Facts, trends and research to include in your customer conversations when speaking about testing for heart disease in the physician office lab.
By Jim Poggi
As consultants to the clinical practices we call on, we sometimes wonder “What do I REALLY need to be able to communicate to be considered valuable? Is the lab and clinical information that I provide considered credible and actionable? Will my customers think I am trying to show I know more than they do? Will my consultative activities grow my business?”
As I write some of my more clinically oriented columns, I try to keep these thoughts in mind and answer the key question on your mind: “How can I effectively use this information to grow my business?”
In this column, like others in the past, my answer is that being well informed allows us to have more meaningful and deeper conversations with our customers. We are not trying to be a peer-to-peer resource, but we should show an understanding and respect for the information physician offices use every day as they seek to provide the best patient care possible.
I believe using this information properly allows us to have better conversation starters to discuss the value of lab. If used properly, it certainly sets us apart from those who do not know or use this information. Along the way, I learned the most useful approach to weave this information into conversation. In my rookie years, I often asked “did you know” questions using a clinical tidbit. The customer reaction was rarely positive. When I switched to “In my research on (clinical topic) to prepare for our meeting, I learned some interesting information I would like to share with you…” the reaction was uniformly more positive.
It is best, when using this type of approach, to ALWAYS have your payoff in mind as you begin the conversation. As an example: “I always thought heart disease and heart attack spiked in the winter. As I researched, I learned it also has a summer peak. This leads me to wonder how this information impacts the use of our screening for diabetes, lipids, hypertension and cardiac marker assays. I would be interested in how you use this information in your practice, particularly in how you use lab tests for heart disease. (Pause to allow customer to respond).”
With this context in mind, I have a few interesting facts regarding heart disease to pass along. It is my hope that you find them useful in your customer conversation and that you learn new ways to discuss the importance of having lab tests available at the point of care for the benefit of your customers and their patients.
Latest heart disease morbidity and mortality trends
From 2019 to 2020, age-adjusted death rates increased for 6 of 10 leading causes of death and decreased for 2. Heart disease continues to be the leading cause of death in the United States and its rate is increasing. The rate increased 4.1% for heart disease (from 161.5 in 2019 to 168.2 in 2020). Cancer death rates declined during this time, widening the gap between heart disease as number one and cancer as number two. Overall life expectancy in the U.S. has declined post-COVID and I am confident this fact is on the minds of many of your customers. As we discuss the importance of effective screening for lab tests related to heart disease, we need to be mindful of how our customers view these morbidity and mortality trends and how they are managing them. Do they feel the need for more intensive pre-diabetes screening with A1C? What about lipid testing? Has their patient counseling protocol changed? How can we help?
Heart disease seasonal risk statistics
As I mentioned earlier, the conventional wisdom has been that heart attacks and stroke spike in the winter.
As a native of western New York, where long winters meant cold temperatures and lots of snow to shovel, this felt logical to me, especially with lower levels of winter exercise coupled with the exertion of shoveling snow. What I did not realize is that heart attacks also have a summer peak. CDC, NIH and numerous recent studies have clarified this data and it is becoming more well known. While not as high as the winter peak and with fewer reported heart attacks in the summer, it is becoming clearer that managing to get through winter without a heart attack does not mean that your customers’ patients are in the clear.
The implication: all manner of preventive strategies should be year-round efforts. Counseling for lifestyle improvements, especially regarding proper exercise and weight control measures will have benefits for quality of life and prevention of premature heart attack. Glucose, hemoglobin A1c and lipid tests all factor into a proper preventive strategy along with vital signs measurements for every patient visit, particularly those who present with risk factors, including hypertension, diabetes, obesity or lipid disorders. I will present some interesting lifestyle information later. How you live makes a difference in your risk of heart attack, but I learned that where you live also has an impact.
Heart disease and where you live
The incidence of heart disease varies considerably, based on where you live in the U.S. Based on scores for seven well established risk factors for heart disease, the South has the highest risk level, followed by the Midwest, Northeast and West regions respectively. The data summarized below are from large-scale studies conducted by the NIH over more than 10 years.
