CDS Connect: Healthful Diet and Physical Activity for CVD Prevention in Adults With Cardiovascular Risk Factors

Healthful Diet and Physical Activity for CVD Prevention in Adults With Cardiovascular Risk Factors

Description

This artifact provides patient-centered, evidence-based preventive health information to patients identified as overweight or obese with at least one cardiovascular disease (CVD) risk factor to:

1) raise awareness of the importance of a healthy diet and physical activity level to reduce their risk of CVD, and  

2) encourage patients to discuss the information presented to them with a clinician and explore the possibility of participating in intensive behavioral counseling to support their effort to ensure a healthy diet and physical activity level 

CVD risk factors include hypertension, dyslipidemia, impaired fasting glucose, and metabolic syndrome.

Creation Date
Version
0.1
Status
Experimental
False

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 USPSTF.

Additional information about MITRE's health expertise is available here

Additional information about the USPSTF's preventive 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.

IP Attestation The author asserts that this artifact has been developed in compliance with the intellectual property rights attributed to the source material.
Copyrights
This recommendation is copyrighted by USPSTF and is administered by AHRQ.
Implementation Details
Engineering Details
This CDS logic is expressed using Clinical Quality Language (CQL) and the FHIR Draft Standard for Trial Use 2 (DSTU2) data model. All value sets referenced in the logic are published on the Value Set Authority Center (VSAC). Additional details about these resources can be accessed via the following URLs:
     CQL: https://ecqi.healthit.gov/cql-clinical-quality-language
     FHIR DSTU2: https://www.hl7.org/fhir/DSTU2/index.html
     VSAC: https://vsac.nlm.nih.gov/
Repository Information
Approval Date
Publication Date
Last Review Date
Knowledge Level

Structured code that is interpretable by a computer (includes data elements, value sets, logic)

Purpose and Usage
Purpose

Identifies patients who are overweight or obese with one or more CVD risk factor and provides preventive health recommendations to patients to:

1) raise awareness of an identified risk (i.e., that the individual is overweight or obese with one or more CVD risk factor) 

2) provide information about the risk(s) identified 

3) provide resources that will support the patient to act on the information (e.g., a link to a heart-healthy cookbook)

4) encourage them to discuss the identified risk and preventive health recommendation with their clinician and explore the possibility of initiating behavioral counseling to support a healthy diet and physical activity level 

Intended Population
This artifact is intended for use in a broad population of adults (aged 18 years old and older) who are overweight or obese and who have at least one CVD risk factor (i.e., hypertension, dyslipidemia, impaired fasting glucose, or metabolic syndrome)
Usage

This CDS artifact is designed to be implemented in a patient-facing information technology (IT) system (e.g., a patient portal or health and wellness app) to deliver preventive health recommendations outside of a traditional encounter with a clinician. Organizations that might consider implementing this logic range from a large self-insured healthcare organization that seeks to provide health and wellness resources to their employees and patients, to a healthcare innovator that culls patient data from numerous sources (e.g., electronic health records, claims, pharmacy-based management systems, biometric devices, patient-reported data) to provide personalized wellness information via a mobile app.

It is intended for use by patients to provide patient-centered, evidence-based information on preventive treatment options to consider based on that patient’s individual health history and risk factors. The patient is provided with user-friendly notifications, educational materials, and tools in lay language to facilitate patient action and encourage collaborative decision-making between the patient and their clinician and caregiver(s) to determine the most appropriate treatment or care choice. 

Cautions

Evidence-base is in the process of being updated: As of September 3, 2020, the evidence this artifact was derived from is nearing the end of the recommendation development process (i.e., it appears to be in “Step 3: Finalizing the Recommendation Statement” of the update process). The public comment period for the update is now closed. Implementers are encouraged to monitor the USPSTF website to view the updated evidence when it is released. Of note, there are two related recommendations moving through the development process (i.e., Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Risk Factors: Behavioral Counseling and Healthy Diet and Physical Activity to Prevent Cardiovascular Disease in Adults With Risk Factors: Behavioral Counseling Interventions). Both appear to be in “Step 2: Review the Evidence and Develop a Draft Recommendation”). These recommendations are valuable to track also.

