Secondary Prevention for Heart Attack in Alaska:
A Summary of Present Practices and Future
Take Heart Alaska Secondary Prevention Task Force
April 13, 2004
The Present: Secondary Prevention for Heart Attack in Alaska
According to the 2003 Behavioral Risk Factor Surveillance System (BRFSS) a self report
statewide telephone survey, 2.4% of Alaskans report they have been told they have had a
heart attack. An additional 2.8% report they have been told they have unstable angina.
These percentages, taken together, represent an estimated 22,500 people in our state at
risk for an initial or subsequent heart attack.
When the Secondary Prevention Task Force formed in July 2003, they had 2 goals for the
year. The goals were:
1. To understand what resources and practices are currently in place in Alaska to
address secondary prevention of an initial or subsequent heart attack.
2. To determine where deficiencies and gaps exist in the medical, behavioral,
preventive, rehabilitative services, and public health provided for these
patients and where better evidenced-based medical and public health care can
To accomplish these tasks, surveys were developed to collect information from those
involved with providing care and support to people who have had a heart attack. The
groups identified to survey were patients, providers (physicians, advanced nurse
practitioners, physician assistants, cardiac rehabilitation specialist, public health nurses
and community health aides), insurers, employers and non-profit organizations.
Task Force members met by teleconference to discuss the surveys and provide feedback
to the assessment. Based on that feedback, the surveys took final form. The surveys asked
for information that reflected the use of the secondary prevention guidelines put forth by
the American Heart Association and the American College of Cardiology (AHA/ACC).
These guidelines from AHA/ACC and therefore the surveys, focused on these areas:
• Smoking cessation
• Blood pressure control
• Blood lipid management
• Physical activity
• Weight management
• Diabetes management
• Use of antiplatelet agents (i.e., aspirin, etc.)
• Use of angiotensin-converting enzyme (ACE) inhibitors
• Use of beta blockers
The Task Force also advised against surveying physicians (they typically have a very
poor response rate) and public health nurses, (they rarely see these patients). The
remaining groups were surveyed via telephone interviews.
The purpose of this report is to summarize the findings to date for the Secondary
Prevention Task Force.
According to the Hospital Discharge Data1, 2,125 people were discharged with a
diagnosis of ischemic heart disease in 2001. In Alaska, there is a significant gender gap,
with males (69%) outnumbering females (31%) at a level far in excess of their over-
representation in the population at large. Fifty-two per cent (52%) of those discharged in
Alaska are under 65 years old. Alaska data for mean charges per hospital stay show
substantially higher costs associated with cardiovascular admissions than most other
diagnoses. This is especially true when the primary diagnosis is ischemic heart disease.
Ischemic heart disease patients are in the hospital an average of 4.4 days at a total cost of
In the United States, discharges for ischemic heart disease is more equally divided
between the sexes with 59% being males and 41% being females. Nationally, 36% of
those discharged with ischemic heart disease are under 65 years.
The Centers for Medicare and Medicaid Services (CMS) became interested in what was
happening for those patients during the 4.4 days they spent in the hospital. Around 1999,
they implemented a program to measure and track the quality of the care for which
Medicare pays. CMS simultaneously committed to using its quality improvement
organization (QIO) contractors to systematically promote improved performance of the
quality measures tracked under this program using a voluntary, collaborative, and
nonpunitive educational strategy. The QIO in Alaska is Qualis Health.
