Why is San Diego’s heart attack rate 20 percent lower than the rest of the state?

Be There San Diego, an organization leading a wide-ranging effort to reduce heart disease by getting doctors from different organizations to work together, is getting national attention for reducing the region’s heart attack risk.

A newly published study released Tuesday highlights a 22 percent drop over five years in the number of local heart attack hospitalizations, a result that is a full 14 percentage points better than the 8 percent decrease observed across the state.

Appearing in the September issue of Health Affairs, one of the nation’s most influential medical journals, the paper’s authors estimate that San Diego County saw 3,826 fewer heart attack hospitalizations than expected from 2011 to 2016, saving nearly $86 million in avoided medical costs.

The observational study does not prove conclusively that Be There San Diego’s efforts caused the drop in heart attack hospitalizations. Only a randomized controlled trial could deliver ironclad proof.

But the correlation between the start of the program and the drop in hospitalizations is nonetheless a strong statistical signal, said Dr. Deepak Bhatt, a cardiovascular program director and professor of medicine at Harvard Medical School.

A double-digit gap between San Diego’s results and those of the other 57 counties in the state, he said, is too large to ignore.

“Unless there was some other cardiovascular program in operation with the same sort of scope, I tend to believe there is something here,” Bhatt said. “My hope is that other cities and counties read this and say, ‘hey, look what they did in San Diego. Why can’t we do that here?’”

Dr. Sandra Tsai, a professor of primary care and population health at Stanford University School of Medicine, agreed that the results could be influential beyond California as health providers nationwide are increasingly compensated for their ability to treat chronic disease through prevention.

She noted, though, that comparing one county to the average performance of an entire state tends to mask the performance of other regions that might also be delivering stellar results.

“The results are, I think, really impressive, but I’d also like to see San Diego’s performance in relation to other similar counties rather than just the global average,” Tsai said.

Researchers, it turns out, were thinking along the same lines. An addendum to the study breaks out results for Los Angeles and Sacramento counties which had similar heart attack-reducing programs in operation at the same time.

According to the report, Los Angeles County saw a 5 percentage point reduction in heart attack hospitalizations while Sacramento County saw a 6 percentage point increase.

What led to the difference in results?

The Be There San Diego program didn’t use newly-developed medications or medical devices to reduce heart attack risk. The most effective tool employed by the program is a table that doctors from throughout the region sit around every month, said study co-author Dr. Anthony DeMaria, a UC San Diego cardiologist who helped lead the effort.

For years, this core group of physicians from every major medical group across the region, including the area’s robust network of community health centers, have shared data on the percentage of their patients who are in control of critical factors such as blood pressure, blood sugar levels and cholesterol levels.

For years now, doctors from organizations that regularly compete for patients have gathered to share their numbers and also the specific methods they’re using to get risk factors under control.

“We organized our community in a way that we were goal-oriented to reduce heart attacks and strokes,” DeMaria said. “That orientation allowed us to share the data with each other that’s necessary to identify the patients who are most at risk and make sure they are aggressively treated.”

While efforts in other counties have had similar collaborative meetings, he said, the extent to which San Diego systems have been willing to share their data is thought to be unique.

Once patients with high blood pressure or out-of-range cholesterol or blood sugar are identified, participating groups became more aggressive with prescribing a “bundle” of medications shown to protect heart health, including aspirin, statins and anti-hypertension drugs.

A federal grant also helped pay for medical groups to hire health coaches to work one-on-one with a group of 4,000 residents countywide who were judged to be at the highest risk of heart attack or stroke. These workers were available to help participants change eating and exercise habits and make sure that they were taking their medications as prescribed.

Grant money also paid to hire a small professional staff in 2013 to coordinate the program countywide.

Kitty Bailey, executive director of Be There San Diego, said it was unclear at the outset whether health coaches could be a cost effective way to change patient behavior over the long term. But, with the marked decrease in heart attack hospitalizations observed since the program started in 2011, many are now convinced.

“The grant that paid for those health coaches actually ran out last year, but many of our medical groups have kept the coaches they hired because they were able to show value through avoided costs,” Bailey said.

Bhatt, the Harvard cardiologist, said there have been similar collaborative efforts among groups of competing doctors in other communities but ventures with such widespread participation are rare.

The San Diego study and others that have managed to move the needle on preventing heart disease all have a factor in common: They’re able to pursue relatively simple actions across very broad bases of doctors and patients and sustain those actions for many years.

“That’s the thing about coronary artery disease,” Bhatt said. “A lot of it’s not about sexy interventions. It’s just a matter of taking care of the usual risk factors day in and day out year after year. There is no magic bullet. Everyone has to do the work.”

Sharp HealthCare was a big part of the effort, enrolling more people in the 4,000-patient grant-funded project than any other local health system.

Dr. Parag Agnihotri, medical director of population health at Sharp Rees-Stealy Medical Group, cited collaboration among doctors as another key to Be There San Diego’s success. Defining the goal properly, he said, made doctors from competing providers willing to work with each other and share their methods.

“The people in the room have a lot of passion for their work because we know that we’re fighting against chronic disease, not against each other,” Agnihotri said.

Efforts have not been confined to doctors offices. An important part of the overall effort has included work in nearly 20 Southeast San Diego churches which have taken broad action in recent years to add exercise classes and preach healthy eating and exercise and even add blood pressure check stations before Sunday services.

Dr. Nick Yphantides, chief medical officer for San Diego County, said the results that Be There San Diego has delivered hint that a similar collaborative approach could work for other chronic diseases.

“If we can do it with heart attacks, I’ve very excited to see what we can do to expand this beachhead to the greater wellness war,” Yphantides said.


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