1. Implementing 2013 ACC/AHA Cholesterol Management Guidelines Into Clinical Practice
Safi U. Khan MD; John Pamula MD
Guthrie/Robert Packer Hospital, Sayre, PA, USA
Disclosure
Background
Platelet Function Analysis
in study groups
Figure 1 showing project design, strategy and implementation
Patient Demographics
The 2013 American College of Cardiology/American Heart Association guideline on the treatment of blood cholesterol shifted the secondary prevention strategy from low density lipoprotein cholesterol (LDL-C) targets to a risk-based algorithm, recommending high-intensity statins for all patients age ≤75 years with documented ASCVD in whom such therapy is tolerated. 1
Methods
Subjects
Aim
To improve use of high intensity statins amongst statin benefit groups. Target population belonged to patient’s pool of selected providers in Guthrie Internal Medicine Clinic, Robert Packer Hospital, Sayre, PA.
Figure 2 showing prevalence of various statins amongst benefit groups. X-axis: statin type with respective dosages; Y-axis :percentage prevalence
Project design & Strategy
C-Reactive Protein
and Clotting Time
We collected 6 months data from EPIC for selected providers including internal medicine residents and faculty members to get a convenient sample size.
Patients were divided into 4 benefits groups (Table 1). Data for each group separately and then collectively for all the groups was analyzed for: a) appropriate statins (high intensity statins); b) inappropriate statins (different intensity statin) and c) participants not on any statins.
Atorvastatin (40-80 mg) and Rosuvastatin (20-40 mg) are considered high intensity statins. Many participants were using Simvastatin 80 mg/day; FDA does not support this dosage because of high risk of rhabdomyolysis. Therefore for practical purposes, Simvastatin 40 mg was considered to be acceptable alternative for appropriate statin. 1
Figure 5: survey feedback
Changes made
Outcomes & Lessons Learned
More robust campaign favoring high intensity statin was conducted amongst selected providers.
EPIC medicine clinic patient list was modified to include ASCVD score and age for quick review for physicians to consider indication in deserving patients
Reminders were placed for physicians to discuss and convince patients regarding statin benefit.
A special importance was given to the transition to high intensity statin for patients who were already on low intensity statin.
Patients who suffered intolerance to Atorvastatin were offered Rosuvatatin and patients who were already on Atorvastatin and Rosuvastatin, optimal up titration of dose was done.
We achieved a positive trend with 15% improvement in high intensity statin use after 6 months. This project enabled as to achieve following targets:
Education of providers regarding risk based guidelines
Evaluation of limiting factors for prescribing appropriate statins
Improvement in high intensity statin use amongst benefit groups
This project also educated us on certain issues:
Time constraint is one of the major limiting factors in providing effective secondary prophylaxis.
With small changes such as EPIC patient sheet modification effective results can be obtained
Patients are fixated in their beliefs based on the input they receive from surroundings. A continuous effort involving various visits can achieve desired targets.
Figure 3: run chart showing initial pre and post intervention (red arrow) analysis. X-axis: time line in days; Y-axis :percentage prevalence of high intensity statins
Statin Benefit Groups:
Individuals with clinical ASCVD (acute coronary syndrome, or history of MI, stable or unstable angina, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin; without NYHA class II-IV heart failure or receiving hemodialysis.
Individuals with primary elevation of LDL-C ≥190 mg/dl.
Individuals years of age with diabetes, and LDL-C mg/dl without clinical ASCVD
Individuals without clinical ASCVD or diabetes, who are years of age with LDL-C 189 mg/dl, and have an estimated 10 year ASCVD risk ≥ 7.5
Benefit groups
High intensity statin (%)
Low intensity statin (%)
No statin (%)
ASCVD 46 32 22
All individuals with LDL≥ 190 mg/dl 17 23 60
Patients (40-75 years) with diabetes & LDL-C mg/dl without clinical ASCVD 25 40 35
Patients without clinical ASCVD or diabetes (50-75 years)with LDL-C 189 mg/dl &an estimated 10 year ASCVD risk ≥ 7.5 11 24 65
All groups 30 56
Next steps
Implementing the model for all the providers in Guthrie Internal Medicine Clinic.
References
1. Stone NJ, Robinson JG, Lichtenstein AH, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol Jul 1;63(25 Pt B):
Table 1 defines statin benefit groups 1
Figure 4: run chart showing final pre and post intervention (red arrow) analysis. X-axis: time line in months; Y-axis :percentage prevalence of high intensity statins
Table 2 presents pre intervention status of benefit groups