Chapters Transcript Video Lipids QI in Pediatric CArdiology Hello, everyone. Thank you so much for the warm introduction. Thank you all for sacrificing your Saturday mornings to join us. Um Hopefully, this will be engaging if you need to move around a little bit to get through the rest of the afternoon. I totally understand. Um And we will be talking about our own local lipid uh initiatives as well as our quality improvement project. And so just as an overview, we'll be discussing how Atlantic health and our own institution here at Morristown has approached the lipid concerns in the community. We will also discuss how we have developed a Q I project, which I think will be hopefully helpful to some of you in in organizing um a similar initiative and how we could potentially help provide some tips and tricks on that as well and then discuss future directions. So doctor Brothers set this up beautifully. Um She discussed very, very uh in detail about the risk factors for hyperlipidemia in Children. And as we know, early atherosclerosis is seen in Children who have uh elevated lipids, which has been shown on pathology specimens as well. And we know that early intervention can reduce the risk for patients to go on and develop hypercholesterolemia. In adulthood, there are approved uh pharmaceutical interventions which we've discussed as well including statin therapy. But really it it starts with you. It starts with lipid screening that identifies at risk patients that then get referred to us and we can help facilitate the risk reduction. So the need for early intervention has prompted an amazing uh am G lipid working group which includes some of the members I believe in our audience here today, which is great. Um We have from pediatric endocrinology. Doctor Mani Ker from our own team. Doctor mc Phillips and Doctor Donna Tempe uh have been the uh representatives from pediatric cardiology. And this is truly a multidisciplinary effort that includes general pediatrics with doctor Cher and adult cardiology and nephrology as well as family medicine. Um And they all have been working together to develop guidelines in how to identify the patients within our community and to help uh elevate the conversation within the different subspecialties. Importantly, pediatric nutrition is also part of this uh especially through endocrinology. So I know we've discussed a lot about different numbers in terms of referral and when to refer. But just to break down for you, what we have recommended within our community is if you have a fasting lipid panel result that shows that an LDL is greater than 160 or a non HDL cholesterol is greater than 190 that's an automatic reason to refer to us or to uh pediatric endocrinology. If you have an LDL in a patient, that's between 131 150 or a non HDL cholesterol between 100 45 and 189 then we dis we discussed based off of other risk factors. So if there's a family history, which I'll review in box one, then that requires referral for further work up. So that includes a family history of premature cardiac disease in a parent, grandparent and uncle or sibling. So with uh M I and uh angina angioplasty or cabbage in under 55 years in males and under 65 years in females or a parent who has a total cholesterol greater than 240. And as doctor brothers alluded to, it is often hard to figure out this level of detail in the information. But I think what's helpful is figuring out who needs to be involved uh in the screening process in terms of how far out you really need to go and where you can provide reassurance. The second aspect of this going back to um the the initial fasting results is that if there is no family history that's relevant, but there are risk factors, then the next step would be to repeat the fasting lipid panel after 3 to 6 months of dietary and lifestyle interventions. And then if that remains elevated with an LDL greater than 130 or a non HDL cholesterol greater than 145. Then you would refer to us. So the risk factors would be risk factors such as hypertension BM, I greater than 95th percentile history of smoking. Um and risk factors such as diabetes, chronic inflammatory disease, kidney disease, or heart transplantation, uh or a history of regress aneurysms and Kawasaki disease. So this is, you know, a very important uh I think referral pattern that we can use. But the number one part of this is to actually get the lipid screening done first because without that information, um referring for just a family history can often lead to appointments where patients don't really know why they're there and we don't have much information to help provide guidance as well. So we've reviewed this, I think in a lot of detail. But uh I like using this chart and I try to put it in all my notes just highlighting the NHL B I and A AP guidelines uh for lipid screening. And so obviously, between nine and 11 and 17 and 21 we do universal guidance uh excuse me, lipi lipid screening. And then there if there are risk factors between two and eight years of age or between 12 and 16 years of age, we develop an understanding of new risk factors or new concerns with the family members or if they have an elevated BM I greater than 85th percentile, which is actually not that high. Um then we would, we would screen that population as well. So based off of the gap that we noticed in the amount of patients that were being screened within our community practice, we de decided to develop a quality improvement initiative to help work on the the lack of uh screening that we were seeing. And so we developed a smart aim which is a spe specific measurable achievable, relevant and time bound uh aim for the project. So our goal was to improve adherence to lipid screening from for all age appropriate outpatient visits in our pediatric Q uh cardiology practice from a baseline of 35% to a goal of 90%. And we gave it a time frame of November 2021 to July 2023 which is about 18 months, which is a good amount of time. And so this is a key driver diagram which some of you might be familiar with. But the thing I love about Q I is that it's very intuitive. So, you know, we really just put in our, our global aim, our smart aim who we're aiming to address in the population and then key drivers which are who is gonna cause what is gonna cause this metric to change. So, having physicians that are aware of the need for screening and having knowledge of who needs to be screened and also being able to