Fact: People who have had one heart attack or stroke can be at risk for having another one.

Fact: Patients with diabetes are at similar risk even if they have never had a prior heart attack or stroke.

Fact: Many of these heart attacks and strokes can be prevented.

By paying proper attention to managing risk factors—doing a better job of keeping blood pressure, cholesterol and blood sugar under control; helping people quit smoking; and prescribing aspirin and the right medicines—fewer people will die or be disabled from these preventable problems.

But doing a better job isn't simple. It is a complex task that requires coordination between patients, doctors and other caregivers.

The goal of the Secondary Cardiovascular Risk Team was to develop the processes, tools and support systems to help practices do a better job of managing these risks. Clinical team members involved in the care of people with diabetes and heart disease include a broad spectrum of disciplines including internal medicine, cardiology, endocrinology, family practice, nursing, dietary and dental. Other team members include patients and families and other supports within the community.

The team conducted a convenience sample to learn how well secondary risks were being managed. Records from 13 offices, some with and some without electronic health records, were sampled. A total of 180 charts were reviewed. Patients in the sample were age 18 and over, had been seen at least once during the year, and had a diagnosis of coronary artery disease, carotid stenosis, and diabetes mellitus.

The team wanted to see what percentage of patients were on target for reaching all recommended care targets for the following factors: blood pressure, cholesterol, blood glucose, a daily aspirin, cholesterol medicine and not smoking. They considered this a tough standard but felt it was right for patient care.

The study showed that less than 5 percent of patients in the sample were reaching all treatment targets. The convenience sample, while not a statistically valid sample, showed there was significant room for improvement.

The team realized that in order to be able to get better results, practices need better tools to support the management of cardiovascular risks. The first step will be for practices to be able to identify groups of patients through a registry.

Team

Team Co-Leads: Steven Hippler, MD and Craig Kurtz, MD
Black Belt: Phil Baer

Team Members:
Tom Dorsch, MD
Vicki Keller
Jean Kestner
Rick Luetkemeyer, MD
Tina Miller
David Trachtenbarg, MD
Tim Vega, MD
Mary Vojta
Robert Wombacher, MD
Tom Zimmerman, MD