Basic Tools for cardiovascular disease risk factor modification

Improvement Objective: Reduce future cardiovascular disease (CVD) mortality and morbidity via improved screening & reduction of modifiable CVD risk factors (ambulatory)

Key Interventions:

  • Systematic Screening +Modification/treatment:  Behavioral Risk Factors: tobacco, alcohol, unhealthy diet, physical inactivity; Physiologic risk factors: HTN, Hyperlipidemia, Obesity, High glucose
  • Primary prevention: individuals w/ > 20% risk CVD event (MI or CVA) 10 yrs or diabetes: Statin + BP med + ASA
  • Secondary prevention for patients with CAD: Beta blocker, ASA, ACE I, Statin

Printable and downloadable versions

 

Case Management Categories

 

 

Essential Care Elements

 

Documentation of Major CVD Behavioral and Physiologic risk-factors at least once in chart (anywhere in chart)

  • Tobacco status: current, former, or never smoker (if current or past smoker quantify tobacco use & duration)
  • Family history: early CAD, Stroke and HTN
  • Height (for calculation BMI)
  • BMI (calculated within last year)
  • Nutrition and Physical Activity status (within last year)
  • Alcohol Consumption (if drinker, quantity, frequency & alcohol type)
  • Total Cholesterol > age 45 and if high blood pressure, diabetes,  obesity or (overweight), tobacco, early family history CAD or previous diagnosis of CAD (calculated within last 5 years)
  • Summary list chronic medical conditions and regular medications
  • Fasting or random blood sugar at least once per year if + HTN
  • 10 year CVD risk calculation (Framingham scale) if 2 CVD risk-factors (> age 45 and if high blood pressure, obesity or (overweight), tobacco, early family history CAD N/A for  diabetes,  previous diagnosis of CAD, heart failure or stroke

CVD Risk Factor Assessment Interventions every clinical visit

  • BP measure
  • Weight  (if BMI>25)
  • Tobacco status

Treatment Interventions  Every Visit for identified CVD Risk Factors

 

(Behavioral & Physiologic)

  • + Obesity: nutrition & exercise counseling; targets and follow-up
  • + Tobacco Use: Tobacco Cessation Plan & treatment interventions (patch, oral medication, etc.)
  • + Hypertension:  Verify BP control and Medication adherence every visit; adjust medication as needed to achieve BP control per evidence-based guidelines. 
  • +Hyperlipidemia: Initiate statin in all patients with > 20% risk of CVD event or diabetes in 10 years using standard risk calculator (e.g. Framingham risk calculator) 
  • Systematic Statin + BP medication + ASAall individuals with > 20% risk of CVD event in next 10 years or diabetes

CVD Secondary Prevention  (after Myocardial Infarction): verify & update every visit for all patients with history of coronary artery disease

  • Beta blocker; Aspirin; ACE-I/ARB; Statin
  • Tobacco screening & intervention
  • Nutrition & exercise counseling

CVD Secondary Prevention  (after stroke): verify & update every visit for all patients with history of stroke

  •  ASA; low-dose thiasids ACE-I/ARB; Statin
  • Tobacco screening & intervention
  • Nutrition & exercise counseling

Management of Acute Chest Pain and suspected Acute Coronary Syndrome  in Ambulatory Setting

Immediate assessment & Interventions:

  • Assess Chest Pain and breathing
  • Vital signs: Blood Pressure, pulse, respiratory rate, Temperature
  • EKG
  • Aspirin
  • Nitroglycerin (if available)
  • Oxygen (if available)

Referral:

  • Standard referral form completed per protocol including: reason for referral, treatments given in ambulatory center
  • Transport plan documented in chart
  • Follow up plan documented in chart as communicated to family

INPUT INDICATORS

  • I.1 % of charts with standardized place to document & track behavioral risk factors
  • I.2. % of charts with standardized place to document & track physiologic risk factors
  • I.3.% of charts with standardized place to document Regular Medications
  • I.4. % of charts with standardized place to document Chronic Medical Conditions
  • I.5. % availability of essential key inputs for monitoring CVD risk 
  • I.6 Availability of inputs for assessment and initial treatment acute chest pain

PROCESS INDICATORS 

  • P1.% charts with current  list of regular medications that reflects prescribed medications in the last visit
  • P2.% charts that document BP measurement during last visit
  • P3. % charts of patients with BP ≥ 140/90 x 2 (or x 1 if history of HTN)  for whom BP medication prescribed or adjusted
  • P 4. % charts that document BMI past 12 months
  • P 5. % charts that document nutrition and physical activity counseling during last 12 months
  • P 6. % of charts that document tobacco status last visit
  • P 7. % of charts of current smokers with tobacco cessation interventions (patch, oral medications or counseling)
  • P. 8 % charts that document planned Total Cholesterol if at least one CVD risk factor (> age 45 or HTN, overweight, tobacco, early family history of CAD or personal history of diabetes or CAD)
  • P. 9.  % charts that document measured Total Cholesterol  if at least one CVD risk factor (> age 45 or HTN, overweight, tobacco, early family history of CAD or personal history of diabetes, CAD or stroke)
  • P. 10  % of charts of patients with at least 2 CVD risk factors (> age 45 or HTN, overweight, tobacco, early family history of CAD) in which risk of CVD event in next 10 years calculated (if not diabetes, CAD, Stroke, Heart Failure)
  • P.11.  % of charts of patients with established risk of CVD event in 10 years > 20% or diabetes treated with multi-drug therapy
  • P.12  % of patient charts with CAD on secondary prevention

OUTCOME

  • O.1 % of charts of patients with established HTN with control of BP last visit
  • O.2.% of charts of patients on statin therapy with TC < 200 last check
  • O.3. % of charts of patients treated for tobacco use who discontinued tobacco after intervention initiated (any time)
  • O.4. % of charts of patients counseled and treated for overweight or obesity with weight loss >5% after intervention initiated