The quality measures for heart attack are 1) aspirin at hospital arrival and discharge; 2)
beta blockers at hospital arrival and discharge; 3) ACE Inhibitors for patients with left
ventricular systolic dysfunction (LVSD); and 4) in-patient smoking cessation
CMS data on acute myocardial infarction (CMS/ Joint Commission on Accreditation of
Healthcare Organizations Quality Standards from Alaska hospitals for the second quarter
of 2003) show high levels of compliance on all factors but one, tobacco cessation
Inhospital Treatment % Patients receiving treatment
Aspirin at arrival 89%
Aspirin prescribed at discharge 93%
ACE Inhibitor for LVSD 82%
Adult smoking cession counseling 53%
Beta blocker prescribed at discharge 95%
Beta blocker at arrival 87%
The National Registry of Myocardial Infarction (NRMI), a national database, had 3
Alaska hospitals enrolled in 2001. They collected data on referrals to cardiac
rehabilitation (CR), percent of eligible patients placed on statins, and those placed on
other lipid lowering drugs, as well as the quality standards mentioned above. The NRMI
data for 2001 showed the following:4
Inhospital Treatment % Patients receiving treatment
Referred to cardiac rehabilitation 34%
Placed on statins 59%
Placed on other lipid lowering drugs 19%
Another approach to looking at inpatient care for heart attack patients was to look at
formalized written protocols.
Ten of the 22 hospitals (small, medium, and large) in Alaska were contacted to learn
about their facility protocols and guidelines for managing coronary events. We were able
to speak with case managers, cardiac rehabilitation personnel, nurse managers, and heath
care providers about their guidelines for admission to and discharge from the facilities.
Findings included the following:
1. There appears to be a wide array of approaches to management of cardiac events in
the different hospital facilities, although all hospital emergency room staff and
operating room staff must be certified in advanced cardiac life support. Some
facilities had extensive protocols, suggested guidelines, pathways, and algorithms
from the point of entry at the emergency department to the medical ward, intensive
care unit, or coronary care unit. Other facilities had little or no specific guidelines in
place and the patient management was left to the discretion of each health care
2. Standardized medications were suggested at some of the facilities and included
aspirin, beta blockers, ACE inhibitors, statins, heparin, morphine, Ativan, anti-
coagulants, anti-arrhythmics, nitroglycerin, and calcium channel blockers. This had
rather wide variation at different facilities. Eight of the 22 hospitals are designated as
critical access hospitals and are being encouraged by CMS to meet guidelines for
administration of aspirin, beta-blockers, and ACE inhibitors for eligible patients.
3. Smaller hospitals stabilized and transferred heart attack patients. Heart attack patients
were rarely kept at the facility.
4. Hospital inpatient education on activity levels, nutrition, medication, and life style
was present at larger facilities. Seven of the hospitals have a formalized cardiac
rehabilitation (CR) program which carries out the inpatient education. The inpatient
CR program is called Phase 1, with Phase 2 being the outpatient CR program. Use of
cardiac rehabilitation services requires a physician referral. This appears to be lacking
in a number of facilities, especially for the outpatient phase, or Phase 2. There
appears to be under-utilization of these available resources for on-going patient care.
5. Some of the facilities had specific discharge planning for the patient.
6. A frequently stated issue at the facility level addressed the communication and patient
information exchange from the tertiary health care provider/facility to the primary
health care provider and/or the Community Health Aide (CHA). Some tertiary
providers indicated it was as though the patient went home and “vanished”. A similar
concern was also expressed from the patient’s primary health care provider and the
Community Health Aide, noting that discharge summaries and treatment plans were
not received for detail follow-up treatment. This disconnect in communication results
in medications not being titrated for effectiveness, difficulty in monitoring and
treating a patient’s changing condition, and offering further rehabilitation work. The
current system has significant challenges to maintain the flow of information among
patients, tertiary health care providers, primary health care providers, Community
Health Aides, and the support health care providers (rehabilitation, nutrition,
occupational therapy, physical therapy).
This Task Force may consider recommending a strategy to develop (if need be),
disseminate, and implement, some general guidelines that can be utilized at hospital
facilities in the admission, patient management, transfer, and or discharge planning for
all patients with coronary events to arrive at the appropriate flow of communication for
In Alaska, patients sometimes travel great distances to be treated for a heart attack. Once
patients leave the hospital, those returning to larger communities have both clinical and
community resources to help continue their treatment. For those patients returning to
smaller communities, both clinical and community resources may be more limited. In
smaller communities, the primary care providers may be a primary care physician, an
advanced nurse practitioner (ANP), a physician’s assistant (PA), or a community health
aide (CHA) working under the direction of a physician. If a patient is Alaska Native and
has traveled to Anchorage for treatment, that patient’s care will be coordinated through
the Alaska Native Medical Center (ANMC). At ANMC there are two cardiologist and
three case managers for all patients, regardless of the hospital in which they were treated.
