Put on a Happy Face: A fun, easy and evidence-informed way to use an interactive Cardiovascular Disease

Risk Calculator tool in office practiceDr. Michael Dillon

Klinic Community Health, Winnipeg MB Assistant Professor, Dept. of Family Medicine, U of M

Declaration of Conflict of Interest

• No current involvement with pharmaceutical industry (Boards, consultations, sponsorship). Past academic contribution to Accredited Educational activities that have had some Pharma support

• Mutual Funds not specifically invested in Pharmaceutical Industry, but in some for-profit medical facilities in the Northern USA

• No Mutual Fund investment in “Big Agriculture”

https://commons.wikimedia.org/wiki/File:Capsule,_g%C3%A9lule.svg

Goals of Presentation

• Same as goals of a good office visit:

• Start on time, end on time, share some useful content

• Give some ideas to take home and consider

• Promote good communication and lifestyle

Why do we need to do this better?

• We as Primary Healthcare Providers are NOT witches and wizards with “Magic Solutions” for our patients

• We’re NOT all that good at “translating” ideas of risk and benefit

We are not so good with Numeracy

We have a hard time explaining risks, benefits, NNT etc.

sDARKDefence Against the

We dole out Potions

• Without Really Knowing the Counter-Spells

Patient 1: Linda

• Celebrating her 50th Birthday

• Had just been to the office for Periodic Health Review: Pap smear done, information to call re ColonCheck FOBT and BreastCheck

• Agreed to have Lipid Profile and Glucose screen done

Linda’s Cardiovascular Risk Data

• Important data:

• Cigarette Smoker

• Mother had Heart Attack aged 60

• Anishinaabe

.

• BP 130/80

• A1c 5.6%

• T.Chol 7.1

• HDL 1.1

So doc, what’s this mean?

• Time for the BS

• (“Best Science”)

Therapeutics Education Collaboration

“BS Without the BS”

James P. McCormack. BSc, BSc (Pharm), PharmD.Faculty of Pharmaceutical Sciences, UBC

G Michael Allan, MD, CCFPProfessor and Director of EBM, Dept of Family Medicine, U of ADirector of Evidence and CPD, Alberta College of Family Physicians

So doc, what’s this mean?

• http://chd.bestsciencemedicine.com/calc2.html

• (or just Google “BS Medicine CVD Risk Calculator”)

Age

GenderSmoker?

Diabetes?Blood Pressure

T. CholesterolHDL

Family History “slider”

Relative Benefit

of actions (*can’t really combine on calculator

“Icon Array” AKA

“Bunch o’Smileys”

Can print a copy for patient and EMR

Patient 1: Linda

• Next steps: Literal ones!

Patient 2: Kostas• 48 years old

• Greek background

• Smoker, trying to quit with “vapes”

• Diabetes diagnosed past two years, struggling with metformin (severe GI upset)

• Blood Pressure high

Kostas• A1c 9.8

• Total cholesterol 8.6

• HDL 0.8

• TG 15.2

• BP 160/90

“I don’t like taking meds!”

• Note: Crazy high Triglycerides are actually an IMPROVEMENT (fasting specimen this time, usually non-fasting is fine)

• “ BUT I HAVE BEEN STICKING TO THE MEDITERRANEAN DIET!”

So doc, what’s this mean?

• http://chd.bestsciencemedicine.com/calc2.html

• (or just Google “BS Medicine CVD Risk Calculator”)

Patient 2: Kostas Next Steps

• Try some metformin (if can tolerate!)

• Nudge the BP meds up a bit

• Consider a “statin” in higher dose if tolerated

• Refer to Clinical Pharmacologist

0"0.1"0.2"0.3"0.4"0.5"0.6"0.7"0.8"0.9"1"

Death"

Major"stroke"

Dialysis"

Blindness"

AmputaBon"

Comprehensive"diabetes"care"

Angina"

Neuropathy"

Intensive"glucose"control"

Mild"stroke"

Intensive"BP"control"

ConvenBonal"glucose"control"

ConvenBonal"BP"control"

CholesterolKlowering"drug"

Aspirin"

Diet"

Exercise"

Perfect"health"

Diabetes Care 2007;30:2478–83

Quality of Life

Comprehensive Diabetes Care has same negative burden on quality of life as a mild stroke

Patient 3: Etienne

• 53 year old man from Sub-Saharan Africa

• Generally feeling well

• Lipid screening done as he is on Ritonavir + Protease inhibitor as part of HAART for HIV

D:A:D and CV Risk 11 cohorts; 23,437 patients; >94,000 patient years

44CVD: CV disease, D:A:D: Data collection on Adverse events of anti-HIV Drugs, DM: diabetes mellitus, PI: protease inhibitor, TC: total cholesterolThe DAD Study Group. N Engl J Med 2007;356:1723-1735.

Relative Rate of MI Per 5 years of PI use = 1.61 (95% CI = 1.21-2.29) Per 5 years of ! age = 1.32 (95% CI = 1.23-1.41)

0.1

1

10

Rel

ativ

e R

ate

PI use Age Male Current Prior DM TC HDL(per 5 yrs) (per 5 yrs) smoker CVD (per mmol) (per mmol)

m

• No indication Diabetes• T. Cholesterol 5.6• HDL 1.4• BP 140/60• HIV +ve (risk slider)

x

So doc, what’s this mean?

• http://chd.bestsciencemedicine.com/calc2.html

• (or just Google “BS Medicine CVD Risk Calculator”)

Patient 3: Etienne Next Steps

• Using AAC/AHA ASCVD Calculator, he decides to forego a “statin” for now

• Continue to be active with his two young kids

• Continue to eat balanced “Mediterranean-style” diet

• CONTINUE HAART

How all this helps

• Shared decision-making and realistic understanding of what “risk” actually is

• In conversation with patient there may be more “buy-in” to whatever intervention patients choose

• In conversation, we can “check off” many of our Primary Care Quality Indicators!

How all this helps• I now order more “baseline” lipid profiles but less

overall (not repeating less than q 5 years, no monitoring on Statins etc.)

• I am learning how to pronounce “empagliflozin” and “liraglutide”

• I gained Mainpro + Credits by doing a “Linking Learning” Exercise

Unintended and surprising outcomes

• Stopped Rx’ing Atenolol

• Stopped just automatically adding insulin or sulfonylureas to metformin when the sugars are high

• I actually am prescribing “statins” for primary prevention

• I share my favourite ratatouille recipes with people

Thank you/Migwitch