Moving Forward Together to Prevent DVT

RADM Steven Galson M.D., M.P.H
Acting Surgeon General
U.S. Department of Health and Human Services
 

Keynote Address to the Coalition to Prevent Deep Vein Thrombosis Annual Meeting

January 22, 2009

Washington, DC

Thank you, Sam (Samuel Z. Goldhaber, MD, Harvard University Professor of Medicine and chair, Venous Disease Coalition) for the gracious introduction.

It is my pleasure to be with you this morning. You have done so much to emphasize the importance of Deep Vein Thrombosis and Pulmonary Embolism in the public health and clinical arenas and I am enormously thankful.

Before I start, I want to express my appreciation to everyone whose hard work made this annual meeting happen.

I especially salute Melanie Bloom and the Coalition, our conference hosts, for:

your commitment to the issue;

- your pro-activity; and

- for the resources you are marshalling to address two serious conditions that, historically, have received comparatively little attention.

Melanie, because of your and your allies, things are changing.

You and the coalition were instrumental in helping to roll out the Call to Action last September, and I’ve no doubt your leadership will be equally important as we widely share the word that DVT and PE result in preventable death and disability.

At HHS we are honored to count the coalition membership among our most valuable partners.

This meeting is a great opportunity to:

1) advance clinical understanding of Deep Vein Thrombosis and Pulmonary Embolism (DVT and PE);

2) identify best practices for effectively managing DVT/PE; and

3) ultimately, make progress toward the day when we can prevent both;

Your conference agenda is ambitious and impressive.

This meeting, coming on the heels of the DVT/PE Call to Action, is especially timely. I am sure that this meeting will:

- further stimulate public and medical awareness of venous disease its causes and complications.
    and

- improve momentum as the health professions become increasingly successful in combating DVT.

I would like to commend a few individuals in particular who contributed so greatly to the Call to Action:

They are:

Dr. Sam Goldhaber, who of course, introduced me a moment ago - Professor of Medicine at Harvard Medical School and chair of the Venous Disease Coalition. Sam is a staff cardiologist at Brigham and Women’s Hospital (BWH), in Boston, where he practices general cardiology, attends to patients in the Coronary Care Unit, and oversees the BWH Thromboembolism Consultation Service. Dr Goldhaber is Founder and Director of the Anticoagulation Service at BWH, which cares for about 1,500 patients.

Dr. Thomas Ortel - Professor of Medicine and Pathology at Duke University Medical Center. He is the Medical Director of the Hemostasis and Thrombosis Center at Duke, which is supported as one of the initial Thrombophilia Pilot Programs by the Centers for Disease Control & Prevention. He is also Medical Director of the Clinical Coagulation Laboratory and the Platelet Antibody Laboratory at Duke, as well as the Duke Anticoagulation Clinic

As Scientific Editors of the Call to Action, Drs. Goldhaber and Ortel made immensely valuable contributions.

Their expertise was critical to producing what is surely a pioneering document.

Because of their leadership, we are poised to realize ongoing and meaningful progress in addressing Deep Vein Thrombosis, Pulmonary Embolism and the consequences they exact.

This issue fits in perfectly to much of my work during the last 15 months.

It is one element of a broader, far-reaching necessity: to effect a real change in the way we think about health care in the United States.

I want to reflect for just a moment on the dramatic change taking place in Washington.

One cannot help but be stirred by it.

Significant policy prescriptions, senior leadership, and agency personnel changes have begun and we already know that

Continually improving the health of the Nation is going to be at the top of the new Administration’s agenda.

We know there are three fundamental problems plaguing the American health care and service delivery system today: skyrocketing costs, lack of access, and disparity of quality care.

Today, 47 million Americans lack health-care coverage.

It is projected that the U.S. will spend nearly $2.4 trillion on health care this year. That is almost $7,500 per person.

Premiums have increased nearly 98% since 2000. And this increase is nearly four times faster than the growth of wages during the same period.

Too often, for individuals who lack health care coverage, the quality of health care they receive is inadequate.

For instance, the U.S. lags behind other industrialized countries in basic health measures such as life expectancy and infant mortality.

Moreover, we have less same-day access to primary-care physicians as individuals in other countries.

The situation illustrates what virtually every stakeholder interested in a healthier, fitter Nation understands: a profound cultural change is required.

OSG Priorities

We need to establish and maintain a system of care based on Disease Prevention.

If prevention is the future - and it is - then the future is now.

As Acting Surgeon General, I serve as our nation’s chief “health educator” - responsible for giving Americans the best scientific information available on how to improve their health and reduce the risk of illness and injury.

