that can be
objectively measured through analyses of claims data and
other verifiable criteria. More than 2400 participating physi-
cians, psychologists, and optometrists (about 84% of those eli-
gible) are enrolled in the Practitioner Quality and Service
Recognition program. Three criteria pertaining to secondary

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prevention of CAD that are used in determining the awards
for providers are the following: (1) the use of lipid-lowering
agents, (2) the use of ACE inhibitors or ARBs, and (3) the use
of β-blockers. The mean amount of money awarded to
providers participating in the Practitioner Quality and Service
Recognition program is approximately $4800, and the largest
award amounts to $16 000.
Working in tandem with the Practitioner Quality and
Service Recognition program is the HMSA’s Hospital Quality
and Service Recognition program. The Hospital Quality and
Service Recognition initiative rewards participating hospitals
that achieve specified performance standards based on the
best practice guidelines, one of which is Get With the Guide-
lines established by the American Heart Association.19
Hospitals are awarded monies in relation to their adherence to
secondary prevention measures, namely, aspirin therapy on
discharge, statin therapy on discharge, ACE inhibitor therapy
on discharge, β-blocker therapy on discharge, and smoking
cessation counseling.
A third pay-for-performance initiative in the health main-
tenance organization setting, the Quality and Performance
Program, serves more than 150 000 lives and provides mone-
tary awards to health centers for adherence to secondary pre-
vention in following CAD guidelines.
Clinical Practice Guidelines. The HMSA’s provider ad-
visory committees recommend or amend national treatment
guidelines to best fit Hawaii’s population, and more than
220 local physicians participate on these committees to
help ensure quality and cost-effective healthcare for mem-
bers. In an effort to maximize the effectiveness of second-
ary prevention of CAD, the HMSA has developed clinical
practice guidelines since 2001 for prevention and treat-
ment of CVDs that conform to those established by the
American Heart Association and the American College of
Cardiology.20These clinical practice guidelines are continu-
ally updated by incorporating feedback from participating
providers and through consultation with the provider adviso-
ry committees and are disseminated annually to providers.
Value-added Services for Healthcare Providers. To pro-
vide physicians with support in their efforts to improve sec-
ondary prevention of CAD for their patients, the HMSA
gives physicians reports concerning their prescribing of lipid-
lowering agents, ACE inhibitors, and β-blockers. For each
physician, the report includes the names of their patients who
have CAD and 3 columns indicating whether these patients
were taking each of the 3 types of medications. These reports
use an algorithm similar to that used for the quality indicators
in the Practitioner Quality and Service Recognition program.
In addition, conferences are held for physicians that offer con-
tinuing medical education credits. At the meetings, experts
review the literature on the importance of secondary preven-
tion in patients with CAD, and physician-specific reports are
distributed. Physicians who do not attend the meetings are
mailed their reports.
We aimed to evaluate the effectiveness of the HMSA’s
multifactorial approach in secondary prevention for its mem-
bers with CAD. Therefore, the following retrospective study
was conducted.
METHODS
Study Design
A retrospective observational analysis of claims data was
conducted to evaluate the effect of the HMSA’s multifac-
torial approach on members’ use of medications for the
secondary prevention of CAD. The study included mem-
bers of the HMSA aged 18 to 75 years who were continu-
ously enrolled during the reporting year and who were
identified as having CAD by satisfying at least 1 criterion
from inclusion criteria A or from inclusion criteria B dur-
ing the year before the reporting period through the end of
the reporting period (the reporting period was 2000-2004).
Inclusion Criteria A (Evidence of Event). At least 2
diagnoses, on separate dates, of acute myocardial infarction,
ischemic heart disease, old myocardial infarction, angina,
chronic ischemic heart disease, or coronary artery bypass
graft.
Inclusion Criteria B (Evidence of Intervention). (1) Status
diagnosis of coronary artery bypass graft or percutaneous
transluminal coronary angioplasty or (2) procedures for coro-
nary artery bypass graft or percutaneous transluminal coronary
angioplasty.
