Process Mapping the Lipid Management Patient Pathway in Six Health Systems for Identification of Barriers to Guideline-Directed Care

Abstract

Study Funding

Novartis Pharmaceuticals supports the American Heart Association's Integrated ASCVD Management Initiative.

Background/Synopsis

The American Heart Association (AHA) began implementation of a 3-year multi-site, health system initiative in 2021 aimed at improving guideline-directed lipid management for patients with atherosclerotic cardiovascular disease (ASCVD). In alignment with the 2018 Guideline on the Management of Blood Cholesterol, the initiative worked to identify and refine lipid management care models and monitored adherence to quality performance metrics focused on guideline-directed care.

Objective/Purpose

To document existing lipid management care pathways, as one component of an implementation initiative, to identify gaps and barriers to care and inform strategies for increasing adoption of guideline-directed care.

Methods

Six U.S. health systems and their associated clinics were selected for the initiative. They varied in size, geography, rural or urban populations, and by teaching or non-teaching health system status. Virtual, qualitative interviews were held in 2022 and 2023 with health system staff to map lipid management care pathways. Positions interviewed varied by health system, but included: C-suite/Chiefs, service line directors, cardiologists, neurologists, pharmacists, quality directors, abstractors, primary care program management, and program administration. Interviewees were asked to describe the inpatient lipid management pathway for acute coronary syndrome patients from admission to discharge, as well as the outpatient secondary prevention process for the same population after discharge. Resulting process maps were created and reviewed with interviewees for accuracy. Results were analyzed by AHA initiative program consultants for gaps or deviations from guideline-directed care. Proposed interventions to address the gaps and deviations were incorporated into future calls with individual systems.

Results

Mapping revealed wide variations in lipid management patient pathways across health systems in both inpatient and outpatient prevention care. Gaps included: underdefined processes for post-discharge follow up of stroke patients, inadvertent exclusion of incoming transfer patients from defined follow-up processes, inconsistency in ownership of patient follow-up, and inconsistency in multi-disciplinary team collaboration among primary care, cardiology, and neurology. Mapping revealed consistent adherence to secondary prevention guidelines for follow-up lab cadence after statin initiation or dosing change, with most systems seeing the patient 1-2 weeks post-discharge and then again within 3 months.

Conclusions

Process mapping is an effective tool for identifying gaps in care in large-scale quality improvement projects and supports organizational alignment to identified processes. The gaps identified allow for further improvement projects to be identified and pursued. This initiative continued working with the health systems after reviewing our results and developed interventions adopted in each of the six systems.