The ASCVD Initiative
Atherosclerotic cardiovascular disease or ASCVD is the leading cause of morbidity and mortality in the United States. What makes this high disease burden particularly frustrating is that many of the important preconditions, like hypertension and hyperlipidemia, are often easy to diagnose and have safe and effective treatments. With perfect adherence, low-cost cardiovascular drugs could reduce cardiovascular events by 62-88%, highlighting the opportunity to reduce ASCVD risk through translation of known treatments. However, only about 1 in 4 adults nationally with elevated ASCVD risk have well-controlled lipids and about half have well-controlled blood pressure.
Conventional approaches to broad population care gaps often include layering more responsibility on primary care clinicians, sometimes with financial incentives for clinical targets but often with little practice support to facilitate reaching those targets. Given that primary care clinicians have high and increasing levels of burnout, improving population health may be better achieved by providing operational support so primary care clinicians can do less rather than financial incentives to encourage them to do more.
About the ASCVD Initiative
Given the health and economic benefits of reducing ASCVD risk and the challenges of achieving them by giving primary care clinicians more to do, we launched the ASCVD Risk Reduction Initiative in June 2021. The ASCVD Risk Reduction Initiative is improving the ways that primary care clinicians help patients with ASCVD and those at higher risk of ASCVD improve their heart health. Our flagship program is Penn Medicine Healthy Heart, an innovative care delivery model for heart disease risk reduction.
The Initiative is funded from the National Institutes of Health (NIH) Clinical and Translational Science Award (CTSA) Program through the Perelman School of Medicine Institute for Translational Medicine and Therapeutics. The Initiative is also supported by funding from Penn Medicine.
Building a learning cycle
In the first two years of the Initiative, we conducted a series of strategically selected pilots to test feasibility and effectiveness of components of the intervention. These included a number of successful pilots that contributed core components to the intervention: an asynchronous centralized statin prescribing model, the use of algorithms to provide frequent ongoing feedback to patients, and remote blood pressure management by a centralized clinician. We also ran several pilots that iteratively tested ways to increase participant engagement.
Our flagship program
Penn Medicine Healthy Heart is a 6-month, text-based program that employs user-friendly remote monitoring technologies, behavioral science strategies, and a centralized support service of non-clinical navigators with clinician back-up to help patients improve hypertension and cholesterol control. The program includes four modules: blood pressure monitoring and medication management, lipid management focused on appropriate dose statin prescribing, heart healthy nutrition, and smoking cessation.
Penn Medicine Healthy Heart was designed with several key principles in mind:
- Alignment with health system priorities related to value-based care and population health
- Use of technology to automate interaction, workflows, and documentation
- Clinical protocols vetted by health system clinical leaders in HTN and lipid management
- Use of lower cost staffing, such as non-clinician navigators, where possible
- Back-up by experienced clinicians
- Simplicity and ease of use for patients
- Emphasis on equity in design and evaluation
- Transparency to primary care clinicians
- Use of behavioral science strategies to increase engagement
To test program effectiveness, we designed a randomized controlled trial, which is currently active in 35 primary care practices in Philadelphia and Lancaster counties to test whether we can significantly improve systolic blood pressure and LDL-C among patients at elevated risk of ASCVD in urban and rural populations. The trial launched in March 2024 and will conclude in spring of 2025.