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CENTERS FOR
DISEASE CONTROL AND PREVENTION
Volume 17 • Number 1 • Fall 2004
Return to index of articles
State CVH Programs: The
Heart of the Matter
Heart disease and stroke
are the first and third leading causes of death among men and women of all
U.S. racial and ethnic groups. To help reduce the health and economic impact
of these diseases, in 1998 the U.S. Congress directed CDC to establish a
national, state-based heart disease and stroke prevention program and
provided funding for eight states. The program has now grown to support 32
states and the District of Columbia.
According to George A.
Mensah, MD, FACP, FACC, FESC, Acting Director of NCCDPHP and former Chief of
CDC’s Cardiovascular Health Branch, “the goal of the state program is to
help states plan, establish, monitor, and sustain population-based
interventions. These interventions help to improve the heart health of
Americans by addressing rates of heart disease, stroke, and related risk
factors such as high blood pressure, high blood cholesterol, tobacco use,
physical inactivity, and poor nutrition,” he said. “They also help to
improve outcomes in the chain of survival by improving emergency response
and public knowledge of emergency symptoms. And they help to improve the
health of people who are already living with CVD or who have already
suffered from a first event.”
Establishing a Focus for
Change
States funded for heart
disease and stroke prevention focus on three types of interventions:
educational programs, policy development, and environmental or systems
changes. (See box for examples.)
Supporting Activities at
Different Levels of Funding
Nancy Watkins, MPH, a CDC
Public Health Educator and heart disease and stroke program team leader,
points out that the activities of the 33 states funded for heart disease and
stroke programs vary according to the funding level. “The majority of the
states are funded at the lower capacity-building level, but we are able to
provide funding for basic program implementation in some of the states,” she
said.
Activities in the 22
states funded for capacity building focus on increasing collaboration among
public and private organizations concerned with preventing heart disease and
stroke, defining the state’s CVD burden, assessing current activities,
developing and updating a comprehensive state plan, identifying culturally
appropriate approaches, and helping state residents become more aware of the
signs and symptoms of heart attack and stroke.
The remaining 11 states
receive funding for basic implementation. These states expand their
activities to enhance all capacity-building program activities; implement
and evaluate interventions in health care sites, work sites, schools, and
communities; and provide training in heart disease and stroke prevention to
public health and health care professionals and partners.
Providing Evaluation
Expertise
To help states ensure
that their heart disease and stroke prevention programs are most effective,
CDC helps states evaluate their programs. “Carefully evaluating
interventions and using the evaluation results to make necessary adjustments
is a critical part of building a successful heart disease and stroke
program,” Ms. Watkins said.
“By providing technical
assistance and support, CDC helps states expand their evaluation capacity.”
CDC’s contributions include
- An annual evaluation
training workshop where experts train state program staff to improve
program surveillance, evaluation techniques, and use of evaluation data
for program improvement.
- The development of a
CVH Management Information System to provide CDC with an improved,
real-time ability to collect intervention data and monitor program
effectiveness across states.
- Publication of
guidance documents, an evaluation framework, a program logic model, and
evaluation reports to help states enhance their programs.
- Monthly conference
calls to exchange information and share lessons learned between states.
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States funded by CDC
to prevent heart disease and stroke have three areas of focus:
Education
- Conduct
campaigns to let people know that having their blood pressure checked
regularly is an important first step in reducing their risk of heart
disease and stroke.
- Sponsor campaigns to raise public awareness of the
signs and symptoms of heart disease and stroke and the urgency of
calling 9-1-1 for help.
- Promote education and training programs for
health care professionals on systems that support quality health care.
- Increase the public’s awareness of the role of lifestyle changes— such
as quitting smoking and getting more exercise—in reducing risk for CVD.
Policy
- Promote the
development of policies to increase adherence to national guidelines
for preventing and controlling high blood pressure.
- Support the
development of state-based policies for universal enhanced 9-1-1
coverage.
- Promote policies
for treating stroke as an acute emergency.
