Cardiovascular Risk Educational Outreach Visits
Cardiovascular Risk Educational Outreach Visits Barriers and Objections ‘Cheat Sheet’ – Distributed Version 3 (9/29/2016)H2N Intervention Arm Goals: Goal #1: To support providers in shifting CV disease risk management from a focus on individual risk factors such as cholesterol to overall CV disease risk.Goal #2: To use the CV disease risk estimator as a tool for facilitating conversations between providers and patients about lowering CV disease risk by managing CVD risk factors.Goal #3: To use CVD risk scores rather than LDL cholesterol levels to drive statin recommendations (For primary prevention among individuals with LDL cholesterol under 190).Key Message The “Ask”: What are we asking the practice to do or change to implement this goal in their practice?Practice Barrier (B), Objection (O)Suggested Responses to Bs and Os Materials and Resources to reference or review Key Message #1: Routinely estimate an overall 10-year cardiovascular disease risk score for adults 40-75 years without prior ASCVD, diabetes, or an LDL cholesterol over 190. For those with ASCVD, DM, or LDL > 190, the guidelines recommending prescription of a statin have not changed. Following the new guideline requires checking a lipid panel every 4-6 years. Features/Benefits, KM #1: An important reason to calculate the 10-year CVD risk score is that the benefits of statins are not restricted to people with high cholesterol—in fact, the studies that restricted inclusion to people with low-normal cholesterol showed the same benefits as the ones that enrolled people with high cholesterol. The second is that the magnitude of benefits from statins depends on what the 10-year risk is—the bigger the risk, the greater the benefit.? For adults 40-75 years without prior ASCVD, diabetes, or an LDL cholesterol over 190, routinely estimate ASCVD risk every 4-6 years. Develop a practice level workflow for clinic staff as well as providers to use the ASCVD risk estimator in routine care. #1 “The time it will take to address global risk… now BP, smoking, cholesterol all in one visit while using a calculator…it’s too time consuming” (B)#2 “How do we message to the patient the changing nature of the guidelines?”(B) #3 “Not all providers will want to adopt this recommendation.” (B) #4a “You are asking us to do more with same or less resources”. (O)#4b “We’ve had recent staff turnover.” (B)#5 “From MA perspective: “We have so much time pressure… this is another thing to do before the MD arrives in the exam room” (O) #6 “We don’t have a place in our chart to reliably record CVD risk.” #7 “How can I bill for estimating the CVD risk score and discussing this score with my patients?”#1 “Some practices find that developing a workflow to show the change in daily flow and who does what can be very helpful. I’d like to show you a template we’ve put together on implementing CVD risk that could be modified by your team. #1 “Some practices have the MA calculate the score before I enter the exam room. #2 Medicine is constantly advancing. This new guideline is based on new evidence that we did not have before about how to decrease the leading cause of death in this country – heart disease, even among individuals without very high cholesterol.#3 In group practices, there are always early adopters of new evidence. Many times it takes a few early adopters to lead other providers to take up new evidence-based practices. #4 Using the risk estimator is a way of addressing several CVD risk issues all together… if you are using global risk calculation, can use for cholesterol and aspirin… and it is a lead-in to better BP control and tobacco cessation, if applicable. This may create some efficiencies.#5 By developing clear workflows for using the CVD risk calculator, the clinic can determine how to make sure that this work fits in the context of all of the other work that you are doing.For example, our workflow schematic shows how the MA can efficiently review the chart to make sure she is only calculating the risk score on eligible patients. (Tool #4_Workflow, Protocol and Decision Support for CV Assessment)#6 If you are unable to create a discrete field in your EHR to record CVD risk, some providers choose to use an ICD-10 diagnosis like Z13.6 “screening for cardiovascular disorders” and then record the date and 10 year risk score there.