Treating cardiometabolic syndrome means convincing patients that small steps lead to big changes.
High blood pressure, poor control of diabetes, lipid disorders, excess body fat around the waist, high cholesterol levels-sounds like a typical day of diagnoses and observations for many primary care physicians. Separately, these are all serious problems. Combined in one patient, they are the hallmarks of cardiometabolic syndrome, a condition that brings a higher lifetime risk of heart disease, stroke, and more.
An estimated 47 million Americans have twice the average risk of heart disease because they are affected by these inter-related conditions. Patients who suffer from cardiometabolic syndrome are five times more likely to develop diabetes, according to the National Heart, Lung, and Blood Institute.
Cardiometabolic syndrome is a major public health issue in the United States, and as with many chronic, yet treatable, problems, primary care physicians are the frontlines of care.
Advising patients to eat healthier is something physicians know they should do, and many try, but time often gets in the way. Almost one-third of diabetic patients said they had not been advised to follow a low-fat diet, according to a study published in 2012 in Preventing Chronic Disease. The study found that low-fat dietary advice was more closely associated with the total number of diabetes risk factors than the presence of diabetes.
Continuing to push the message of healthy living is worth the effort. The Medical Expenditure Panel Survey released in May found that the five costliest therapeutic classes of prescription drugs ranked by total expense among Medicare beneficiaries in 2010 were metabolic agents, cardiovascular agents, central nervous system agents, respiratory agents, and gastrointestinal agents. Among the Medicare population age 65 and older in 2010, expenditures for these classes totaled $63.4 billion and represented 68.3% of annual expenditures for prescription drugs. Expenses for metabolic agents accounted for nearly one-quarter of total prescription drug expenses in this group.
At the 2013 Cardiometabolic Health Congress in early October, a key message was that integrated management of all aspects of cardiometabolic risk is the only way to approach the rapidly growing epidemic of cardiovascular and metabolic disease.
“The combined impact of obesity, diabetes, and cardiovascular disease is one of the biggest health challenges in the U.S. today, and the group advocates for the importance of healthcare providers to understand the predictive relationship between metabolic risk factors and cardiovascular disease and employ aggressive intervention strategies to prevent and/or delay disease progression,” according to the congress.
Cardiometabolic disease is really a compilation of risk factors for conditions such as stroke, heart failure, and peripheral artery disease. In recent years, mortality from cardiovascular disease decreased but the problems associated with it have not.
“Certain risk factors are inevitable such as genetics but you can’t blame all of your problems on your family,” says Jeff Levine, MD, a professor in the Departments of Family Medicine and Obstetrics, Gynecology & Reproductive Sciences, at the University of Medicine and Dentistry-Robert Wood Johnson Medical School. “Smoking, being overweight, having high cholesterol, or diabetes are all factors over which patients and physicians have some control.”
Levine notes that two-thirds of Americans are overweight or obese. Poor diet and physical inactivity are the primary culprits. Excessive alcohol consumption also plays a role.
The importance of preventative care
Most primary care visits are for managing chronic conditions such as obesity diabetes, hypertension, and dyslipidemia. Treating them can be frustrating for many reasons, not the least of which is that patients might not be experiencing symptoms, so it can be hard to convince them that they are risking a stroke, for example, unless they make a lifestyle change or start taking medication.
“The biggest challenge to primary care physicians is trying to move from tertiary prevention, which means the patient already has heart disease, diabetes, peripheral artery disease, to keep them from dying or their disease progressing, moving more toward secondary preventive care, screening these patients early. Or even more important, to primary prevention, stopping these risk factors from occurring at all,” Levine says. “That’s easier said than done.”
Many healthy patients do not come in regularly for preventive care and screenings, and when they do, it takes time to effectively counsel them. “It is easier to write a prescription or order a test than to take the time and effort to effectively counsel someone to eat healthy, to exercise, to not smoke,” Levine says.
Studies show that patients who come for regular checkups are less likely to die from colon cancer, probably because they are more likely to have a colonoscopy, he says. They are also more likely to stop smoking or lose weight because they hear the physician telling them to.
“Getting patients in regularly and counseling them on healthy lifestyles and early screening is the most effective way because if you can prevent these diseases, you will be much more effective at preventing the complications and mortality than if you are treating someone who already has them,” Levine says.
Getting patients in the door
How do you get patients into the office? “It’s the challenge. Most patients only come in when they have a problem,” Levine says.
