Speakers
Ken Mahaffey, MD
Professor of Cardiovascular Medicine
Associate Dean for Clinical Research, School of Medicine
Vice Chair for Clinical Research, Department of Medicine
Director, Stanford Center for Clinical Research (SCCR)
Stanford University
Nishant Shah, MD
Assistant Professor of Medicine
Duke University School of Medicine
The REVEAL Project: Identifying Real World Gaps and Areas for Improvement
Neha Pagidipati, MD, MPH
Associate Professor of Medicine
Duke University School of Medicine
Test to Treat – Improving lipid management on a health system level
Keywords
CardioHealth Alliance, Research, ASCVD, LDL-C, REVEAL, Test 2 Treat
Key Points
- The CardioHealth Alliance is focused on establishing a health system alliance with engaged clinicians, data scientists, and healthcare leaders to develop new care-pathways and real-world data to improve cardiovascular, renal disease, and metabolic disease outcomes for patients.
- The CardioHealth Alliance wanted to do this work to establish a reusable real-world data platform to rapidly answer clinical questions, shorten implementation of evidence into practice, generate real-world evidence to inform stakeholders, and establish an alliance to address the value of care through policy.
- Since its inception in November 2020, 9 health systems and 6 industry partners have joined the Alliance. The Alliance has 4 pillars that include partnering with clinical scientists to use real-world data to inform real world care; scaling and optimizing best practices; developing and testing new pathways and practices; continuously addressing the value of care through effective policy.
- The CardioHealth Alliance REVEAL study looked at the current landscape for atherosclerotic cardiovascular disease (ASCVD) management because even though the guidelines are clear, implementation of LDL-C management across the world has not been optimal.
- REVEAL looked at two cohorts. One cohort looked at LDL-C testing and management patterns. The study wanted to understand, within a chronic ASCVD population, how many ASCVD patients had LDL-C guideline-recommended goals, what factors were associated with achieving LDL-C goals in patients with ASCVD, and what patterns of liped lowering therapy (LLTs) prescriptions before and after LDL-C test by LDL-C level.
- REVEAL also wanted to assess Lipoprotein (a) (Lp(a)), a biomarker that can lead to early onset and aggressive ASCVD. REVEAL wanted to find out what the proportion of patients with ASCVD had a LP (a) test, what factors associated with undergoing Lp(a) testing in patients with ASCVD, and whether or not Lp(a) testing influenced lipid management.
- REVEAL identified a patient population across the Alliance that had an LDL-C value during the study period, had at least 2 outpatient encounters, and an ASCVD event within the last 5 years. The study identified 216,074 patients with ASCVD across 5 health systems. REVEAL found that only 86,188 (40%) had guideline-recommended LDL-C goals.
- Patients who were at their goal tended to be male, white, had established coronary disease, heart failure, diabetes, and atrial fibrillation. Several factors were independently associated with not achieving the target: female sex, Black race, and Hispanic ethnicity.
- For the Lp(a) cohort, REVEAL identified about 595,000 patients who were active within the health systems and either had or did not have an Lp(a) test. The study found that only 2,588 (0.4%) were tested for Lp(a) and those who were older, Black, or Hispanic were less likely to have Lp(a) testing. Those with a family history of hypercholesterolemia, ischemic stroke/TIA, PAD, prior LLT, or LDL-C greater than 130mg/dL were more likely to be tested for Lp(a). Having elevated Lp(a) was associated with higher initiation of non-statin lipid-lowering therapy (LLT); however, overall initiation of any LLT after an elevated Lp(a) test was low.
- The CardioHealth Alliance study Test 2 Treat is an implementation science project aimed at improving LDL-C management after an ASCVD event by improving coordination of care between inpatient and outpatient teams, with the goal of preventing downstream morbidity and mortality in this high-risk population.
- There is a window of opportunity when a patient is admitted for a coronary event to review medications and understand where there are gaps and risk factors, but this is not happening. Less than half of patients get their LDL-C checked within 6 months of the MI. The goal of Test 2 Treat is to bridge the transition from inpatient to outpatient care.
- Test 2 Treat has two programs one focused on the inpatient, hospital-level intervention, the other focused on patients as they transition to the outpatient setting.
- For the inpatient program, a hospital level intervention to address barriers and measure the proportion of patients who get their LDL-C measured and their LLTs adjusted in the hospital.
- For the outpatient program, Test 2 Treat is looking at whether or not a nurse champion can navigate the transition verses usual care. The nurse champion or medical assistant will remotely go along with the patient to navigate inpatient-to-outpatient transition, including addressing questions about LDL-C medications, goals, and access to medications, ensuring follow-up, and facilitating communication with the outpatient team.
- Test 2 Treat will develop intervention components that will be publicly available after the study if it is effective. Test 2 Treat has identified patient stakeholders to make sure the study is making sense from a patient perspective.
Learn more
Visit the CardioHealth Alliance website
Discussion Themes
-What do you see as the major challenges that the Alliance can solve? I think what we have learned through the initial work in the Alliance and other programs is that we have an incredible amount of data. We have learned we can access an incredible amount of data and touch an incredible amount of patients. But the data are messy. We need to continue our efforts in data mapping to curate the data more rigorously to allow us to answer more questions.
–What kind of topics or questions will the Alliance take on in the future? We are starting with cardio/kidney/metabolic and the principles of implementation should be applicable more broadly. I anticipate moving beyond CKMI and anticipate moving outwards beyond the traditional patients that we always reach and moving toward patients that are not traditionally included in routine care or clinical research. We want to move toward equitable care. We also want to leverage the idea of the platforms to address patients in a comprehensive manner, across interventions and diseases, to get at all of the issues but in a way that does not cost too much or is not feasible for health systems.
Tags
#pctGR, @Collaboratory1