The Design and Implementation of a Heart Disease Reversal Program in the Veterans Health Administration: Before and During the COVID-19 Pandemic
Background: Heart disease continues to be the leading cause of death in the US, and the number of people with cardiovascular disease (CVD) is rising. CVD is more prevalent among military veterans than nonveterans, and veteran status is associated with higher risk of incident heart disease after controlling for socioeconomic status, other medical diseases, depression, and lifestyle. Many patients seeking care in the Veterans Health Administration, including those who undergo cardiac catheterization, meet the criteria for multimorbidity (defined as ≥ 2 chronic diseases).
Observations: The Heart Disease Reversal Program (HDRP) is a novel interdisciplinary, multicomponent lifestyle program at the US Department of Veterans Affairs (VA) Sacramento VA Medical Center. This program is a streamlined adaptation of behavioral/lifestyle interventions aimed at promoting partial reversal (regression) of atherosclerotic heart disease and achievement of comprehensive cardiovascular risk reduction. HDRP was developed and implemented within a VA behavioral medicine clinic and successfully adapted for delivery through videoconferencing during the COVID-19 pandemic. Patient satisfaction survey data indicate a very high level of patient acceptability. We found direct-to-patient clinical outreach an effective method for launching a disease reversal program.
Conclusions: Beyond the clinical benefits to patients, there is significant value and benefit added to the health care system by offering an intervention within the disease reversal paradigm. Efforts of the health care team to reverse a disease can be considered the highest aim of medicine and health care.
Design
HDRP is an adaptation of interdisciplinary lifestyle interventions that have resulted in regression of atherosclerotic blockages confirmed with invasive coronary angiography.15-17,22,28 HDRP currently is offered in a Behavioral Medicine Clinic at the Sacramento US Department of Veterans Affairs (VA) Medical Center (VAMC) in California. Program staff include a clinical health psychologist who organizes, coordinates, and act as the lead facilitator of the program; registered dietitians; clinical pharmacists; and a consulting physician. Patients engage in the 4-month core HDRP program in small cohorts (ie, 6-10 patients), and spouses/partners are highly encouraged to attend all sessions.
Components
Telephone screening. Patients are screened for the inclusion and exclusion criteria (Table 1). Patients engaging in a traditional CR program are included in the screening. Patients are informed that the program consists of lifestyle intervention, including emphasis on following a WFPB diet.
Health assessment. Once approved, all patients are instructed to complete baseline laboratory tests and questionnaires. Along with an electronic health record (EHR) review, a psychosocial assessment is completed by a licensed clinical health psychologist who assesses CVD history, eating behavior, exercise/physical activity, sleep, mental health, substance use, and social history, with the aim of enhancing our ability to help the patient to benefit from HDRP.29 The patient data are used to develop a case conceptualization (ie, integrated understanding of the particular patient’s psychiatric and medical diagnoses, behavioral patterns, social supports, lifestyle habits, strengths and weaknesses, and their interrelationships with each other and the patient’s environment), resulting in an individualized plan. Patients are encouraged to ask questions about the program, and those who are still interested are invited to attend a seminar. A request for medical clearance to participate in the program is initiated through the EHR or by patients scheduling an appointment with their HCP. All patients are medically cleared by their HCP for participation. Safe exercise recommendations also are provided and guide patient goals.
CVD risk profile. Patients complete psychosocial questionnaires and fasting laboratory tests to produce a tailored CVD risk profile. Laboratory tests include fasting lipid, fasting glucose, hemoglobin A1c (HbA1c) C-reactive protein, vitamin B12, and vitamin D. The same tests (excluding HbA1c) are completed 1 month later (after completing 4 group sessions) and again posttreatment (including HbA1c). Self-reported questionnaires are completed at the same time points, which include the Rate Your Plate dietary composition questionnaire, CHAMPS physical activity questionnaire for older adults, Beck Depression Inventory-II, and the Perceived Stress Scale.
Seminar. A 2-hour seminar provides patients and families with an opportunity to meet HDRP program staff, learn the background and rationale for chronic disease reversal, obtain a summary of the program, and hear a patient testimonial. Patients are asked to make a commitment, and the informed consent process includes all patients signing a behavioral contract.
Assessment and feedback. A licensed clinical health psychologist provides feedback to patients on their comprehensive CVD risk profile, using motivational interviewing.30,31 Smokers are encouraged to quit, and those interested are referred to their HCP and/or facility smoking cessation program.
Group sessions. Twelve weekly group sessions cover nutrition education and cooking, physical activity and exercise, stress management training, and medication reconciliation and adjustment. The nutrition component is the centerpiece of HDRP and is delivered by registered dietitians (Table 2). Patients are instructed to use the 3-week period between the HDRP seminar and the first core group session to try new recipes and prepare their kitchens, pantries, and mind-set to adopt the HDRP diet with 100% adherence. The WFPB diet used is consistent with the current guidelines of Caldwell Esselstyn, MD, and Dean Ornish, MD.32-34
