Digital Care Transformation
Authors: Benjamin M. Scirica, Christopher P. Cannon, Naomi D.L. Fisher, Thomas A. Gaziano, David Zelle, Kira Chaney, Angela Miller, Hunter Nichols, Lina Matta, William J. Gordon, Shawn Murphy, Kavi B. Wagholikar, Jorge Plutzky, Calum A. MacRae
Journal: Circulation (2020)

cholesterol ◼ hypertension ◼ risk U ndertreatment of hypercholesterolemia and hypertension (HTN) remains a persistent clinical challenge, even among patients at high cardiovascular risk.Approximately 30% to 50% of patients do not receive optimal medical treatment, even though most of these treatments are generic, established, are guideline-directed, and cost effective. 1,2 We designed and are actively implementing a remote, algorithmically driven, disease management program that uses navigators and pharmacists, supported by specialists, to initiate and titrate medications within the Mass General Brigham health system.We enrolled patients with uncontrolled low-density lipoprotein cholesterol (LDL-C) and/or blood pressure identified through medical record screening or direct referrals not meeting current guideline-directed therapeutic targets.Patients in the lipid program were categorized according to current guideline-specificied 3 hierarchical groups-established atherosclerotic cardiovascular disease, diabetes, severe hypercholesterolemia (LDL-C >190 mg/dL), or high-risk primary prevention-to determine treatment thresholds.Blood pressure was measured with digitally connected home blood pressure cuffs.Following guideline-recommended clinical algorithms, pharmacists (prescribing under collaborative drug therapy management programs) initiated and titrated medications.The supervising physician was readily available for additional clinical management.Nonlicensed navigators were the primary communication channel with patients, ordering laboratory tests and providing education at preset intervals until treatment targets (LDL-C guideline-directed thresholds 3 and average home blood pressure <130/80 mm Hg) were achieved.Primary care physicians were notified of identified patients and could defer patient enrollment.Clinical staff were supported by a custom-built software program (CardioCompass) external to the electronic health record that provided decision support, patientrelationship management and communication tools (eg, texting). 4,5No in-person visits were required.The project was approved by our institutional review committee with a waiver for informed consent.We encourage investigators interested in data sharing and collaboration to contact the corresponding author.Between January 1, 2018, and May 21, 2020, we screened 18 810 patients and enrolled 5000 patients in the cholesterol and HTN programs.During March to May 2020, during the coronavirus disease 2019 (COVID-19) pandemic, enrollment increased by nearly 25%.The median age was 64 years, 55% were female, and 26% non-White.Of the 3939 patients enrolled in the cholesterol program, 1385 (35%) had established atherosclerotic cardiovascular disease group, 995 (25%) had diabetes but no atherosclerotic cardiovascular disease, 1247 (32%) had LDL-C >190 mg/dL group, and 312 (8%) were primary prevention patients at elevated cardiovascular risk.To date, 1343 (34%) patients completed the initial titration phase; 1623 (41%) remain under active titration; and 973 (25%) were referred to a clinician, withdrew, or became unreachable.To date,