Practical Pearls: A Clinician’s Foray into Population Health Management

In 2007 I was a graduate fresh from medical school with a set of preconceived notions about what my role as a physician would be. I imagined a clinical practice busy with office visits, in-patient consultations, testing, billing, paperwork, and a general schedule similar to that of my mentors at the time. I had no idea that, during the short six years of my residency and fellowship, the world of healthcare in the U.S. was about to completely change. Suddenly, I noticed a whirlwind around me from the financial collapse and takeover of major medical institutions, the mass consolidation of private medical groups, the furious debate and eventual passage of the Affordable Care Act, and the sudden emergence of terms like “value-based care” and “population health management.”¹

It became obvious as I approached the final year of my cardiovascular disease fellowship that the centuries-old expectation of physicians caring for the sick individual was to be supplemented with a very different call that asked us to be stewards of health, prevention, and lifestyle for entire communities.

As I noticed changes in my professional world, I also awoke to a startling issue in my personal community. As a 30-something South Asian, I noticed a number of my friends and relatives suffering from severe and startling cases of premature heart disease. I started seeing similar patterns in my clinical practice and as I delved into the research, I found South Asians, who derive their ethnic origin from the Indian subcontinent, are at a disproportionate risk for heart disease at a startling rate. South Asians account for roughly 25 percent of the world population but hold 60 percent of the world’s cardiovascular disease burden.² In North America, the prevalence of heart disease in this ethnic group is more than 1 out of 10, with mortality rates that are at least two times greater than any other major minority group.^3,4 Even more striking is when South Asians are affected by heart disease, with clinical studies finding nearly 25 percent of first-time myocardial infarctions occurring under the age of 40 among men.⁵ As I saw the wide gap between prevalence and awareness, I realized there existed an opportunity for me to go beyond the walls of my clinical office and make a humble attempt to move on the expectations of population health management. It was in that vein and with the support of Advocate Health Care that I formed the South Asian Cardiovascular Center (SACC), a population health entity that attempts to raise awareness of South Asian heart disease and provide clinical and community solutions through a three-part model: (1) a commitment to transformative community outreach backed by (2) advanced culturally sensitive clinical care and committed to (3) investigative research.

We began our mission by forming a key group of community representatives that serve as our council of advisors. The council meets quarterly to provide feedback, vet our ideas, and serve as ambassadors in a Chicagoland South Asian community that is nearly a quarter- million strong with a wide range of faith traditions, socioeconomic backgrounds, and languages.⁶ With the right feedback we proceeded to create a communication network that was widely distributed and easy to understand. In addition to a strong commitment to grassroots community lectures via faith centers, we also developed an elaborate set of social media tools, from healthy-cooking videos featuring “MasterChef” season 2 finalist Suzy Singh to a Facebook and Twitter platform that provides quick, easily accessible education. Finally, we looked at atypical venues through which to educate and raise awareness. For example, South Asian movie theaters often provide an intermission during lengthy Bollywood productions, offering a key moment in which to insert educational public service announcements on the screen. However, we wanted our community outreach to be transformative and thus we had to go beyond education by inspiring change and empowering individuals.

We started by supplying and training lay volunteers within faith communities to conduct wellness screenings after weekly services, providing consistent feedback on blood pressures and glucose levels to a group of people who often don’t utilize preventive primary care services. We then partnered with the Chicago Department of Public Health and launched South Asian Health Eating Benefits Chicago (SAHEB – Chicago), which had a registered dietitian train chefs at some of Chicago’s top South Asian restaurants to reduce sodium content by a minimum of 10 percent. Initial food analysis thus far has shown an average sodium reduction of nearly 20 percent across participating restaurants.

We also are partnering with Patel Brothers, a national South Asian grocery chain, to insert consumer education up and down the aisles of their nearly 60 stores around the country and advise them on sodium and fat reduction in their packaged food.

To complement our community efforts we developed a preventive clinical program that aggressively searches for risk factors and signs of heart disease, from Lp(a) analysis to coronary calcium scoring. This program is supplemented by a South Asian diabetes education class to help the nearly 30 percent of South Asians who are diabetic and need culturally sensitive dietary counseling on carb counting.⁷

South Asians admitted for inpatient care have the benefit of a SACC nurse navigator to provide bedside education to the patient and the family. Finally, we maintain a commitment to research, from investigating genetic factors that drive early cardiac-related death within the community to objectively assessing unique lifestyle interventions that easily can be scaled and applied with mobile app technology.

Population health is clearly evolving, with variable interpretations, iterations, and a hope that better outcomes, lower costs, and saved lives will manifest. The manner in which this evolution occurs likely will depend on the active involvement and dedication of clinicians who can identify the needs of their patients and scale them to the communities to which they belong.

Disclosure statement: Dr. Sitafalwalla has no disclosures to report.

References are listed on page 38 of the PDF.