- Strengthen
policies that encourage healthy lifestyles.
Environmental/Systems Changes
- Promote
employer-provided insurance that includes coverage for prevention
services.
- Collaborate
with states to develop systems and intervention programs to detect
and control high blood pressure among high-risk groups.
- Promote health
care system changes—such as instituting reminder systems for blood
pressure checks—to ensure appropriate preventive care for people
with high blood pressure, high cholesterol, heart disease, and
stroke.
- Promote health
care system supports to increase adherence to guidelines for
preventing and controlling heart disease and stroke.
- Promote
environmental supports, such as blood pressure monitoring, to help
people control risk factors and improve their cardiovascular
health.
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Bringing Key Personnel
Together
Two other mechanisms that
CDC has developed to help states improve their heart disease and stroke
programs are the Cardiovascular Health Collaboration and the Heart Disease
and Stroke Practitioners Institute.
Cardiovascular Health
Collaboration
At the National Center
for Chronic Disease Prevention and Health Promotion, many different groups
work to promote cardiovascular health. In October 2000, the Cardiovascular
Health Collaboration (CVHC) was founded to improve communication and
coordinate activities among these groups. According to Darwin Labarthe, MD,
MPH, PhD, Acting Director for CVH and Chair of the CVHC, “one of the major
accomplishments of the collaboration has been to provide states with a model
integrating different elements of chronic disease programs at the state and
local level.” In collaboration with the Chronic Disease Directors and the
Maine Department of Human Services, the CVHC held a 2-day workshop on
working across programs in September 2003 in Maine for the New England
Region states and New York. “The workshop included examples of key ways in
which chronic disease programs are partnering to better address chronic
diseases, including heart disease and stroke,” Dr. Labarthe said.
Heart Disease and
Stroke Prevention Practitioners Institute
In 1999, CDC worked with
the American Heart Association (AHA), the Association of State Chronic
Disease Directors CVH Council, and the University of Rochester’s Department
of Community Medicine to conduct a 5-day intensive training program for
staff from CVH state programs. The training program focused on developing
knowledge and skills in the following areas:
- Communication and
advocacy.
- Partnership
development and maintenance.
- Use of data and
assessment for program development.
- Policy and
environmental strategies to promote cardiovascular health.
The
first institute had participants from 10 to 12 states and the AHA state
affiliate partners. According to CDC Health Education Specialist Linda
Redman, MPH, MA, CHES, “The institute provided a stimulating environment for
states to learn from each other, AHA partners, CDC staff, and an
international faculty. In fact, some important long-term relationships
evolved out of this institute.” In 2003, CDC restructured the annual
institute to include representatives from all 50 states as well as the AHA
State Health Department representatives from funded states.
The focus of the 2003
institute was on the two core capacities that state program coordinators
identified as priorities for training:
- Developing and
maintaining successful heart disease and stroke prevention partnerships.
- Implementing
strategies for effective policy and environmental changes.
Ms. Redman said that the
training included general sessions on the evidence-based foundations of the
CVH program, small-group interactive sessions, and concurrent practice/skill-building
sessions targeting different levels of skill and experience. “In addition,”
she said, “all states had the opportunity to share activities and lessons
learned in their state.”
The next institute will
be held in 2005. A training workshop will be offered in August 2004.
Pulling It All Together:
Examples from the States
The following four
examples illustrate the vital work that CDC-funded states are doing to help
reduce the burden of heart disease and stroke in the United States.
 Wisconsin
In 2000, heart disease
and stroke were the first and third causes of death in Wisconsin, claiming
the lives of more than 18,000 of the state’s residents each year. As part of
its efforts to address the burden of heart disease and stroke in the state,
the Wisconsin Cardiovascular Health (CVH) Program joined the Wisconsin
Diabetes Collaborative for Quality Improvement Project and expanded the
focus of the collaborative to incorporate cardiovascular health issues,
including high blood pressure and cholesterol management. The health plans
that make up the collaborative have been collecting data on the following
five cardiovascular disease-related measures from the Health Plan Employer
Data and Information Set (HEDIS) since 2000:
- Beta-blocker treatment
after a heart attack.
