Cardiometabolic Interventions Focus on Accessibility, Evidence-Based Medicine

The American Journal of Accountable Care. 2024;12(2):43-45. https://doi.org/10.37765/ajac.2024.89571

An evening of presentations by experts from Sutter Health illuminated the current state of cardiometabolic health care and offered a glimpse into the future. With discussions of innovation in pharmacology and approaches aimed at mitigating health disparities, the Institute for Value-Based Medicine^® event, hosted by The American Journal of Managed Care^® (AJMC^®) in partnership with Sutter Health in San Francisco, California, offered valuable perspectives on disease management, specialty pharmacy services, health equity, and evidence-based medicine.

Expanding Access to Care Using Virtual Population Health Teams

In the first presentation, event cochair Ryan Stice, PharmD, BCPS, chief pharmacy officer at Sutter Health, emphasized understanding patient needs and utilizing programs such as the 340B Drug Pricing Program to provide comprehensive patient care support through specialty pharmacy services. He showcased the success of a clinical study within Sutter Health’s virtual pharmacy ambulatory care clinic, which resulted in a 75% reduction in cardiac-related hospital admissions and a significant 39% increase in patients achieving their medication goals (full guideline-directed medical therapy).

“Because of my passion for health care leadership, the area of my focus is access to medications,” he said. “I picture prescription bottles surrounded by barbed wire; it really speaks to me. It’s something that I’ve seen throughout my career, the barriers that our patients experience when trying to access medical care: high costs, growing high-deductible plans, and so forth.”

Stice gave a comprehensive overview of 3 primary models of care, each tailored to specific needs within health care. He shifted the conversation from the traditional fee-for-service model toward innovative approaches within the realm of value-based care and specialty pharmacy services. In the value-based care framework, Stice emphasized achieving improved outcomes while alleviating financial burdens for patients. The concept of providing ambulatory care with no out-of-pocket costs was demonstrated as a proactive measure to keep patients out of the hospital, thereby reducing overall health care expenses and enhancing patient well-being.

Exploring the intricacies of leveraging the 340B program to provide comprehensive patient care support through specialty pharmacy services, Stice explained that this model, characterized by integration, hinges on understanding patient populations and identifying key areas for intervention. The 340B program requires manufacturers to sell covered outpatient drugs to eligible entities—including children’s hospitals, critical access hospitals, and hospitals with a disproportionate share of low-income individuals—at a price not to exceed an amount determined under a statutory formula, resulting in significant discounts.¹ By identifying more than 11,000 patients with heart failure and analyzing internal data to pinpoint areas for improvement, Sutter refined the strategic approach to addressing health care challenges through 340B, Stice said.

He further delved into the process of translating clinical outcomes into financial benefits, acknowledging the importance of demonstrating a positive return on investment. By analyzing real-world data and applying financial metrics, Stice demonstrated the potential financial benefits of implementing innovative health care interventions.

Key action items emerged from Stice’s discussion, including expanding the virtual pharmacy ambulatory care clinic program to encompass additional disease states and address capacity issues. There was also a consensus to continue presenting results from the program at conferences such as the American College of Cardiology to share insights and foster learning within the health care community. Additionally, collaboration with specialist physicians was deemed essential to establish robust referral processes between advanced-practice pharmacists and specialists, facilitating seamless patient care. Further developing the pharmacotherapy clinic model to treat more patients with high-cost drug therapies and streamlining the prior authorization process were identified as crucial steps to enhance patient outcomes and program efficacy.

“We find that just leaving a physician’s office with that prescription is not enough—they need that coach, that frequent follow-up, that partner in their journey to achieve the right level of care that they need,” Stice said in an interview with AJMC.

Equitable Treatment in Cardiometabolic Health Across the Lifespan

“It’s really important to think through, not only that these [racial and ethnic disparities] are happening, but they’re [also] happening for a reason,” Rashon Lane, PhD, MA, senior health equity researcher at Sutter Health, said in an interview with AJMC. “And in the way that we intervene on those things, we need to be mindful of what root causes we’re addressing to fully address the issue. Not just understanding pharmacological treatment or understanding access to care but [understanding] that there are issues within an individual’s community, within society, within policies that all impact an individual’s cardiovascular and cardiometabolic health.”

Lane, who previously worked at the CDC, shared in her presentation how she developed health equity indicators for cardiovascular disease after closely examining 20 years of peer-reviewed literature to understand the significant health disparities affecting racial and ethnic minority communities. Looking beyond the outer layer of her construct, which included racism, classism, genderism, and sexism, she drew attention to social determinants of health, calling for the adoption of a multifaceted approach encompassing policy changes, community engagement, and cultural competency training for health care providers to effectively address disparities.

These disparities even precede birth, Lane explained, focusing on data on neonatal outcomes among women with diabetes. “Across our system, we see that Black or African American [individuals] and those who are American Indian, Alaskan Native, or Indigenous were more likely to have gestational diabetes but also experienced preeclampsia, had higher [cesarean delivery] rates, were more likely to have a neonatal death, and [had] other neonatal poor outcomes,” she said.

