Every year, Americans suffer approximately 1.5 million heart attacks and strokes at a cost of more than $312 billion in health care expenditure and lost productivity annually. Cardiovascular disease (heart disease and stroke) also causes premature death, serious illness, disability, and decreased quality of life. The good news, however, is that many of the major risk factors for these conditions can be prevented and controlled. For example, high blood pressure (hypertension) is one of the leading causes of heart disease and stroke. Lifestyle choices, such as eating healthy and exercising regularly, can help control blood pressure and health care professionals may prescribe other treatments (antihypertensive medication) if lifestyle changes are not enough. However, nearly 1 in 3 Americans, or about 67 million adults, have high blood pressure and, despite the availability of antihypertensive medications, only half have it under control (<140/90). The ability of people to continue using their medications as prescribed by their doctor—also known as medication adherence—is a key challenge.
To tackle this important issue, the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) teamed up to discuss how to improve antihypertensive medication adherence. This effort became known as the Million Hearts ® Epi-Exchange because of the similarities to CDC’s “Epi-Aid” program which provides epidemiological support within the United States and throughout the world to assist with emergency responses, investigate infectious and environmental disease outbreaks, and quantify impact of diseases.
The Epi-Exchange is a part of the larger Million Hearts® initiative, co-led by CMS and CDC, to prevent 1 million heart attacks and strokes by 2017. Million Hearts® aims to focus, coordinate, and enhance prevention activities across a wide variety of sectors, and includes many public and private partners. Core to the prevention of heart disease and stroke is the focus on the ABCS—aspirin use, blood pressure control, cholesterol management, and smoking cessation. We selected high blood pressure as the main topic for the Epi-Exchange, because substantial efforts are already underway to improve blood pressure control. Lessons learned during the Epi-Exchange can readily be used to help evaluate disease risk, along with other leading heart disease and stroke risk factors.
We decided to focus the Epi-Exchange on expanding the ability of Million Hearts® to use pharmaceutical claims data (billing data collected when a person has a prescription filled) to guide current and future activities. The use of pharmaceutical claims data to assess the burden of illness in the population and identify possible areas for intervention is relatively new. However, pharmaceutical claims data can be used as an alternate way to evaluate appropriate and evidenced-based treatment of health conditions. In addition, through the Medicare Part D Prescription Drug Program, which provides prescription drug coverage to the majority (>60%) of US adults ages 65 and older, CMS has a valuable source of pharmaceutical claims data. Focusing on pharmaceutical data was also a good fit because it meant that we could combine CMS’ detailed understanding of the Part D program (variations across health plans, deductibles, coverage gaps) with CDC’s expert clinical knowledge of pharmaceutical products and hypertension treatment. To facilitate the sharing of information between CDC and CMS we decided to hold an in-person meeting in late October 2013. Over the course of only a few months, several preparatory meetings involving CMS and CDC subject matter experts were held to identify priority areas for the in-person meeting, which was held from October 23–25 at the CMS offices in Baltimore, MD.
The main objectives of the Epi-Exchange included: (1) coordinating Million Hearts® research activities across CMS and CDC, (2) developing a plan for Million Hearts® public health surveillance using Part D data, and (3) identifying opportunities for CMS and CDC scientist collaboration.
For the first objective, we held several discussions regarding the alignment and coordination of CMS and CDC surveillance and research methodologies. It was quickly determined that selecting the appropriate populations (e.g., denominators) allows for consistent messaging and reporting. While the group was excited to see that there was already much consistency in the state-of-the-art research methodologies being employed despite working independently in different agencies, we agreed that continued movement towards standardization across platforms and methodologies is imperative to a successful collaboration. Also, consistency in the manner in which medication adherence is regularly reported by CMS using a validated and standardized approach was discussed, and it was determined that it can be replicated and tracked for Million Hearts® surveillance, and applied to other CDC data assets as well.
The second objective involved the broad understanding of CMS pharmaceutical data availability, which included a common understanding of available data files to aid in analyses as well as linkage options with other data assets. This portion of the collaboration involved a live programming session in which a representative Part D sample was used to replicate antihypertensive medication surveillance questions CDC has used with another prescription medication data asset (IMS Health data). Statistical code developed during this session was provided to CDC to allow for additional analysis replication.
The final objective focused on enhanced opportunities for consistent communication of Million Hearts® messages across agencies. During this session, we reviewed the Million Hearts® Dashboard. The Dashboard is being developed to track Million Hearts® related events, like heart attack hospitalizations, among Medicare beneficiaries. Subject matter experts made informed decisions to select appropriate reporting measures and align the Dashboard with other CMS surveillance activities.
Overall, this Epi-Exchange event resulted not just in increased transparency of institutional knowledge and information, which is expected to lead to incremental improvements in the way the Million Hearts® program will be monitored, but it also validated that open-data approaches and research collaboration can provide synergies that may not be possible in our usual research silos. Lessons learned and methodologies from this Epi-Exchange are currently guiding the development of an informed data use agreement between CMS and CDC to gain expanded access to CMS data through the CMS Virtual Research Data Center. Collaborations are also continuing through the Million Hearts® initiative.
Authors: Christopher Powers, PharmD, Acting Director, Information Products Group, Office of Information Products and Data Analytics, CMS; Fleetwood Loustalot, PhD, FNP, Lead, Epidemiology, Surveillance and Health Services Team, Division for Heart Disease and Stroke Prevention, CDC; Matthew Ritchey, DPT, MPH, Epidemiologist, Epidemiology, Surveillance and Health Services Team, Division for Heart Disease and Stroke Prevention, CDC