American Heart Association National Integrated ASCVD Initiative: An Implementation Initiative to Improve Lipid Management Among Patients With ASCVD.
Aug 19, 2025DOI: 10.1161/circoutcomes.124.011627Journal ArticleAHA
Written by: Chiadi E NdumeleAnkeet S BhattLynne T BraunSteven ChenSeth S MartinMichael T MullenNishant P ShahStephen L SigalTracy Yu-Ping WangRebecca AlickiChandler BeonHaoyun HongSara O'KaneKatherine J OvertonKathie ThomasHoward Haft
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Dr. Ankeet Bhatt
General Cardiology · Kaiser Permanente
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Dr. Nishant Shah
Preventive Cardiology · Duke Hospital
Goals and Vision of the Program
The goal of the AHA’s National Integrated ASCVD Initiative is to strategize, adopt and implement national measures to facilitate the use of high-intensity lipid-lowering therapies for patients with ASCVD, to initiate appropriate referrals for lipid management upon hospital discharge, and to optimize LDL-C control for patients with ASCVD seen in outpatient settings. To achieve these goals, the initiative is designed to address gaps in system-wide performance and adherence to secondary prevention guidelines for hospitalized patients with ASCVD who are postacute coronary syndrome or stroke, and for outpatients with ASCVD seen in Cardiology or Primary Care settings.
Design of the Initiative
The 3-year initiative, from Quarter 3 of 2021 through Quarter 2 of 2024, included 6 geographically and demographically diverse health systems with varying hospital bed capacity, involving both teaching and nonteaching health systems (Table S1). Each health system included 2 to 3 hospital settings and 2 to 3 connected outpatient locations. Three of the health systems had experience abstracting data as active participants in the AHA Get With the Guidelines (GWTG)-Coronary Artery Disease (CAD) program, and the other 3 systems were active participants in abstracting data for the GWTG-Stroke program. Clinical champions were identified at each site. All hospitals were required to newly abstract a Referral to Lipid Management measure, defined as referrals at discharge for a clinic visit specifically indicated for LDL-C monitoring and lipid-lowering intensification as needed. Longitudinal tracking of patients between the inpatient and outpatient settings was facilitated by the new development and deployment of unique patient identifiers. Outpatient settings were asked to implement a Fast Healthcare Interoperability Resources-based interoperable registry that pulled patient-level data with access to cholesterol-based measures. The outpatient cholesterol measures of interest for this initiative were Monitoring LDL-C for Patients with ASCVD and LDL-C Control for Patients with ASCVD.
Implementation of the National Integrated ASCVD Initiative
A learning collaborative of clinical, quality, and administrative representatives was formed across the 6 health systems with quarterly calls to share successes, challenges, and experiences. Monthly 1:1 quality improvement calls were held to strategize opportunities for improvement and implementation of lipid management strategies. Process mapping for each health system visualized the patient’s journey from discharge through outpatient care, with a focus on lipid management, allowing health centers to address gaps and streamline care processes through order sets, best practice alerts, and utilization of care coordinators. Key strategies for standardizing lipid management were defined and applied within participating health systems (Table S2).
Education regarding lipid management for ASCVD was provided via lectures and webinars to address barriers identified within the cohort, which were also made available nationally, and through model sharing by participating organizations. Patient education was supported through informational tools and workshops. In addition, a pilot app designed for both Apple and Android devices, Heart and Stroke Helper, was developed to help patients self-manage their clinical condition and track lifestyle activities and cholesterol values (Figure S1). Patient education regarding LDL-C control goals was provided to support patient activation in clinical encounters.
Local Challenges in Implementation
Technological, institutional, and financial challenges were encountered during implementation of this initiative. The need for a high level of familiarity and comfort with Fast Healthcare Interoperability Resources-based application interfaces to ensure the integrity of the registry product and to achieve timely implementation required close collaboration with the technology teams of participating health centers. Financial incentives were provided to support technical implementation and care improvement opportunities. In addition, clinician champions were identified at each organization to help address gaps in care for patients in both the inpatient and outpatient settings.