Quality Measures
Based on the inclusion criteria, a study group of members
with established CAD was identified. Among them, the fol-
lowing 3 indicators of quality of care were measured:
Members Taking Lipid-lowering Agents. Those in the
study group who filled 1 or more prescriptions for the follow-
ing lipid-lowering agents during the reporting year: 3-
hydroxy-3-methylglutaryl coenzyme A reductase inhibitors,
niacin preparations, and bile salt sequestrants.
Members Taking ACE Inhibitors or ARBs. Those in
the study group who filled 1 or more prescriptions for any of
the ACE inhibitors or ARBs during the reporting year.
Members Taking β-Blockers. Those in the study group
who filled 1 or more prescriptions for any of the β-blockers
during the reporting year.

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Data Analysis
Claims-based data of members with documented CAD
were used to measure the percentages of members who met
the criteria of filling 1 or more filled prescriptions for lipid-
lowering agents, ACE inhibitors or ARBs and β-blockers used
in secondary prevention of CAD. Percentages of patients in
compliance were tracked over time from 2000 to 2004. The
denominator was the number of members with documented
CAD who were continuously enrolled in the plan during
the reporting year. The numerators for each category were the
numbers of members who filled at least 1 prescription of the
respective medications during the reporting year. χ2Tests of
proportion for statistically significant changes were per-
formed for each calendar year from 2000 to 2004.
RESULTS
Patient Characteristics
The Table summarizes the characteristics of the study pop-
ulation. Fifty-seven percent of the study population was
between the ages of 40 and 64 years, while 41.2% were 65
years or older. Thirty-four percent were female. Fifty-five per-
cent had a major or severe morbidity rating, measured using
the Johns Hopkins University Adjusted Clinical Group Case-
Mix System (http://www.acg.jhsph.edu). Ninety-one percent
were in the fee for service plan, while 9.2% were in the health
maintenance organization plan.
Changes in Quality Measures
The process outcomes demonstrated that the prescription
rates for all 3 medications used in secondary prevention of
CAD consistently improved from 2000 to 2004. The Figure
shows the annual percentage changes in the prescription rates
for these 3 medications during the reporting period. Use of
lipid-lowering agents increased from 55% in 2000 to 71% in
2004 in a cross-sectional cohort consisting of a sample rang-
ing from 12 421 to 13 408 members. Likewise, use of ACE
inhibitors or ARBs increased consistently over time from 44%
to 55% in a sample ranging from 12 421 to 13 408 members.
Use of β-blockers also increased from 36% to 47% in a sam-
ple ranging from 12 407 to 13 394 members. Changes in each
measure were statistically significant at P < .001 for each of
the years during the study period.
DISCUSSION
Healthcare providers do not always consider secondary
preventive therapy during a patient’s hospital stay arising from
an acute coronary event, missing an opportunity to improve
outcomes. The literature suggests that initiation of these ther-
apies in the inpatient setting aids long-term compliance with
these therapies.19Practitioners lose a critical opportunity in
secondary prevention of CAD by failing to provide patients
with drug therapy during the important transition from hos-
pital care to an outpatient setting. As a result, patients fail to
receive medications intended for secondary prevention after
an acute episode of CAD.
When patients are treated effectively using secondary pre-
vention strategies, cardiovascular morbidity and mortality can
be reduced in a population of patients with CAD. Managed
care organizations are uniquely poised to provide their mem-
bers with a multidisciplinary approach to improve the overall
quality of healthcare. By optimizing secondary prevention of
CAD, MCOs can expect fewer myocardial infarctions, revas-
cularization procedures, hospitalizations, and deaths among
their members.
Several MCOs have published their experience with pro-
grams to improve secondary prevention of CAD. The experi-
ence of United Healthcare of Illinois provides strong support
for the effectiveness of intervention programs among its mem-
bers with CAD.20The institution of secondary prevention
programs and the establishment of diagnosis-related groups by
United Healthcare of Illinois decreased hospitalization rates
among these members by approximately 25%. In another
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I Table. Demographics of the Study Population
Characteristic%
Age, y
<40 2.0
40-64
>65
56.8
41.2
Sex
Male66.4
Female33.6
Morbidity level
None 1.7
Minimum
2.2
Minor
10.8
Moderate30.1
Major24.4
Severe 30.8
Plan type
Health maintenance organization9.2
Fee for service
90.8

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study, Goff et al11examined the effectiveness of a quality
improvement program to increase the use of pharmacological
therapies among patients with coronary heart disease in a
network-model managed care setting. An analysis of claims
data for more than 700 patients from 1999 to 2002 showed
that medication use rates increased steadily over time from
38.5% to 44.3% for β-blockers and from 22.9% to 30.3% for
ACE inhibitors; an exception was a decrease in statin use in
the final year from 53.9% to 46.4%.
