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Fact Sheets and At–a–Glance Reports
The Stroke and Heart Attack Prevention Program (SHAPP) Fact Sheet
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What is SHAPP?
The Stroke and Heart Attack Prevention Program (SHAPP) is an
educational and direct–service program targeted to low–income Georgians
with hypertension. Patient services are provided through county health
departments and include screening, referral to doctors, diagnosis, and
treatment. SHAPP was initially funded by the Georgia Legislature in 1974.
Of the more than 15,000 patients served by SHAPP, most are aged 30–59
and are African Americans. Most are not covered by either public or
private health insurance or thus "fall between the cracks" of the health
care system.
Why is SHAPP important?
SHAPP is vital to Georgia given that:
- In 2001, Georgia's cardiovascular disease (CVD) mortality rate was
11% higher than the national average.1
- High blood pressure is a major risk factor for CVD.
- One in four Georgians has high blood pressure.2
Why evaluate SHAPP?
When people keep their blood pressure under control, they can
potentially avoid the debilitating and expensive complications of CVD:
heart attack, stroke, and kidney disease. Although SHAPP advocates have
long believed that the program more than pays for itself by preventing
these complications, no formal study had been undertaken to prove it.
The Research Triangle Institute, under contract with the Centers for
Disease Control and Prevention and in cooperation with the Georgia
Department of Human Resources and SHAPP district staff, conducted a study
to determine whether SHAPP is cost–effective, and why.
The evaluation involved in–depth case studies of two SHAPP programs—in
the Augusta and Brunswick district clinics—with noteworthy blood pressure
control rates. In the SHAPP Annual Report for 2003,3 one
district reported a 64% blood pressure control rate and the other a 60%
rate. Both are significantly higher than the national average.4
Statewide, SHAPP clients had a median control rate of approximately 60% in
2003.
This first evaluation of SHAPP provides preliminary evidence of the
effectiveness of the hypertension program. Data was collected in the two
clinics by:
- In–depth interviews with administrators, staff, and patients.
- Abstraction of medical records.
- Cost analyses to compare patient costs to the potential costs of not
treating those patients.
How does SHAPP improve the lives of Georgians?
According to interviews with administrators and clinic staff in these
of two SHAPP clinics, the most important patient outcomes include:
- Better awareness of the causes and effects of high blood pressure;
- Better medication compliance; and
- Better likelihood of keeping appointments.
High blood pressure is often referred to as the "silent killer,"
because most patients have no symptoms until they suffer a complication,
such as heart attack or stroke. That's why improved medication compliance
is one of SHAPP's significant accomplishments.
In these two clinics, SHAPP achieved better blood pressure control
rates for several reasons: easy enrollment, nonjudgmental and
supportive care, frequent monitoring and perhaps most importantly, free or
low–cost mediations.
- Patients said staff made time for them, were accepting and
nonjudgmental of their low–income status, and treated them well.
- SHAPP staff write prescriptions for only 1–3 months to encourage
frequent checkups.
- SHAPP clinic staff remind patients of their appointments by phone,
and follow up with patients who don't keep appointments.
- Patient access to affordable medications through SHAPP is critical
for medication adherence and is a cornerstone of the program.
Patients said they could not afford high blood pressure medication if
SHAPP did not exist. Most patients with high blood pressure require
some type of medication in addition to making lifestyle modifications.
Patients said that through SHAPP they learned the importance of eating
a nutritious, low–sodium diet, increasing physical activity, and taking
medication consistently. The use of a protocol–driven, systematic, and
comprehensive treatment system aided patient counseling.
How much money does SHAPP save Georgia?
Cost analyses compared overall SHAPP costs with two other hypothetical
scenarios: if SHAPP did not exist and 1) its clients received no treatment
(worst–case scenario) or 2) if its clients received treatment typical of
the private sector (best–case scenario).
Because SHAPP achieved above–average blood pressure control rates and
offered care to all patients, it is estimated that clients in the two
clinics would be expected to experience lower rates of hemorrhagic stroke,
ischemic stroke, heart disease, and kidney failure compared with
alternative worst-case and best–case scenarios.
- Differences in the estimated number of expected adverse outcomes
translated into substantial differences in costs; assumptions are based
on medical literature. For example, it was estimated that the 543
patients in the Augusta SHAPP were expected to experience roughly 10
fewer adverse events than if they had received no treatment and 7 fewer
than if they had received care in the best–case scenario.
- These projected differences translated into substantial cost
differences among the three treatment scenarios. For the Augusta clinic
alone, total annual costs were estimated at $289,617 for worst–case
scenario, $323,095 for best–case scenario, and $209,800 for SHAPP
treatment. In both districts, SHAPP was the least expensive of the three
treatment scenarios.
- The estimated cost per patient for those in the no–treatment group
was $534 for adverse events alone versus $595 for the best–case scenario
group and $486 for SHAPP patients, which both included preventive
medical care and adverse–events costs.
It should be noted that SHAPP clients would be far more likely to
experience the worst–case than the best–case scenario if SHAPP did not
exist.
How does the program save money?
Factors that contribute to SHAPP's cost–effectiveness are:
- All patients in SHAPP receive care, and many services are provided
by nurses instead of physicians.
- Patients get frequent checkups, which encourages adherence to
treatment protocols, both in terms of services (e.g., visits, lab work)
and medications.
- SHAPP buys medications through state purchasing mechanisms that
negotiate low prices.
- The SHAPP program does not begin treatment by using new and
expensive (and not necessarily more effective) medications. Medications
are added or changed according to a nationally accepted, evidence–based
protocol.5
Critical SHAPP Components
- Easy enrollment.
- Dedicated staff.
- Affordable medication.
- Evidence–based treatment protocols for medications and lifestyle
counseling.
- Ongoing patient follow–up and monitoring.
- Nurse–driven treatment program.
"How would clients manage their BP if there were no SHAPP? They
wouldn't."
—Staff interviews, RTI
References
- Georgia Department of Human Resources. 2004 Georgia Highlights:
Heart Disease and Stroke. Atlanta: Georgia Department of Human
Resources, Division of Public Health; February 2004. Available at
http://health.state.ga.us/epi/cdiee/cardio.shtml.*
- (http://www.health.state.ga.us,*
2002).
- Georgia Division of Public Health. "Cardiovascular Health—Stroke and
Heart Attack Prevention Program (SHAPP)."
http://www.health.state.ga.us.*
(2003)
- Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment,
and control of hypertension in the United States, 1988–2000. JAMA
2003;290(2):199–206.
- Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr,
Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ. Seventh
report of the joint national committee on prevention, detection,
evaluation, and treatment of high blood pressure. Hypertension
2003;42(6):1206–52.
- Rein DB, Constantine R, Orenstein, D,
et al. Cost–effectiveness evaluation of the Georgia stroke and heart
attack prevention program. Preventing Chronic Disease
http://www.cdc.gov/pcd/issues/2006/jan/05_0143.htm
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*Links to non–Federal organizations are provided solely as a service to our users. Links do not constitute an endorsement of any organization by CDC or the Federal Government, and none should be inferred. The CDC is not responsible for the content of the individual organization Web pages found at this link.
Date last reviewed:
08/22/2006
Content source: Division for Heart Disease and Stroke
Prevention,
National Center for Chronic Disease Prevention and
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