Implementation of New Guidelines to Detect and Control High Cholesterol to Prevent Cardiovascular...

Implementation of New Guidelines to Detect and Control

High Cholesterol to Prevent Cardiovascular Events

Jennifer G. Robinson, MD, MPHProfessor, Departments of Epidemiology & Medicine (Cardiology)

Director, Prevention Intervention CenterUniversity of Iowa

Disclosures

Received in the past year:Research grants to the institution: Amarin, Amgen, Astra-Zeneca, Daiichi-Sankyo, Eli Lilly, Esai, Glaxo-Smith Kline, Merck, Pfizer, Regeneron/Sanofi, Takeda

Consultant: Amgen, Eli Lilly, Merck, Pfizer, Regeneron/Sanofi

CVD EVENTS

MI/Unstableangina

Ischemic stroke/TIA

Critical legischemia

Intermittentclaudication

CV death

Atherosclerosis progression

Conceptualizing interventionsAtherosclerotic Cardiovascular Disease

Progression Through the Lifespan

Illustration Adapted from Libby P. Circulation. 2001;104:365-372.

2013 ACC/AHA Cholesterol Guideline to Reduce ASCVD Risk Major recommendations for initiating statin therapy based on

patient’s level of RISK

I A

I A

I B

I A

IIa B

Stone NJ, Robinson JG, Lichtenstein AH, et al.. J Am Coll Cardiol. 2014;63(25, Part B):2889-2934.

2013 ACC/AHA Cholesterol Guideline to Reduce ASCVD Risk Major recommendations for initiating statin therapy based on

patient’s level of RISK (cont)

IIb C

I A IIa B

I B

IIa B

Stone NJ, Robinson JG, Lichtenstein AH, et al.. J Am Coll Cardiol. 2014;63(25, Part B):2889-2934.

2013 ACC/AHA Cholesterol Guideline to Reduce ASCVD Risk

Monitoring Therapeutic Response and Adherence

Stone NJ, Robinson JG, Lichtenstein AH, et al.. J Am Coll Cardiol. 2014;63(25, Part B):2889-2934

*

**

Nonstatins shown to reduce ASCVD events in RCTs preferred

I A

IIa B

IIa B

If baseline LDL-C unknown, may use LDL-C <100 mg/dl

High intensity statin >50% LDL-CMod intensity statin 30-<50% LDL-C

Regularly measure lipid

panel

Treatment gaps• Clinical ASCVD

• 42-52% women/35-43% men not on a statin• White - 42% not on a statin• African American -59% not on a statin• Hispanic - 67% not on a statin

• Genetic hypercholesterolemia – LDL-C >190 mg/dl• >80% with FH are undiagnosed/untreated

• Diabetes age 40-75 years • 48-51% are not on statin

Virani SS, et al. Am J Cardiol 2015; 115: 21-26Johansen ME, et al. Ann Fam Med 2014; 12: 215-223Goldberg AC, et al. J Clin Lipidol 2011; 5: S1-S8

Treatment gaps• >7.5% 10-year ASCVD risk

• Risk-guided treatment better identifies individuals at high risk of MI and stroke

• Data don’t support LDL-C to guide statin treatment• Especially African American Women & Men, and White Women

• Pooled Cohort Equations work well in general population• Cost effective $37,000 QALY

• Statins cost effective at lower risk thresholds• >4% 10-year ASCVD risk $100,000 QALY

• Social benefits • Even a modest LDL-C reduction 21 mg/dl for 10 years : $34,926

surplus per statin user or a benefit-to-cost ratio of 4:1.

Muntner PM, et al JAMA 2014; 311: 1406-15; Karmali KN, et al. JACC 2014; 64: 959-968; Pursnani A, et al JAMA 2015; 314: 134-41; Grabowski DC et al. Health Aff 2012; 31: 2276-85

Kaiser Permanente Southern CaliforniaBest practice example

• CV prevention lead - Ronald Scott, MD

• Sophisticated decision support generates actionable lists daily.

• Organized by statin benefit group, those missing or with low adherence to statins.

• May “drilldown” from KPSC, to Medical Center area, to medical team of 10 clinicians, to individual provider, to member.

• Facilitates team care, systemic tactics, internal comparisons and sharing of best practices.

Interactive Registry

Pharmacy Analytic Services (PAS)

KPSC as of Oct 2015

ASCVD DM A-Risk 15+0

10

20

30

40

50

60

70

80

90

NHANES primary prevention

% fi

lled

stati

n in

the

last

yea

r

NCQA Field Testing National Average

NCQA Field Testing National Average

Automated Outreach Improves Statin Non-Adherence: A Randomized Controlled Trial

• Primary Non Adherence : Automated call/letter outreach to patients who fail to fill their 1st statin prescription within 1-2 weeks after electronic order.

• Increase fill OR 2.2. Spanish 3.0

• Secondary Non Adherence : Automated refill reminder calls to patients overdue by 2 to 6 weeks for refills

Derose et al, JAMA Intern Med 173:1, Jan 14, 2013

Based on AHA graphic on CV Med Adherence

More Med Adherence Tactics

• KPSC outpatient pharmacists: discuss CV med adherence when members come into KP pharmacy for other meds.1

• KP Mail-Order Pharmacy with free shipping: Members using achieved better cholesterol control, higher medication adherence, and lower rates of ER visits. 2,3

• KP.org: Med adherence promotion and customized member engagement. Inclusion of A-Risk.

1 Spence et al, J Manag Care Pharm 2014;20:1036-45. 2 Schmittdiel et al, JGIM 2011; 26 (12) 1396-1402. 3 Schmittdiel et al, Am J Manag Care. 2013;19(11):882-887.

National Forum Cholesterol Initiative

The National Forum will launch a pilot program to raise public awareness about the importance of cholesterol screening and management.

Pilot to launch in an identified high risk area• High LDL-C populations• High event rates• Health equity factors

National Forum Cholesterol Initiative

Potential Pilot Cities:• Tulsa, OK

• San Antonio, TX

• Austin, TX

Our target audience is women and families• Women make 80% of family health care decisions1

• Women are 50% more likely to be a caregiver21 U.S. Department of labor (http://www.dol.gov/ebsa/newsroom/fshlth5.html)2 KFF (http://kff.org/disparities-policy/report/women-and-health-care-a-national-profile)

Points of intervention

Patients

Parents

Clinicians

(Healthcare systems)

(Schools)

(Workplace)

(Pharmacies)

ACTIVATE

Adults 21-75 years

Children 9-11 & 17-20 years (age 2 if fam hx)

Relatives of FH patients

IDENTIFY

Lifestyle - Everyone

Statins –At risk patients

- Adults 21-75 years- Children with FH by

age 10

Nonstatins – High risk patients who might benefit from additional LDL-C lowering

TREAT

Long-term therapeutic relationships to improve adherence

- Lifestyle- Statins - Nonstatins

Systems of care

- EMRs- Teams- Costs

CONTROL

Media campaignsProfessional education

Performance standards

Etc…

Universal screeningEMR searches

Etc…

Professional educationPatient educations

Performance standards

ReimbursementEtc…

Professional educationPatient educations

Performance standards

ReimbursementEtc…

Improving cholesterol identification, treatment & control

• Personal wish list• Social media campaign – “Statins are miracle drugs!”

• Cheap• Safe• Save lives, prevent strokes & heart attacks • Work with lifestyle to keep people healthier longer• Save money for health care system and society