Plenary III Ask About Aspirin Stanton Shanedling, PhD, MPH Supervisor, Heart Disease & Stroke Prevention Unit, Minnesota Department of Health

Colleagues Alan T. Hirsch, MD Professor of Medicine, Epidemiology & Community Health Director, Vascular Medicine Program, Lillehei Heart Institute, University of Minnesota - Medical School John R. Finnegan, PhD Professor & Dean, Vice President of Public Health, University of Minnesota - School of Public Health Russell V. Luepker, MD, MS Mayo Professor of Public Health, Division of Epidemiology &Community Health, University of Minnesota - School of Public Health  Niki Oldenburg, DrPh Research Team Leader, Vascular Medicine Program

Goal: Statewide initiative to reduce CVD by promoting a community intervention to increase the appropriate use of low dose aspirin in target populations

Utilize United States Preventive Services Task Force (USPSTF) aspirin recommendations for the primary prevention of cardiovascular disease: ▪▪Encourage men age 45 to 79 years to use aspirin when the potential benefit of a reduction in myocardial infarctions outweighs the potential harm of an increase in gastrointestinal hemorrhage. (USPSTF “A” recommendation) ▪▪Encourage women age 55 to 79 years to use aspirin when the potential benefit of reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. (USPSTF “A” recommendation)

Background Baseline data prior to intervention % of men age and 37% of women age reported taking ASA (MN Heart Survey) 19% of all deaths in Minnesota due to Heart Disease (18% in 2011) 6% of all deaths in Minnesota due to Stroke (5% in 2011)

Interventions to increase use of low-dose ASA 1. Health Professional Education – reaching physicians, pharmacists, nurses and other health professionals to disseminate new practice tools to improve aspirin use in the target patient population 2. Shared Media – engaging the public through the use of on-line resources to engage adherence to aspirin use; 3. Mass Media – reaching the public via use of traditional mass media, including television, newspapers, radio station, billboards, etc.

Goals Increase aspirin intake by an absolute 10% in Minnesota adult population of men age and women age Reduce the number of first heart attacks and strokes in the target population in Minnesota. Verify the impact of newly developed prevention tools and measure the effects of the campaign, in order to assure that the most effective tools can be disseminated across the State of Minnesota, as a national model.

Clinic Based Interventions: Hibbing, MN Three Health Systems 1.Patient identification and activation 2.Provider and team behavior awareness and activation 3.Community Systems Change – Community Health Coordinator

Public Awareness 85% liked the ads 72% found the ads engaging 95% found the ads believable 87% trusted the ads 87% had a favorable reaction

Aspirin Use in Hibbing: Self-Report and Assay Results ASA use Total Group (n=103) Primary Prevention (n=74) Secondary Prevention (n=29) Self-reported use52 (50.5)28 (37.8)24 (82.8) Self-reported daily use49 (47.6)27 (36.5)22 (75.9) Regularly take aspirin to prevent MI or stroke 50 (48.5)26 (35.1) Assay results (n=54) Thromboxane <25ng/ml36/54 (66.7)23/38 (60.5)13/16 (81.3) Self-reported use*32/54 (59.3)18/38 (47.4)14/16 (87.5) Self-reported daily use**31/54 (57.4)17/38(44.7)14/16 (87.5) 37% 79% Before the campaign the primary prevention group rarely asked their clinician about aspirin use to prevent a heart attack or stroke (less than 1 in 5 individuals).

Self-Reported Aspirin Use in the Primary Prevention Cohort ASA use Pre-Campaign (n=74) Post-Campaign (n=85) Self-reported daily use*27/74 (37%)44/85 (52%) Regularly take aspirin to prevent MI or stroke 26/74 (35%)39/85 (46%) *Answered “daily” to the question “How often do you take aspirin”? 36% 52% Over four months aspirin use increased Increased aspirin use This rate of change is higher than temporal trends

Goals for Next 12 Months 1. Create improved public awareness campaign messages 2. Improve the efficacy of clinic-based ASA use intervention and metrics > Expand use of the EHR as a tool for medication mgmt and adherence > Achieve > 90% health professional engagement of ASA primary prevention learning module 3. The program is prepared to expand to a State or wider intervention in 2014

Some key questions Focus on prevention vis a vis intervention messaging? Given ABCS why no concerted campaign to support ASA? Ambiguity in information exchange? Are there concerns?

Contacts Alan T. Hirsch, MD Stanton Shanedling, PhD, MPH

Plenary III Ask About Aspirin Q and A