To Get Americans Healthier, U.S. Targets the Heart

HealthDay
April 25, 2011

People urged to eat better, exercise more before risk factors develop

U.S. health officials and the American Heart Association have put forth an ambitious set of goals for reducing deaths from heart attack, stroke and coronary heart disease.

The goals go further than just setting targets for limiting death and illness, however. They place even greater emphasis on prevention, calling for behavioral change that could benefit overall public health, if successful.

“The goal is to shift the population to a healthier lifestyle,” said Dr. Ralph L. Sacco, president of the American Heart Association and chairman of neurology at the University of Miami Miller School of Medicine. “It’s a much more prevention-oriented goal than we have had in the past.”

The goals are part of the Healthy People 2020 goals, issued by the U.S. Department of Health and Human Services and aimed at improving the nation’s health in the next decade. But with heart attack and stroke ranking first and third, respectively, on the list of leading causes of death in the United States, heart-oriented objectives form a substantial part of the initiative.

The program’s heart-health goals start with typical targets, calling for a 20 percent reduction in deaths from coronary heart disease and stroke. But then Healthy People 2020 goes further, setting goals for specific prevention activities, including:

• Increasing the number of people who have had their blood pressure and cholesterol tested recently. 

  ·         Increasing the number of people who have taken preventive measures to reduce high blood pressure or high cholesterol.

  ·         Raising awareness of the early warning signs and symptoms of heart attack and stroke.

  The American Heart Association takes this approach even further with what the organization calls its 2020 Impact Goal: to improve the cardiovascular health of all Americans by 20 percent while reducing deaths from cardiovascular diseases and stroke by 20 percent.

  The association has identified a set of health measures it refers to as “Life’s Simple 7,” which, if followed, will lead to good cardiovascular health. The measures are:

  ·         Get active. For most people this means at least 150 minutes of moderate intensity exercise or 75 minutes of vigorous intensity exercise each week.

  ·         Control cholesterol. Aim for a total cholesterol level of less than 200 milligrams per deciliter (mg/dL).

  ·         Eat better. Increase consumption of vegetables and fruits, whole grains and fish and cut back on fats and sodium.

  ·         Manage blood pressure. Keep the reading below 120/80.

  ·         Lose weight. Keep your body mass index (BMI) below 25. BMI is an indicator of body fatness calculated from a person’s weight and height.

  ·         Reduce blood sugar. Fasting blood glucose should be less than 100 mg/dL.

  ·         Don’t smoke.

  “The focus expands pretty broadly the concept of prevention, in that not only should we focus on prevention after someone has developed high-risk factors, we should also try to prevent someone developing those risk factors in the first place,” said Dr. Donald Lloyd-Jones, chairman of preventive medicine at Northwestern University’s Feinberg School of Medicine.

  Lloyd-Jones calls such an approach “primordial prevention” because it focuses on improving and maintaining the health of people who are already healthy.

  “Once you’ve developed risk factors, treatment can never restore you to the baseline risk factor of someone who has never had them,” he said. “Your chances of living a healthier, longer life with better quality of life are substantially better.”

  The cornerstone of “Life’s Simple 7″ are the goals related to diet, exercise and smoking, Sacco and Lloyd-Jones said, because improving those three factors will prompt better overall health.

  “When you start with behavior like diet and physical activity, it improves everything else,” Sacco said. “They’re all kind of interlinked.”

  To pursue these goals, health officials will have to change their own behavior as well, Sacco and Lloyd-Jones said.

  Sacco predicts that health behavior scientists who study how people view and pursue a healthy lifestyle will have a greater role to play over the next decade. Motivational counselors and fitness counselors also will be needed to help keep people focused and inspired.

  “People who are in advertising work very effectively to advertise products and change behavior,” he said. “We have to do just as well to market healthy behaviors. We also have to constantly assess what programs or procedures or activities are effective in changing the behavior. It’s one thing to understand the cause and it’s another thing to intervene, and we really want to focus on intervention.”