Although intervention programs aimed at improving sec-
ondary prevention of CAD vary in their effectiveness,
researchers agree that multifaceted interventions are more
likely to succeed than single strategies. Among combination
strategies, those that focus on increased reimbursement for
appropriate therapy seem to be more effective in improving
adherence to performance measures than other methods such
as centralized mailings of guideline summaries, performance
feedback reports, and medical record reminders.21
The American Heart Association has launched
Get With the Guidelines,19an acute care hospital-
based program that helps manage risk factors in
patients with CAD and myocardial infarction. The
HMSA has adopted the program’s recommendations
for patients in the general population identified as
having CAD and has focused on the 3 components
of lipid-lowering agent use, ACE inhibitor or ARB
use, and β-blocker use. The HMSA’s multifactorial
programs enable its members to receive evidence-
based appropriate pharmacological and behavioral
interventions to stabilize and prevent or delay dete-
rioration of CAD. Medication use rates in our study
showed consistent increases every year from 2000 to
2004 in the 3 classes of medications (from 55% to
71% for lipid-lowering agents, from 44% to 55% for
ACE inhibitors or ARBs, and from 36% to 47% for
β-blockers), suggesting the effectiveness of a multifaceted and
integrated intervention program targeted at secondary pre-
vention of CAD. In 2006, the HMSA’s Health Plan Employer
Data and Information Set performance ranked in the 90th
percentile for CVD measures.
The primary limitation of our study is the use of adminis-
trative claims data, the validity of which may not be as robust
as that of data in a controlled study. The absence of a control
group of health plan members who were not part of the inter-
vention program makes it difficult to determine to what extent
the trend in medication use was due to the intervention or due
to forces outside of the intervention. Measures for adherence
to secondary prevention of CAD guidelines in this study rep-
resent a low threshold. They only required that a patient fill 1
or more prescriptions among target medications in a calendar
year. A more stringent requirement would measure 80% med-
ication possession ratios in the 3 therapeutic classes.
Moreover, administrative claims data may underestimate
medication use, as some members may receive sam-
ples from their physicians or medications through
prescription benefits under a different insurer.
CONCLUSIONS
Although there is vast knowledge about the ben-
efits of secondary prevention for patients with CAD,
a large gap continues to exist between this knowl-
edge and actual clinical practice. In addition to the
need for clinician adherence to evidence-based clin-
ical guidelines, patient compliance is a critical factor
in successful secondary prevention of CAD. The
success of multifactorial intervention programs
I Figure.Trends in the Rates of Appropriate Medication Use
for Secondary Prevention of Coronary Artery Disease
80
70
60
50
40
30
20
10
0
% of MembersTaking at Least
1 Prescription Per Year
Year
20002001200220032004
55%
60%
64%
68%
71%
44%
48%
52%
54%
55%
38%
40%
43%
45%
47%
Lipid-lowering Agents
ACE Inhibitors or ARBs
β-Blockers
ACE indicates angiotensin-converting enzyme; ARBs, angiotensin receptor blockers.
Take-away Points
The American Heart Association predicts an epidemic of cardiovascu-
lar diseases because of an alarming increase in unattended risk factors in
younger generations.
I
I
angiotensin receptor blockers are proven to be effective in secondary pre-
vention of coronary artery disease (CAD).
Lipid-lowering agents, angiotensin-converting enzyme inhibitors, and
I
that optimizes members’ and providers’ adherence to guidelines for
secondary prevention of CAD.
Managed care organizations should use a multifactorial approach
I
Association comprises disease management programs, a practitioner
and hospital performance incentive system, CAD-specific clinical practice
guidelines, and value-added services for healthcare providers.
The multifactorial intervention program of the Hawaii Medical Service