Ueda2016 new horizon in the management of dyslipidemia - diaa ewais
INSIDE Dyslipidemia Management · INSIDE Dyslipidemia Management | 2 INSIDE Dyslipidemia Management...
Transcript of INSIDE Dyslipidemia Management · INSIDE Dyslipidemia Management | 2 INSIDE Dyslipidemia Management...
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INSIDE Dyslipidemia Management | 1
INSIDE Dyslipidemia ManagementINspiring System Improvement with Data-Driven Excellence
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INSIDE Dyslipidemia ManagementProgram Goals
Benchmark current lipid management and goal attainment for high-risk CV patients
Identify and prioritize specific clinical process/management challenges that affect goal attainment
Systematically make clinical changes to improve goal attainment processes and outcomes
Measure the results and share best practices via educational workshops, online CME and publications
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Clinical Sites & QI Team Leaders
•Michael H. Davidson, MD (PI)
•Karen Wickens, RN
University of Chicago Lipid Clinic
•Amita Singh, MD
•Luke Laffin, MD
•Lane Benes, MD
University of Chicago Section of Cardiology
•David Liebovitz, MDChief Medical Information
Officer
•Divisions of Cardiology and Endocrinology
•David Davidson, MD (PI)
NorthShore Department of Medicine
•Roy Furman, MD, PhD
•Elise Furman, RN, MEd, MBA
ADA Quality Improvement Services
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Population Health Data
Science
Care System Redesign
Healthcare Provider Support
Patient Self-Management
Support
Patient Education
Community Integrated
Health
Local Disease Registries
Visualized QI Metrics
QI Training, Coaching & Facilitation
Shared Learning
Professional Development
Standards of Care
Recognition & Dissemination
Diabetes Excellence
Designation
Publication in ADA Journals &
Sci Sessions
INSIDE Program Features
C o n t i n u o u s I m p r o v e m e n t C y c l e s
Advocacy
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Program Design at a Glance
INSIDE Dyslipidemia Management is based on ADA’s successful Diabetes
INSIDE program that has improved diabetes care processes at health systems
across the US since 2012
Quality Improvement ArmPopulation Health Analytics
Care System Re-Design
Education ArmProvider EducationPatient Education
Improved Processes & OutcomesPublication
Chicago-area Clinical Care Sites
Local Data
18
-24
Mo
nth
s
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Quality Improvement Arm at University of Chicago
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Goals of Quality Improvement in Population Health
Reducing clinical variation
• In processes over time
• In outcomes between rational subgroups
Achieving clinical guideline standards
• For all patients
• Safely and appropriately
Time/groups
Standards
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Baseline Data – DemographicsTotal N=20,871; Mean Age=64 N %
Gender
Male 10,658 51.1%
Female 10,213 48.9%
Race
African American 9,978 46.9%
White 9,750 46.7%
Asian/Mideast Indian 643 3.1%
Other 419 2.0%
American Indian or Alaskan Native 81 0.4%
CVD/CV Risk Diagnoses
Hypertension 10,781 49.0%
Dyslipidemia 7,632 34.7%
Coronary Artery Disease 6,681 30.4%
Diabetes/prediabetes 1,658 7.5%
Peripheral Vascular Disease 955 4.3%
Patient selection is visit-level data for all adults following ICD-9 or ICD-10 codes for major cardiovascular disease, dyslipidemia, diabetes, hypertension, or smoking history
Joshy G, Korda R, Abhayaratna W, Soga K, Banks E. Categorising major cardiovascular disease hospitalisations from routinely collected data. Public Health Research & Practice. 2015;25(3). doi:10.17061/phrp2531532
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Visit Distribution by Location, Department, Provider
608,517 visits for 21,986 patients with 177 providers over 5.2 years; mean age=64
Treemap displaying hierarchical (tree-structured) patient data as a set of nested rectangles. Each rectangle has an area proportional to the specified dimension of the data.
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Distribution of ICD 9/10 Diagnoses
608,517 visits for 21,986 patients with 177 providers over 5.2 years; mean age=64
ICD 9 ICD 10
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Cardiovascular Risk Factor Diagnoses (ICD 10)21,983 patients; mean age=64Obesity, prediabetes, diabetes underdiagnosed as risks
Prediabetes prevalence in Illinois 2015 = 33% (48% 65yo)
Obesity prevalence in Illinois 2016 = 32%
Actual = 21%
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Baseline Data - Rx Frequencies
953,675 prescriptions for 20,230 patients using 1,427 drugs over 5.2 years; mean age=64
Treemap displaying hierarchical (tree-structured) patient data as a set of nested rectangles. Each rectangle has an area proportional to the specified dimension of the data.
