In 2013, the American College of Cardiology (ACC) worked with the American Heart Association (AHA) to update and revamp the clinical practice guideline for the assessment of cardiovascular risk and management of elevated blood cholesterol levels in adults.
This has been a source of great controversy and confusion among organizations and primary care providers, both in training and in practice, due to the abrupt elimination of targeted treatment with pharmacological therapy for patients with hypercholesterolemia. The evidence highlights 4 patient populations whom would benefit from pharmacological therapy, specifically statins, based on reduction of ASCVD events in primary and secondary prevention. The intent of managing hypercholesterolemia is to reduce the risk of cardiovascular disease. This requires assessing a patient’s risk for such atherosclerotic events. The ASCVD risk estimator©, a pooled cohort risk prediction tool created by the Risk Assessment Work Group, calculates a patient’s 10 year risk for atherosclerotic events based on several risk factors. It accurately identifies individuals at higher risk for total Cardiovascular Disease (CVD) whom would benefit from statin therapy in addition to lifestyle modification.
The practicality of the ASCVD risk estimator is to effortlessly provide an immediate analysis of a patient’s long term risk for such events. Befittingly, it is now available as an electronic calculator to both providers and the general public as a web version and a mobile application for smart phones. Therefore, incorporating the ASCVD risk score in conjunction with the updated guideline would optimize our management in prevention of ASCVD events in relation to hypercholesterolemia. Unfortunately, many health care providers are not comfortable with the updated recommendations and the applicability of the ASCVD risk estimator. Despite the strong evidence supporting the utility of the ASCVD risk estimator in partnership with the new cholesterol guideline, the shift towards its application into clinical practice has been challenging for most physicians. The general consensus is that most providers did not read or completely understand the guideline. This problem, however, is not specific to this particular guideline.
It is well known that evidence based medicine can take years before being integrated into everyday clinical practice. This is likely a result of the rapidly evolving advancements in the world of the medicine, making it frequently overwhelming for health care providers to stay continually informed on the most recent health care recommendations. Improving physician adherence of a medical guideline is contingent on the need for change in behavior. However, first and foremost, one must identify and then evaluate the barriers to adherence. Supplementing this with a multifaceted approach customized for a specific health care system would likely enhance the learning experience while simultaneously improving the quality of care provided to a patient having implemented the most recent developments in standardized care.
Therefore, we conducted a quality improvement initiative aimed towards improving our medical resident’s understanding of the 2013 ACC/AHA cholesterol guideline by identifying and addressing the prospective barriers that may be hindering our providers in training from incorporating the new recommendations into clinical practice. The quality improvement project was a pre and post-intervention study conducted in our primary care clinic using a questionnaire to identify the potential barriers. The areas of deficiencies deemed as barriers in guideline application, that were identified were categorized under knowledge, attitude, and behavior. The educational platform created to resolve these concerns consisted of a series of lectures, a custom-made algorithm, and supervised estimation and application of the ASCVD risk score during actual patient encounters.
Upon completion of the study, our providers in training medical achieved a 30% improvement in their total scores. Based on this study, our providers in training encountered substantial barriers towards the application of the 2013 ACC/AHA cholesterol guideline into clinical practice. All things considered, it is reasonable to imply that a barrier in accessing, reading, and interpreting evidence based medicine may exist, despite the continued growth and widespread availability of medical literature via legitimate healthcare internet sources and electronic resources. There is clearly a need to engage learners through a more personalized and interactive educational approach that goes beyond the mere supplementation with reading material. Creating a curriculum that is focused on addressing the specific needs of a selective group of providers may be the onset of a much anticipated and necessary solution to a growing problem. Ultimately, we need more studies that demonstrate similar improvements in the educational experience of providers in training regarding the understanding and application of medical guidelines and evidence based medicine.
In summary, our quality improvement initiative to improve our medical resident’s comprehension and applicability of the 2013 ACC/AHA cholesterol guideline into clinical practice was successful. We achieved our aim of increasing our medical resident’s overall knowledge of and attitude towards the cholesterol guideline by 30%, which in turn impacted their behavior. It is evident that a multi-faceted educational approach tailored towards addressing specific barriers in each domain can improve the educational experience for providers in training. Further studies are needed to assess the demand and reception of an all-encompassing approach, moreover, its applicability to other providers and medical guidelines. We will be conducting more quality improvement initiatives to improve the educational experience for our medical residents and in turn positively impact our patient’s care in the primary care clinic.
Dr. Larissa Hernandez-Cabarga