Addressing racial and ethnic disparities in access to care and medication use was prominent in her talk, with a focus on rectifying inequities in medical treatment and pharmaceutical access. Lane concluded by reflecting on the structural inequities contributing to health disparities, such as housing inequities, and prompting the audience to think about “where we are in health care right now and what still remains unexamined.”

Cardiometabolic Benefits of SGLT2 Inhibitors

Cochair Sophia Humphreys, PharmD, MHA, BCBBS, director of system pharmacy formulary management and clinical programs at Sutter Health, gave a presentation on the critical role of evidence-based medicine and cost reduction strategies in chronic disease management, particularly focusing on diabetes and heart failure. Humphreys explained the importance of understanding risk factors and mechanisms of action when expanding medication usage across multiple integrations.

She addressed the issue of financial burden associated with medications for patients with diabetes and heart failure, particularly those reliant on Medicare, citing study results showing that higher out-of-pocket costs lead to prescription abandonment among this population. She also emphasized the necessity of comprehensive care and reduced overall care costs to enhance patient clinical outcomes and quality of life.

“As you know, our population is aging. As our population ages,…we’re seeing obesity become more and more prevalent. With obesity, we see higher risk and higher incidence of diabetes. That’s why we see the growing epidemiology of diabetes,” Humphreys said in an interview with AJMC. “Diabetes is a higher risk factor for both stroke and cardiovascular issues. And we are seeing a high burden on our patients as well as our health care system.”

Her presentation delved into the cardiometabolic benefits of sodium-glucose cotransporter 2 (SGLT2) inhibitors in type 2 diabetes and their capacity to reduce glucose and sodium reabsorption, lower blood pressure, and mitigate inflammation. She emphasized the significance of managing heart failure and chronic kidney disease in patients with type 2 diabetes, shedding light on the pivotal role of SGLT2 inhibitors in addressing these comorbidities.

“When we looked at the glucose reduction, and when we compared it [with] other classes of medication that also reduce blood glucose level, we saw other agents that lower glucose level—either similar to SGLT2s, or even to a better degree than SGLT2s—did not display the same cardiovascular benefits as SGLT2s,” she said.

She emphasized providing comprehensive and integrated care, fostering a collaborative team approach to patient care, and leveraging evidence-based guidelines and decision-support documents to guide physician and pharmacist practice.

Improving Cardiometabolic Health Using a Continuous Glucose Monitor

“Heart disease does continue to be the No. 1 global cause of death in men and women, and nearly 40% of the US population has prediabetes,” Ronesh Sinha, MD, an internal medicine physician at Sutter Health, said in his presentation.

Sinha detailed the challenges associated with managing cardiometabolic disease in primary care settings. He stated the necessity of scalable interventions to assist patients in making lifestyle changes, particularly regarding diabetes management. Sinha emphasized lifestyle changes overreliance on medication alone to address the root causes of diabetes, and he discussed the potential of continuous glucose monitoring (CGM) coupled with personalized coaching.

This approach can be implemented for diverse ethnic groups as a means to improve disparities in diabetes management, Sinha noted. He discussed successful interventions from his CGM program at Sutter Health, including how CGMs can help improve health equity.

The US population has seen a notable increase in heart attack deaths among millennials,² said Sinha, who also explained insulin resistance’s detrimental impact on health, including its contribution to fat accumulation in the liver and elevated blood sugar levels. He offered practical ways to identify insulin resistance, such as waist circumference measurements and liver function tests, and noted insights from Sutter Health indicating a high prevalence of insulin resistance among adult patients, prompting the development of scalable interventions.

Sinha explored the benefits of patients using CGMs, which provide real-time glucose data for both patients and health care providers. He explained the workings of the scalable metabolic program incorporating CGM data and lifestyle changes, which has led to success in reducing hemoglobin A1C levels among patients with insulin resistance. Collaboration with health care systems and internal resources was crucial for scaling the program, he said.

“The nice thing about growing a program within the health care system is our physician colleagues learned about it very early on. They have a lot of trust in our program, so they’re referring patients into it,” Sinha said in an interview with AJMC. “We’ve had a very critical partnership with Sutter Pharmacy, and Sutter Pharmacy is the one that actually helps prescribe with me.”

Concluding his presentation, he expressed the importance of customizing nutrition information for different ethnic groups and how CGMs are valuable tools in improving dietary habits and reducing diabetes risk across diverse populations.

Author Information: Ms Grossi is an employee of MJH Life Sciences^®, parent company of the publisher of The American Journal of Accountable Care^®.

REFERENCES

1. Jeremias S. Panelists highlight gaps in research on whether 340B discount program is working. AJMC. October 19, 2023. Accessed April 30, 2024. https://www.ajmc.com/view/panelists-highlight-gaps-in-research-on-whether-340b-discount-program-is-working

2. Smith MB. Doctor sounds alarm: millennials having more heart attacks. Sutter Health. April 13, 2023. Accessed May 1, 2024. https://vitals.sutterhealth.org/doctor-sounds-alarm-millennials-having-more-heart-attacks