|This artifact provides patient-centered, evidence-based preventive health information to patients between 40-75 years old who have one or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year CVD event risk score of 10% or greater. The intervention text prompts them to discuss the possibility of initiating statin therapy with their primary care clinician to prevent CVD.
Artifact Creation and Usage
This artifact was developed by MITRE software engineers and clinical informaticists, in collaboration with clinical subject matter experts and leaders from the U.S. Preventive Services Task Force (USPSTF).
Additional information about MITRE's health expertise is available here.
Additional information about the USPSTF's preventive health expertise is available here.
|Recommendation is copyrighted by USPSTF and administered by AHRQ
This CDS logic is expressed using Health Level Seven International (HL7) Clinical Quality Language (CQL) and the HL7 Fast Healthcare Interoperability Resources (FHIR) data model. All value sets referenced in the logic are published on the Value Set Authority Center (VSAC). In addition, a FHIR Clinical Reasoning representation has been provided to demonstrate how the CDS logic can be contextualized using FHIR PlanDefinition and Library resources. Additional details about these resources can be accessed via the following URLs:
Structured code that is interpretable by a computer (includes data elements, value sets, logic)
This artifact provides an opportunity to present information to at-risk patients through a patient-facing health IT system (e.g., a patient portal, health app) to:
This artifact applies to adults 40-75 years old who have one or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year CVD event risk score of 10% or greater.
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.
Statin therapy recommendations for the primary prevention of CVD may vary: Professional societies, academic institutions, government entities, etc. may have varied recommendations on how statin therapy should be approached for the primary prevention of CVD. Their recommendations may align with this artifact in some areas and diverge in others. Viewers are encouraged to thoroughly evaluate all aspects of the evidence that informed development of this artifact, along with evidence from other guideline authors, prior to implementing this artifact. Detailed information on the development of this CDS can be found in the implementation guide attached to the artifact.
|This guideline follows USPSTF recommendations which exclude all pregnant patients: In 2021 the FDA issued updated guidance supporting use of statins in pregnant persons with conditions such as coronary artery disease or familial hypercholesterolemia which put them at high risk of heart attack or stroke. Implementers may wish to modify the logic to allow those patients to be included in the group who are contacted and offered education and a recommendation to contact their clinician.
|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 on GitHub here.
This artifact is derived from the USPSTF Statin Use for the Primary Prevention of CVD in Adults: Preventive Medication recommendation.
US Preventive Services Task Force. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2022;328(8):746–753. doi:10.1001/jama.2022.13044 https://jamanetwork.com/journals/jama/fullarticle/2795521
Chou R, Cantor A, Dana T, et al. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2022;328(8):754–771. doi:10.1001/jama.2022.12138 https://jamanetwork.com/journals/jama/fullarticle/2795522
The USPSTF recommends that clinicians prescribe a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or more CVD risk factors (i.e. dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year risk of a cardiovascular event of 10% or greater.
Grade B (Grade definition information is available here)
See the full recommendation report, available here.
|Artifact decision notes are outlined in Appendix A of the implementation guide attached to this artifact.
|The pilot organization ran this logic every night as a batch report. Other implementers may opt for a different triggering event.
Patient is >=40 and <=75 years of age
AND one or more risk factor:
LDL-C lab result > 130 mg/dL, MOST RECENT VALUE within the past 6 years (final, amended)
OR HDL-C < 40 mg/dL, MOST RECENT VALUE within the past 6 years (final, amended)
OR diabetes (Type 1 or Type 2) (active, relapse)
OR hypertension (active, relapse)
OR smoking, MOST RECENT STATUS within the past 6 years (final, amended)
AND 10-year CVD risk score >=10 percent, MOST RECENT VALUE within the past 6 years (final, amended)
OR LDL-C lab result >190 mg/dL, MOST RECENT VALUE within the past 6 years (final, amended)
OR known familial hypercholesterolemia (active)
OR pregnancy (active)
OR pregnancy observation within the past 42 weeks (final, amended)
OR breastfeeding (active)
OR breastfeeding observation, MOST RECENT within the past 1 year (final, amended)
OR ESRD (active)
OR ESRD encounter, within the past 1 month (in progress, finished)
OR dialysis procedure, within the past 7 days (in progress, completed)
OR dependence on dialysis (active, relapse)
OR cirrhosis (active, relapse)
OR rhabdomyolysis (active, relapse)
OR statin medication order, within the past 2 years (active, completed)
OR statin medication statement, within the past 2 years (active)
Display notification to patient: You may have some things putting you at risk (in other words, making it more likely) for getting cardiovascular disease (heart disease and stroke).
Common risk factors for cardiovascular disease (CVD) include high blood pressure, high LDL cholesterol (the “bad” kind of cholesterol), low HDL cholesterol (the “good” kind), diabetes, or smoking.
Recommendation: Experts (i.e., The U.S. Preventive Services Task Force) find that if you are 40 years or older and have one or more risk factors for CVD, you should consider taking a medication called a statin. Statins are medications that help to lower your LDL cholesterol (the ‘bad’ kind of cholesterol).
If you smoke, you should consider quitting.
Contact your doctor to schedule an appointment to discuss steps you can take to prevent heart disease and stroke, including whether taking a statin medication is right for you.
In addition, here is some additional information you may want to review:
- Keep your heart healthy (available here)
- Treating cholesterol (available here)
- Medicines to Prevent Heart Attack and Stroke: Questions for the doctor (available here)
- The U.S. Preventive Services Task Force Recommendation on “Statin Use for the Primary Prevention of Cardiovascular Disease in Adults” (available here)
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 (also posted on the CDS Connect Repository):
- Healthful Diet and Physical Activity for CVD Prevention in Adults with CV Risk Factors
- Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Part 1, Screening
- Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Part 2, Counseling
- 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.
As the 2022 USPSTF guideline did not change any of the recommendations this earlier pilot experience is still valid.
|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.