Not all preventive care is reimbursed, such as addressing obesity that is not accompanied by other medical conditions. However, he hopes that national changes in healthcare will get more healthy people to come in for true well visits during which risk factors can be identified and addressed.
Finding ways to get paid for that will help make it happen. For example, Levine is involved in two initiatives that reward physicians for meeting quality indicators. He advises physicians to look for strategies to get involved in arrangements that truly promote health and are not so much about prescribing medication. Medicare is now promoting an annual wellness exam for older patients. and many insurers waive copays for well visits as well.
“This is an opportunity for clinicians to promote these visits to patients,” Levine says. “Things like a $5 or $10 or $15 co-pay is a barrier for some patients.”
The art of convincing
It can defeat the purpose if the patient comes in with 10 medical problems they want to discuss. The physician runs out of time long before he or she gets to the preventive messaging. One way to avoid this problem, Levine says, is have your staff educate patients about what a well visit is and isn’t.
“Patients come in with an agenda, and it is rarely that they want to prevent disease,” he says. “There is an art to convincing them that they need to come back later for some of those other things. As physicians, we want to try to cover everything in one visit and it’s just not realistic.”
As practices move toward more Patient-Centered Medical Home and team-based care, physicians need to let nurses do some of the initial screenings or counseling with patients. Levine serves more to direct and motivate patients but often lets someone with more expertise handle the specifics.
He has found that the more specific the advice given to patients, the more likely they are to follow it. Don’t just tell them to eat better. Refer them to a specific nutritionist for a consult.
“Patients love them. They give them immediate feedback and reminds them about things like screenings, and makes work more efficient for healthcare providers,” he says.
Stages of change
Providers can get frustrated if, despite their best efforts, patients still do not make changes. Understanding the stages of change that patients go through is crucial, Levine says.
They must recognize the need to change and want to change. Your role as healthcare provider is to provide repeated positive messages, such as on smoking or overeating, get the patient to a point where they want to change, then help provide the tools they need, he says.
Do not give lectures but assess where they are through motivational interviewing. For example, ask what they like about smoking. Ask what they would get out of quitting. Where could they travel if they saved the $8 a day they spend on cigarettes now?
Questions like this can start patients on the road to real change.
This is often called the cornerstone of cardiometabolic disorders. With two-thirds of adults and one-third of children and adolescents in the United States overweight or obese, annual medical spending related to obesity nearly doubled from $74.1 billion in 1998 to $146.6 billion in 2006, according to the 2006 National Health Expenditure Accounts studies conducted by the Centers for Medicare and Medicaid Services.
Most of these costs are due to treating the consequences of obesity, such as diabetes and hypertension, not the actual obesity itself. Successful intervention requires comprehensive patient education with interdisciplinary coordination among healthcare providers.
IMPAIRED GLUCOSE METABOLISM:
In the U.S., 25.8 million people have diabetes – 8.3% of the population. Of these,
7 million do not know they have it, according to the National Diabetes Education Project.
The project estimates that 13 million men have diabetes (11.8% of all men ages 20 years and older) and 12.6 million women have diabetes (10.8% of all women ages 20 years and older).
It also estimates that 79 million adults aged 20 and older have prediabetes-their blood glucose levels are higher than normal but not high enough to be called diabetes. Being counseled to lose weight and increase physical activity can help them avoid progressing to diabetes.
According to National Health Expenditure Account data, annual medical costs for patients with diabetes are $190.5 billion. Diabetes is the seventh leading cause of death listed on U.S. death certificates.
The estimated direct and indirect costs of hypertension for 2009 was $73.4 billion. Among U.S. adults, 29% have hypertension, and 78% of them are aware of it. High blood pressure is particularly prevalent among African-Americans, at 41.4%, and the incidence continues to increase.
Approximately 68% of patients with high blood pressure are taking antihypertensive medication, and of these, more than 64% are controlled. Despite this, hypertension-related deaths increased by 25.2% between 1995 and 2005, and the actual number of deaths increased by 56.4% during that time.
“Prehypertension” affects about 25% of the adult population. These patients are
1.65 times more likely than those with normal blood pressure to have elevated cholesterol levels and diabetes, and to be overweight or obese.
Fewer than half of patients qualifying for lipid-lowering therapy according to treatment goals for low-density lipoprotein (LDL) levels receive therapy – including those with symptomatic coronary heart disease. Further, only one-third of patients receiving lipid-lowering therapy are treated to target lipid levels and fewer than 20% of those with coronary heart disease are at goal levels, according to the American Heart Association.