ealize the benefits that we could deliver with currently available best practice paradigms for chronic condition management. This is what takes place in Primary Care 2.0.
Using the prevention of CKD as an example again, we see that physicians aggressively and cost-effectively manage diabetes and hypertension using drugs that go beyond traditional risk factors.
They also follow guidelines that advocate focused, multifactorial interventions based on scientific evidence. And, they take cost into account by using generic drugs that target root causes. They also set aggressive clinical targets following their patients closely so they can tweak the interventions as needed.
The Steno-2 Trial
The Steno-2 trial is a great example of such an intervention. Participating physicians followed a protocol that combines ACE inhibitors for hypertension, statins for cholesterol, metformin for diabetes, and aspirin to prevent clots.
When applied, this approach has produced impressive results:
- six-fold reduction in dialysis compared with usual care
- four-fold reduction in heart attacks
- five-fold reduction in strokes
- eleven-fold reduction in coronary stents
- three-fold reduction in amputations
- three-fold reduction in dialysis
Optimal medical therapy
Luckily, optimal medical therapy can be systematized, industrialized, and scaled. There is no reason why patients cannot reliably receive this type of treatment regardless of whether they live in a big city or a small town.
Similar approaches could also (Note: this article is behind a paywall) be used to reduce the incidence of Alzheimer’s disease and other expensive chronic conditions in addition to dialysis. We believe that Primary Care 2.0 is a much more effective way to manage cardiometabolic diseases.
Primary Care 3.0
It is only with Primary Care 3.0 that we begin to see its full potential. There are thousands of people developing the new science of molecular medical management. However, few are working on translating the new science from bench to bedside.
This is unfortunate because this new approach can move us beyond a system arranged around traditional risk factors and organ systems. It can move us to a much more precise approach targeting the molecular biology that forms the basis of chronic diseases and accelerated aging.
Understanding the full potential of primary care redesign requires a very short trip into the basic science weeds. If you just understand the rest of this article and the links, you will understand what next-generation chronic disease management could be. It is not that hard.
For example, elevated LDL cholesterol levels are a traditional target for therapies to reduce the risk of cardiovascular events, such as heart attacks and stroke. However, about half of all heart attacks occur in people with normal levels of LDL cholesterol. This suggests that other factors may be contributing to the risk in those people. Several seminal studies have pointed at inflammation as a critical pathway in the pathogenesis of atherosclerosis.
The Jupiter Trial
Paul Ridker is a cardiologist at Harvard Medical School. He is the leading proponent of the “inflammatory hypothesis” of cardiovascular disease. The 2008 Jupiter trial made him famous in medical circles.
The trial enrolled 17,802 healthy patients with normal LDL cholesterol levels (according to guidelines at the time) but a high level of the inflammatory marker C-reactive protein (CRP). Half of the patients were randomly assigned to receive the statin and half did not.
Although many in the public think of statins as cholesterol-lowering drugs, they also have significant effects in reducing inflammation. The results were dramatic leading the cessation of the trial after a median of ~2 years. Rosuvastatin treatment cut the incidence of a first cardiovascular event in these individuals by half. LDL levels were reduced by 50% and CRP by 37%.
The CANTOS trial
Dr. Ridker expanded this concept in the 2017 CANTOS trial designed to determine the impact on cardiovascular events if inflammation was reduced but cholesterol levels were