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Integrated Program Improves Heart and Stroke Risk Factors in Those With Diabetes

Kaiser Permanente’s Preventing Heart Attacks and Stroke Every day (PHASE program) consistently outperforms nation

OAKLAND, Calif. — Over a 10-year period, control of three key cardiovascular risk factors improved faster for Kaiser Permanente diabetes patients in Northern California than in the rest of the United States, according to research published today in the American Journal of Medicine.

Jamal Rana, MD, Kaiser Permanente cardiologist and adjunct researcher at the Division of Research

This study marks the first investigation to systematically assess the effects of Preventing Heart Attacks and Strokes Everyday (or PHASE) program, launched in Northern California in 2004, on multiple risk factors. The study reviewed annual blood pressure, blood sugar and blood lipid levels in approximately 100,000 PHASE patients with diabetes in Northern California, and compared them with data on commercial enrollees from the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set (or HEDIS).

“People with diabetes face a higher risk of stroke and heart attack, but controlling key risk factors is a real challenge,” said lead author Jamal S. Rana, MD, PhD, cardiologist at Kaiser Permanente Oakland Medical Center and adjunct researcher at the Division of Research. Bringing blood pressure, blood sugar and blood lipid levels under control is a major focus of the PHASE program at Kaiser Permanente, which uses lifestyle changes and medications to improve patients’ heart health.

The PHASE program was designed for members with an elevated risk of cardiovascular disease, including people who have had a heart attack, stroke or diabetes. The use of a patient registry identifies these patients who might benefit from intensive risk-factor control, and each patient is treated by a comprehensive care management team according to a continually updated treatment algorithm.

“Our encouraging findings speak to the strength of the PHASE program,” Dr. Rana said. “This study shows that the PHASE program addresses the daunting challenge of controlling risk factors in a high-risk population consistently and over an extended period of time, by the systematic application of a simple treatment protocol, a comprehensive registry, performance metrics, and task sharing with care managers.”

According to the new study, “Improved Cardiovascular Risk Factors Control Associated with a Large-Scale Risk Reduction Population Management Program among Diabetes Patients,” PHASE has been particularly successful for diabetes patients, who make up two thirds of the program’s participants.

Notably, the proportion of diabetes patients with better blood pressure control consistently remained 20 percentage points higher at Kaiser Permanente than among U.S. health systems reporting performance to HEDIS, in accordance with the findings of previous research among Kaiser Permanente members in Northern California with hypertension. The proportion of patients with good blood pressure control started out higher at Kaiser Permanente and remained so throughout the study, rising from 77 percent in 2007 to 82 percent in 2013, versus an increase from 57 percent to 62 percent in the national HEDIS reports.

From 2004 through 2013, the percentage of people with diabetes who had poor blood sugar control fell both nationally and for Kaiser Permanente patients, but only the Kaiser Permanente group’s decline was statistically significant. During the same period, the proportion of individuals with diabetes with good lipid control rose from 47 to 71 percent for the Kaiser Permanente patients, but there was no significant change seen in the national HEDIS reports.

Since 2006, Kaiser Permanente has partnered with community health to share and implement evidence-based PHASE strategies for reducing heart attacks and strokes in high-risk patient populations.

And now study senior author Marc G. Jaffe, MD, of Kaiser Permanente’s South San Francisco Medical Center and the Resolve to Save Lives Cardiovascular Health Initiative, is leading efforts to spread a similar approach worldwide to help low- and middle-income countries implement proven strategies to prevent cardiovascular disease.

“We are excited to share our experiences with others who treat high risk individuals, not only in California, but also across the world,” Dr. Jaffe said.

This study was funded by a Kaiser Permanente Northern California Community Benefit grant.

In addition to Drs. Rana and Jaffe, co-authors were Andrew J. Karter, PhD, Jennifer Y. Liu, MPH, and Howard H. Moffet, MPH, of the Kaiser Permanente Northern California Division of Research.


About the Kaiser Permanente Division of Research

The Kaiser Permanente Northern California Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 350 epidemiological and health services research projects. For more information, visit or follow us @KPDOR.

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