Abstract 19: Impacts of the Million Hearts® Cardiovascular Disease Risk Reduction Model on the Initiation or Intensification of Statins and Anti-hypertensive Medications: A Pragmatic, Cluster-randomized Trial
Authors: Peterson G. G , Pu Jia , Magid David J , Barterian Linda , Barna Michael , Conwell Leslie , Rose Adam , Kranker Keith , McCall Nancy , Markovich Patricia 
Published: May 2020

Introduction:
The Million Hearts® Cardiovascular Disease (CVD) Risk Reduction Model pays providers for measuring cardiovascular risk among their Medicare beneficiaries and for reducing risk among their high-risk patients. The Centers for Medicare and Medicaid Services (CMS) is testing whether this model can improve cardiovascular care and reduce the incidence of first-time heart attacks and strokes over 5 years. This study assesses whether, in its first 2 years, the model (1) increased use of CVD medications among those with elevated blood pressure or cholesterol, and (2) increased provider awareness of CVD risks among their patients.

Methods:
In this pragmatic, cluster-randomized trial, CMS enrolled 516 organizations (primary and specialty practices, health centers, and hospitals) throughout the country and assigned half to the intervention group. Organizations enrolled beneficiaries (age 40-79 without a prior CVD event) during routine office visits. We linked enrollment and clinical data with Medicare Part D claims and estimated impacts as intervention-control differences in outcomes. We surveyed one randomly selected provider in each organization about their use of risk CVD stratification (70% response rate).

Results:
The intervention and control organizations enrolled 300,550 Medicare beneficiaries. In both groups, 18% of enrollees were high risk per CMS definitions (≥30% or higher risk of a heart attack or stroke in the next 10 years), 40% were medium risk (15-30% risk), and the remainder were low risk (<15% risk). While almost all high-risk enrollees were taking anti-hypertensive medications or statins at baseline, most (90%) had elevated blood pressure, cholesterol, or both. High-risk enrollees in the intervention group were 4 percentage points more likely than control enrollees (28 vs 24%, p<0.001) to initiate or intensify statins or anti-hypertensive medications within 6 months of enrollment. When including the larger medium-risk group—for whom CMS does not separately pay for CVD risk reduction—rates of initiation or intensification were 3 percentage points higher in the intervention versus control groups (23 vs 20%, p<0.001). According to the survey, intervention group providers were much more likely than control group providers to risk assess at least half of their Medicare patients (71 vs 39%, p<0.001). Most intervention group providers (73%) said that their greater use of risk stratification helped them better identify beneficiaries at risk of CVD events.

Conclusions:
The Million Hearts model significantly improved use of CVD medications among high-risk enrollees, mainly through intensification, and had positive spillover to the much larger medium risk group. These improvements were likely driven, at least partly, by providers become more aware of their patients’ CVD risk through greater use of risk stratification.