About the Best Practices Guide

Public health strategies to detect, prevent, and control chronic disease can be implemented at many levels, from individual behavioral interventions to environmental or cultural strategies affecting entire communities. Making changes to health system practices can eliminate barriers to quality care and improve the health of many people. Nowhere is the need for such approaches more apparent than in the efforts to prevent heart disease, the leading cause of death in men and women in the United States. Although treatments for hypertension and hyperlipidemia—two key risk factors for cardiovascular disease (CVD)—are very effective and relatively inexpensive, most people with these conditions do not have them under control. Research on strategies to lower blood pressure and cholesterol levels in health care settings offers insights about effective practices, but more work is needed to translate this evidence into action.

Best Practices for Cardiovascular Disease Prevention Programs: A Guide to Effective Health Care System Interventions and Community Programs Linked to Clinical Services is intended as a translation resource. It highlights strategies that have been found to be effective—but are not yet widely used as standard practice—for control of hypertension and hyperlipidemia.

Best Practices Guide Lunch and Learn Cdc-pdf[PDF – 3 MB]
This webinar builds on the information from the December 2017 Coffee Break Presentation and takes a deeper dive into the content of the Best Practices Guide while also walking the audience through a demo of the guide in its PDF and web-based versions.

Together, heart disease, stroke, and other vascular diseases claim more than 800,000 lives in the United States each year and cost over $300 billion in annual health care costs and lost productivity.1–3 An estimated one in every seven U.S. dollars spent on health care goes toward CVD.3,4 This costly and deadly disease is at the forefront of public health priorities at the Centers for Disease Control and Prevention (CDC), and health care practitioners at many levels are looking for solutions. Several modifiable risk factors for CVD are well known, including hypertension, hyperlipidemia, smoking, being overweight, being inactive, and eating an unhealthy diet.

Identifying effective ways to directly lower high blood pressure and cholesterol in the U.S. population is a priority for CDC’s Division for Heart Disease and Stroke Prevention (DHDSP). Other divisions in CDC’s National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) prioritize other risk factors, such as smoking, diabetes, diet, and obesity. DHDSP supports all 50 states and the District of Columbia to work toward achieving DHDSP’s mission to improve cardiovascular health for all, reduce the burden of CVD, and eliminate disparities associated with heart disease and stroke.

NCCDPHP takes a multifaceted approach to chronic disease detection, prevention, and control by focusing on four key domains: epidemiology and surveillance (Domain 1), environmental approaches (Domain 2), health care system interventions (Domain 3), and community programs linked to clinical services (Domain 4).5

  • Domain 1: Epidemiology and Surveillance
    Epidemiology and surveillance involves the use of systems to regularly track and monitor current and emerging trends in chronic diseases and their related risk factors. Investing in this domain allows data to be collected to understand the incidence, prevalence, and risk factors of chronic diseases; identify effective approaches for detection, prevention, and control; and monitor and assess progress toward key program goals.5,6 Surveillance is essential for monitoring the detection, prevention, control, and treatment of CVD. CDC uses data from communities, health systems, and administrative systems to assess the burden of CVD. CDC tracks trends in cardiovascular risk factors and disease and shares findings with partners and collaborators working to apply public health strategies to improve cardiovascular health. Grantees of CDC-funded heart disease and stroke prevention programs collect surveillance data and use this information to guide, prioritize, and monitor program delivery.
  • Domain 2: Environmental Approaches
    Environmental approaches involve the use of policy and structural changes to create environments where health is promoted and healthy choices are reinforced. Changes can be made to social and physical environments to make healthy behaviors easier and more convenient for individuals, while maintaining broad reach and sustaining health benefits for overall populations.5,6 CDC and its partners are working to make healthier environments a reality for those at greatest risk for CVD. Environmental strategies that can help reduce heart attacks and strokes include creating smoke-free environments and increasing access to healthier foods, including those with less sodium.
  • Domain 3: Health Care System Interventions
    Health care system interventions are strategies used to improve the delivery and quality of care in clinical settings. Health system and quality improvement changes, such as using electronic health records (EHRs) and requiring reporting on blood pressure control, can encourage health care providers to better monitor and address key risk factors for CVD.5,6 Such strategies can result in earlier detection, improved disease management, and even prevention of the onset of CVD.
  • Domain 4: Community Programs Linked to Clinical Services
    This domain—sometimes called community-clinical links—refers to strategies that connect community programs with health systems to improve chronic disease prevention, care, and management.5 Because this strategy relies on links between community and clinical settings, activities often overlap Domains 3 and 4. Community-clinical links aim to ensure that people with, or at high risk for, chronic diseases have access to quality community resources and support to prevent, delay, or manage chronic conditions. Strategies can include referrals by clinicians to community supports to improve chronic disease self-management or referrals by community programs to clinical services.5,6 These links can also involve community delivery and third-party payment for effective programs, which can reduce barriers and increase adherence to clinician recommendations.

