Co-Author: Michael W. Hartley, M.H.A.
The VA Cooperative Studies Program and the Canadian Institutes of Health Research conducted the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial. The randomized, controlled study, whose results were presented at the 56th Annual Scientific Session of the American College of Cardiology and published online in the New England Journal of Medicine, involved 2,287 patients with stable coronary artery disease treated at 15 VA Medical Centers, as well as 35 other U.S. and Canadian medical facilities. Dr. William E. Boden, of the Western New York VA Healthcare System in Buffalo, led this study, which was conducted between 1999 and 2004. Results of the study showed that coronary angioplasty combined with treating patients with medications is no better at reducing the risk of heart attack or death in patients with stable heart disease than treating patients with medications alone. All participants received optimal medical therapy, which consisted of multiple medications including drugs to lower blood pressure and cholesterol and prevent clots and lifestyle programs for smoking cessation, physical activity and nutrition. The Veterans Health Administrations (VHA) cardiovascular health initiatives are built on disease prevention, patient education and the expansion of knowledge and skills of clinicians. The initiatives include aggressive risk factor modification, such as the patients weight and general fitness, blood pressure control, hypertension, diabetes control, cholesterol levels, and tobacco use. The VHA has developed rigid preventative programs targeting each of these risk factors, including the routine monitoring and tracking of blood pressure and cholesterol levels for all patients. Effective smoking cessation programs have helped to significantly reduce the disproportionately high number of veteran smokers (34%), compared to the general population (23%). Examples of these programs include the elimination of co-payments for outpatient smoking cessation services, access to highly effective smoking cessation medications such as the nicotine patch or gum through VA pharmacies, and counseling and treatment have become a routine part of care for patients who smoke. The VA also has developed programs to train mental health professionals on how to integrate smoking cessation into routine mental health care for their patients, as individuals with psychiatric disorders are at a much higher risk for smoking-related illnesses. Additionally, a national weight management program, designed by the VA National Center for Health Promotion and Disease Prevention (NCP), was instituted to help veterans lose weight and improve their health. The program, titled Managing Overweight/Obesity in Veterans Everywhere (MOVE), emphasizes health and wellness through nutrition and physical activity behavioral change, is patient centered, and is individually tailored to meet each patients needs. We have made significant progress at the West Palm Beach VA Medical Center in working towards these goals. In-depth chart reviews by an independent external review organization indicate the following: 85% of patients with previous acute myocardial infarction maintain their LDL-c < 100 and have had a full lipid panel in the past two years, 95% of outpatients with an active diagnosis of hypertension had a blood pressure less than or equal to 160/100 at their last visit, 100% inpatients diagnosed with either community acquired pneumonia or heart failure received tobacco counseling during their hospital stay, and only 7% of patients reported using tobacco in the past twelve months. Also noteworthy is an internal study conducted by our board-certified cardiologists, whose results indicated of the 6,300 patients who have been seen and treated during the first two quarters of FY 07, 100% were on aspirin, 95% were on beta blockers, and 95% were on cholesterol lowering medications. Through fundamental ideological and organizational changes, the Veterans Health Administration has developed a system of clinical measurement tools that enables us to monitor and improve on the quality of care delivered to our most deserving veteran patients. We have become the benchmark in the delivery of high quality, cost effective health care and are well established in the clinical research and medical education community.