Once the patient has been seen at ANMC, he or she returns to the village and the care of a
primary provider. If the patient is not Alaska Native, she or he leaves the hospital and
returns directly to the primary care providers in their community without an interim stop.
One option for patients living in Anchorage, Juneau, Soldotna, Fairbanks, Kodiak, and
Wasilla for follow-up care is a cardiac rehabilitation program operating in the local
hospital. Cardiac rehabilitation is a proven method for improving outcomes for heart
attack patients. It provides a structure to deliver health education information, build skills
in making lifestyle changes and medication to be managed in a timely way. Patients
participating in this structured approach have a greater exercise tolerance, fewer cardiac
symptoms, lower blood fat levels, more cessation of smoking, improved psycho-social
well-being, and reduced risk for illness and death.5 Meta-analysis of data from random
controlled studies indicates a 20% to 25% reduction in mortality in patients participating
in cardiac rehabilitation following myocardial infarction as compared to controls.6
Even with compelling data to support this standard of treatment, only 35% of Alaskans
who have angina, a heart attack, or stroke, reported they had participated in cardiac
rehabilitation. (BRFSS, 2003)
We did key informant interviews with all the cardiac rehabilitation programs to learn
what they offered, whether the patients referred to them had treatment plans that reflected
the AHA/ACC Secondary Prevention Guidelines and what their barriers and successes
were. Our questions focused on the outpatient or phase 2 of the program.
1. All programs had monitored exercise as a central piece of their program.
2. Programs addressed lifestyle issues such as weight management, nutrition, and lipid
management in different ways. Some used formalized class structures, others used
more informal one-on-one discussions or referrals to nutritionist and diabetes
3. Some programs addressed depression by referring to mental health clinicians.
4. All programs closely monitored blood pressure and reported elevated levels to the
1. Almost all patients had been assessed for tobacco use; some had also received
pharmacological prescriptions to assist with tobacco cessation.
2. Programs reported that as many patients on blood pressure medication became more
active, their present medication levels were inappropriate and needed to be adjusted.
All programs utilized both formal reporting methods (written progress reports, exit
reports) as well as informal methods to communicate with the physicians on this
3. Programs reported that 70% to100% of patients were on statins. The patient’s current
lipid level appeared to be one of the hardest pieces of information to attain from the
referring physician or facility.
4. Most programs worked closely with diabetes educators. They reported the majority of
their diabetics had good control.
5. Weight management was assessed in all the programs and patients could choose if
they were ready to address it.
1. There was a lack of referrals from physicians.
2. There was difficulty getting from the hospital/physician the patients’ papers that
outline medications, lipid levels and other baseline information.
3. There was lack of community resources for tobacco cessation programs.
This Task Force may consider recommending a strategy to increase support for use of
cardiac rehabilitation, especially Phase 2.
Primary Care-for Patients Within the Alaska Native Medical System
In small rural communities, CHA’s provide much of the daily medical care under the
direction of a physician. The physician may visit on a periodic schedule; otherwise much
of the consultation is done by phone. Key informant interviews were conducted with the
regional directors of the Community Health Aide Program (CHAP) to discuss their
experiences of working with heart attack survivors in these remote settings. The CHAP
program is part of the Native medical system. CHAP directors were either advanced
nurse practitioners or physician assistants. Again, we asked questions that reflected
whether the patients returning had treatment plans that followed the AHA/ACC
Secondary Prevention Guidelines, and whether the CHA’s were able to provide follow-up
that was consistent with the guidelines.
CHAP directors reported that:
1. The majority of heart attack patients return to their clinics on aspirin and beta
blockers. If a patient has diabetes as a co-morbidity, they are likely to be on ACE
inhibitors as well.