document that in the elec electronic medical record it's quite simple actually. And then the interventions will go through more individually as well. So in terms of our methods, we included all visits to pediatric cardiology clinic for the appro age appropriate range that were for established patients or for new patients. And then we went through and actually did manual chart review and also generated an epic uh report to identify the patients that would be included in the project. And so initially, we really focused more on ensuring that our epic generated report coincided well with the manual chart review. And then once we felt comfortable with that, we were able to kind of slowly phase out a lot of the manual chart review as well. And then we use plan do study a cycles to implement the project, which again we'll go through right now. And so the interventions we proposed were physician education on the guidelines. And so essentially, we just reviewed in our MD meeting what the guidelines were, who needs to be screened and what our project was gonna be. We then developed a lipid screening dot phrase and epic. And so this was actually something we worked with in conjunction with it. Um who were actually very receptive to this idea and very eager to try to help us, but also um develop something that would be useful to us uh in a day to day time frame. And so the results of the lipid screening dot phrase could be that your result was that you discussed the screening with the patient and the result was normal that they said that they had an abnormal screening or that they didn't have it done. And if it wasn't done, then you would indicate whether you recommended having the screening test done with the pediatrician at the next visit. Or if you ordered the panel yourself, we then provided group and individual performance feedback for physicians that were in the in the project. And we finally, our last uh intervention was to create a best practice alert or advisory, which is that little yellow box that pops up for those of you who use Epic and would open up with any encounter for an age appropriate patient um as a reminder with uh the need to screen them and also the most recent lipid panel results. And so just before we go into some of the results of our study, I just wanted to briefly mention control charts and I know it's a Saturday. So I'll try to make this light. Um you know, there the basics of a control chart is that it's a way to measure compliance and demonstrate how a process changes over time. And so you have a center line which is basically an average line, you have an upper and lower control limit, which is basically a standard deviation. And then beyond that, there's a bunch of dots and if the dots are eight points above the center line or eight points below the center line, then you have a shift. And other than that, you can have um a trend which is six points in one direction or the other. And there are other ways to have a change or a shift, but we don't need to go into that. So looking at our actual results from this project focusing on the 9 to 11 year old age range, um we had a really nice uh improvement overall. There were over 1650 patients that we saw during this time frame of this project that were between nine and 11 and 17 to 21 years of age at baseline, 35% of them were screened. And we did a baseline of about eight weeks where we collected the data just to see where are we, how many, how many patients are being documented in our charts having had lipid panels done. It was quite simple and then we basically introduced the lipid screening dot phrase and saw that there was a shift or an increase to 57% adherence in people documenting in their, in their notes, whether the panels were done or not. And then after several weeks of that, um we introduced group feedback through an individual feedback as well where we reviewed with the group, you know what the overall results were. And I'll go through in a little bit more detail about the individual feedback. And then finally, we had a BP A alert what that went live. And overall, throughout this entire time period, um the average adherence went up to 83% which was very close to our goal. And what's really nice is that we've been able to maintain this adherence over over nine months including six months after the project has been completed. And so in the 17 to 21 age group, the baseline was 33% of patients screened and there was a positive shift that occurred to 62% after the lipid screening dot phrase. Um what's interesting is that with the 17 to 21 year old age group when the BP A went live, that, that prompted the last uh shift to 83%. And I wonder if that's because sometimes these are more of our established patients and we might be more likely to forget about doing the screening unless if something pops up on our screen. So personally, I found that that was very helpful. Funnel chart is just a, a way to show um individual kind of data. So, uh in this particular instance, what we did is we anonymize the individual uh providers adherence. And so each physician is represented here by a letter. And as you can see, everyone had basically had some, at least some improvement in their adherence to the lipid screening. So what's great is that this project was not driven by one or two people. It was really across the board that everyone really uh got involved and, and stepped up with the project. And so you can see that after the first initial um adherence, you can see that after we provided individual feedback, there was improvement pretty much across the board on the second data point and that perpetuated throughout most of the project for most of the providers. And so, you know, with all this great Q I work that we were able to do, um I wanted to talk a little bit about the actual lipid testing results that we were able to obtain because I think this tells a lot about the community that we're serving and what are the results in our, you know, in our local population. So there were 1000 and 37 patients that were screened during our project and of them, 466 or 46% had already had lipid testing done by you guys at the time of the visit. So 24% of them had normal results as per what they told us. And 24% said that I had abnormal testing results. And so, um, of the patients that we asked the question of whether they had been screened, 24% of them, we decided needed to uh have a test ordered by us. For whatever reason, the