And creating a culture of health and wellness, emphasizing preventive care and encouraging healthy decisions is what the Office of the Surgeon General is all about.

Today, we spend the vast proportion of our health care dollars in this country treating preventable diseases.

We know that consistently investing in preventing these diseases will save lives and health dollars.

A consensus exists that prevention-based and value-driven system of care is essential.

Today, providers cannot offer the best care they are capable of and consumers do not have the ability to consider value when they make their health care purchasing decisions.

Accordingly, the future must be one in which consumers:

…are able to find out which hospital in their area has the highest success rate for the procedure they need

…can compare doctors, not just on what they charge, but also in the quality of the care they give, and

…approach health care they way they would any other major purchase - by consulting an impartial source of information on quality and cost.

All Hazards Preparedness

We know also that the most efficient health care system is one based on 21^st century Preparedness.

Quite simply, we must be ready to meet and overcome challenges to our individual and collective health and safety, whether caused by nature or humans.

Increasingly, emergency preparedness has become a major part of our mission to protect, promote, and advance the health and safety of the nation.

PHS Commissioned Corps

The Office of the Surgeon General oversees the 6,000-member Commissioned Corps of the United States Public Health Service.

As the world shrinks, collaboration across borders is being fostered worldwide around health issues.

In this, officers of the Commissioned Corps participate in places and ways nearly too numerous to count.

I am not just talking about health diplomacy and emergency response.

Even in the environment and medical product regulatory world, there is more and more international collaboration and the Corps is positioned to be in the middle of this profound change.

Whether -

• providing clinical services for Haitian, Cuban and Southeast Asian refugees
• identifying and isolating three separate acute hemorrhagic fever viruses (Ebola, Lassa, and Marburg) in Africa
• helping to restructure Iraq Ministry of Health

- the PHS Commissioned Corps is ideally prepared to serve.

At the same time, notably, President Obama has discussed the prospect of investing in electronic health information systems to not only improve routine health care, but also ensure that these systems will give health officials the information they need to deploy resources and save lives in an emergency.

Since preparedness is multi-dimensional, we recognize that it must also involve planning by every level of society, including every family.

To help communities and families prepare, HHS maintains preparedness checklists on the OSG website.

These include checklists for individuals, families, schools, hospitals, and community organizations. In addition, there is a focused checklist for businesses recognizing their important role in protecting employees’ health and safety and helping to minimize negative impacts to the economy and society in the event of a national pandemic.

These efforts are premised on the recognition that the foremost challenge to our technological and medical expertise in treating diseases is getting to the disease before it uses our technology to spread.

Health Disparities

Meanwhile, disease prevalence and outcomes disproportionately affect certain populations.

Eliminating Health Disparities is a moral obligation as well as public health objective and talking about this critical issue has been another one of my priorities.

Too many Americans in minority groups still suffer from illnesses at a disproportionate rate. They live sicker and die sooner from a wide variety of acute and chronic conditions

For instance:

- African Americans are more likely than any other racial and ethnic group to develop cancer, and 30 percent more likely than whites to die from it.

- Hispanics living in the United States are 50 percent more likely than whites to suffer from diabetes; and the incidence of diabetes among Native Americans is more than twice that for whites.

- African-Americans (and Whites) are more likely than other ethnic groups to develop a DVT or a pulmonary embolism. African-Americans are estimated to be at 30 percent greater risk compared to whites.

These are just a few examples.

Successfully minimizing the impact of health disparities requires an aggressive approach that includes public outreach, advocacy, and education.

The Agency for Healthcare Research and Quality produces each year a National Healthcare Disparities Report on behalf of the Department which tracks disparities related to quality of health care and access to health care.

The 2007 Disparities Report found that disparities in health care quality and access are not getting smaller. Progress is being made, but many of the biggest gaps in quality and access have not been reduced.

The good news is that opportunities for reducing disparities remain.

Cultural Competency

Data-driven, culturally competent, evidenced-based approaches are critical to moving science into practice and, in turn, reducing disparities in every population.

Without racial and ethnic data, health care providers, insurers, and government agencies cannot work to identify or mitigate racial and ethnic disparities in health and health care. 

Moreover, as public health stakeholders - as well as health care providers/insurers - place greater emphasis upon measuring quality and outcomes and do it by race and ethnicity, our ability to identify solutions will likewise improve.

The last broad issue I want to talk about is health literacy.

More than forty-six million people - 17 percent of the U.S. population - speak a language other than English at home. The vast majority of non-English speakers are Spanish-speaking although more than 300 other languages are spoken.

Numerous studies show that effective language services improve outcomes for patients with limited English proficiency by increasing satisfaction levels, use of health services, and compliance with recommended medical advice.