Best Practices for CVD Prevention Programs focuses specifically on strategies used in Domains 3 and 4: health care system interventions (Domain 3) and community programs linked to clinical services (Domain 4). Improvements made in these areas can help create environments where people are better able to receive quality care, make healthier choices, and take control of their health. CDC funds state and local programs and key partner organizations to put health care system interventions and community-clinical links into action to prevent CVD. See Appendix A Cdc-pdf[PDF – 478 KB] for a summary of effective strategies within these domains.

  • Health Care System Interventions (Domain 3)
    Examples of health care system interventions include efforts to increase identification of undiagnosed hypertension, adopt clinical hypertension protocols, improve medication adherence, increase the use of health information technology to implement the ABCS (Aspirin when appropriate, Blood pressure control, Cholesterol management, and Smoking cessation), and make other quality improvements in health care practices.
  • Community-Clinical Links (Domain 4)
    Activities involving community-clinical links include health care systems collaborating with community groups that provide evidence-based lifestyle programs; using community health care extenders (i.e., non-M.D. health care professionals) to support self-managed blood pressure; and collaborating with chronic disease programs for effective program planning, implementation, and evaluation.

Best Practices for CVD Prevention Programs was developed for state and local health departments, decision makers, public health professionals, and other stakeholders with an interest in implementing effective strategies to improve cardiovascular health. To develop this publication, we searched for interventions and strategies that have been found to be effective for CVD prevention in multiple research and practice settings, but which are not yet widely used or considered standard practice. For each selected strategy, we provide brief summaries of the research evidence and links to information and resources on how to implement the strategy. The information presented here is not comprehensive, but instead provides a quick reference to selected strategies. Best Practices for CVD Prevention Programs can be used as a resource by decision makers and stakeholders who wish to implement CVD prevention strategies that offer the best chance for successful outcomes in their communities and health care systems. In addition to the strategy summaries, this publication provides several appendices with additional information, including a glossary of important terms (Appendix D Cdc-pdf[PDF – 478 KB]).

The strategies presented in this publication were identified and confirmed through an extensive review process, with input from subject matter experts (SMEs) and practice partners both within and external to CDC. Internally, strategies were reviewed and vetted by DHDSP senior leadership and staff in DHDSP’s Program Development and Services Branch, Epidemiology and Surveillance Branch, Applied Research and Evaluation Branch, Million Hearts® team, and Office of Policy, External Relations, and Communications. Externally, we worked with academics, partners, and program directors with expertise in chronic care delivery, CVD prevention and control, and public health program management.

In addition to the review process, Best Practices for CVD Prevention Programs was conceptualized and developed using several theoretical models. The concept of identifying public health best practices for hypertension and cholesterol control was primarily guided by the best practices framework developed by a CDC work group.7 This framework also guided how we selected strategies, reported their impact, and offered considerations for implementation.

According to the best practices framework (Figure 1), strategies considered best practices should be evidence-based; have high-quality evidence to support them; and demonstrate a positive impact in terms of effectiveness, reach, feasibility, sustainability, and transferability.7

Where a particular practice falls on the best practices continuum at any point in time is dependent on the evidence available at that point. Thus, being labeled a “best practice” is not a static designation, but one that can change as new evidence becomes available. Practices can be categorized as emerging, promising, leading, or best.