physician chose to order the test, whether it was because that was their routine practice or because they might have had more concerns about that particular patient, of those patients who had a lipid panel ordered by us. 42% actually went and got the lab done in a way that we could see it in epic. So I could have some patients that had it done at an outside facility and I can't see the results because it's scanned into media. So, you know, of the ones that did it about 42% and of the ones who actually had the test done that I can see the results, 39% of those were abnormal, which is quite concerning because this is potentially a gap in the patients that would have been missed. Uh had we just relied on family history or other general screening. But again, these patients did meet criteria or indication to be screened based off of their age alone. And so looking at what our actual results results were for the lipid abnormalities, we found that um of the abnormalities, 50% had high LDL, um almost 50% and also interestingly, 37% had high VLDL, which is pretty concerning because that's one of the most kind of high risk factors for um for atheros atherosclerosis. Other elevated uh abnormalities included triglycerides and total cholesterol as well as a low HDL, which is possibly indicative of the lack of physical activity in the population as well. So just to conclude about the Q I project lipid screening adherence definitely did improve uh from 35 to 83%. And we almost reached our goal of 90% which was quite a, a high goal, to be honest. Um electronic health record was really incremental in getting us to develop a really high reliability, automated set of reminders and to be able to implement this in other, you know, in other modalities as well, it can absolutely be spread to other clinics. There's really nothing about this project that requires more than a simple electronic medical record and somebody who's willing to look at the data, um and it could very well be applied to general screening guidelines for other things that you guys all do in your day to day practice. So just some take home points, um A quick show of hands, how many of you guys have to do Q I as part of your A BP, pretty much everyone, right? How many of you have some sort of idea of what you might do with it? Couple people, how many of you feel comfortable with starting a project or having something like that done? OK. So maybe like one or two people. So that's awesome. And hopefully this will give you a little bit more insight on that. What I've learned in my little bit of experience so far is that start with a small idea or a question that's measurable and it in actionable and the person who generates the idea doesn't have to be the person who implements it. And so our team really brought this up and I thought that was really helpful. And just as a small side note, when I was a fellow in pediatric cardiology, uh I was interested in Q I and we thought that decreasing the no show rate in our fellows clinic would somehow be a project we could manage. And all we learned was that patients don't show up when it rains, so do something that you can actually impact. Um because I couldn't change that don't re don't re invent the wheel. Um There's a lot out there in epic that I still have yet to learn, but there's a lot of reports out there, use them, make it easy for yourself, automate your data, just kind of a similar theme, bring in support staff and trainees. Um There's a lot of people who are probably interested in this because it will help their workflow most likely, right? So those people in is very helpful, trainees are awesome. Um Doctor Rachel Rusty Magnan in pediatrics. Now at PGY three, who will be going into pediatric cardiology fellowship at Mayo Clinic. This fall was incremental in getting all of this done. She was the first author on our manuscript, she presented this research. And honestly, if she was in a driving force for this, I'm not sure it would have gotten so far identify your stakeholders, um which is really who is this gonna affect and bring them in, write it down uh and write it up. I mean, if I keep a list of all the dates because I know that a week from then I'm not gonna remember. So I would say it would be a good idea to keep track of what you do interventions. And then if you have the ability, put it in something, whether it's a local, uh you know, local manuscript, a local um newsletter or something like that. And then the other thing that helps, I think for our project was that we were able to incorporate this as our divisional compensation. So we all have parameters within a ahs or AM G that we need to have a certain amount of percentage for Q I. And it was easy to incorporate this and it helps to provide a secondary motivator and then a time frame stick to it, do the best you can. I had my second and final child during this process. So, you know, things happen, life happens, but we can kind of keep get through it. And then finally, you know, one thing I really appreciate about Atlantic health is that really Q I culture goes through every level here. I've actually been very impressed by how genuinely interested the uh the hospital is. It's not really just, you know, uh a local level, it's really throughout the the institution. And I think they have a lot of true Q I science, not necessarily just quality assurance. So there's a lot of venues for this, there's Simon symposiums, there's people who have training. So I think tack on to them and see what you can develop and you know, it might come out to be something awesome. Um And then finally, just a plug for something that might be very helpful for you in the future that we're still in the very nascent stages of is that we were recently um approved to be an A B PM OC portfolio sponsor. Uh This was an application that we uh put in. It was Doctor Tom Murphy was the leader on this. And um what this means is that as the portfolio manager, I'll be able to, with our team to provide MOC credit for those of you guys within A HS who want to submit a project and get approval. You don't have to go directly to A BP. We can do it for you as long as it meets the criteria. So hopefully it makes it a little bit easier, helps facilitate and hopefully we can help provide a little bit of guidance on the project too. Um And so I know this was a lot, but thank you so much for your attention and feel free to ask any questions. Published Created by
