VA Research: Cardiovascular Care

By Craig Collins

CARDIOVASCULAR DISEASE (CVD) IS THE LEADING cause of death among American men and women, killing about 610,000 people every year. In the Department of Veterans Affairs (VA) health care system, it’s the leading cause of hospitalization, and it’s of particular concern to the veteran population because of its association with a number of other diseases or disorders, including diabetes, hypertension (high blood pressure), spinal cord injury, and post-traumatic stress disorder (PTSD).

CVD is defined as a condition that arises from problems of blood flow, many of which are related to narrowed or blocked blood vessels, and which can lead to heart attack, coronary heart disease, stroke, or chest pain (angina). Risk factors for the disease include: age; obesity/overweight; smoking; lack of exercise; diet; high blood pressure; diabetes; alcohol use; stress; high LDL or low HDL cholesterol; and heredity. Eighty percent of veterans have two or more risk factors for CVD. This may be partly attributable to the fact that veterans are older, on average, than other Americans, but a recent study, published in The Journal of the American Board of Family Medicine in January 2019, found that veterans also reported higher numbers of CVD conditions at younger ages than nonveterans.

Researchers in VA’s Office of Research and Development (ORD) examine hereditary and lifestyle risk factors for CVD and conduct studies ranging from lab experiments to large clinical trials, involving thousands of patients, in search of new or improved treatments. For example, using data from its ambitious nationwide Million Veteran Program, which links patient health records and biospecimens with DNA from veteran volunteers, VA researchers have identified potential genetic markers for CVD risk factors, including cholesterol levels and high blood pressure. These findings may lead to new, targeted treatments that can prevent or effectively treat CVD.

A veteran gets his blood pressure checked at the VA North Texas Health Care System. High blood pressure, or hypertension, is a risk factor for cardiovascular disease (CVD), which can lead to heart attack, coronary heart disease, or stroke.

When new treatments are devised, it’s up to VA’s health services researchers to discover the most effective and efficient way of implementing them in a VA health care system that serves more than 9 million veterans. Within the ORD, the Health Services Research and Development (HSR&D) Service funds investigations into the factors that affect health care quality and outcomes for veterans with CVD, including the effectiveness of telemedicine in managing CVD risk factors for rural veterans; the impact of CVD on operating costs; and differences in CVD risk among groups of veterans. The overall aim is to optimize care for veterans who are either at risk for CVD or living with CVD conditions.

HSR&D investigators have pioneered evidence-based practices and approaches that have reduced risks for veterans and extended the reach of VA resources – for example, peer coaching and support. In the Seattle area, Karin Nelson, MD, a core investigator with HSR&D’s Center of Innovation and a professor of medicine at the University of Washington, is evaluating the effectiveness of a peer coaching program she developed for veterans with high blood pressure. The Vet-COACH (Veteran Peer Coaches Optimizing and Advancing Cardiac Health) study will test whether trained veteran coaches, visiting other veterans in their homes, can help improve blood pressure control and at least one other risk factor for CVD. Nelson designed the approach based on her previous collaborations with community health workers to reduce veterans’ risk for chronic diseases. “We’re using a community health worker model,” Nelson said, “where people who are not health professionals get training in coaching and some basic health education, and then they do community-based visits.”

Smoking is another risk factor for CVD. In addition to looking at systolic blood pressure changes, the Vet-COACH study will also measure reductions in CVD risks like tobacco use or cholesterol levels.

During these visits and telephone support sessions, coaches in the program talk with veterans about their daily lives and help them set goals for managing high blood pressure and reducing CVD risks – through physical activity, healthier eating, taking medications, smoking cessation, or other approaches that fit the veterans’ lifestyles. Veteran coaches in the program will also connect participants with community-based and clinical resources.

Nelson will compare results from program participants to those of veterans receiving regular VA primary care. The primary outcome to be compared is systolic blood pressure, from the beginning of the study to a one-year follow-up, but Nelson will also measure reductions in other cardiovascular risks such as tobacco use or cholesterol. The study is ongoing and it’s too early to tell whether the peer coaching program will lower blood pressure, but “We’ve had some really positive responses to the program,” said Nelson. “People really like the fact that they’re working with another veteran, and they feel like they can talk to that person in a different way than to a doctor.”

Studies such as Nelson’s Vet-COACH investigation are aimed, ultimately, at working closely with at-risk veterans to reduce their risk of worsening disease, improving their health and quality of life, and making optimal use of VA resources. Another ongoing HSR&D study, implemented on a broader scale, is similarly designed to evaluate a project for improving the quality of care for veterans with transient ischemic attack (TIA). The project is known as PREVENT (Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms).

TIA occurs when a temporary blockage of blood flow to the brain causes neurological symptoms such as slurred speech, numbness, or paralysis. While it’s sometimes referred to as a “minor stroke,” a TIA is a major warning: About a quarter of the people who have a TIA go on to have a more severe stroke or other serious adverse health event within a year. According to PREVENT program manager Barbara Homoya, MSN, a research nurse at HSR&D’s Center for Health Information and Communication (CHIC) at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana, the mortality for people with TIA is similar to that of patients who present to an emergency department with chest pain. “About 11 to 12 percent of them die within a year,” she said. “And the problem with TIA is these patients look fine. They’re not clutching their chests. So there’s often a lack of urgency.”

