Cardiovascular disease (CVD) is the leading cause of mortality both in the United States and in the world, and
is one of the most costly chronic conditions. The incidence of CVD triples at age 40-50 compared to younger
age, and increases 50% or more at each decade of age after that, is also strongly associated to race and
ethnicity. Though CVD related preventive cares have been recommended by USPSTF guideline, only less than
40% at risk patients complete one of those preventive cares timely. The objective of the project is to develop,
implement, and evaluate an electronic health record (EHR)-based preventive care dashboard management
tool and team-based intervention to improve compliance of CVD related preventive care for primary care
patients 50 years and older. The proposed dashboard is seamlessly integrated within the electronic health
record (EHR) to: (a) identify adults with CVD risk; (b) suggest personalized CVD related preventive
components and associated recommendations of action (e.g. screening test order, medication order, etc.) at
point-of-care visit with primary care providers; and (c) engage population health management teams between
visits. The development and pilot test will take place during R61 phase. In the R33 phase, we rigorously test
the impact of the tool using a cluster randomized controlled trial with ~200 primary care physicians and assess
intervention impact on completion of 4 key preventive care elements for patients at risk for CVD: (1) diabetes
screening, (2) blood pressure monitoring; (3) lifestyle (smoking cessation, diet and physical activities); (4)
appropriate aspirin and statin use. The intervention, referred to as CVD Preventive Care Dashboard
Management (CVD-PCDM) tool, provides patient-specific and clinician-specific CVD preventive care
recommendations and risk estimate in low-literacy format to the primary care provider (PCP) and patients at
each primary care encounter to facilitate shared decision making and patient education. This CVD-PCDM will
be co-designed with clinicians using a successful digital solution development and test cycle which has been
tested in other similar dashboard systems current running at Sutter, and implemented in primary care clinics.
Scalability of the CVD-PCDM will be first tested within Sutter in two geographically and racially distinct
operation units. Meanwhile, we will also identify one health care system from Health Care System Research
Network (HCSRN) to duplicate the intervention and assess the effect. HCSRN consists of large health care
systems in the US, and has actively promoted collaborative research. If the CVD-PCDM is effective at Sutter,
the codes and development package will be shared with the second site. We will design a digital solution
scalable pipeline that can be rapidly and consistently translates this guideline-based preventive care into
delivery of personalized and coordinated CVD care within primary care settings.
