Big Strides with Small Uphill Steps

“Million Hearts,” which launched in 2012, is a national initiative by the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS). Its 5-year aim was to prevent a million acute cardiovascular events by improving specific cardiovascular disease risk factors. Although current data suggest that they achieved only about half their goal, they may still have prevented as many as 500,000 cardiovascular events – a major accomplishment.

A new JAMA Viewpoint by Wright and colleagues discusses Million Hearts 2022, the strengthened initiative which began in 2017. More than 200 community health centers have earned recognition from the Health Resources & Services Administration (HHS) for exceeding 70% performance on aspirin use, blood pressure control, and smoking cessation. I’ve been following the initiative because I love its bold simplicity.

The successful Million Hearts campaign focuses on 3 basic things that no one would disagree with. That’s why, to improve the outcome of patients with lower extremity ulcers, the US Wound Registry decided to focus on 3 simple things: arterial screening of all patients with lower extremity wounds and ulcers, adequate venous leg ulcer (VLU) compression, and appropriate diabetic foot ulcer (DFU) off-loading. In the first year of the USWR “Do the Right Thing™” initiative (2017) we showed that honestly-reported VLU and DFU healing rates improved by 10%.

The Million Hearts campaign demonstrates that big wins can be achieved with small steps. What isn’t obvious is that those small steps are supported by a massive federal infrastructure and millions of federal dollars. It’s likely that you or your institution are participating in Million Hearts because there are dividends for hospitals and practitioners who do, not limited to recognition as a “Champion” or “Partner” on the attractive website. The individual activities (e.g. encouraging smoking cessation) are quality measures under the Merit Based Incentive Payment System (MIPS). Every possible federal or state quality program is on board, as are the relevant medical specialties. Take a look at the website. It’s downright sexy to be part of this program.

In contrast, consider that chronic wounds may cost CMS more than $94 Billion a year; the prevalence of chronic wounds among Medicare beneficiaries is higher than heart failure and the mortality rate of major amputations is worse than most cancers. However, there are no quality measures relevant to chronic wounds in MIPS and the CDC doesn’t have a “Million Legs” campaign. CMS doesn’t recognize any “Champions in Limb Salvage.” In 2017, a small group of dedicated wound care practitioners actually paid to report those 3 USWR Qualified Clinical Data Registry (QCDR) measures to CMS. However, we can prove that the outcomes of their patients were better than practitioners who didn’t report these 3 QCDR measures, even though these simple interventions are considered the “standard of care.” Unfortunately this means that the standard of care is not being implemented routinely for either cardiovascular disease prevention or leg ulcer management. It also means that there’s an opportunity to make big strides in the outcome of patients with lower extremity ulcerations with only a few small steps.

If mortality and amputation rate among patients with leg ulcers are going to improve, it will only be through the activism of wound care practitioners. It won’t be through a program supported by HHS, promoted by the CDC, or funded by federal dollars. It will be accomplished in spite of the barriers erected by hospitals and electronic medical records vendors that continue to block registry participation. CMS is not going to recognize wound care relevant quality measures at the national level. There won’t be a beautiful, federally funded website recognizing practitioners who provide exemplary care and directing patients or payers to those practices. No wound care clinical association is ever going to promote this program, and no manufacturers are going to help fund it. Nevertheless, a group of committed practitioners and several small wound care management companies dedicated to quality of care are going to Do the Right Thing. Because that’s just what we do. We have already proved we can make big strides with small steps. However, there’s no denying that it would be easier to take these small steps if they weren’t all uphill.


Million Hearts 2022 Small Steps Are Needed for Cardiovascular Disease Prevention
Janet S. Wright, MD1; Hilary K. Wall, MPH1; Matthew D. Ritchey, PT, DPT, OCS, MPH1

AMA. 2018;320(18):1857-1858. doi:10.1001/jama.2018.13326