Evaluation of the Initiative
The primary outcomes of the initiative were referrals to lipid management at hospital discharge and LDL-C monitoring, as well as achievement of LDL-C control in the outpatient setting (Table S3). LDL-C control was defined as LDL-C<70 mg/dL. Additional outcomes of interest included documentation of LDL-C during admissions for ASCVD and prescription of high-intensity statins upon discharge for an ASCVD hospitalization (with high-intensity statin therapy defined as atorvastatin 40 or 80 mg or rosuvastatin 20 or 40 mg daily). In the inpatient setting, outcomes were stratified by CAD and stroke for sites involved in the AHA GWTG-CAD and GWTG-Stroke programs, respectively. The data below are from all 6 health systems, although data from 1 inpatient site that was unable to complete technology adoption for data abstraction or to participate in the interventions during the initiative period were not included. A summary of key outcomes is provided in the Table and described below. Pre/post between initial and final measurements during the initiative were assessed using Z tests, with a 2-tailed P value of <0.05 indicating a statistically significant difference between the 2 time points.
Summary of Key Outcomes From the American Heart Association National Integrated ASCVD Initiative
Referrals to lipid management increased over the implementation project for patients with CAD from 90.5% at baseline assessment to 99.0% at the end of the initiative (+8.5% absolute change, P<0.01). Referrals for lipid management for stroke patients had a much lower baseline assessment of 13.4%, but increased to 38.1% at the end of the initiative (+24.7% absolute change, P<0.0001).
Documentation of LDL-C levels during CAD admissions remained high through the initiative, with rates of 91.3% at the beginning of the initiative and 90.7% at the end of the initiative (−0.6% absolute change, P=0.84). Over the same time period, documentation of LDL-C levels during stroke admissions similarly remained high, from 94.5% to 96.2% (+1.7% absolute change, P=0.24).
Discharge prescription rates of high-intensity statin therapy were also consistently high, with starting and ending rates of 99.4% and 97.9% for CAD admissions (−1.5% absolute change, P=0.22), and 97.8% and 98.2% for stroke admissions (0.4% absolute change, P=0.72) during the implementation initiative.
LDL-C monitoring increased from 68.8% preinitiative to 71.6% postinitiative (+2.8% absolute change, P<0.0001) across all outpatient settings.
The proportion of ASCVD outpatients with LDL-C control (<70 mg/dL) increased modestly but significantly from 48.4% preinitiative to 49.5% at the end of the initiative (+1.1% absolute change, P<0.005).
Programmatic Successes
Programmatic successes included successful adoption of the AHA Outpatient Quality registry with tool functionality, including unique identifiers for longitudinal tracking of patients from inpatient to outpatient settings. There was targeted dissemination of patient education materials, including 3 infographics in English and Spanish and a short-form video for patients with ASCVD. A Ready, Set Go—Standardizing Lipid Management implementation guide was developed and has been disseminated nationally. The Heart and Stroke Helper app was deployed during the initiative with 3628 downloads and 2902 registered users to date.
Translation to Other Settings
This initiative was performed among a diverse and representative group of health systems to ensure generalizability. Most approaches from this initiative to enhance lipid management can be translated across diverse settings, including process mapping to uncover key gaps and guide health system quality improvement efforts, the identification of clinical champions, and the use of established educational resources to reinforce best practices in lipid management. The program helped to establish conditions required for successful lipid management, including lipid clinic coordination, care team model adoption, and pharmacy integration. However, multilevel barriers, including a higher burden of patient-level adverse social determinants of health, a low density of subspecialists, and geographic impediments found in rural settings, would likely preclude optimal implementation of the approaches in this initiative. The initiative measures, including referrals to lipid management, have been expanded widely to health systems within AHA national registries.
