# Presentation: 719951

## Stroke & Heart Attack Prevention Program(SHAPP)

**Patricia Jones, R.N., CDE**
**State Nurse Consultant**
**September 20, 2007**

**Notes:**
It is a pleasure to be here and talk with you about GA’s Stroke and Heart Attack Prevention Program.
Thank planning committee, Linda, Margaret and Sherene, and folks at ORISE for their assistance.
The early beginnings started in 1964 with a grant from US Public Health Service to GA PH to test the effectiveness of PHN intervention on BP control. After 2 years BP control rates improved from 50 to 80%.
1973 Killers and Cripplers Program showed need for new public health programs to address heart disease, cancer and stroke.
1974 Gov Carter and the Legislature appropriated state funds for PH Hypertension Program. Five districts initially funded then with addition of federal funds in 1976, a total of 15 districts were funded in addition to one contracted agency.
The early beginnings started in 1964 with a grant from United Public Health Service to GA PH to test the effectiveness of PHN intervention on BP control. After 2 years BP control rates improved from 50 to 80%.
1973 Killers and Cripplers Program showed need for new public health programs to address heart disease, cancer and stroke.
1974 Gov Carter and the Legislature appropriated state funds for PH Hypertension Program. Five districts initially funded then with addition of federal funds in 1976, a total of 15 districts were funded in addition to one contracted agency.

## Evaluation of The Stroke and Heart Attack Prevention Program

**Full report of the CDC commissioned study may be found in Preventing Chronic Disease: Public Health Research, Practice and Policy, Vol.3: No.1, January, 2006.**
***	***
***	******A Cost Evaluation of the Georgia Stroke***
***	******and Heart Attack Prevention Program***
**	**
**Rein DB, Constantine RT, Orenstein D, Chen H, Jones P, Brownstein JN, et al.**

**Notes:**
I do not plan to go into detail of the evaluation but will be happy to answer questions during the discussion part of this session.

## Participant’s Comments

**“****Because the prescriptions they give me, I have so many, they cost anywhere from $90 to $120 I do fine, you know. I have got off of it and it shot right back up. So I think it saved my life.”**

**Notes:**
These are participant comments during the focus groups that RTI conducted during the CDC funded study of SHAPP in 2004-05. The comments are similar to those we hear at the state office and when we conduct site visits and basically sum up what SHAPP means to many citizens of Georgia.

## Major Components

**Education/Awareness, Screening and Detection Services **
**Monitoring and evaluation**
**Pharmacological and non-pharmacological management based on Nurse Protocol **
**Hypertension Workshops-Staff Training**

**Notes:**
This slide lists the major components of SHAPP.
-Education/awareness, screening is the outreach and early detection component.
-Monitoring and evaluation-clients often referred by physicians for monitoring and counseling. 
Pharmacologic and non-pharmacologic management is based on the Hypertension Nurse Protocol. JNC (currently is the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure). The protocol undergoes annual review and revision and is approved by an outside specialist.
-In Georgia, advanced practice nurses do not have prescriptive authority so PHN’s work under Nurse Protocol Law which requires training in each component of the Protocol. The workshops are a 2 day program  that provides training in nutrition, pharmacology, physical activity, tobacco cessation, education principles, and program evaluation. Under the QA/QI requirements, PHN’s must complete the training every 3 years in addition to annual updates on changes in the protocol.  HCP’s from outside of PH are invited and we often have participants from the federally qualified CHC’s attend.

## Eligibility for SHAPP

**Education and awareness, screening and detection provided to all sectors with special emphasis on populations at higher risk**
**Diagnosed with Primary Hypertension**
**18 years of age or older**
**Not to exceed 200% of poverty**
**Proof of no prescription drug coverage**

**Notes:**
In 2006, 15, 718 clients were served in 137 SHAPP Clinics.
55% were African Americans.
71% were females
74% were less than 65 years of age.