2. HbA1c (Glycosylated hemoglobin) levels were mostly well controlled in diabetics,
perhaps due to a strong Alaska Native Diabetes Program.
3. Blood pressure levels were often inadequately controlled once patients returned to
their everyday activities. Blood pressure needed to be monitored closely, with
possible medication adjustments. Often midlevel practitioners were unsure to what
level the physician wanted the blood pressure controlled, and they were hesitant to
4. Many patients were on lipid lowering medication, but there was a wide variation
regarding information on level of control and when to do follow-up testing.
5. CHA’s felt they lacked the expertise to address nutrition, physical activity, and
weight management. They depend heavily on the diabetes educators from the Alaska
Native Diabetes Program in communities where one is available to provide this
1. Delayed receipt of discharge summaries and treatment plans was the barrier most
often mentioned. More often than not the patient arrives for their first follow-up
appointment in the CHA office before any of the paperwork has arrived.
2. There was a wide range in detail of treatment plan based on individual referral
3. One CHAP director said the problems they encounter about heart attack patients’
getting follow-up treatment back in the communities is reflective of a much larger
issue of a rural patient traveling to an urban area for any treatment and then returning
back to the rural setting. He encouraged the Task Force to address this as a system
wide issue rather than just for cardiovascular health.
4. There is a need for practitioners to have an understanding of the social, language,
cultural, health literacy and other issues when working cross culturally.
1. While it appears treatment plans for heart attack patients may sometimes slip through
the cracks, this rarely happens for diabetics. The Alaska Native Diabetes Program
seems to have achieved the consistency in standard and delivery of care at both the
primary and secondary prevention level that we would like to see for cardiovascular
disease. Communication seems to be strong in diabetes programs across disciplines of
This Task Force may consider recommending consulting with the Alaska Native Diabetes
Program to see how to improve care for heart attack patients in rural settings. They may
also want to consider working with the CHA program and the cardiovascular case
managers at ANMC to develop training or materials that provide basic follow-up
information to be covered at clinic visits.
Primary Care-for Patients Outside the Native Medical System
Patients who are outside the Native medical system return to their primary care providers
after being released from the hospital. If they do not participate in cardiac rehabilitation,
they depend on their primary care providers for their follow-up care. In 2003, the BRFSS
asked heart attack, angina and stroke patients a series of questions to learn if, in the last
12 months, their physician, nurse or health professional had talked with them about
lifestyle changes related to prevention. They found:
• 13% had been advised to eat less fat/high calorie foods
• 21.5% had been advised to eat more fruits and vegetables
• 24.9% had been advised to be more physically active
In addition they found that 27.4% of these heart attack, angina and stroke patients take
aspirin daily. Of that 27.4%, two-thirds reported they were taking aspirin to reduce the
risk of a heart attack.
Attempts to collect information from physicians, advanced nurse practitioners and
physician assistants statewide have proven to be very difficult. A provider survey was
conducted on behalf of the State Diabetes, Tobacco, and Cardiovascular Health Programs
in 2002 to examine clinicians’ practices around prevention. Over 50% of the respondents
were from the Anchorage area, and this limited the ability to generalize the data
statewide. What can be said is that, of the 384 respondents, 93% said they provided
lifestyle counseling to their patients with chronic disease. This 93% reflects a very
different perspective on the amount of prevention education occurring than from the point
of view in the BRFSS data.
Access to Care
Access to care plays a critical role in a patient’s ability to receive follow-up care after a
heart attack. In Alaska, 81% of Alaskans reported they have some sort of health care
coverage (BRFSS 2000). Of those insured, the vast majority are covered through their
employer (73%). The remainder are covered through plans they have purchased as
individuals (7%), through Indian Health Services (3%), by Medicaid/Medicare (2%) or
some unspecified other source (15%).