Implementation consideration: The patient notifications included in the structured CQL expression of this artifact are fairly general, enabling implementing organizations to expand upon and personalize the interventions based on their unique needs and patient population. Information provided to the patient translates the preventive care recommendation into lay language and provides additional resources in a user-friendly format and method. This user-friendly information facilitates patient action through the provision of vetted resources, and in the case of the customized piloted CDS, an opportunity to provide personalized motivational messaging and logistical support for appointments and followup. 
Additional information and resources: CQL Services, an open source publicly-available tool that facilitates integration of CQL code with a health IT system, was used during the pilot implementation of this artifact. CQL Services is available here
Supporting Evidence
Source Description
Derived from USPSTF Recommendation on Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Behavioral Counseling. Grade B recommendation, available here
References
LeFevre ML, on behalf of the U.S. Preventive Services Task Force. Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2014;161:587–593. doi: 10.7326/M14-1796
Recommendation
The USPSTF recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention.
Strength of Recommendation

Grade B (Grade definitions are available here.)

Quality of Evidence
See full recommendation report for details, available here
Decision Notes

Artifact decision notes are outlined in Appendix A of the implementation guide attached to this artifact.

Artifact Representation
Triggers

The pilot organization ran this logic every night as a batch report. Other implementers may opt for a different triggering event.

Inclusions
Patient is >=18 years old
AND BMI >=25kg/m2, MOST RECENT VALUE
AND one or more of the following:
     Hypertension (active, relapse)
     OR low-density lipoprotein-cholesterol (LDL-C) lab result >130 milligrams/deciliter (mg/dL), MOST RECENT VALUE within the past 6 years
     OR high-density lipoprotein-cholesterol (HDL-C) lab result <40 mg/dL, MOST RECENT VALUE within the past 6 years
     OR impaired fasting glucose (IFG) within the past 12 months (active, relapse)
     OR impaired glucose tolerance (IGT) within the past 12 months (active, relapse)
     OR presence of three or more of the following measurements (as a representation of metabolic syndrome):
          Waist circumference in men >=40 inches, MOST RECENT VALUE within the past 6 years
          OR waist circumference in women >=35 inches, MOST RECENT VALUE within the past 6 years
          OR triglyceride lab result >=150mg/dL, MOST RECENT VALUE within the past 6 years
          OR HDL-C <50mg/dL in women, MOST RECENT VALUE within the past 6 years
          OR HDL-C <40mg/dL in men, MOST RECENT VALUE within the past 6 years
          OR systolic blood pressure (SBP) >=130 mm Hg, MOST RECENT VALUE within the past 6 years
          OR diastolic blood pressure (DBP) >=85 mm Hg, MOST RECENT VALUE within the past 6 years
          OR fasting glucose lab result >=100mg/dL, MOST RECENT VALUE within the past 6 months
Exclusions
CVD
OR pregnancy (active)
OR pregnancy observation within the past 42 weeks
OR one or more of the following:
     Behavioral counseling for nutrition and activity referral within the past 12 months (requested, active, accepted, completed)
     OR Behavioral counseling for nutrition and activity order within the past 12 months (requested, received, accepted, in-progress, completed)
     OR Behavioral counseling for nutrition and activity procedure within the past 12 months (in-progress, completed)
     OR Behavioral counseling for nutrition and activity encounter within the past 12 months (in-progress, finished)
Interventions and Actions

Display notification to patient: You may be at risk for (in other words, more likely to have) heart disease or a stroke based upon your weight and other risk factors you may have.
Additional risk factors include high blood pressure, high LDL cholesterol (the “bad” kind of cholesterol), low HDL cholesterol (the “good” kind), high Triglycerides, high blood sugar, or too much weight around your middle.

Recommendation: Experts (i.e., The U.S. Preventive Services Task Force ) find that one way to lower the risk of heart disease and stroke is through counseling and coaching programs that help you eat healthy foods and increase your physical activity (exercise and movement). These programs typically involve a trained counselor who can teach you, help you set goals, share ways to eat a healthy diet and increase physical activity and regularly follow up with you.
Contact your doctor to discuss whether coaching and counseling are right for you.
In addition, the experts know that all adults, whether they are at an increased risk for heart disease and stroke or not, can improve their health through healthy eating and being more physically active. 
Here are some links to resources to help you get started:

  • Tips for healthy eating from healthfinder.gov (available here
  • Online cookbook with recipes for heart-healthy, tasty meals (available here
  • Ways to get more active! (available here)
  • The U.S. Preventive Services Task Force Recommendation on “Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors” (available here)
Testing Experience
Pilot Experience