#7 You can use the ICD-10 code Z71.89: Other specified counseling, then use your usual E&M codes (e.g., 99213, 99214) and indicate how long that you have spent in the visit, and that more than 50% of the visit was spent in counseling. You must also specify the topics you covered in your counseling.This site describes this strategy for coding for counseling in more detail: Message The “Ask”: What are we asking the practice to do or change to implement this goal in their practice?Practice Barrier (B), Objection (O),Suggested Response to B, O’s and E’s. Materials and Resources to reference or review Key Message #2:Use the risk score to foster a partnership with the patient and potentially increase his or her motivation to make changes that will lower CVD risk.” Features/Benefits KM#2:Patients can be resistant to taking a new medication. By sharing the risk score with patients and how the different components of the score contribute to their level of risk, you have the opportunity to increase their motivation for lifestyle change and medication adherence, leading to more successful CVD risk reduction. Share CVD risk scores with patients, and use the scores to facilitate conversations with patients about how to lower their CVD risk. Use motivational interviewing and shared decision making to collaborate with patients in setting goals to lower their CVD risks.#1 “I don’t know which estimator to use.”(B) #2 “I’ve heard that risk estimators vary in how the score is calculated” (B) #3 “Which patients should I use the risk score with?” (B) #4 “I am unfamiliar with how to calculate a risk score” (B) #5 “I need help on how to explain a risk score to my patients.” (B)#6 “I do not feel that using the risk estimator is useful in practice” (O)#7 “I can’t see how a calculator/estimator will influence care” (O)#1: We illustrated the use of the new ACA/AHA estimator. We did so because it was developed using a more diverse set of patients, including both African-American and Caucasian patients. It is easy to put on clinic desktops, or onto your phone via an app. However, we feel that what is most important is to use a calculator, so if you are already using a different calculator, that is just fine.”#2: There are some potential advantages of the ACC/AHA calculator over the ATP III calculator—specifically that it includes DM as a risk factor and looks at stroke as well as other CV outcomes.? Also it was derived from cohorts that included black and white persons, while ATP III mainly was based on Framingham data and predominantly white.? Some initial critiques of the ACC/AHA calculator were that it overestimates risk, but subsequent studies have shown that the degree of overestimation may be no worse and better than ATP III and that the overestimation mainly occurs in people at high (>10%) risk, where it wouldn’t matter in terms of the decision to recommend therapy anyway.? The bottom line is that there is no perfect calculator but the lead physician in the USPSTF review of this literature thinks that the advantages of the ACC/AHA outweigh its disadvantages.#3 Per the AHA guidelines this applies only to individuals 40-75 years of age who have not had CVD, diabetes, or who have an LDL cholesterol of over 190. For those with CVD, DM, or LDL > 190, the guidelines have not changed. Following the new guideline requires checking a lipid panel every 4-6 years. #4 The CVD risk calculator is designed to be used by either health professionals or patients. Once you have looked up the information in the patient’s chart that is needed for the calculation, plugging the information in is straightforward.#5 We taught patients about LDL and were able to get many motivated to follow/lower their LDL, so can adapt that framework to risk score.#6, #7 “As you saw in the video, Dr. Dodd was able to run ‘what if’ scenarios with his patient that enabled a conversation about how together they could work to lower the risk. This is not possible with an LDL-targeting approach. I share the evidence that suggests that a low-moderate dose statin will decrease the risk of a cardiovascular event like an MI, stroke, or sudden death by 30% and a high dose statin will decrease this risk by about 50%. I then run a what-if scenario. For example, a patient with a 20% risk would decrease their risk to roughly 13-14%.Resource: Tool 3_Cardiovascular risk management in primary care Key Message The “Ask”: What are we asking the practice to do or change to implement this goal in their practice?Practice Barrier (B), Objection (O),Suggested Response to B, O’s and E’s,Materials and Resources to reference or review Key Message #3Base statin recommendations for primary prevention on a patient’s estimated 10-year CVD risk score.Again, this is for patients ages 40-75 whose LDL is 190 or lower.The AHA recommends initiating a statin