- Cholesterol screening
after acute cardiovascular events.
- Cholesterol control
after acute cardiovascular events.
In 2001, the
collaborative established the Cardiovascular Risk Reduction Project. The
project required the establishment of a workgroup made up of quality
improvement managers from the health plans.
According to Mary Jo
Brink, MS, RN, Coordinator of the Wisconsin CVH Program, “one goal of the
Cardiovascular Risk Reduction Project is to promote standardized practices
that follow recommendations in clinical practice guidelines. The project
hopes to reach more than 7,000 health care providers, including nurse
practitioners and physician assistants, who have a role in preventing heart
disease and stroke among Wisconsin residents,” she said. “Of the several
tools that were developed for this project, the foremost is guidelines for
treating adults who are at risk for or have had a cardiac event.”
Some of the health care
providers practice in Federally Funded Health Centers (FFHCs), which serve
poor and uninsured or underinsured Wisconsin residents. The FFHCs are also
participating in a cardiovascular and diabetes quality improvement project
that addresses the five HEDIS measures mentioned above and other quality
improvement measures. “We expect these projects to affect the quality of
preventive care for over 85% of Wisconsin residents who are covered by
health insurance and all of those who are members of FFHCs. However, this
impact will take several years to realize,” Ms. Brink said.
Montana
When it was first funded
for capacity building in 2000, the Montana Cardiovascular Health Program
developed the 5-year Montana Cardiovascular Disease Prevention and
Control Plan 2000 to prevent and control heart disease and stroke, the
leading cause of death in Montana. The plan addresses major cardiovascular
risk factors and identifies children, American Indians, and older adults as
its priority populations. In 2003, Montana began receiving funding for basic
implementation. Some of the milestones that the program has helped to
achieve include
- Collaborating with St.
James Healthcare and the Montana Chapter of the American College of
Cardiology to implement Guidelines Applied in
Practice (GAP), which were first
developed in Michigan. At the first pilot site in Butte, Montana, staff
members received training on quality improvement techniques and were
encouraged to adapt GAP pathways, standing orders, discharge materials, and
patient education examples. According to Crystelle Fogle, Montana
Cardiovascular Health Program Manager, “a greater percentage of patients at
the pilot site are now counseled on quitting smoking, have their LDL
cholesterol tested within 24 hours of admission, are discharged from the
hospital on lipid-lowering medication, and receive dietary counseling.” GAP
is now being replicated at other hospitals in Montana.
- Organizing a statewide
Cardiovascular Health Summit for health professionals that focuses on ways
to prevent and treat CVD and promote cardiovascular health. “This annual
conference, which will be held for the third year this April, is unique in
Montana because it emphasizes cardiovascular disease prevention and
treatment with a public health perspective,” Ms. Fogle said.
- Using an adapted
version of New York’s “Heart Check” survey to conduct a work site survey
of Montana businesses, tribal health organizations, Indian Health Service
units, and colleges and universities. According to Ms. Fogle, “the CVH
Program will use the survey results to recruit work sites for a wellness
intervention and to identify gaps in work sites’ CVH policies.” As a first
step toward implementing these projects, Montana established a Governor’s
Council on Worklife Wellness in January.
North Carolina
The North Carolina
Cardiovascular Health Program focuses on reducing the burden of heart
disease and stroke by creating heart-healthy work sites, health care
systems, schools, and communities. The program collaborates with statewide
partners through the Justus-Warren Heart Disease and Stroke Prevention Task
Force, which was established by the General Assembly in 1995 to increase
awareness of signs and symptoms of heart attack and stroke, improve control
of high blood pressure and cholesterol, and improve the quality of care for
people with cardiovascular disease.