This artifact was tested by b.well® Connected Health over an 8-week period from June 2019 - August 2019, along with the following 4 artifacts (which are also posted on the CDS Connect Repository):

  • Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Part 1, Screening
  • Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Part 2, Counseling
  • Statin Use for the Primary Prevention of CVD in Adults: Patient-Facing CDS Intervention
  • CMS's Million Hearts® Model Longitudinal ASCVD Risk Assessment Tool for Baseline 10-Year ASCVD Risk

b.well offers a platform with personalized health management resources targeted to consumers to help them self-manage the entire healthcare process. AHRQ and MITRE would like to thank b.well for their partnership on the pilot. The collaborative effort provided a valuable opportunity to test the CQL CDS expression and learn from the implementation process and end user experiences. High-level details are outlined below. Detailed information on the pilot implementation can be found in the CDS Connect Pilot Report: Preventive Health CDS Interventions document posted within this artifact.

1. What went well?
·         The CDS was successfully integrated into the pilot site’s platform.
·         The pilot partner was extremely collaborative and responsive, meeting all deadlines and exceeding expectations despite a very tight timeframe.
·         The use of several communication tools helped streamline the sharing of documentation and software and enhanced the collaboration between the CDS Connect and b.well technical teams (i.e., Accellion kiteworks and Slack).
·         Leveraging the pilot partner’s expertise in patient/consumer engagement and health management resources and tools enhanced the pilot intervention process and contributed greatly to a successful pilot.
2. What did not go well?
·         The pilot technical team did not have prior experience with the standards used (e.g., Fast Healthcare Interoperability Resources [FHIR], CDS Hooks, and Clinical Quality Language [CQL]), which extended the technical integration time and efforts.
·         Data mapping consumed almost 25 percent of the pilot partner’s technical resource hours (80 hours) and an additional 20 hours of clinical and data/analytics resource time.
·         Some required data was simply not available. Given more time, the pilot partner could have enhanced existing capabilities to obtain the required data directly from the end users.
3. What would you do differently?
·         Initiate the pilot partnership no later than March to allow more time for integration and testing efforts, as well as end user engagement.
·         If more time was available, consider implementing  the CDS using the FHIR Release 4 (R4) in addition to FHIR Draft Standard for Trial Use 2 (DSTU2).
   4. What enhancements were suggested by the pilot partner?
·         Allow the calculation of an “inferred” diagnosis or potential “at risk” status for end users without a confirmed diagnosis, based on other available data. This would enable reaching a larger population of end users and providing them with education that may be valuable. The CDS Connect team opted not to implement this enhancement since expansion of the target population would diverge from the USPSTF recommendation.
·         If time had allowed, it would have been helpful to obtain end user input on the educational materials prior to implementing them. Instead, the pilot partner used health literacy and health communication best practices when developing the educational content.
·         It would have been helpful to survey a larger number of end users, and to provide the survey to the user directly after the intervention. This would allow more conclusive analysis of the survey results; however, the project team was required to follow Paperwork Reduction Act requirements which limited the number of survey recipients to 9 or less
·         Provision of more detailed information from CDS Hooks, to provide information such as the specific user data that qualified that user for the CDS intervention. This information could be used for both testing purposes as well as personalization of the intervention text.
   5. What were the key takeaways/lessons learned from the pilot experience?
·         Aggregating data from multiple sources provides a rich source of clinical information, but also presents challenges when using the data to satisfy CDS logic requirements. This is primarily due to the lack of standards employed by each data source (e.g., claims, electronic health systems, pharmacy benefits management systems, reference laboratories, and patient-generated health data). Much of the data were not linked to a standard clinical terminology code, and many of the required FHIR attributes were missing (e.g., “status,” “verificationStatus,” “onsetDateTime,” “valueQuantity”).
·         Data mapping to account for the issues listed above is a resource-intensive process that also requires knowledgeable clinical informatics expertise. The mapping efforts can impact the integration timeline.
·         The experience of the pilot technical team with FHIR and other evolving standards should be considered during the technical evaluation and planning stages.
·         Patient-facing CDS pilots should consider a pilot partner with consumer/patient-facing experience and expertise and should ensure a pilot timeframe that allows end user personalization and engagement opportunities to be realized.