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Baseline Data – Demographics
Category Patients With Known Risks And LDLC
On any Rx 20,219 16,464 8,939
On lipid Rx 15,262 11,169 5,659
On statin Rx 14,096 10,911 5,521
On PCSK9 Rx 112 55 25
953,675 prescriptions for 20,230 patients using 1,427 drugs over 5.2 years; mean age=64EHR data gaps in structured fields
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LDLC Levels vs Rates of Coronary Events
1. Raymond C, Cho L, Rocco M, Hazen SL. New cholesterol guidelines: Worth the wait? Cleveland Clinic Journal of Medicine. 2014;81(1):11-19. doi:10.3949/ccjm.81a.131612. Cholesterol Treatment Trialists’ (CTT) Collaboration. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170 000 participants in 26 randomised trials. Lancet. 2010;376(9753):1670-1681. doi:10.1016/S0140-6736(10)61350-5
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2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol
to Reduce Atherosclerotic Cardiovascular Risk in Adults
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Dyslipidemia Guidelines2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce
Atherosclerotic Cardiovascular Risk in Adults
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Summary of Statin Initiation Recommendations to
Reduce ASCVD Risk (Revised Figure)
4 S
tati
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Summary of Statin Initiation Recommendations to
Reduce ASCVD Risk (Revised Figure)
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Clinical Outcomes2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce
Atherosclerotic Cardiovascular Risk in Adults
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LDLC and Statin Prescribing by AHA/ACC Guidelines
of 5,337 patients
Only includes patients on lipid-lowering drugs
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LDLC and Statin Prescribing by AHA/ACC Guidelines
of 7,819 patients
Patients with any prescriptions
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LDLC and Statin Prescribing by AHA/ACC Guidelines
of 2,896 patients
Only includes patients with diabetes
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Baseline Data – LDLC Distribution by # of Risk Factors
N=12,823 patients
Density distribution of LDLC values stratified by number of ASCVD risk factors.
N = 77
N = 427
N = 4,335
N = 7,984
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AACE 2017 Guidelines for Management of Dyslipidemia
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Dyslipidemia GuidelinesAACE 2017 Guidelines for Management of Dyslipidemia
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AACE 2017 Guidelines for Management of DyslipidemiaMajor Atherosclerotic Cardiovascular Disease Risk Factors
Major risk factors Additional risk factors Nontraditional risk factors
Advancing age Obesity, abdominal obesity Lipoprotein (a)
Total serum cholesterol Family history of hyperlipidemia Clotting factors
Non-HDL-C Small, dense LDL-CInflammation markers (hsCRP; Lp-PLA2)
LDL-C Apo B Homocysteine levels
Low HDL-C LDL particle concentration Apo B4 isoform
Diabetes mellitusFasting/post-prandialhypertriglyceridemia
Uric acid
Hypertension PCOS TG-rich remnants
Chronic kidney disease Dyslipidemic triad
Cigarette smoking
Family history of ASCVD
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AACE 2017 Guidelines for Management of DyslipidemiaAtherosclerotic Cardiovascular Disease Risk Categories and LDL-C Treatment Goals
Risk category Risk factors/10-year risk
Treatment Goals
LDL-C(mg/dL)
Non-HDL-C(mg/dL)
Apo B(mg/dL)
Extreme risk
• Progressive ASCVD including angina in patients after achieving LCL-C <70 mg/dL
• Established clinical cardiovascular disease in patients with DM, CKD 3/4, or HeFH
• History of premature ASCVD (<55 male, <65 female)
<55 <80 <70
Very high risk
• Established or recent hospitalization for ACS, coronary, carotid or peripheral vascular disease, 10-year risk >20%
• Diabetes or CKD 3/4 with 1 or more risk factor(s)• HeFH
<70 <100 <80
High risk• 2 risk factors and 10-year risk 10-20%• Diabetes or CKD 3/4 with no other risk factors
<100 <130 <90
Moderate risk • ≤2 risk factors and 10-year risk <10% <100 <130 <90
Low risk • 0 risk factors <130 <160 NR
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AACE 2017 Guidelines for Management of DyslipidemiaLipid Goals for Patients at Risk for Atherosclerotic Cardiovascular Disease
Lipid parameter Goal (mg/dL)
TC <200
LDL-C
<130 (low risk)<100 (moderate risk)<100 (high risk)<70 (very high risk)<55 (extreme risk)
Non-HDL-C 30 above LDL-C goal; 25 above LDL-C goal (extreme risk patients)
TG <150
Apo B