Because North Carolina
already had a Task Force in place and a plan for addressing the burden of
heart disease and stroke under development, it was one of only two states
awarded funding for basic implementation in 1998, the first year of the CDC
program. According to Libby Puckett, Head of the North Carolina Heart
Disease and Stroke Prevention Branch in the Division of Public Health,
“receiving CDC funding made it possible to fully implement the statewide
plan.” Important elements of the plan that are now in place include the
following:
Reaching people
throughout the state. To reach those at greatest risk for cardiovascular
disease, the program has established six county-level programs designed to
build regional partnerships, help develop local goals and objectives, and
serve as a resource for local efforts to reduce heart disease and stroke.
Two additional county-level programs focus on reducing the disproportionate
burden in death rates and risk factors among African Americans.
Providing coverage for
proven prevention measures. The program collaborates on the BASIC Preventive
Benefits Initiative with the North Carolina Prevention Partners, which
includes a variety of health plans and employers. The initiative is working
to ensure that benefits to prevent CVD are voluntarily purchased by
employers, voluntarily covered by insurers, and offered by providers and
health systems. As a result of these efforts, the number of health plans
that offer tobacco cessation, nutrition, and physical activity insurance
products to employer groups increased by 75%.
Promoting partnerships to
prevent stroke. The program coordinates the activities of the Tri-State
Stroke Network, which is made up of public health and medical professionals,
policy makers, and advocates from North Carolina, Georgia, and South
Carolina. The network facilitates collaborative efforts to improve stroke
awareness and advocacy, prevention and treatment of stroke, and data
collection and surveillance.
Mississippi
Funded since 1999, the
Mississippi Cardiovascular Health Program has achieved the following
milestones in preventing and controlling heart disease and stroke, the
leading causes of death and disability in Mississippi:
- Developed a state plan
in conjunction with the legislatively mandated Task Force on Heart Disease
and Stroke Prevention and Control. According to Tennille Howard, Mississippi CVH Program Coordinator, “the overarching target areas are preventing and
managing risk factors.” The plan integrates relevant sections of the State
Tobacco Prevention and Control Plan and the Mississippi State Plan for
Diabetes Prevention and Control with other sections on priorities such as
hypertension, cholesterol, quality patient care management, and public
awareness of signs and symptoms of heart attack and stroke.
- Expanded the social
marketing campaign Know Your Numbers to increase public awareness of
important risk factors—body mass index (BMI), cholesterol, glucose, and
blood pressure— for heart disease and stroke in partnership with Subway®
restaurants, the Mississippi Chronic Illness Coalition, and Mississippi
State University Extension Service staff.
- Held a luncheon for
state legislators to inform them of the Know Your Numbers campaign and the
importance of prevention in reducing health care costs and improving
quality of life statewide. The Mississippi Chronic Illness Coalition
conducted this activity in conjunction with the annual Capitol Day event
with strong support from the American Heart Association (AHA) Southeast
Affiliate and the Mississippi State Department of Health Office of Health
Promotion. Ms. Howard said that more than 200 legislators and staff were screened
and educated on BMI, cholesterol, glucose, and blood pressure during Capitol
Day.
- Worked with
Mississippi State University Extension Service staff to provide a 3-day
training course for the Mississippi Chronic Illness Coalition members and
other program partners on coalition building, strategic planning, reaching
consensus, and conducting evaluations. “Participants were engaged in
practical workgroup learning sessions that can be used with community
groups and other coalitions,” Ms. Howard said.
- Developed the 2004
Mississippi State of the Heart and Stroke Report, which
contains the latest available data from BRFSS and vital statistics. The
report will provide information on the health disparities both within the
state and between Mississippi and the nation. Additionally, the report
will include county-level data on deaths related to heart disease and
stroke in all 82 Mississippi counties.
- Participated in the
Delta States Stroke Consortium (DSSC), whose purpose is to develop plans
to reduce the high rates of stroke in Mississippi, Alabama, Arkansas,
Louisiana, and Tennessee. The Mississippi Chronic Disease Director chaired
the committee on risk factor prevention and control and was a member of
the DSSC Steering Committee.
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