Low health literacy is another health issue that disproportionately affects minority populations.

Patients with low health literacy - the ability to read, understand, and act on health information - have greater difficulty than do others in dealing with the health care system and understanding and following the recommendations of their providers.

They are 50 percent more likely to require hospitalization and have poorer health outcomes.

We cannot make improvements in health care and prevention if our messages aren’t being understood.

In 2003, an estimated 77 million American adults, about 36 percent of the population, were reported to be at or below basic health literacy levels (Source: National Center for Education Statistics, Institute for Education Sciences).

When a patient does not understand that certain triggering events (being hospitalized or confined to bed rest, having major surgery, breaking a leg, or perhaps traveling over a period of several hours) all increase the risk for DVT and PE….that is a problem.

When a patient is not cognizant that DVT and PE risk increases with age, especially after age 50….that is a problem.

When an individual with an inherited blood clotting disorder…or women who take hormones are not conscious of their increased risk…that is a problem.

When users of tobacco, or persons significantly overweight, remain unaware that smoking and obesity are risk factors for DVT and PE, it is a problem.

We must provide clear, understandable health information to the American people.  In the absence of clear communication, we cannot expect people to adopt the healthy behaviors we champion.

The promises of medical research, health information technology, and advances prevention - and the improvements in care of DVT and PE all of us want - cannot be fully achieved if we do not simultaneously address health literacy.

This includes making sure that every health professional is fully aware of how we understand DVT and PE today.

Does every practitioner properly appreciate that our concepts of DVT and PE have changed?  Does every care giver recognize these conditions usually represent a chronic illness, analogous to CAD or diabetes?

We must make certain they do.

The Office of the Surgeon is pursuing key opportunities to do so as they arise.

This brings me to next steps necessary to make real the vision of the future articulated by the Call to Action.

Already, my office has moved to capitalize on the release of the CTA.

Last October, Assistant U.S. Surgeon General James Galloway, Health Administrator for HHS Region V, discussed the state of DVT PE medical science at the 74th annual international scientific assembly of the American College of Chest Physicians, or CHEST 2008, in Philadelphia.

Moreover, just as science has helped us learn a great deal about factors that increase the risk of DVT, still more research in the pipeline holds promise as well.

The first multi-center, randomized, clinical trial of genotype-guided dosing of warfarin therapy, the most commonly used blood-thinning treatment (sponsored by the National Heart, Lung and Blood Institute, within the National Institutes of Health) is at hand.

Investigators will examine whether the use of clinical plus genetic information during the initiation of warfarin can lead to better and safer treatment in patients, especially those with DVT, atrial fibrillation, who are at risk for stroke, or who require warfarin therapy following orthopedic surgery.

This and other NIH-sponsored research complements the efforts of the six established Thrombosis and Hemostasis Centers supported by the Centers for Disease Control and Prevention.

By sharing resources and data from the network's patient registry, we are significantly enhancing our Federal research investment in DVT.

The Future

Together with the groundbreaking work of the Coalition to Prevent Deep Vein Thrombosis – I understand that in 2008 alone, the Coalition’s message has reached more than 300 million people – these activities represent the future.

They signal an era when evidence-based practices for screening, diagnosing, treating and preventing DVT/ PE are clearly understood and routinely applied by all medical professionals in all settings.

They illustrate a near future when discoveries relevant to DVT and PE are regularly and expeditiously integrated into clinical practice.

Think of what we’ve learned in the last 10 years alone: to cite but one example, we identified the prophylactic value of low molecular weight heparin to individuals on bed rest.

Perhaps another scientific advance which moves forward our ability to manage DVT/PE will be hastened by collaborations initiated at this conference!

Earlier this morning, Dr. Geno Merli described certain successes in ramping up consumer awareness of DVT/PE;

I know also that, during the panel discussion to follow my remarks, Dr. Jeff Brady, of the HHS Agency for Health Care Research and Quality will discuss the “Consumer’s Guide to Preventing and Treating Blood Clots.”

These are merely two of the many reasons to be encouraged.

Closing
I am confident that, in time, the benefits to be realized from additional advances, improved diagnosis and, enhanced provider and patient literacy about DVT and PE will be considerable.

As the Call to Action makes clear, we know more than enough to move forward with confidence now.

Time seldom waits, and it won’t wait on us.

We know more than enough to redouble our commitment to translate the dynamic science of venous disease - as promptly as new findings emerge - into risk and incidence reduction.

As we do so, we will have increased the years and quality of life of tens of thousands of people whose names we will never know.

I can scarcely imagine a greater reward.

Let us step up together and make this happen.

Thank you.