One point of caution: much of the data was collected by phone and was “self-reported” by the patient or a family member. This is likely to explain why the reported level of diabetes in this study does mirror CDC data for confirmed diabetics, but is likely not to include prediabetics. CDC estimates that in addition to 37 million diagnosed diabetics, there are 96 million more prediabetics. Early detection of the prediabetic population with urinalysis, hemoglobin A1c and lifestyle counseling would have a major impact on this data. How are your customers diagnosing prediabetics? Are they seeing an increase in the number of first-time adult diabetics diagnosed? Ask to learn more and recommend broader scale screening especially in the at-risk population: older, obese, history of heart disease, and elevated lipids.
Age-Adjusted Cardiovascular Mortality Across the United States: 2017
| Northeast | Midwest | South | West | |
| AAMR (95% CI) | AAMR (95% CI) | AAMR (95% CI) | AAMR (95% CI) | |
| Overall | 207.3 (206.3-208.3) | 227.7 (226.7-228.7) | 233.0 (232.2-233.8) | 197.5 (196.6-198.5) |
But Exactly WHERE you live is also a factor, which was news to me
The data tends to vary somewhat from one area of the country to another, but except for the West, rural populations tend to have the highest rates of heart disease. Is it about access to quality health care, more physical labor, different lifestyle choices or another factor? Discussing this information can lead to some interesting dialogue with your customers. In my area of rural Virginia, it is widely believed that access to quality health care is a big factor, along with lifestyle choices (we tend to smoke more and eat less well) than other parts of the state. No matter what the underlying cause may be, early diagnosis via proper lab and vital signs screening methods will lead to better patient health outcomes.
Racial and ethnic makeup also makes a difference
Black Americans have the highest level of heart disease incidence no matter which area of the country they live in. Non-Hispanic White Americans have the second highest rate. Asian and Hispanic Americans have the lowest rates. There are likely to be access to care, socioeconomic and other factors in play here. There is little doubt that your customers are aware of these differences and that they factor in their screening and care planning.
How you live
The NIH has developed and tracks cardiac risk factors based on seven classic risk factors in their Behavioral Risk Factor Surveillance System database. These factors are: ideal blood pressure, blood glucose, lipid levels, body mass index, smoking, physical activity and diet. Their data from a long-term study are summarized in the graph above. It shows what every clinician counsels their patients daily: eat right, exercise, do not smoke and be tested for risk factors like blood pressure and diabetes frequently. The data correlates well with the observed levels of heart disease in each area of the U.S. Follow your doctor’s orders, get screened annually and your risk of heart disease is reduced.
New therapeutics: Hope around the corner?
For every person who follows their doctor’s advice, there are several of us who “hope for the best” and expect a magic bullet to show up just in the nick of time. Is it possible there is a magic bullet for diabetes, weight loss and heart disease? The data is shaping up that way so far. GLP-1 agonists (semaglutide and others) have been prescribed for diabetes control. They have also been used, sometimes off label, for weight loss and the results have been impressive.
A recent study conducted by the manufacturer of one of these medications involving over 17,000 patients without diabetes but with heart issues conducted over 5 years has shown to reduce heart problems by 20%. While these drugs are shown to reduce weight, the study showed independence of heart risk reduction from weight loss suggesting another mode of action or multiple modes of interaction. Reduction in inflammation as well as improved utilization of insulin are factors being evaluated to understand the overall mechanism of interaction.
This information is worth some conversation. Do your key customers use these medications? Are they seeing a reduction in prediabetes, diabetes, and better weight control? It is likely too early for them to see changes in heart disease, but the data point in the direction of a reduction in heart disease for patients on these medications. It’s a great conversation starter. And follow up questions could include: How does this impact your patient screening activities? Are you seeing long-term improvement? Is your use of these medications increasing? What impediments to their use are you experiencing? Note: for weight loss indications, Medicare does not pay for these medications and private insurance companies are reluctant to do so, believing that weight loss is largely a cosmetic benefit. The emerging data is very likely to change the reimbursement landscape.
In summary, what you know can be useful. But, it’s more important to tailor your message so it is properly perceived to be useful and actionable. There is a lot to know here and many pathways to interesting and involving interaction. Use it wisely as you grow in your consulting skills. As your skills grow, your business will grow also.