  • Other Guiding Frameworks
    In addition to using the best practices framework to develop this publication, we also followed a process adapted from the Rapid Synthesis and Translation Process (RSTP).8 For more information on RSTP, see Appendix B Cdc-pdf[PDF – 478 KB]. RSTP provides a structure for working with SMEs and practice partners to develop an evidence-based translation product. In addition, two evidence reviewers used an interactive, online tool called the Continuum of Evidence of Effectiveness to assess and rate the strength of evidence for each proposed best practice.9 For more information about this tool, see Appendix C Cdc-pdf[PDF – 478 KB].

Although Best Practices for CVD Prevention Programs is a useful resource on evidence-based strategies for preventing CVD, it has several limitations. First, it does not include every strategy found to be effective in CVD prevention. Other strategies may be used in practice that are not included here because of the approach we used to select and assess the evidence. This guide focuses on practices that are best characterized in the research literature and therefore most amenable to meaningful assessment by the methods we used. Second, this publication provides only a condensed version of the evidence available on each strategy. It is not a systematic review, like The Guide to Community Preventive Services, and thus could be missing potentially relevant information about strategy weaknesses and research limitations. References to longer and more detailed systematic reviews and meta-analyses are provided when available.

Third, our presentation of evidence is limited by the available literature. Consequently, if key data (for example, on economic factors) were not available at the time we reviewed the evidence, this information will be missing. Fourth, information on the economic impact of the strategies is presented using a variety of methods, which limits the ability to make direct comparisons across practices. The numbers presented should be read only as examples of the best available evidence demonstrating positive economic impact. They should not be directly compared to examine the comparative efficiency of the different practices. Fifth, this initial version of Best Practices for CVD Prevention Programs does not provide detailed information on strategy implementation or the estimated costs of implementation. Although we have provided links to available implementation resources when possible, providing complete implementation guidance for each strategy was beyond the scope of this publication. Such information may be included, to the extent possible, in future versions.

Centers for Disease Control and Prevention. Best Practices for Cardiovascular Disease Prevention Programs: A Guide to Effective Health Care System Interventions and Community Programs Linked to Clinical Services. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; 2017.

References
  1. Xu J, Murphy SL, Kochanek KD, Arias E. Mortality in the United States, 2015. NCHS Data Brief. 2016;267.
  2. Centers for Disease Control and Prevention. Underlying Cause of Death 1999–2015. CDC WONDER Online Database. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; 2016. http://wonder.cdc.gov/ucd-icd10.html. Accessed February 3, 2017.
  3. Agency for Healthcare Research and Quality. Medical Expenditure Panel Survey. Table 7: Total Expenses and Percent Distribution for Selected Conditions by Type of Service: United States, Average Annual 2012–2013. https://meps.ahrq.gov/mepsweb/data_stats/tables_compendia_hh_interactive.jsp?_SERVICE=MEPSSocket0&_PROGRAM=MEPSPGM.TC.SAS&File=HC2Y2013&Table=HC2Y2013_CNDXP_C&_DebugExternal. Accessed May 19, 2017.
  4. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017;135:e1–e458.
  5. Centers for Disease Control and Prevention. The Four Domains of Chronic Disease Prevention: Working Toward Healthy People in Healthy Communities. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; 2016.
  6. Bauer UE, Briss PA, Goodman RA, Bowman BA. Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA. Lancet. 2014;384(9937):45–52.
  7. Spencer LM, Schooley MW, Anderson LA, et al. Seeking best practices: a conceptual framework for planning and improving evidence-based practices. Prev Chronic Dis. 2013;10:130186. doi: http://dx.doi.org/10.5888/130186External.
  8. Thigpen S, Puddy RW, Singer HH, Hall DM. Moving knowledge into action: developing the Rapid Synthesis and Translation Process within the Interactive Systems Framework. Am J Community Psychol. 2012;50(3-4):285–294.
  9. Puddy RW, Wilkins N. Understanding Evidence Part 1: Best Available Research Evidence. A Guide to the Continuum of Evidence of Effectiveness. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept. of Health and Human Services; 2011.
  10. S. Department of Commerce. Bureau of Economic Analysis National Data. Table 2.5.4. Price Indexes for Personal Consumption Expenditures by Function. https://bea.gov/iTable/index_nipa.cfmExternal. Accessed June 11, 2017.