The technical feasibility of using unique identifiers provides an important new tool for facilitating appropriate follow-up for patients with ASCVD postdischarge. Such follow-up is important for ensuring that patients receive lipid monitoring and lipid-lowering therapy intensification as needed. It is also important for identifying patients with ASCVD with statin intolerance, who may benefit from alternative LDL-C lowering therapies. Deployment of this tool across multiple cardiovascular registries will support ongoing and future initiatives focused on improving transitions of care from inpatient to outpatient settings, with the goal of optimizing primary and secondary prevention.
Several outputs of this initiative can also be used to support other health systems. The development of a robust implementation guide for lipid management can help to standardize approaches across diverse health systems. With more widespread deployment, the Heart and Stroke Helper App can also serve as a resource in efforts to support patient education and self-management.
Summary of the Experience, Future Directions, and Challenges
This implementation initiative incorporated multiple strategies to enhance lipid management for patients with ASCVD. Strategies included using a learning collaborative, direct quality improvement engagement with participating sites, process mapping to visualize site-specific gaps in lipid management and facilitate targeted activations to enhance care, identification of clinical champions, education to address identified knowledge gaps, and the development of tools to support health system implementation across diverse settings, as well as patient education and awareness. Over time, there was significant improvement in multiple key outcomes, including referrals to lipid management and LDL-C monitoring and control. The approaches and insights gained from this initiative can be used to inform a national roll-out across AHA registries and other health systems to enhance adherence to guideline-directed lipid management.
For some outcomes, such as inpatient documentation of LDL-C and high-intensity statin prescription at discharge for patients with ASCVD, metrics within the participating health systems were high at baseline and remained high throughout the initiative. However, for other metrics, such as LDL-C monitoring and LDL-C control in the outpatient setting, the data demonstrated substantial room for further improvement. Longitudinal LDL-C monitoring is needed for identifying and addressing nonadherence to prescribed therapies, and for uncovering the need for adjunctive or alternative lipid-lowering therapies to statin medications to achieve LDL-C control. Optimizing LDL-C control is associated with more favorable outcomes among patients with ASCVD.5 The implementation of strategies to increase LDL-C monitoring as a desired impact point to actualize LDL-C control should, therefore, be a major focus of ongoing quality improvement efforts, and the data from this initiative identifies challenges and opportunities related to augmenting these key measures.
In addition, while postdischarge referrals for lipid management were observed for >90% of patients with CAD, the rate of such referrals only reached 38% for patients with stroke among the participating sites. This indicates that more targeted engagement with clinicians providing neurological care poststroke will be critical for optimizing ASCVD management across diverse practice settings. There is also a need to further elucidate the multilevel social determinants of health that contribute to disparities in lipid management. Specific barriers faced by health systems should be identified and characterized to inform personalized approaches to implementation.
In conclusion, the AHA National Integrated ASCVD Initiative provides a foundation for efforts to enhance ASCVD care management across the global network of health systems within AHA registries. Widespread adoption of the implementation approaches described is critical for translating guidelines to clinical practice and improving outcomes for patients with ASCVD worldwide.
ARTICLE INFORMATION
The American Heart Association’s National Integrated atherosclerotic cardiovascular disease (ASCVD) Initiative is made possible by national sponsor, Novartis. Dr Bhatt reports consulting fees from Merck, Amgen, AstraZeneca and Novo Nordisk. Dr Martin is on the advisory board for Care Access, is a cofounder of Corrie Health, and reports personal consulting fees from Amgen, Arrowhead, AstraZeneca, Chroma, Heartflow, Kaneka, Merck, NewAmsterdam Pharma, Novartis, and Verve Therapeutics. Dr Wang is an employee of the Patient-Centered Outcomes Research Institute (PCORI), but the perspective presented in this article is solely the responsibility of the author(s) and does not necessarily represent the views of PCORI. The other authors report no conflicts.
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Tables S1–S3
Figure S1
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Dr. Nishant Shah
Cardiology · Preventive CardiologyDuke University Hospitalnishant
