How Our Approach to the Patient with Multiple Chronic Diseases is Different
If practices or commercial programs have a chronic disease management program it is generally focused on a single problem like diabetes, high blood pressure, or heart failure. That goes back to thinking about individual risk factors for late catastrophes like heart attack. The diabetes programs are designed to get the sugar down using anything that lowers glucose. Patients with diabetes don’t die of a high sugar, they die of heart attacks and strokes. Programs that focus only on getting the sugar down don’t prevent heart attacks, strokes, and death. That is because the patient with diabetes seldom presents with diabetes alone. The often have high sugar, high blood pressure, high LDL-cholesterol, low HDL cholesterol, high triglycerides, and chronic kidney disease. To prevent heart attack and stroke, all those conditions must be addressed in a coordinated and integrated fashion.
Our approach to patients like this makes our program unique. New science helps us all to understand that all cardiometabolic diseases are related and driven by the same epigenetics and molecular biology. Diabetes, hypertension, hyperlipidemia, heart attack, stroke, chronic kidney disease, congestive heart failure, atrial fibrillation, abdominal aortic aneurysm, and peripheral arterial disease are all driven by the same biology. We have learned that chronic diseases are not caused by gene mutations or abnormal genes. They are instead caused by genes that are essential in fetal development and response to trauma, but cause disease later in life when inappropriately activated by abdominal fat, poor diet, smoking cigarettes, and aging itself. When these genes are abnormally switched on, they increase oxidant production and activate signaling cascades that increase scar formation, kill the functional cells in organs, and increase inflammation. Increased oxidant production switches on the master metabolic switch mTOR and switches off AMPK
Lisinopril, losartan, spironolactone, and eplerenone for hypertension along with statins for cholesterol block the effects of these genes to reduce oxidant production precisely. Metformin, SGLT2 inhibitors and the rapamycin in the drug eluting cardiac stent all directly switch off mTOR and switch on AMPK to block the core mechanisms in chronic disease and accelerated aging. Caloric restriction, intermittent fasting, and exercise impact these same pathways. These interventions together define our protocol-driven approach that provides optimal medical therapy (OMT) for chronic cardiometabolic conditions. They don’t merely lower the risk factor. They also protect cells and organs by blocking the biology that damages them. These interventions together are optimal medical therapy (OMT).
The entire state of Minnesota has recognized the benefits of OMT. Minnesota tracks OMT achievement for vascular disease (V4) and diabetes (D5) for 500 medical practices and they report on performance to the public.
The V4 has 4 components
1. Blood pressure less than 140/90.
2. On a high intensity statin
3. Off cigarettes
4. On aspirin
The D5 has 5 components
1. Blood pressure less than 140/90.
2. On a high intensity statin
3. Off cigarettes
4. On aspirin
5. Hemoglobin A1c less than 8
The main clinical measure for cardiometabolic patients is % achievement of OMT components concurrently. That has the greatest impact on cardiovascular and financial outcomes. OMT is achieved in only about 20% of diabetics nationally with a huge adverse impact on diabetes outcomes. Our benchmark is 55%. Teams and individuals that achieve that benchmark receive advance certification. That ties our education, systems, and performance together.
We have developed a comprehensive education system for cardiometabolic condition teams and patients to help them understand how this all ties together. It prepares teams to deliver the OMT product consistently. When you tie all of this together, your patients have one fourth as many heart attacks and one fifth as many strokes.