At this time, heart attack patients who are covered by Medicaid have no restrictions on
what is being paid for follow-up care. Cardiac rehabilitation is covered for as long as is
necessary for the patient. Beta blockers, ACE inhibitors, statins and other medications
prescribed to treat patients post-heart attack are covered as well. Medicaid does not cover
tobacco cessation programs, counseling, or pharmalcological aids related to tobacco.
Aetna insures 37%, and Premera Blue Cross Blue Shield insures 38%, of all Alaskans
privately insured or insured by their employers.7 Blue Cross and Aetna both offer
members a disease management program that coordinates follow-up care for coronary
artery disease, congestive heart failure and diabetes. The disease management programs
also provide educational, treatment, medication and health care navigation support.
Neither Aetna nor Premera Blue Cross have a benefit to pay for tobacco cessation
counseling or aids. They do cover statins, beta blockers, ACE inhibitors and antiplatelet
medications in their pharmacy benefits. They cover cardiac rehabilitation if it meets the
“medically necessary” criteria. (See Appendix C) Hypoglycemic therapy is covered for
diabetics. Nutrition counseling is covered on a limited basis, but weight management is
Worksites are integral for working Alaskans as the provider of health insurance.
Worksites may also assist in promoting healthy lifestyle changes that heart attack
survivors are attempting. This may be in the form of a formalized worksite health
promotion program, or a more informal approach that offers health promoting activities
Approximately 45% of working adults in Alaska are employed by organizations that
employ 250 or more employees.8 Because larger organizations are also the most likely
groups to have worksite programs, telephone surveys were administered to human
resource/personnel directors for 97 out of the 115 (84.4%) employers where more than
250 people worked.
1. Many employers indicated that screenings for risk factors are covered by their health
insurance. Blood pressure (69 employers), blood sugar (68 employers), and
cholesterol (65 employers) are covered most often. Thirty-one employers reported
that tobacco cessation is covered by their health insurance.
2. In addition to traditional screenings performed at a doctor’s office, some worksites
offer screenings on site to encourage employee participation. Fifty-one (57.0%) of the
companies surveyed said that they have offered blood pressure screening at some or
all of their worksites. Another thirty-five companies offered screening for cholesterol,
and thirty-four companies offered blood sugar screening in the past year.
3. Once an employee has been screened and identified as high risk, there are various
strategies to reduce their future risks. Distribution of information/literature was the
most common (21 employers) response to a high risk designation as a result of a
screening. Less common responses included referral to a clinician (19 employers),
and referral to a counseling/education program (10 employers).
Worksites can be instrumental in encouraging physical activity.
1. More than half of businesses surveyed (49) sponsored an employee sports team or
physical activity event in the past year.
2. Fifty-three of the employers we surveyed have exercise facilities present in at least
some of their worksites.
3. Only six out of ninety respondents indicated that they have signs in the workplace
promoting the use of stairs.
4. Forty-three surveyed employers indicated that they offer some kind of discount to an
off-site exercise facility.
5. Thirty-five employers reported having a policy that allows flexibility in work
schedules to allow for physical activity.
1. All but two employers make food or snacks available to their employees at work. The
most popular healthy options available are 100% fruit juice (79) and fresh fruit (67).
Sixty-two employers offer cooked vegetables, fat free/low fat yogurt, and fresh
salads. Fifty-five offer fat free/low fat salad dressings, and fifty-nine have 1% or skim
The Task Force may want to recommend strategies to support worksite health promotion
programs at work.
Other groups that may provide support for heart attack patients are non-profits involved
with cardiovascular health. Two non-profits currently have programs targeting secondary
prevention. The American Diabetes Association provides educational materials that
increases the awareness of healthy lifestyle among diabetic and at risk populations. The
American Heart Association provides educational materials that increase the awareness
of healthy lifestyles for heart attack survivors, as well as supporting the Mended Hearts
organization. Mended Hearts is made up of heart attack survivors who volunteer their
time to go into the hospital and visit with heart attack patients. They offer
encouragement, support, and information on what it takes to get back to the business of
1. Eberhart-Phillips JE, Fenaughty A, Rarig A. The Burden of Cardiovascular
Disease in Alaska: Mortality, Hospitalization and Risk Factors. Anchorage, AK:
Section of Epidemiology, Division of Public Health, Alaska Department of Health
and Social Services, 2004.