for those 40-75 with a CVD risk of 7.5% or higherThe USPSTF draft recommendations suggest initiating a statin for those 40-75 with one or more CVD risk factors (i.e. dyslipidemia, diabetes, hypertension, or smoking and a CVD risk score of 10% or higher, and to consider statins for those with a CVD score of 7.5% or higher. Features/Benefits KM#3The benefits of statins with regard to reduction in all- cause mortality, CV mortality and CV events outweighs harm.There is no evidence of adverse cognitive effects or cancer. The studies demonstrate benefit in lowering CVD risk for individuals even if their cholesterol is not elevated. These studies have only been conducted among patients with CVD risk factors, though, so translating to patients without CVD risk factors is an extrapolation. Use CVD risk scores to guide discussions with patients about statins. Consider calculating the risk score in real time with the patient so they can see how the risk score is estimated.Use published recommendations that suggest initiating statins when the 10-year CVD risk is somewhere between 7.5% and 10% or higher, depending on which recommendation the provider chooses to follow.Use shared decision-making in developing a plan to lower CVD risk with a patient.#1 “I don’t trust the new guidelines. 174 cholesterol and still giving them a statin no matter what?!” #2 “The video says that guidelines recommendations for risk score vary. Why is that?” (B)#3: “What if my patient doesn’t want to take a statin?” #4 “I think the 7.5% 10-year CVD risk threshold for starting a patient on statins is too low.” #1 The studies demonstrate benefit in lowering CVD risk for individuals even if their cholesterol is not elevated. These studies have only been conducted among patients with CVD risk factors, though, so translating to patients without CVD risk factors is an extrapolation. #2 The AHA recommends initiating a statin for those 40-75 with a CVD risk of 7.5% or higher.There is no magic number at which statins should suddenly be recommended or not.Supplemental Resource: Tool 2_JAMA Editorial (“the majority of events occur in folks that are lower risk”) #3 In the video, Dr. Dodd provides communication/ and messaging to a patient showing resistance to starting a statin. He used shared decision making techniques to come up with a 3 month plan w/ commitment to come back to have another discussion about risk management and statins ” You can also use ‘what if’ scenarios to show how taking a statin will lower 10 year CVD risk.#4 There is variation in the recommended thresholds for when to start a statin. The AHA recommends initiating a statin for those 40-75 with a CVD risk of 7.5% or higher. The USPSTF draft recommendations suggest initiating a statin for those 40-75 with one or more CVD risk factors (i.e. dyslipidemia, diabetes, hypertension, or smoking and a CVD risk score of 10% or higher, and to consider statins for those with a CVD score of 7.5% or higher. That said, there was a recent editorial in JAMA that we sent that shows that a threshold of 7.5% is cost effective, and that some are advocating for an even lower threshold, since most CVD events occur among individuals with lower risk thresholds.#5 What if my patient is concerned about side effects?#5 and have excellent responses to the types of questions that patients may have about side effects from statins.Key Message The “Ask”: What are we asking the practice to do or change to implement this goal in their practice?Practice Barrier (B), Objection (O),Suggested Response to B, O’s and E’s, Materials and Resources to reference or review Key Message #4:Follow-up with the patient and monitor to enhance or improve adherence to the plan to lower CVD risk. Features/Benefits KM #4: By reviewing adherence and side effects with the patients a few months after starting a statin, you have the opportunity to increase their motivation for medication adherence, and can review lifestyle changes, leading to more successful CVD risk reduction. There is no recommendation to follow lipids after starting a statin, other than to monitor adherence to the medication.If statins are started, schedule a follow-up visit within 3 months to monitor adherence and address any concerns the patient has with the medication.#1 “What is an alternative to an after visit summary? It could be a challenge to program the summary to include risk score and scenarios.” (B)#1 Most after visit summaries have a place to briefly type in the risk score, treatment recommendations, and follow up plans. ................
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