## SHAPP Funding 

**Preventive Health Block Funding=$1.2 Million**
**State Funding=$1.1 Million**
**Distributed to Districts as Grant in Aid=$1.1 Million**

**Notes:**
Current funding level is on the slide.
I do not have earlier funding levels but know that in the early 90’s and again in the mid 90’s funding was significantly reduced and every year elimination of the program has been proposed but thanks to the efforts of AHA, community advocates and friends, and several legislators funding has been restored to the budget.

## SHAPP Costs

**Annual medication cost in 2006 approximately $12.76 per patient.**
**Clinic costs range from $20 to $55 per visit.**
**Clients generally seen on quarterly basis.**

**Notes:**
Drugs are purchased using MCAP pricing. 
Clinic costs vary across the state and depend on the extent of the visit and whether services are provided by contract physicians, Nurse Practitioners or expanded role nurses.
Clients are generally seen quarterly once BP control is established and maintained. It should be noted that when clients are seen more frequently the mean control rate for the clinic is higher.

## Cost Effectiveness 

**One calculation estimated that every $1 spent for SHAPP resulted in $9 societal savings (AHA)**
**Cost per patient receiving**
**No Treatment=$534**
**National Treatment=$595**
**SHAPP=$486**

**Notes:**
The first estimation is based on calculations done by Drs. Mike Frankel (Emory), Dr. Ken Powell (GDPH) and Dr. George Howard from UAB that estimated that SHAPP treatment prevented about 300 events (85 strokes and 213 MIs) and translated that to $63,000 saved for each event prevented.
The second set of figures were calculated by RTI economists as part of the study commissioned by CDC.

## SHAPP Control Rates

|  | FY99 | FY01 | FY02 | FY03 | FY04 | FY05 | FY06 |
| --- | --- | --- | --- | --- | --- | --- | --- |
| # 
Clients
served | 17,875 |  |  | 19,611 | 17,138 | 15,289 | 15,718 |
| Mean 
BP 
Control
Rate | 48% | 47% | 51% | 58% | 58% | 59% | 65% |

**Notes:**
Earlier control rates were based on random sampling by the District SHAPP Coordinators. In FY03, Dr. Kristen Mertz who was with GDPH Epi section and I revised reporting requirements in response to a need to demonstrate more accurately the accomplishments and impact of SHAPP. Now each clinic submits an aggregate report that reports # clients seen, age, race and gender, #of visits, control rates, # of medications required, and counseling components among other elements. Also, it was in FY02 when the QA/QI requirements were implemented.

##  Internal Partnerships

**Cardiovascular Health Initiative**
**Epidemiology**
**Office of Nursing**
**Office of Nutrition **
**Office of Pharmacy**
**Physical Activity Program**
**Tobacco Use Prevention Program**

**Notes:**
-CVHI-support and efforts to increase awareness and importance of hypertension control.
-Epi with guidance and assistance with data collection and interpretation
-OON-Nurse Protocols, QA/QI efforts
-OO Nutrition-workshops and protocol
-OO Pharmacy-drug purchasing and protocol
-PA-workshops and protocol
-TUPP-One year after adding assessment for tobacco use and referral to the QuitLine, the % of SHAPP smokers declined 2% in one year. workshops

## External Partnerships

**American Heart Association**
**American Stroke Association**
**Community Cardiovascular Council of Savannah**
**Participating Public Health Districts**
**Tri State Stroke Network**

**Notes:**
AHA and ASA support and advocacy
CCC contract services and outreach efforts, training of Savannah Firefighters to do BPs and outreach about the S&S heart attack and stroke, and to call 911
PH Districts for outreach and providing SHAPP services in the clinics
TSSN for support and opportunities for collaboration

## Contact Information

**Karen Boone, MN, MPH, APRN, BC**
**Nurse Consultant, SHAPP Program Manager**
**Phone: 404-657-663 Fax: 404-657-4338**
**kaboone@dhr.state.ga.us**
**or**
**Patricia Jones, RN, CDE**
**Phone: 404-657-6636 Fax 404-657-6631**
**pmjones@dhr.state.ga.us**

**Notes:**
As of Feb. 2007, Karen Boone is the SHAPP Nurse Consultant and Program Manager
I am now working with the HDSP program.