2. Jencks SF, Cuerdon T, Burwen DR, Fleming B, Houck PM, Kussmaul AE,
Nisasena DS, Ordin DL, Arday DR. Quality of Medical Care Delivered to
Mecicare Beneficiaries: A Profile at State and National Levels. JAMA.
3. Qualis Health. Alaska Statewide Cardiovascular Rates Medicare Inpatient data,
CMS and JCAHO Quality Standards, 2003, unpublished data.
4. National Registry of Myocardial Infarction. Quarterly Data Report of
Alaska/Nation, March 2002.
5. Receipt of Cardiac Rehabilitation Services Among Heart Attack Survivors – 19
States and the District of Columbia, 2001. Morbidity Mortality Weekly Report.
6. Clinical Policy on Cardiac Rehabilitation, AETNA Clinical Policy Bulletin,
Number 0021, February, 2004.
7. Phone interview with Holly Williamson of Premera Blue Cross, 2003.
8. Alaska Department of Health and Social Services Division of Medical Assistance.
Preliminary Findings: Alaska Employer Survey, 2001, An internal report October
Future Considerations: Recommendations and Priorities
The Secondary Prevention Task Force met on Wednesday, April 21. The Task Force
discussed the strengths and weakness in each of the settings discussed in the report. The
settings followed a patient through their treatment process and included inpatient,
discharge, cardiac rehabilitation, primary care, in both the Alaska Native medical system
and the non-Native medical system. We also looked at other issues that impacted
treatment such as access to care, employer support, and community support via non-
profits. After strengths and weaknesses were identified, the group determined what most
needed to be addressed to improve quality of care. The priorities were:
1. Standardize discharge information given to heart attack patients as they leave the
Develop a patient toolkit which includes target numbers for blood pressure
levels, cholesterol levels, weight, blood sugars (if appropriate), etc. so
patients can be self directed in working to achieve those levels. Perhaps
talk with diabetes to determine why their self-care program is so
Include standard patient education information, in an easy to read and find
format at discharge.
2. Increase the utilization of cardiac rehabilitation.
Work to establish cardiac rehabilitation referral as a preprinted order, so a
physician would have to strike through it if they did not want the patient to
Consider professional education on the benefits of cardiac rehabilitation to
Look into other methods for delivering the information included in a
cardiac rehabilitation program for places where there is no cardiac
rehabilitation program established.
3. Work to establish consistent written protocols in all hospitals where they do not
4. Support American Heart Association’s Get With the Guidelines in interested
5. Work with insurers to be sure that the best preventive practices are represented in
insurance plans and that employers are made aware of them.
Develop strategies to link providers and employers to discuss best
6. Improve both in-hospital and discharge standard of treatment for heart attack
patients by working with the quality improvement (QI) teams at hospitals.
Ask the QI teams for data that shows hospitals where they stand in
achieving consistent delivery of the quality indicators. Consider either
Centers for Medicaid or Medicare Services or the American heart
Association/American College of Cardiology Secondary Prevention
Standards for quality indicators.
7. Support those in the Native Medical System to improve the quality of care in rural
Consider developing a cardiovascular training module for Community
Health Aides similar to the special training on diabetes.
Provide a field cardiac rehabilitation clinic in conjunction with the
cardiologist’s visit to the regional hubs.
Have more local and regional case managers.
In addition to these seven specific goals, the Task Force identified three overarching
needs that spanned all of the settings. They are:
Address the lack of tobacco cessation available around the state.
Improve the communication across settings between the tertiary providers,
the primary providers, the health aide (where appropriate), and the patient
in both directions.
Engage the university and its resources for distance delivery of health
education for heart attack patients.
Collaborate with diabetes to learn from their experience in raising the
standards and consistency of care.