Does Inclusion of a Framingham Score in a Cholesterol Result Letter Improve Appropriate Aspirin Reco

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Does Inclusion of a Framingham Score in a
Cholesterol Result Letter Improve Appropriate
Aspirin Recommendation?

• Melissa Boisclair, MD
• Elizabeth Koorie, MD
• Hunterdon Medical Center
• Third Year Family Medicine Residents
• Resident Principal Investigators

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Background

• Heart disease and Stroke are the 1st and 3rd
  leading causes of death for both men and women in
  the United States1
• Rate of deaths in Hunterdon County from
  cardiovascular disease (CVD) is lower than the
  state and national rates
• BUT still the Leading Cause of Death in the
  county2
• More Hunterdon County adults have angina or
  coronary heart disease compared to national
  percentages2

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Background

• Aspirin has been shown to significantly reduce3
• All cardiovascular events by 15
• Heart attacks by 30
• All deaths by 6
• One national study has shown that even in
  patients at high risk, rates of Aspirin primary
  prevention are only 57 percent.4
• In Hunterdon County, only 29 take a daily
  aspirin to prevent heart attacks compared to 34
  percent nationally.

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Our Idea Development

• Aspirin is a simple, inexpensive, readily
  available therapy for reducing CVD complications.
  
• Despite proven efficacy, aspirin is clearly
  underused
• USPTF strongly recommends considering aspirin
  therapy if the 10-year cardiovascular event risk
  is greater than 6 5
• Framingham Risk Score is any easy to use
  effective tool for determining a patients 10
  year risk of CVD
• An appropriate time to calculate a patients
  Framingham risk score consider the need for
  aspirin would be following cholesterol screening

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Our Research Question

• Does modifying a cholesterol result letter to
  include the Framingham Risk Score improve rates
  of physician recommendation of aspirin when
  appropriate?

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Methods

• IRB Approval Attained
• Chart Review and Baseline data
• Selection of patients charts, who had a lipid
  profile done during a 45 day period during 2007
  were reviewed from 2 health centers.
• Inclusion Criteria
• Age gt 20 yo and Age lt 79
• Lipid Panel Done during selected period
• Exclusion Criteria
• Age lt 20 yo or gt 79 yo
• Chart could not be located and pulled for our
  review

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Methods

• Baseline Data Review, cont.
• Total Charts Reviewed 407
• Health Center 1 226, Health Center 2 181
• Baseline Data Collected
• Was cholesterol letter sent?
• Framingham Score calculated and 10 year risk
  determined on each patient
• Evidence of DM or CHD /equivalent
• Evidence of Aspirin Recommendation (continued or
  started after results)
• This data was collected without identifiable
  patient information

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Methods

• Cholesterol Letter Modified
• Prompts physician to calculate the Framingham
  score and 10 Year CVD risk.
• Forces a decision point for the physician
  Prescribe ASA or not
• Cholesterol letter presented at Provider Meetings
  and noon conference
• Letter edited based on feedback
• Providers and Residents Notified of initiation of
  new modified letter

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Former Cholesterol Result Letter
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Modified Cholesterol Result Letter - Men
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Modified Cholesterol Result Letter -Women
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Methods

• Post Modified Letter Review
• Modified Letters sent to patients from a 5-6 week
  period were copied and collected for our review
  without any identifiable data.
• Inclusion Criteria
• Age gt 20 yo and Age lt 79
• Modified Letter Sent during Collection Period
• Exclusion Criteria
• Age lt 20 yo or gt 79 yo
• Risk score not Documented with no documentation
  of DM or CHD (16 charts)
• Used Wrong sheet for Sex (1 chart)
• Former Letter Used during review period (3
  Charts)
• Erroneous Risk Score documented (2 Charts)

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Methods

• Post Modified Letter Review Cont.
• Total Charts Included 219
• Health Center 1 146, Health Center 2 73
• Data Collected
• Risk Score
• Was Aspirin Indicated?
• Evidence of DM or CHD/equivalent
• Evidence of Aspirin Recommendation (continued or
  started after results)

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Data Analysis

• Comparison of rate of letter use
• Comparison of appropriate ASA recommendation/cont.
  before after modified letter
• Comparison of inappropriate ASA
  recommendation/cont. before after modified
  letter
• Comparison of ASA recommendation/cont. in
  patients with DM/CHD/equivalents before after
  modified letter
• Providers view of modified cholesterol letter
  based on questionnaire
• All Statistical Analysis Performed with 2 x 2
  Contingency Table and the Fischers Exact Test.

