CMS’s Million Hearts® Model Longitudinal ASCVD Risk Assessment Tool for Shared Decision Making

Description

This artifact provides the ability to facilitate a discussion between a provider and patient while considering the initiation of therapy after an ASCVD risk of >=5% is calculated. It provides the display of two additional fields beyond what is offered in the baseline risk assessment so that a PROSPECTIVE 10-Year ASCVD risk estimate can be calculated. The underlying equation provides calculations that consider the benefit of therapies, alone or in any combination that the patient selects.

It addresses the second of 3 clinical scenarios where the Million Hearts® (MH) Model Longitudinal ASCVD Risk Assessment Tool might be used:
1. Calculation of a baseline 10-Year ASCVD risk assessment score
2. Prospective estimations of ASCVD risk in support of shared decision making while considering the benefits of therapies, alone or in combination
3. Calculation of updated ASCVD risk after preventive therapies have been initiated

CDS guidance that facilitates baseline calculation of 10-Year ASCVD risk and updated ASCVD risk calculation post-initiation of therapy is included in separate CDS artifacts.

Creation Date
Version
0.1.1
Unique Identifier
CDS 004
Status
Experimental
True

Artifact Creation and Usage

Contributors

This artifact was developed by MITRE software engineers and clinical informaticists, in collaboration with clinical subject matter experts and leaders from the Million Hearts® Model Initiative.

Additional information about MITRE's health expertise is available here.

If you would like further information, would like to give us feedback, or have any questions about this artifact, please contact us at ClinicalDecisionSupport@ahrq.hhs.gov.

License
IP Attestation The author asserts that this artifact has been developed in compliance with the intellectual property rights attributed to the source material.
Repository Information
Approval Date
Publication Date
Last Review Date
Knowledge Level

Semi-structured text that describes the recommendations for implementation in CDS

Purpose and Usage
Purpose

Provides the ability to calculate and display a patient's prospective ASCVD risk while considering the potential harms and benefits of one or more forms of therapy. This artifact is triggered by the calculation of a 10-Year ASCVD risk score >=5%

This capability is part of a larger effort that is undergoing a 5-year study (i.e., Million Hearts® Cardiovascular Disease (CVD) Risk Reduction Model). Details on the study are available here, and the first annual update is available here

The American College of Cardiology has an app and web-based version of this calculator available here titled the ASCVD Risk Estimator Plus.

Intended Population

This artifact is intended for use in a broad population of individuals aged 40-79 years and eligible for primary prevention of ASCVD. It supports shared decision-making discussions between the patient and provider after a baseline 10-Year ASCVD risk score >=5% is calculated, as recommended in the 2013 ACC/AHA cholesterol guidelines.

Usage

This artifact is intended for use by providers while delivering care in an outpatient setting.

Cautions

This tool is not indicated for individuals that have ASCVD.
The guidelines recommend individualized care decisions for individuals <40 and >79.
Risk scores calculated on patients with a history of familial hypercholesterolemia may under-represent the patient's true ASCVD risk.

Patient population information: "At present, the risk equation applies most accurately to non-Hispanic Whites and African Americans.  For non-White and non-African American ethnic groups, the equations for Whites of the same sex were used, which may provide overestimation of risk for some groups (e.g., East Asian Americans) and underestimation in others (e.g., South Asian Americans)." Source: 2013 Report on the Assessment of Cardiovascular Risk: Full Work Group Report Supplement

"Patients with end-stage renal disease require individualized care with respect to use of aspirin and blood pressure–lowering therapies, and data on use of statin medications in patients with end stage renal disease do not indicate overall benefit. For some patients with symptomatic or advanced heart failure, similar considerations and individualized decision-making may be necessary. However, recent data reinforce the importance of ASCVD risk-reducing therapies even among patients with heart failure of ischemic etiology." Source: AHA/ACC Special Report: Estimating Longitudinal Risks and Benefits from Cardiovascular Preventive Therapies Among Medicare Patients: The Million Hearts Longitudinal ASCVD Risk Assessment Tool.

Risk calculator selection: If statin therapy has already been initiated for primary prevention, consider use of the "Calculation of Updated Risk" portion of the MH Model Longitudinal ASCVD Risk Assessment Tool since that equation has additional capabilities to adjust the risk score based on initiated therapies.

Additional information and resources: CDS Connect artifacts are not “standalone” and are not intended to be completely plug-and-play (i.e., healthcare systems will need to integrate each artifact with components of their health information technology (IT) system for the artifact to work. CQL Services, an open source publicly-available tool that facilitates integration of CQL code with a health IT system, can be used by organizations that build out a coded expression of this artifact for pilot implementation in their healthcare organization. CQL Services is available here: https://github.com/AHRQ-CDS/AHRQ-CDS-Connect-CQL-SERVICES. Implementers should conduct extensive testing, including clinical testing in real-life workflows, of all artifacts. It is expected that artifacts will be customized and adapted to local clinical and IT environments.

