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Spreading Health: Reducing heart attacks and strokes with those at highest risk.

What if there were a simple treatment that was proven to prevent heart attacks and strokes in people with diabetes?

In truth, this isn’t a “what if” scenario.  This exists right now.

In fact, Kaiser Permanente is furthering its reach to low-income populations with this simple treatment that has been preventing thousands of heart attacks and strokes in diabetic patients.

The organization released a video (posted above) to 55 community clinics across the country to help patients understand the significance of a treatment that could save their lives. The video (also available in Spanish) explains about a program – called “ALL/PHASE” – that includes the use of three low-cost medications to reduce heart attacks and strokes.

Since 2007, more than 60 of Kaiser Permanente’s community partners in California, the Northwest, Mid-Atlantic States and Colorado have implemented ALL/PHASE, improving the health of nearly 100,000 low-income diabetic patients.

To learn more about the benefits of the program and community outreach, we reached out to Kaiser Permanente’s Jim Dudl, MD, diabetes clinical lead, Care Management Institute, and Winston Wong, MD, medical director and community benefit director, Disparities Improvement and Quality Initiatives.

How did Kaiser Permanente’s ALL/PHASE program come about?

Dr. Dudl: “The ALL (Aspirin, Lisinopril, and a lipid-lowering medication) initiative was developed by Kaiser Permanente in 2003 to reduce cardiovascular disease among our diabetic patients over age 50 by prescribing the ALL triad of medications. It was critical to us because heart disease and stroke was – and still is – the leading cause of death and disability in the United States and the world. People with diabetes are two to four times more likely to have a heart attack or stroke and 65 percent of those will die from one of those events. But it can be prevented with this very simple and cost effective treatment.

There have a few regional variations to the program over the years to include the promotion of healthy lifestyle changes. Northern California added PHASE (which stands for Preventing Heart Attacks and Strokes Everyday). In Southern California, we have ALL HEART (Heart Smart Diet, Exercise, Alcohol Limits, Rx Medicine Compliance, and Tobacco Cessation Aspirin Lisinopril and Lipid lowering). Whether it’s ALL/PHASE or ALL HEART, the central component is the same, which is the use of the three medications.

What benefits did this program have on Kaiser Permanente members?

Dr. Dudl:  We found that over a three year period, 70,000  Kaiser Permanente members who took both the Lisinopril and the lipid lowering pills lowered their incidence of heart attacks and strokes by more than 60%. The evaluation also proved that if administered to the entire Kaiser Permanente diabetic population, ALL/PHASE would prevent more than 8,000 hospitalizations for heart attacks and strokes each year.

Based on this great success, we knew we wanted to share ALL/PHASE more broadly.

Why did you reach out to community clinics specifically?

Dr. Wong:  Kaiser Permanente is committed to its partnerships with the institutions that serve on the front lines of health care for the uninsured and underserved. These relationships are critical to fulfilling our mission, which is to provide affordable, high quality healthcare services to improve the health of our members and the communities we serve. We do this by investing in quality improvement and population health and support efforts which will transform care and improve health care access for our most vulnerable populations. Sharing our ALL/PHASE initiative is a perfect example of how we can do that.

In 2007, we began working with our partners to support them with ALL/PHASE implementation. Our strategy was to keep the central focus on the simplified delivery of the three medications and community partners could use the tools, teams and approaches that are unique to their own systems. We could further assist them with funding, technical assistance, and other support to help expand the program within their clinics.

Are low-income populations and minorities more at risk for cardiovascular disease?

Dr. Wong:  Consider this statistic – while death rates from heart disease and stroke have declined overall, premature cardiovascular deaths among non-Hispanic blacks remain 50% higher than non-Hispanic whites. That’s disturbing. It is not tolerable. We are not just talking about death rates; we are talking about premature death rates -individuals who are in the prime of their life. It is not natural that African Americans have a premature death rate and this country’s health care system has to take some accountability. Equity needs to be at the core and the basis in achieving success around health care quality and that’s where ALL/PHASE work comes to be.

Are you pleased with the results ALL/PHASE has been having on community clinics?

Dr. Wong:  More than 60 of our community partners throughout California, the Northwest, Mid-Atlantic States and Colorado have implemented ALL/PHASE, improving the health of nearly 100,000 low-income diabetic patients. It’s a remarkable story and I wish we had more stories like this throughout medicine.

What can’t be undermined is the importance of partnerships. Our relationships with our community partners have never been one of ‘Here’s a grant, good luck to you.’ Instead we allow them to customize the program to their patients and to think about how they can activate their own physicians, health care teams and their communities. As much as we do at Kaiser Permanente and what our community partners do to bring best practices to communities, it doesn’t change the needle on the dial around disparities until you think about what partnerships really mean.

What was the reason for the patient video and how will it be used?

Dr. Dudl:  To make implementation happen. A key principle of implementation is to “make it easy to do the right thing.” We show the patient how safe and easy it is to just take the three medications. We also make it easy for the provider by giving the patient all the standard information they need before starting the medication. This allows the practitioner time to focus on the patients’ questions and concerns, which are critical to starting the medication.



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