<90 (patients at high risk of ASCVD, including those with diabetes)<80 (patients at very high risk with established ASCVD or diabetes plus 1 additional risk factor)<70 (patients at extreme risk)
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Clinical OutcomesAACE 2017 Guidelines for Management of Dyslipidemia
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Baseline Data – Cholesterol and Triglycerides StratifiedMost recent labs for 12,921 patients grouped by AACE risk category and gender
150
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Baseline Data – LDLC StratifiedMost recent labs for 12,750 patients grouped by AACE risk category and gender
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Baseline Data – Non-HDLC StratifiedN=5,183 patients, mean interval = 2.1 years (6 days to 5.1 years)
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Baseline Data – Composite AACE Lipid Goals
N=5,183 patients, mean interval = 2.1 years (6 days to 5.1 years)
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Baseline Data – LDLC Guideline Outcomes ComparedMost recent labs for 12,750 patients grouped by guideline risk category and gender
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Baseline Data – Evolving Individual LDLC ChangeN=5,125 patients, mean interval = 2.1 ± 1.3 years (6 days to 5.1 years)
LDLC increasing
LDLC decreasing
LDLC increasing
LDLC decreasing
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Baseline Data – Evolving Individual LDLC ChangeStratified by AACE Risk Categories: Low and Moderate
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Baseline Data – Evolving Individual LDLC ChangeStratified by AACE Risk Categories: High and Very High
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Baseline Data – Evolving Individual LDLC ChangeStratified by AACE Risk Categories: Extreme
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Quality ImprovementReducing clinical variation and achieving guideline standards
Time/groups
Standards
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Quality Management in Population Health
Planning, assuring, controlling, improving
Clinical variation
• Are population clinical outcomes stable and predictable?
• Do patient subpopulations have similar outcomes?
Clinical goals
• Do process and clinical outcomes achieve clinical standards?
Clinical change
• Have prior interventions affected outcomes?
• Has patient population changed over time?
Time/groups
Standards
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Process Behavior (Control) Charts Illustrated
A reliable, repeatable process is “predictable” and randomly varies minimally about the mean over time within natural process limits.
UNPL
LNPL
CL ±3σ
We’ll always see at least small variations for any process measured at different times
UNPL = upper natural process limit, CL = center line, LNPL = lower natural process limit
The closer the limit lines, the larger the sample size (~ Τ1 √𝑛).±3σ is 99.7%
Plotting the sample mean over time is a process behavior chart
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Statistical Significance with Control Charts
By Time
• Within control limits
• Mean and control limits analogous to statistical error of the mean
• Runs 7 points above/below mean statistically significant
• Patterns and monotonic trends may be statistically significant
• Otherwise due to random variation
• Outside control limits
• Any point is statistically significant
Rational Subgroup
• Within control limits
• Groups do not have statistically significant between-group variation
• Outside control limits
• Group has statistically significant variation
Simple visual alternative to T-tests, p-values, and other analytical tests
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Population Lipid OutcomesAre population lipid profiles stable over time?
Have prior awareness, education, or quality programs varied lipid outcomes?
Does diagnosis affect lipid levels?
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Population Cholesterol and Triglyceride Variation Over Time
168
127
12,960 patients with 22,911 tests
12,931 patients with 22,833 tests
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How Does Population LDLC Vary Over Time at U of C?
2013 ACC/AHA Guideline
12,828 patients with 22,529 LDLC tests over 5.1 years
91
Stable over last 3 years
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Population LDLC Standard Deviation Consistent Over Time
12,828 patients with 22,529 LDLC tests over 5.1 years
38
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Mean LDLC Variation Over Time in ICHD/CVA/TIA
(4,907 patients)
84
2013 ACC/AHA Guideline
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Population Lipid OutcomesHow does medication choice and intensity affect lipid levels?