Supporting Evidence
References

DeFelippis AP, young R. (2016) Estimating Longitudinal Risks and Benefits from Cardiovascular Preventive Therapies Among Medicare Patients: The Million Hearts Longitudinal ASCVD Risk Assessment Tool. Nov 4, 2016. Accessed on Feb 2, 2017 at: http://www.acc.org/latest-in-cardiology/articles/2016/11/04/08/56/estimating-longitudinal-risks-and-benefits-from-cv-preventive-therapies.

Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB Sr, et al.  (2013) 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;00:000–000.

Goff DC Jr, Lloyd-Jones DM, D’Agostino RB Sr, Gibbons R, Greenland P, et al. (2013) 2013 Report on the Assessment of Cardiovascular Risk: Full Work Group Report Supplement. National Heart, Lung, and Blood Institute.

Lloyd-Jones, DM, Karmali, K. (2016) Final Technical Report: Estimating Benefits in Risk Reduction From Cardiovascular Preventive Therapies in Medicare Patients: Development of the Longitudinal ASCVD Risk Estimator.

 

Recommendation

"Using the Million Hearts tool, the patient and clinician can see the projected absolute risk reduction associated with initiation and continuation of each therapy, or combinations of therapies, and weigh this in the context of other considerations, including patient preferences for taking medications, potential adverse drug reactions or interactions, and where they see the most bang for the buck". Source: AHA/ACC Special Report: Estimating Longitudinal Risks and Benefits from Cardiovascular Preventive Therapies Among Medicare Patients: The Million Hearts Longitudinal ASCVD Risk Assessment Tool.

Strength of Recommendation

N/A. The Million Heart Longitudinal ASCVD Risk Tool is a new body of work supported by the ACC/AHA, Centers for Medicare and Medicaid Services, and the Million Hearts Initiative. Per the ACC/AHA Special Report, the equations that are embedded in the tool come from randomized controlled trials that have tended to last for 3-5 years.

Quality of Evidence

N/A

Artifact Decision Notes

Artifact decision notes are listed in the attached Implementation Guide.

Artifact Representation
Triggers
Trigger Type Data event
Trigger Event Calculation or Documentation of a baseline 10-Year ASCVD risk score
Inclusions
10-Year ASCVD risk score >=5%
Exclusions
History of ASCVD
Interventions and Actions
Intervention

DISPLAY segment of the MH Model Longitudinal ASCVD Risk Assessment Tool that provides the ability to input the following data concepts:

1) Age
2) Gender - (M/F)
3) Race - (White/African American/Other)
4) Total Cholesterol - MOST RECENT within past 6 years (measured as mg/dL)
5) LDL-Cholesterol - MOST RECENT within past 6 years (measured as mg/dL)
6) HDL Cholesterol - MOST RECENT within past 6 years (measured as mg/dL)
7) Treatment with Statin - (Y/N) determined by an active statin medication
8) Systolic Blood Pressure - MOST RECENT within past 6 years (measured as mmHg)
9) Treated for high blood pressure - (Y/N) determined by a diagnosis of Hypertension AND an active anti-hypertensive medication
10) Diabetes - (Y/N)
11) Current Smoker (within last year) - (Y/N) within the past year
12) Aspirin Therapy - (Y/N) determined by an active aspirin medication
  Note: The risk score should be calculated whenever possible to facilitate workflow and provider decision making. To this end, if a patient's lab (i.e., Total Cholesterol and HDL Cholesterol) or systolic blood pressure (SBP) results are outside the range specified by the calculator, then the result should be replaced with the nearest value that will be accepted by the tool. For example, the tool allows a SBP value of 90-200 mmHg. If the most recent patient value is "212", it would be replaced with "200" to enable calculation of the score.
Intervention POPULATE Longitudinal Risk Tool fields based on clinical data (e.g., CQL code will translate the presence of an active diabetes ICD-10 code to a 'Y' for input to the tool to support calculation)
Intervention CALCULATE prospective risk scores
Intervention DISPLAY prospective risk scores
Intervention DISPLAY caveat to risk value if patient has a history of familial hypercholesterolemia (since the value likely under-represents the risk)
*requires evaluation of patient record for this diagnosis
Intervention DISPLAY ERROR notification if patient record is missing data required for the equation (i.e., age, gender, race, smoking status, lab or blood pressure results) or if lab or blood pressure results are older than 6 years.
Intervention DISPLAY changes made to patient data to enable calculation of a risk score, if applicable (e.g., SBP was 212 in the patient record and was replaced with 200 to enable calculation). See the note listed above in the first Intervention.
Intervention DISPLAY link to relevant guidelines related to the tool (e.g., http://www.acc.org/latest-in-cardiology/articles/2016/11/04/08/56/estimating-longitudinal-risks-and-benefits-from-cv-preventive-therapies)
Intervention DISPLAY link to relevant evidence-based reference information, including information on statin and aspirin considerations (e.g., https://medlineplus.gov/druginfo/meds/a682878.html)
Intervention DISPLAY link to statin shared-decision making tool (e.g., https://statindecisionaid.mayoclinic.org/)
Action DOCUMENT preventive therapy that is agreed upon between the patient and provider
Testing Experience
Pilot Experience

This artifact is in draft status and has not been tested in a clinical setting