The ability for providers to identify patients with the greatest potential for cardiovascular disease and manage outcomes using predictive modeling is at the forefront of analytic news today. In an article from Health IT Analytics, Dr. Gerard Martin, Chair of the American College of Cardiology’s (ACC) Population Health Policy Health Promotion Committee, suggests ”we [can] get away from actually treating more heart disease by getting engaged in prevention” using population health strategies and education.

Identifying and Addressing Risk to Reduce Burden

In the interview, Dr. Martin was asked about specific needs for managing and preventing cardiovascular disease. Citing the 57 percent increase in people impacted with cardiovascular disease by 2020, Dr. Martin said “we need to do something to prevent this growing burden of cardiovascular disease.”

Risk segmentation, the population health strategy of identifying patients in clinical practices according to chronic conditions such as diabetes and cardiovascular disease, improves the quality of life for identified patients while reducing the associated spending of managing these chronic conditions. “We’re collecting more data and we are learning so much about who is at risk as we look at the patterns of chronic disease.”

Tools to Improve Health Outcomes

In May 2014, SPH Analytics’ IndiGO decision support tool was included in a pilot project designed by 2 ACC chapters that earned a $15.8 million grant from the Center for Medicare and Medicaid Innovation. The project, SMARTCare, aims “to increase the percentage of stable ischemic heart disease patients with optimal risk factor modification and to reduce imaging procedures and percutaneous coronary interventions not meeting appropriate use criteria while achieving high levels of patient engagement and lower rates of complications” using 5 tools, including IndiGO individualized patient cardiac risk profile. Once affected patients are identified, or stratified, tools used in the project “help physicians and patients work collaboratively to make decisions” in line with care guidelines, reducing complications, and bringing about outcomes that improve quality of life for patients.

Clearly the ACC values risk stratification for collaborative decision making between targeted patients and their providers.

Collaboration That Leads to Patient Engagement (and less clinician intervention)

While Dr. Martin states, people are “now talking about how we need to prevent disease and deliver less care, “ a markedly provocative assertion, tools like IndiGO can create pathways for disease prevention through improved patient engagement and education. Using predictive modeling algorithms, IndiGO measures a patient’s risk of developing chronic conditions and presents them along with recommended interventions that can prevent onset of potential conditions. In the article, Dr. Marin discusses the importance of educating cardiovascular patients about tobacco exposure and the importance of measurement. Using the data available, providers can use IndiGO to discuss the benefits of prescription interventions and educate patients about the impact lifestyle changes, like smoking cessation, can have on the patient’s outcome. This kind of engagement makes Dr. Martin’s goal of preventing disease and delivering less care possible—not outrageous.

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