  The goals also will require some changes in public policy. Examples include designing communities to promote walking, increasing access to fresh fruits and vegetables nationally, and working with manufacturers to reduce levels of sodium in food, Lloyd-Jones said.

  Public policy can be key in promoting overall public health, he said, noting the increasing number of indoor smoking bans across the country.

  “The data are unequivocal,” Lloyd-Jones said. “Hospitalization rates for heart attacks drop dramatically within months of the institution of an indoor smoking ban.”

  Sacco and Lloyd-Jones admit that the goals set by the government and the American Heart Association are ambitious, but well worth striving toward.

  “I think they are what I would call ’stretch’ goals,” Lloyd-Jones said. “But the truth is, if we are even mostly successful in the next decade, then the benefits we will see will be enormous. We must start now.”

Shorter Hospital Stays, More Readmissions After Hip Replacements

HealthDay
April 20, 2011

Many patients also discharged to skilled nursing facilities, long-term analysis of Medicare data shows

People who have hip replacement surgery now spend far shorter recovery time in hospital than they did almost two decades ago, but discharges to nursing facilities and readmissions to hospitals have soared as a result, Iowa researchers report.

Using Medicare data on more than 1 million hip surgeries done between 1991 and 2008, the researchers found that hospital stays are now averaging under four days, compared to more than nine days in the 20th century. However, the number of hip-surgery patients discharged to a skilled nursing facility nearly doubled during that time frame, from 17.8 percent to 34.3 percent; hospital readmission rates went from 5.9 percent to 8.5 percent; and the percentage of those discharged home decreased dramatically, from 68 percent to 48.2 percent.

“Both primary and revision hip arthroplasty are safe and mortality is low, but hospital stays are [now] extremely short. And, as patients’ length of stays go down, there’s less time to recuperate, and even if they’re not yet ready to go home, they have to go somewhere else quickly, and more are being admitted to rehabilitation centers,” explained the study’s lead author, Dr. Peter Cram, an associate professor in the division of general internal medicine at the University of Iowa Carver College of Medicine in Iowa City.

“This is part of what’s so complicated in the political discussions on healthcare,” he added. “You’re really just squeezing a balloon here. If we reduce the length of stay in the hospital, we can save money, or at least it seems like a way to save money. But, when we squeeze the balloon on one end to reduce length of stay, other costs pop up on the other side of the balloon.”

Pointing to the increased hospital readmissions and discharges to nursing homes, he said, “This is why it’s so hard to reduce or contain healthcare costs.”

Results of the study are published in the April 20 issue of the Journal of the American Medical Association.

Each year, about 280,000 Americans undergo hip replacement surgery, at a cost of more than $12 billion, according to background information in the study.

In the current study, Cram and his colleagues reviewed Medicare Part A data on over 1,450,000 total hip arthroplasty procedures (hip replacement surgery) and almost 349,000 revision hip arthroplasties (artificial hip repair surgery) done between 1991 and 2008.

The average age of people undergoing hip replacement rose slightly from 74.1 to 75.1 over the study period. The age of those having revision surgery went up even more, from 75.8 years old to 77.3.

The number of other medical conditions that those undergoing total hip replacement surgery had increased from an average of one to an average of two between the 1990s and 2008. For those undergoing hip repair, the number of other illnesses went from 1.1 to 2.3 during the study period.

The study did have some good news, however: in-hospital mortality rates after total hip replacement fell from 0.5 to 0.2 percent over the study period, while the 30-day post-op mortality rate fell from 0.7 to 0.4 percent.

Still, the upsurge in post-replacement nursing home care and hospital readmissions is worrisome and expensive, one expert said.

“This trend added significant additional costs back into the system,” noted Dr. Joseph Zuckerman, chairman of the department of orthopaedic surgery at the NYU Hospital for Joint Diseases and the NYU Langone Medical Center in New York City.

And he added, “Of greater concern is the fact that, at the same time discharges to skilled nursing facilities were increasing, so did the readmission rate for hip arthroplasty — increasing from 5.9 to 8.5 percent, adding not only additional costs, but raising concerns about the quality of care provided.”