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Results
Health Center 1
Health Center 2
(Health Center 1 before) N 156 (Health Center
1 after) N 168 (Health Center 2 before) N 17
(Health Center 2 after) N 76 (Total Before) N
407 (Total After) N 219
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Results

• Appropriate ASA recommendation before after
  modified letter
• Before Modified Cholesterol Letter
• 6 out of 198 patients who met criteria for ASA (6
  of 407 total charts reviewed) were recommended to
  start ASA after their cholesterol results
• 2 out of 108 at Health Center 1
• 4 out of 90 at Health Center 2
• After Modified Cholesterol Letter
• 45 out of 85 patients who met criteria for ASA
  (45 out of 219 total letters reviewed) were
  recommended to start ASA after their cholesterol
  results
• 31 out of 64 at Health Center 1
• 14 out of 21 at Health Center 2
• This difference was statistically significant (P
  lt 0.0001)

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Results
p 0.0037
18
Results
p 0.0010
19
Results
p 1.0
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Results

• Question 1 Do you feel the new Cholesterol
  forms were helpful in making a decision to
  appropriately prescribe aspirin?
• Question 2Do you feel you prescribed Aspirin
  more frequently now than prior to using these
  forms?

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Results

• Summary of Comments
• I like the new forms and use them frequently
• This is a great project and will help our
  patients to get the care that they need
• Add a line for Fasting Blood Sugar other
  results
• More space to write
• My only problem is logistical and stylistic.  I
  tend to call patients with lab results rather
  than sending letters
• Is there a way to import that to the EMR?
• Would it be helpful to include on the new
  cholesterol letter info.about the percentage risk
  value when one should consider starting ASA.
• Maybe we could categorize the checkbox
  statements at the bottom of the letter
• Have a simpler form available for those to whom
  these guidelines do not apply
• My only concern is the potential to use asprin
  when inappropriate, particularly with
  uncontrolled HTN - can lead to an increased risk
  for hemorraghic stroke

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Discussion

• The modified letter was used much more frequently
  at both health centers compared to the former
  letter
• There was a significant increase in the number of
  patients at high risk who were recommended to
  start ASA after the modified letter
• There was a significant increase in the number of
  high risk patients recommended continued on ASA
  after the modified cholesterol letter
• Prior to Modified letter 54.5 of our high risk
  patients were either cont./recommended to start
  ASA (this is comparable to the 57 national rate)
• After Modified Cholesterol Letter 73 of our high
  risk patients were cont./recommended to start ASA
  

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Discussion

• There was a significant decrease in the number of
  patients recommended/continued on ASA who should
  not have been based on risk after the letter
  modification
• Overall 100 of faculty and residents felt the
  new modified letter was helpful in making the
  decision to appropriately prescribe ASA and 74
  felt they prescribed ASA more frequently since
  introduction of the modified letter.

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Limitations of Study

• No check box for continue ASA on modified letter
• Study not controlled for fact that risk may
  change depending on level of control of risk
  factors
• For example, pt started on meds and blood
  pressure or cholesterol improved. Thus, CV
  risk/score decreased.
• They may have previously met guidelines for ASA
  but now do not. Guidelines for continuation ASA
  unclear in these patients.
• Certain patients do have other risk factors or
  contraindications for Aspirin which was only
  collected in baseline data.
• Based on baseline data 10 of total patients
  for whom ASA was appropriate but not recommended
  had either a documented allergy, side effect, or
  a precautionary condition such as history of GI
  bleed or erosive gastritis/duodenitis
• Some patients may not have been started on ASA
  secondary to being on other antiplatelet agents
  or Anticoagulants

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Limitations of Study

• Data analysis dependent on provider documentation
  
• Possible ASA not always recorded in med list
  since not a prescribed medication
• Likely some providers were not checking off
  CHD/Equivalents on the letter for patients who
  actually have CHD/Equivalents
• Baseline data was based on our review whereas
  post data relied on provider thoroughness in
  completing form
• Increase use of ASA could be related to increased
  awareness of ASA prescribing secondary to the
  process/discussion of our project.
• Increase in letter use seen could be related to
  the discussion/process of our project as well as
  increased awareness of the letter.

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References

• Heart Disease and Stroke Statistics 2007
  Update, American Heart Association.
• 2005 Hunterdon County BRFSS (Behavioral Health
  Risk Factor Surveillance Study).
• Aspirin for primary prevention of coronary heart
  disease safety and absolute benefit related to
  coronary risk derived from meta-analysis of
  randomized trials. PS Sanmuganathan, P.
  Ghahramani, P.R. Jackson, E.J. Wallis and L.E.
  Ramsay Heart 2001, 85265-271.
• American Journal of Preventive Medicine, Aspirin
  Use Among Adults Aged 40 and Older in the United
  States, May 2007
• Aspirin for the Primary Prevention of
  Cardiovascular Events, Topic Page. January 2002.
  U.S. Preventive Services Task Force. Agency for
  Healthcare Research and Quality, Rockville, MD.
  http//www.ahrq.gov/clinic/uspstf/uspsasmi.htm