BACKGROUND Implementation of guideline-directed cholesterol management remains low despite definitive evidence establishing such measures reduce cardiovascular (CV) events, especially in high atherosclerotic CV disease (ASCVD) risk patients. Modern electronic resources now exist that may help improve health care delivery. While electronic medical records (EMR) allow for population health screening, the potential for coupling EMR screening to remotely delivered algorithmic population-based management has been less studied as a way of overcoming barriers to optimal cholesterol management. METHODS In an academically affiliated healthcare system, using EMR screening, we sought to identify 1,000 high ASCVD risk patients not meeting guideline-directed low-density lipoprotein-cholesterol (LDL-C) goals within specific system-affiliated primary care practices. Contacted patients received cholesterol education and were offered a remote, guideline-directed, algorithmic cholesterol management program executed by trained but non-licensed "navigators" under professional supervision. Navigators used telephone, proprietary software and internet resources to facilitate algorithm-driven, guideline-based medication initiation/titration, and laboratory testing until patients achieved LDL-C goals or exited the program. As a clinical effectiveness program for cholesterol guideline implementation, comparison was made to those contacted patients who declined program-based medication management, and received education only, along with their usual care. RESULTS 1021 patients falling into guideline-defined high ASCVD risk groups warranting statin therapy (ASCVD, type 2 diabetes, LDL ≥ 190 mg/dL, calculated 10-year ASCVD risk ≥7.5%) and not achieving guideline-defined target LDL-C levels and/or therapy were identified and contacted. Among the 698 such patients who opted for program medication management, significant LDL-C reductions occurred in the total cohort (mean -65.4 mg/dL, 45% decrease), and each high ASCVD risk subgroup: ASCVD (-57.2 mg/dL, -48.0%); diabetes mellitus (-53.1 mg/dL, -40.0%); severe hypercholesterolemia (-76.3 mg/dL, -45.7%); elevated ASCVD 10-year risk (-62.8 mg/dL, -41.1%) (P<0.001 for all), without any significant complications. Among 20% of participants with reported statin intolerance, average LDL-C decreased from baseline 143 mg/dL to 85 mg/dL using mainly statins and ezetimibe, with limited PCSK9 inhibitor use. In comparison, eligible high ASCVD risk patients who were contacted but opted for education only, a 17% LDL-C decrease occurred over a similar timeframe, with 80% remaining with an LDL-C over 100 mg/dL. CONCLUSIONS A remote, algorithm-driven, navigator-executed cholesterol management program successfully identified high ASCVD risk undertreated patients using EMR screening and was associated with significantly improved guideline-directed LDL-C control, supporting this approach as a novel strategy for improving health care access and delivery.

中文翻译：

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通过远程、算法、导航器执行的程序对低密度脂蛋白胆固醇进行人口健康管理。

背景尽管有明确证据表明此类措施可减少心血管（CV）事件，尤其是在高动脉粥样硬化性心血管疾病（ASCVD）风险患者中，但指南指导的胆固醇管理的实施仍然很低。现在存在可能有助于改善医疗保健服务的现代电子资源。虽然电子病历 (EMR) 允许进行人群健康筛查，但将 EMR 筛查与远程提供的基于人群的算法管理相结合的潜力作为一种克服最佳胆固醇管理障碍的方法的研究较少。方法 在一个学术附属的医疗保健系统中，使用 EMR 筛查，我们试图确定 1、000 名高 ASCVD 风险患者在特定系统附属初级保健实践中未达到指南指导的低密度脂蛋白胆固醇 (LDL-C) 目标。接触的患者接受了胆固醇教育，并获得了由经过培训但未经许可的“导航员”在专业监督下执行的远程、指南指导、算法胆固醇管理计划。导航员使用电话、专有软件和互联网资源来促进算法驱动、基于指南的药物启动/滴定和实验室测试，直到患者达到 LDL-C 目标或退出该计划。作为胆固醇指南实施的临床有效性计划，与拒绝基于计划的药物管理并仅接受教育的接触患者进行了比较，连同他们平时的照顾。结果 1021 名患者属于指南定义的高 ASCVD 风险组，需要他汀类药物治疗（ASCVD，2 型糖尿病，LDL ≥ 190 mg/dL，计算的 10 年 ASCVD 风险 ≥7.5%）并且未达到指南定义的目标 LDL-C 水平和/或治疗被识别和联系。在选择计划药物管理的 698 名此类患者中，总队列中 LDL-C 显着降低（平均 -65.4 mg/dL，下降 45%），每个高 ASCVD 风险亚组：ASCVD（-57.2 mg/dL， -48.0%); 糖尿病（-53.1 mg/dL，-40.0%）；严重的高胆固醇血症（-76.3 mg/dL，-45.7%）；10 年 ASCVD 风险升高（-62.8 mg/dL，-41.1%）（所有 P<0.001），没有任何显着并发症。在报告有他汀类药物不耐受的 20% 的参与者中，平均 LDL-C 从基线 143 mg/dL 降至 85 mg/dL，主要使用他汀类药物和依折麦布，PCSK9 抑制剂的使用有限。相比之下，接触但仅选择接受教育的合格高 ASCVD 风险患者，在相似的时间范围内发生了 17% 的 LDL-C 下降，其中 80% 的 LDL-C 保持在 100 mg/dL 以上。结和交付。在相似的时间范围内发生了 17% 的 LDL-C 下降，剩余 80% 的 LDL-C 超过 100 mg/dL。结和交付。在相似的时间范围内发生了 17% 的 LDL-C 下降，剩余 80% 的 LDL-C 超过 100 mg/dL。结和交付。