Overview

This project at community-based primary care clinics utilized a health data registry identifying patients at higher risk of cardiovascular disease-related complications to improve statin therapy medication adherence.

Organization Name

Heart Health Now, The North Carolina Cooperative for the Agency for Healthcare Research and Quality’s EvidenceNow Program; Cecil G. Sheps Center for Health Services Research

Organization Type

• Community outpatient clinic

National/Policy Context

• In 2016, the United States Preventive Services Task Force (USPSTF) released guidelines for statin therapy for patients depending on their risk for cardiovascular disease. 
• Electronic health records (EHR) are an underused tool to assess and tailor treatment for  patients based on these USPSTF guidelines.

Local/Organizational Context

• Identification of a need (As per Dr. Samuel Cykert via written correspondence)

Patient Population Served and Payor Information

• The patients involved in this intervention had a variety of insurance providers including Medicare (28%), Medicaid (16%), dual insurance (10%), commercial insurance (30%) and some were uninsured (12%).

Leadership

• Samuel Cykert, MD
• Hugh Tilson, JD, MPH, Director, North Carolina Area Health Education Centers Program

Funding

• This project is part of a national research project, EvidenceNow (EN), that is funded by the Agency for Healthcare Research and Quality.

Research + Planning

• 219 primary care practices were recruited to participate in the intervention program; they were either independent or geographically distant from their affiliated home institutions.

Tools or Products Developed

• Dashboard: The team developed a dashboard derived from electronic health records that provided cardiovascular risk stratification for individuals between the ages of 40 and 79 years and listed opportunities to quickly reduce risk for each patient. (As per Dr. Samuel Cykert via written correspondence)

Training

• The staff involved in the project were placed in teams including clinicians, nurses and other personnel. For 12 months, these teams learned Institute for Healthcare Improvement techniques including workflow design, and run charts.
• They also learned population management skills from practice facilitators. (As per Dr. Samuel Cykert via written correspondence)

Tech Involved

• Electronic medical record

Team Members Involved

• Administrative Assistant
• MAs
• NPs
• Physicians

Workflow Steps

• Patient health data was collected from EHR records across these sites, and then each patient aged 40-79 years was assigned an Atherosclerotic Cardiovascular Disease (ASCVD) risk score. 
• The ASCVD score is a tool that utilizes a patient’s health factors, including age, gender, smoking history, and others, to estimate a 10-year and lifetime risk (in percentage) of developing a heart attack or stroke.
• Patients with ASCVD scores >10% were prescribed the necessary statin medication regimen based on the 2016 United States Preventative Task Force. 
• At the primary care sites, practice facilitators improved care at these sites by:
  • forming multidisciplinary teams of clinicians, nurses and clinic personnel.
  • learning and implementing quality improvement measures through EHR chart analysis. 

Budget Details

The following sources of costs were estimated by the CareZooming team:

• Costs associated with extracting EHR data
• Labor costs associated with training health team members

Where We Are

• Date (Month/Year) Project Described Started: January 1, 2016
• Date (Month/Year) Paper Published: In review as of August 9, 2019

Outcomes

• Statin therapy uptake: The project measured the uptake of statin therapy for patients with >10% ASCVD risk score. 49% of the patients with a >10% risk score received statin therapy compared to 38% baseline (P<0.001). 
• 47.1% of practices showed an improvement of > 5%. 
• The small practices with a higher staff-clinician ratio improved more (R-squared 0.44).

Future Outcomes

As per Dr. Samuel Cykert via written correspondence:

• The team is in the process of calculating the overall cardiovascular risk reduction attributable to the intervention. The team expects this data to be published within the next 6 months
• The team is examining issues concerning long term outcomes and costs ( 9 to 12 months away as of August 2019)

Benefits

• The intervention showed that small primary care practices can improve patient health through the use of data-driven care especially for patients are at high risk for cardiovascular disease.

Unique Challenges

As per Dr. Samuel Cykert via written correspondence:

• Getting data from multiple electronic health records is difficult as they are not designed to be interoperable and data fields within which structured data are contained differ. Therefore, each EHR has to be mapped differently. 

Sources

• This primer was developed by the CareZooming team based on our interpretation and analysis of a poster presentation and with consent and permission of the author and/or their representatives. Authors and/or their representatives were able to review the contents of this primer before publication, and all requested edits have been incorporated into the primer as presented above.
• S. Cykert, MD, J. Trogdon, PhD, D. DeWalt, MD, MPH, M. Pignone, MD, MPH &B. Weiner, PhD. (2019 June) Dissemination & Implementation of New Recommendations for Cholesterol Treatment Using Practice Coaches, Quality Improvement, and Cardiovascular Risk Stratification. Poster session at the Academy Health Annual Research Meeting, Washington, D.C., United States
• Institute for Healthcare Improvement: How to Improve. (n.d.). Retrieved July 7, 2019, from http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx
• US Preventive Services Task Force. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;316(19):1997–2007. doi:10.1001/jama.2016.15450