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Effects of the Million Hearts Model on Myocardial Infarctions, Strokes, and Medicare Spending: A Randomized Clinical
Laura Blue1, Keith Kranker1, Amanda R Markovitz2
1Mathematica, Washington, DC.
Insights
The Million Hearts Model successfully reduced first-time myocardial infarctions (MIs) and strokes by incentivizing cardiovascular disease (CVD) risk assessment and management. This study supports using CVD risk scores for primary prevention strategies.
Area of Science:
- Cardiovascular Medicine
- Health Services Research
- Preventive Cardiology
Background:
- The Million Hearts Model aimed to improve cardiovascular disease (CVD) risk assessment and reduction in healthcare organizations.
- Long-term effects of this model on patient outcomes were previously unknown.
Purpose of the Study:
- To evaluate the impact of the Million Hearts Model on the incidence of first-time myocardial infarctions (MIs) and strokes.
- To assess the model's effect on Medicare spending over a 5-year period.
Main Methods:
- A pragmatic cluster-randomized trial involving 516 US healthcare organizations from 2017 to 2021.
- Included Medicare fee-for-service beneficiaries aged 40-79 with high/medium CVD risk (≥15% 10-year risk score) and no prior MI or stroke.
- Intervention group organizations received payment for CVD risk assessment and management, with bonuses for risk reduction in high-risk patients (≥30% risk score).
Main Results:
- The intervention group showed a statistically significant reduction in combined first-time CVD events and CVD deaths (4.2% relative effect; HR, 0.96; P=.02).
- A non-significant trend towards fewer first-time CVD events was observed (3.3% relative effect; HR, 0.97; P=.09).
- Medicare spending for CVD events and overall spending showed no significant differences between groups.
Conclusions:
- The Million Hearts Model effectively reduced first-time myocardial infarctions and strokes.
- Findings support the integration of CVD risk scores into primary prevention guidelines.
- The model demonstrates a viable strategy for CVD risk reduction in clinical practice.
Importance:
The Million Hearts Model paid health care organizations to assess and reduce cardiovascular disease (CVD) risk. Model effects on long-term outcomes are unknown.
Objective:
To estimate model effects on first-time myocardial infarctions (MIs) and strokes and Medicare spending over a period up to 5 years.
Design, Setting, And Participants:
This pragmatic cluster-randomized trial ran from 2017 to 2021, with organizations assigned to a model intervention group or standard care control group. Randomized organizations included 516 US-based primary care and specialty practices, health centers, and hospital-based outpatient clinics participating voluntarily. Of these organizations, 342 entered patients into the study population, which included Medicare fee-for-service beneficiaries aged 40 to 79 years with no previous MI or stroke and with high or medium CVD risk (a 10-year predicted probability of MI or stroke [ie, CVD risk score] ≥15%) in 2017-2018.
Intervention:
Organizations agreed to perform guideline-concordant care, including routine CVD risk assessment and cardiovascular care management for high-risk patients. The Centers for Medicare & Medicaid Services paid organizations to calculate CVD risk scores for Medicare fee-for-service beneficiaries. CMS further rewarded organizations for reducing risk among high-risk beneficiaries (CVD risk score ≥30%).
Main Outcomes And Measures:
Outcomes included first-time CVD events (MIs, strokes, and transient ischemic attacks) identified in Medicare claims, combined first-time CVD events from claims and CVD deaths (coronary heart disease or cerebrovascular disease deaths) identified using the National Death Index, and Medicare Parts A and B spending for CVD events and overall. Outcomes were measured through 2021.
Results:
High- and medium-risk model intervention beneficiaries (n = 130 578) and standard care control beneficiaries (n = 88 286) were similar in age (median age, 72-73 y), sex (58%-59% men), race (7%-8% Black), and baseline CVD risk score (median, 24%). The probability of a first-time CVD event within 5 years was 0.3 percentage points lower for intervention beneficiaries than control beneficiaries (3.3% relative effect; adjusted hazard ratio [HR], 0.97 [90% CI, 0.93-1.00]; P = .09). The 5-year probability of combined first-time CVD events and CVD deaths was 0.4 percentage points lower in the intervention group (4.2% relative effect; HR, 0.96 [90% CI, 0.93-0.99]; P = .02). Medicare spending for CVD events was similar between the groups (effect estimate, -$1.83 per beneficiary per month [90% CI, -$3.97 to -$0.30]; P = .16), as was overall Medicare spending including model payments (effect estimate, $2.11 per beneficiary per month [90% CI, -$16.66 to $20.89]; P = .85).
Conclusions And Relevance:
The Million Hearts Model, which encouraged and paid for CVD risk assessment and reduction, reduced first-time MIs and strokes. Results support guidelines to use risk scores for CVD primary prevention.
Trial Registration:
ClinicalTrials.gov Identifier: NCT04047147.