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INSIDE Dyslipidemia Management | 52
Statin Intensity Does Not Affect Population Mean LDLC
(8,127 patients)
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INSIDE Dyslipidemia Management | 53
LDLC Varies with Selection of Statin and Intensity
(8,127 patients)
Statins used: atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin
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INSIDE Dyslipidemia Management | 54
LDLC Varies with Drug Class Combinations
(8,318 patients)
Classes: Statins, PCSK9s, cholesterol inhibitors, PPAR-alpha agonists, nicotinc acids, bile acid sequestrants, omega-3 fatty acids
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INSIDE Dyslipidemia Management | 55
LDLC Varies with Drug Class
(8,318 patients)
Classes: Statins, PCSK9s, cholesterol inhibitors, PPAR-alpha agonists, nicotinc acids, bile acid sequestrants, omega-3 fatty acids
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INSIDE Dyslipidemia Management | 56
LDLC Varies with Drug Combinations
(8,318 patients)
atorvastatin/simvastatin atorvastatin/rosuvastatin atorvastatin/pravastatin
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INSIDE Dyslipidemia Management | 57
LDLC Varies with Drug Treatment
(8,318 patients)
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INSIDE Dyslipidemia Management | 58
DiabetesHow is diabetes and cardiovascular risk being managed?
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INSIDE Dyslipidemia Management | 59
Mean HbA1c Variation Over Time
(11,211 patients)
12.3
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INSIDE Dyslipidemia Management | 60
Proportion with Poor HbA1c Control on Insulin
(N=15,725) (11,211 patients)
0.42
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INSIDE Dyslipidemia Management | 61
LDLC Variation Over Time in Diabetes
(1,812 patients)
86
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INSIDE Dyslipidemia Management | 62
HbA1c Varies with Drug Class Combos
(4,517 patients)
Insulin/Ins Analog Biguanide/Insulin Insulin Biguanide/Insulin/Insulin Analog
Biguanide/Insulin Analog/SUBiguanide/Insulin/Insulin Analog/SU
Biguanide/SU
GLP1/Ins Analog
11.6
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INSIDE Dyslipidemia Management | 63
HbA1c Varies with Drug Classes
(4,517 patients)
11.6
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INSIDE Dyslipidemia Management | 64
HbA1c Varies with DM Drug Combinations
(4,517 patients)
11.6
aspart metforminaspart/metformin
glargine/aspart/regularglargine/aspart/metformin
glargine/lispro/aspart
glargine/lispro/aspart/regular
glipizide/aspartglargine/isophane/regular
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INSIDE Dyslipidemia Management | 65
HbA1c Varies with DM Drug Class
(4,517 patients)
11.6
DPP4 SGLT2
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INSIDE Dyslipidemia Management | 66
Population Risk ProfilesHow do lipid profiles compare among different risk categories?
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INSIDE Dyslipidemia Management | 67
Mean LDLC Stratified by # of Major Risk Factors
No data
91
(12,828 patients)
Age, Cholesterol, non-HDLC, LDLC, HDLC, DM, CKD III/IV, Smoking
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INSIDE Dyslipidemia Management | 68
Mean LDLC Stratified by AACE ASCVD Risk Category
91
(12,828 patients)
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INSIDE Dyslipidemia Management | 69
Mean LDLC Stratified by ACC ASCVD Risk Category
(12,828 patients)
91
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INSIDE Dyslipidemia Management | 70
LDLC Stratified by Diagnosis
(12,493 patients)
88
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INSIDE Dyslipidemia Management | 71
Population WeightHow does body mass effect lipid outcomes?
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INSIDE Dyslipidemia Management | 72
Population BMI Variation Over Time
(20,787 patients)
30.1
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INSIDE Dyslipidemia Management | 73
LDLC vs BMI
(12,010 patients)
91
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INSIDE Dyslipidemia Management | 74
Triglycerides vs BMI
(12,114 patients)
128
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INSIDE Dyslipidemia Management | 75
Population BMI Variation With Age
(12,010 patients)
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INSIDE Dyslipidemia Management | 76
Population Triglyceride Variation With Age
(12,931 patients)
127
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INSIDE Dyslipidemia Management | 77
LDLC by AACE Risk
CategoriesDo AACE risk categories have different clinical variation?
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INSIDE Dyslipidemia Management | 78
LDLC By Age Compared to AACE Low Risk Goal
89
130
Well below goal
833 patients with 980 tests
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INSIDE Dyslipidemia Management | 79
LDLC By Age Compared to AACE Moderate Risk Goal
91
9,069 patients with 14,607 tests
Well below goal
At goal
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INSIDE Dyslipidemia Management | 80
LDLC By Age Compared to AACE High Risk Goal
112
At goal
117 patients with 2,913 tests
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INSIDE Dyslipidemia Management | 81
LDLC By Age Compared to AACE Very High Risk Goal
106
70
2,913 patients with 3,899 tests
Above goal
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INSIDE Dyslipidemia Management | 82
LDLC By Age Compared to AACE Extreme Risk Goal
97
55
1,907 patients with 2,889 tests
Above goal
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INSIDE Dyslipidemia Management | 83
Treatment DisparitiesDo population outcomes differ with race or gender?
