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