- Kaiser Permanente’s Preventing Heart Attacks and Strokes Everyday (PHASE) program can reduce cardiovascular disease risks in patients with diabetes and improve population health, according to a study published in the American Journal of Medicine.
"People with diabetes face a higher risk of stroke and heart attack, but controlling key risk factors is a real challenge," Jamal S. Rana, MD, PhD, cardiologist at Kaiser Permanente Oakland Medical Center and adjunct researcher at the Division of Research, said in a statement.
PHASE combines medications and lifestyle changes to provide comprehensive, cost-effective treatment for patients with existing heart disease or those at greatest risk of developing it.
The program uses a patient registry to identify patients who may benefit from intensive interventions. Each patient is then treated by a comprehensive care management team according to recommendations from a continually-updated algorithm.
Kaiser Permanente has partnered with different organizations to implement PHASE in communities in its service areas. To help organizations succeed with the program, Kaiser Permanente assists its partners in creating patient registries and panel management systems, optimizing electronic health records, and adopting team-based care and workflow efficiencies.
To assess the effects of the PHASE program on population health, the study reviewed annual blood pressure, blood sugar, and blood lipid levels of approximately 100,000 patients with diabetes in Northern California.
Researchers compared these metrics to data from commercial health plan enrollees using results from the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set (HEDIS).
Twenty percent more Kaiser Permanente patients were able to achieve blood pressure control alongside their diabetes than diabetic patients at other US health systems.
The number of patients with good blood pressure control started out higher at Kaiser Permanente and remained that way throughout the study, rising from 77 percent in 2007 to 82 percent in 2013.
In comparison, the HEDIS data showed a smaller increase in blood pressure control, from 57 percent to 62 percent, at other organizations.
From 2004 to 2013, the percentage of people with diabetes who had uncontrolled blood sugar fell nationally, but at Kaiser Permanente the decline was significantly greater than the national average.
Kaiser Permanente also outperformed other health systems in improving lipid control. From 2004 to 2013, the proportion of individuals with diabetes with good lipid control rose from 47 to 71 percent for Kaiser Permanente patients. The HEDIS surveys, on the other hand, showed few significant changes, with good lipid control only rising from 40 to 44 percent.
The study results show the success of an integrated population health program in boosting chronic care management.
"Our encouraging findings speak to the strength of the PHASE program," said Rana.
"This study shows that the PHASE program addresses the daunting challenge of controlling risk factors in a high-risk population consistently and over an extended period of time, by the systematic application of a simple treatment protocol, a comprehensive registry, performance metrics, and task sharing with care managers."
There are over 50 community healthcare sites currently using PHASE. In 2017, Kaiser Permanente provided nearly $6 million in funding to support the work of 18 organizations for three years.
There are also plans to spread this approach worldwide. Marc G. Jaffe, MD, of Kaiser Permanente’s San Francisco Medical Center, will lead efforts in sharing elements of PHASE to help low- and middle-income countries prevent cardiovascular disease.
"We are excited to share our experiences with others who treat high risk individuals, not only in California, but also across the world," Dr. Jaffe said.