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INSIDE Dyslipidemia Management | 84
Mean LDLC Stratified by Race and Gender
91
Females
Males
(12,828 patients)
Δ=10 mg/dL
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INSIDE Dyslipidemia Management | 85
Mean LDLC Stratified by Age and Gender
86
96
6,359 male patients with 11,071 tests
6,469 female patients with 11,451 tests
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INSIDE Dyslipidemia Management | 86
Mean HDLC Stratified by Age and Gender
47
57
6,441 male patients with 11,300 tests
6,519 female patients with 11,604 tests
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INSIDE Dyslipidemia Management | 87
Mean Triglycerides Stratified by Age and Gender
134
121
6,422 male patients with 11,254 tests
6,509 female patients with 11,572 tests
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INSIDE Dyslipidemia Management | 88
Providers and Risk ProfilesDo providers achieve different outcomes?
Is population risk profile changing over time?
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INSIDE Dyslipidemia Management | 89
LDLC Stratified by Provider
91
(120 providers managing 12,828 patients)
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INSIDE Dyslipidemia Management | 90
LDLC Stratified by PCE 10-Year Risk Estimates
(8,287 patients)
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INSIDE Dyslipidemia Management | 91
LDLC Stratified by Number of CV Risk Factors
(21,950 patients)
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INSIDE Dyslipidemia Management | 92
Potential Quality Issues to Assess and Address
•EHR lab and data gaps for managing and monitoring population healthStructural
•Compare and select among current dyslipidemia guidelines
•Undercoding for ASCVD risk factors of obesity, prediabetes, diabetes
•Better assessment of diabetes populationProcess
•Dyslipidemia undertreatment with progressive increase in ASCVD risk
•Decrease proportion of patients with poor diabetes control
•Gender disparity in dyslipidemia management
•Poorer dyslipidemia control in younger, at-risk patientsOutcome
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INSIDE Dyslipidemia Management | 93
Dyslipidemia ComparisonUniversity of Chicago and NorthShore
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INSIDE Dyslipidemia Management | 94
Baseline Data – DemographicsTotal N=20,871; Mean Age=64 N %
Gender
Male 10,658 51.1%
Female 10,213 48.9%
Race
African American 9,978 46.9%
White 9,750 46.7%
Asian/Mideast Indian 643 3.1%
Other 419 2.0%
American Indian or Alaskan Native
81 0.4%
CVD/CV Risk Diagnoses
Hypertension 10,781 49.0%
Dyslipidemia 7,632 34.7%
Coronary Artery Disease 6,681 30.4%
Diabetes/prediabetes 1,658 7.5%
Peripheral Vascular Disease 955 4.3%
Total N=84,463; Mean Age=64 N %
Gender
Male 43,772 51.8%
Female 40,681 48.2%
Race
White 58,778 69.6%
Other 17,562 20.8%
Asian 4,090 4.8%
African American 3,598 4.3%
American Indian or Alaskan Native
192 0.2%
CVD/CV Risk Diagnoses
Hypertension 44,338 52.5%
Diabetes 18,510 21.9%
Dyslipidemia 14,530 17.2%
Coronary Artery Disease 12,908 15.3%
Peripheral Vascular Disease 2,821 3.3%
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INSIDE Dyslipidemia Management | 95
Cardiovascular Risk Factor Diagnoses (ICD 10)
84,45321,983
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INSIDE Dyslipidemia Management | 97
Baseline Data – Evolving Individual LDLC Change
N=60,670N=5,125
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INSIDE Dyslipidemia Management | 99
Statin Rx for ACC Risk CategoriesOnly includes patients on lipid-lowering drugs
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INSIDE Dyslipidemia Management | 100
Statin Rx for ACC Risk CategoriesOnly includes patients with diabetes on lipid-lowering drugs
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INSIDE Dyslipidemia Management | 101
Baseline Data –LDLC Stratified
N=36,185N=5,445
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INSIDE Dyslipidemia Management | 102
Baseline Data – Patients Not at AACE Goals
N=36,185N=5,445