Optimizing Non-statin Agents for ASCVD

In this prospective study, approximately 1,000 patients with a documented history of clinical ASCVD will be identified from Part 1 of the Zetia Project and a new report, generated after IRB approval, to capture newly diagnosed patients with ASCVD who may benefit from therapy optimization. This population health initiative will occur regardless of the proposed research in this protocol.

CommUnityCare Standard Procedure - Standard of Care As part of routine population health care at CuC, clinical pharmacists assess and evaluate for the optimization of LDL-lowering medications according to the 2018 AHA/ACC Guideline on the Management of Blood Cholesterol and the 2022 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of ASCVD. Clinical pharmacists will review lipid panels drawn within the past 12 months. If there are no recent lab history available, patients will be scheduled for standard of care fasting lipid panel. Labs will be collected by CuC phlebotomists, nurses, or other trained healthcare professionals outside of the research team. Clinical pharmacists will review, assess, and analyze lipid panel lab results. If LDL levels are at goal, the patient will continue their standard lipid-lowering therapy and continue routine follow-up with the clinical pharmacy team. This standard of care follow-up may occur either in-person or through telehealth visits conducted by the clinical pharmacists. The purpose of this routine call of clinical management and patient education as part of standard of care is to ensure medication adherence, safety, and efficacy per established guidelines. For patients not at goal, clinical pharmacists will provide guideline-directed therapy adjustments at a scheduled clinic visit. This may involve adjusting the intensity of the statin therapy or adding a non-statin agent, such as ezetimibe or a PCSK9 inhibitor, if the patient is not already on the maximally tolerated statin therapy. Intensification of statin dose will occur if: (1) LDL is not at goal for respective risk category (LDL ≥ 70 mg/dL for very high-risk ASCVD patients and LDL ≥55 mg/dL for high-risk patients) and (2) Patient is not on maximally tolerated statin therapy. Patients who are on maximally tolerated statins and who are not at respective LDL goals will be considered for the initiation of ezetimibe and/or PCSK9 inhibitors. A follow-up lipid panel will be ordered for 4-12 weeks after therapy adjustments and a follow-up clinical pharmacy appointment will also be scheduled within the same timeframe. Regardless of participation status in the study, all patients will continue to receive the routine care and follow-up from CuC clinical pharmacists described above.

Alterations to Standard Procedure - Intervention The research intervention consists of outreach conducted by a Texas-licensed pharmacist intern under the supervision of CuC-employed pharmacists. Eligible patients will be contacted by a student pharmacist after the clinical pharmacists' appointment (described above in the standard of care) using CuC's RingCentral telehealth system. During this outreach, student pharmacists will review current lipid-lowering therapies, medication adherence, education about lipid-lowering therapies, and review of labs. Student pharmacists will not make independent prescribing or care decisions. All prescribing authority and therapeutic adjustments remain under the direction of CuC-employed pharmacists in accordance with the standard operating procedures. Patients will be informed about the research project during the outreach call or during a separate call dedicated to recruitment prior to the outreach call. Informed consent will be sent and obtained via either the EHR messaging system (MyChart) or text message through the Ring Central application.

Only data from patients who provide informed consent will be included in the research dataset and subsequent chart review. For patients who decline participation after being contacted through the telehealth outreach, any information collected during the call will remain part of their standard clinical documentation in the EHR and will not be included in the research dataset. These patients will continue to receive standard clinical pharmacy care, and no data will be abstracted or analyzed for research purposes. Enrolled patients will then be followed through prospective chart review to evaluate outcomes at 3-6 months after consent and student pharmacist outreach.

Inclusion criteria

• Adult patients (>18 years) who have seen a CommUnityCare provider in the previous 12 months at time of enrollment, who have a documented history of clinical ASCVD, and are not achieving LDL targets (either <55 or <70 mg/dL based on risk factors)

Exclusion criteria

• Patients will be excluded if they do not have a clearly documented history clinical ASCVD, are already achieving LDL targets (either <55 or <70 mg/dL based on risk factors), having cholesterol managed by outside provider (e.g. outside cardiologist/lipid specialist), current pregnancy, have not seen a CUC provider in the previous 12 months, or otherwise do not qualify for clinical pharmacy intervention