Finding Time for Life's Essential Eight in the 27-Hour Day: A Call to Action for AHA and Primary Care

High quality primary care is essential for the health of populations. While this has been demonstrated to be true in numerous scientific studies and government reports, the implementation of high-quality primary care in the United States has continued to be elusive (1). The AHA Scientific Statement "The Role of Primary Care in Achieving Life's Essential 8" by Dr. Madeline Sterling and other members of the American Heart Association (AHA) Primary Care Science Committee of the Council on Quality of Care and Outcomes Research and the Council on Cardiovascular and Stroke Nursing makes it clear that high quality primary care is essential for the cardiovascular health (CVH) of the US population, and that AHA and other organizations committed to improving cardiovascular health should support innovation and advocacy for primary care.

Life's Essential 8 (LE8) are the "key measures for improving and maintaining cardiovascular health," as defined by the AHA (2). Better CVH helps lower the risk for heart disease, stroke and other major health problems. LE8 include both health behaviors (i.e., diet, physical activity, nicotine exposure, and sleep) and health factors (i.e., body mass index, lipids, blood glucose, and blood pressure [BP]) as critical to achieving ideal CVH. High-quality primary care as defined by the WHO and cited by the current scientific statement is "first-contact, accessible, continuous, comprehensive and coordinated person-focused care" that promotes health equity (3).

Primary care is an ideal setting for addressing LE8 because primary care providers (PCPs) are trained in identifying the health factors (i.e., body mass index, lipids, blood glucose, and blood pressure [BP]) in LE8 and delivering brief counseling on health behaviors (i.e., diet, physical activity, nicotine exposure, and sleep). In addition, it is well within primary care scope of practice to treat obesity, hyperlipidemia, diabetes, and hypertension, if these health factors are identified to be in a range warranting treatment. As reviewed in "The Role of Primary Care in Achieving Life's Essential 8," there is good evidence that delivering interventions on individual LE8 measures in primary care settings results in better outcomes. This scientific statement also makes it clear that these improved outcomes are also realized in traditionally underserved and vulnerable populations, underscoring the importance of primary care in achieving health equity.

Despite the promise of primary care in addressing LE8, there are several critical challenges addressed in the scientific statement, including poor patient access, PCP burnout, burden of care coordination, and insufficient support. A recent study published in the Journal of General Internal Medicine quantified the problem in a slightly different way. This study found that to provide primary care to an average-sized patient panel, a PCP would need 27 hours per day to provide all recommended acute, chronic, and preventive care (4). If a PCP were fortunate to be working with a comprehensive care team (including pharmacists, dieticians, and others), the workload would be reduced to 9 hours per day (JGIM). When examining in more detail the care that required the most time, the authors found that many activities included in LE8 are supported by moderate to strong evidence but also quite time-consuming. For example, weight loss to reduce obesity-related mortality was estimated to require four hours per day, and physical activity and diet counseling to support CVH 2.4 hours per day. Collaborating with a comprehensive care team does not necessarily reduce the time required to provide LE8-related care, but rather redistributes it from the PCP to the comprehensive care team. In doing so, patient access and PCP burnout could improve, but clinical revenue to support the work of the care team is often lacking, particularly in a fee-for-service reimbursement model.

I am faced with these challenges daily as a general internist who is practicing primary care and leading the recruitment, retention, and financial operations for an academic division of General Internal Medicine. Therefore, I found the section of the scientific statement discussing novel strategies to address the challenges and leverage primary care to achieve LE8 to be a reinforcing and inspiring call to action. Payment reform to support PCPs and the care team is underway in some states and settings, and much can be learned from the CMS Innovation Center demonstration projects and the Veterans Health Administration (VA) Patient Aligned Care Teams (PACT) model. Thoughtful implementation of health information technology (HIT) to increase patient access and reduce PCP and care team burden is also critical. When designed and implemented well, HIT tools can also help primary care teams implement panel management and population health strategies to ensure that the patients who would benefit most from resources to address and improve LE8 are receiving them. Other strategies we have used in our local setting in Utah include career mentoring programs for PCPs to reduce burnout and increase job satisfaction and retention, better collaboration and integration across the groups providing primary care for adults in our health system (i.e., General Internal Medicine and Family Medicine; academic and community practices), and a successful state grant application to increase funding for primary care physician training slots in our Internal Medicine residency program.

AHA can play a crucial role in supporting primary care's ability to address LE8 and improve cardiovascular health equity. AHA's multidisciplinary membership and support of scientific innovation can foster the collaboration and advocacy needed to make a meaningful impact in helping PCPs find time for CVH in the "27-hour day." "The Role of Primary Care in Achieving Life's Essential 8" provides significant evidence and a blueprint for action to guide AHA efforts.