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A previous VA-funded study by Dawn M. Bravata, MD, a CHIC core investigator and professor of medicine at Indiana University, showed that only 1 in 4 veterans with TIA receive “without-fail care”: all of the care for which they are eligible among processes that have been proven effective and should be routinely available to patients with TIA. After collecting data from the VA’s Corporate Data Warehouse, the research team composed algorithms to calculate which processes of care would provide the most improvement for veterans with TIA, in terms of recurrent events or mortality. The algorithms yielded seven processes that should be considered “without-fail care” for patients with TIA, Homoya said. “They are brain imagining, carotid artery imaging, neurology consultation, antithrombotics, high and moderate potency statins, anticoagulation for those veterans who have atrial fibrillation, and hypertension control,” she said. “And what we’ve found is that timely care – which means within the first few days, when the highest mortality occurs – can reduce recurrent events by 70 percent, and mortality can be reduced by about one-third. This is the kind of improvement that you very rarely see in medicine.”

Transient ischemic attack, sometimes called a “minor stroke,” occurs when a temporary blockage of blood flow to the brain causes neurological symptoms such as slurred speech or paralysis. The VA’s PREVENT program aims to provide VA facilities and health care providers with the resources and information necessary to ensure veterans receive the best possible treatment for TIA.

The goal of the PREVENT program is to provide VA facilities and care providers with the information and resources they need to ensure veterans with TIA receive the kind of care that will yield these outcome improvements. PREVENT resources include professional education and support, clinical support, and data resources to close knowledge gaps. “One of those is an interactive web platform that we call the PREVENT hub,” said Homoya. “It provides data to the sites that previously was not available to them, on over 20 processes of care as well as outcome measures such as mortality, percent of admission, and followup visits within 30 days.” These data are collected from all VA health care facilities nationwide.

PREVENT hub data has yielded valuable information, revealing gaps between the care veterans receive and what VA researchers have identified as without-fail care. For example, Homoya said, it showed that while many veterans with TIA were prescribed statins, not all were receiving the moderate- to highintensity statins recommended in TIA care guidelines. “There was a real deficit there,” she said. “Educating pharmacists and providers about the guidelines was a really key piece for them to improve care to those veterans.”

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PREVENT began in July 2017 as a pilot project at six sites in the VA, where nurse facilitators guided local care teams in reviewing the available evidence that supported the importance and urgency of TIA care, formulating goals based on self-identified quality of care and existing barriers, and then implementing their customized quality improvement programs. The dramatic improvement in TIA care at these six sites led to the VA’s attempt to roll it out to all VA facilities nationally. Homoya and PREVENT staff members have been meeting in information sessions with chiefs of neurology, emergency department directors, and chief medical officers and providing support to patient-aligned care teams (PACTs). “We’ve been getting the word out,” said Homoya. “And we now have almost 80 additional sites that are utilizing the PREVENT hub. We have almost 200 new users. There are a couple of VISNs [Veteran Integrated Service Networks, or regional divisions of VA care facilities] that have made it a requirement for their facilities to do this quality improvement project.”

Emergency department staff and simulation trainers participate in the TeleStroke Program go-live training at the Las Vegas VA Medical Center on Jan. 18, 2018. The TeleStroke program connects veterans with VA stroke neurologists through live bedside telehealth video feeds. The National Evaluation of the VHA TeleStroke Program is currently underway to measure the success of the program’s implementation and to identify any areas for improvement.

The PREVENT project, then, transformed midstream from one type of investigation – measuring the effectiveness of a newly designed treatment, process, or protocol – into a study of how an already validated process is implemented throughout the VA. The rapid translation of research findings and evidence-based treatments into clinical practice is a key mission of HSR&D’s Quality Enhancement Research Initiative (QUERI), which for more than 20 years has been committed to ensuring that research is used to sustain improvements in care for veterans. The PREVENT project was one of five conceived under a nationwide QUERI program, the Precision Monitoring to Transform Care (PRIS-M) QUERI, which focuses on using existing data from VA patients’ electronic health records to improve health care quality and outcomes.

Another PRIS-M QUERI project, led by Linda Williams, MD, a CHIC core investigator and professor of neurology at Indiana University, is aimed at expanding the access of veteran stroke patients to the expertise of stroke specialists. The focus of this investigation, the National Evaluation of the VHA TeleStroke Program, is an intervention launched in 2017 to connect VA stroke neurologists to deliver services remotely through a live telehealth video feed at veterans’ bedsides in more than 30 VA medical centers. More than 1,000 emergency consults have been conducted via iPad tablets since the TeleStroke program began.

Access to expert care is critical for patients who suffer an acute stroke and who may benefit, for up to 4.5 hours after onset, from alteplase, a thrombolytic drug that breaks up blood clots. During every minute acute stroke care is delayed, an average of 1.9 million brain cells die, so access to a stroke specialist is critical. According to Holly Martin, project manager of the National TeleStroke Evaluation, TeleStroke began as a program to serve rural VA facilities that didn’t have access to acute stroke care, but it has since expanded beyond rural sites to reach veterans at any facility that does not have access to a stroke-trained neurologist. About 18 VA stroke neurologists are currently available to teleconference with veterans and VA providers around the country.

Measuring the success of TeleStroke implementation includes measures of baseline encounter rates between stroke patients and stroke specialists; whether stroke patients are being treated or transferred to facilities with stroke specialists; and how many acute stroke patients are treated (and how quickly) with alteplase. “This is a quality improvement project,” Martin said. “At this point, they’re wanting simply to count how many patients are served ... and even to see how many patients are eligible for treatment, because we didn’t have that information before. Because some had to immediately send patients with stroke symptoms to another hospital, the team will also eventually look at the impact of TeleStroke on transfer rates and cost savings for the VA. Our role as the evaluation team is to provide information as it’s being implemented so they can make changes, in real time, to improve the quality of the program.”

It will never be possible for the VA, or any large health care system, to have cardiovascular care experts at every one of its 153 medical centers, more than 700 outpatient, community, and outreach clinics, and 126 nursing home units, but through measuring the effectiveness of evidence-based interventions such as TeleStroke, VA health services researchers are working to ensure this expertise reaches as many veterans as possible.