Aspirin as a Tool to Improve Heart Health Now! 1 Aspirin as a Tool to Improve Heart Health Now!

Transcription

1 Aspirin as a Tool to Improve Heart Health Now! 1 Aspirin as a Tool to Improve Heart Health Now!

2 2 Welcome by Stacey Sheridan, MD, MPH Hello. My name is Stacey Sheridan, and I m coming to you today as your partner in Heart Heath Now, the North Carolina cooperative for the Evidence Now Project. Today, we ll be talking about aspirin as a tool to improve Heart Health Now. Before I begin, I d like to acknowledge our collaborators around the state of North Carolina. Our funder, the Agency for Healthcare Research and Quality, and I d also like to tell you that I m a member of The Council on Aspirin for Health and Prevention and that The Food and Drug Administration has not approved aspirin for the primary prevention of cardiovascular disease.

3 3 Aspirin for Primary Prevention As you may know, multiple guidelines recommend aspirin for the primary prevention of cardiovascular disease. This means aspirin in individuals with no prior history of heart-related chest pain, heart attack, stroke, or symptomatic blockages to the legs. Most guidelines focus on appropriate use of aspirin: encouraging aspirin in those at high risk, sharing decisions about aspirin use in those at intermediate risk, and discouraging aspirin in those at low risk.

4 4 As a result, providers need to As a result, providers need to develop a thorough understanding of aspirin and how to approach aspirin decision making and use.

5 5 Consider. Consider: A 65-year-old white man in good health who presents for care. He s concerned about cardiovascular disease and wants to know what can be done to reduce his risk. He has no diabetes, is a nonsmoker, and has no family history of cardiovascular disease. His blood pressure is 139/82. His total cholesterol 220 mg per deciliter. His HDL 41 mg per deciliter. And his LDL 145 mg per deciliter. He eats a healthy diet and likes to walk. So, how would you approach decision making about aspirin? How would you use risks to guide decisions about prescribing? Take a moment and think about it.

6 6 Now Consider Your Practice Now consider your practice. How does your practice approach aspirin prescribing? Do you as a group routinely calculate cardiovascular risks to support aspirin prescribing? Do you have a system for monitoring and tracking aspirin prescribing, or approaching decision making about aspirin?

7 7 The Objectives Now that you ve taken time to think about that, I want to discuss our objectives for today. In the time together, we ll discuss the rationale for aspirin use, how to approach decisions about aspirin and when to prescribe it, and, also, how to support aspirin use. We ll also share some resources for aspirin decision making and use and encourage you to make a decision about whether your practice would like to work on aspirin as a way to improve heart health now.

8 8 The Rationale for Aspirin Use So, why should I prescribe aspirin? Well, 44-percent of U.S. adults are at high risk of future atherosclerotic cardiovascular disease or ASCD events including myocardial infarction, or heart attack, stroke and cardiovascular death. Despite this, few eligible men and women without known ASCD are on aspirin. Further, many men and women who are taking aspirin are at low risk of events and may be harmed by it including 25% of individuals in national primary care samples.

9 9 The Rationale for Aspirin Use High-risk patients who don t receive aspirin miss out on important benefits over a mean of seven years of follow up. These benefits included 10-12% relative reduction in ASCVD events. Further, an approximately 20% reduction in colorectal mortality.

10 10 The Rationale for Aspirin Use Those patients who inappropriately receive aspirin incur potential harms. These include a 50% relative increase in the likelihood of gastrointestinal bleeding in average-risk individuals, and a 32-35% relative increase in hemorrhagic stroke.

11 11 The Rationale for Aspirin Use Further, intensive aspirin counseling is currently reimbursed by Medicare for men age and in women age And health plans are required to pay for aspirin in high-risk individuals. Because the Affordable Care Act requires payment for A&B recommended services from the US Preventative Services Taskforce. For more information, see:

12 12 How should I approach decision-making about aspirin? So, if aspirin sounds like a good deal, how should I approach decision making about aspirin?

13 13 1) Recognize that the approach to aspirin is based on potential value First, it s important to recognize that the approach to aspirin prescribing is based on potential value. With value based primarily on the balance of benefits and harms, what we call net benefit. If there is moderate net benefit, such as aspirin in high-risk men and women age 50-59, aspirin is considered high value. And you should recommend for aspirin. On the opposite end of scale, if there is the potential for net harm, such as aspirin in low-risk men and women, aspirin is considered low value. And you should recommend against it. In the middle is small net benefit such as aspirin in high-risk men and women age 60 to 69 where aspirin is considered marginal value, or a preference sensitive, dependent on a patient s personal preferences and values. In this setting, you should use shared decision making.

14 14 2) To Determine Your Approach, Calculate and Combine Risk with Age To determine your approach, you should calculate and combine risk with age. You should use an ASCVD risk calculator and combine the risk information with age to determine potential value and your approach. If you determine that aspirin is high value, you should prescribe aspirin. If you determine that it is marginal value, you should share the decision about aspirin. And if you determine its low value, you should discourage aspirin use.

15 15 3) When you prescribe aspirin, When you prescribe aspirin, you want to support adherence. The factor most strongly associated with aspirin use is a discussion with a provider. So, encourage aspirin initiation. Recommend aspirin. State that the benefits outweigh the harms. State that the dose, 81 mg daily, is to minimize harms. And ask about and address concerns including costs and side effects. Then make a plan for long term adherence. You can see our Adherence Webinar for some ideas.

16 16 4) When you share aspirin decisions, 4 - When you share decisions about aspirin, use a standard approach. Indicate that there s a choice. You have a choice about lowering your chances of cardiovascular disease: you can take an aspirin once daily or not take it. Discuss the benefits and harms of each alternative: If you take aspirin, the potential benefits and harms are If you don t take it, you won t get these benefits or the harms. And, finally, encourage decision. So, which option sounds best for you given what matters to you most?

17 17 5) When you discourage aspirin, When you discourage aspirin, make a clear recommendation against it. Say, the chances of harm include major bleeding outweigh the chances of benefit. And specifically say, I recommend that you don t take aspirin. And, then, be prepared to answer questions patients have.

18 18 What resources are available for aspirin decision-making and use? So, what resources are available for aspirin decision making in use?

19 19 Well, there are many risk calculators that are available including the risk calculator at This calculator not only calculates risks but also provides evidencebased recommendations on starting aspirin or not.

20 20 Other Websites, Apps, and Decision aids There are also many other, apps, and decision aids that can be used. These include the welltested decision aide and adherence counseling program called Heart to Health and apps which have been developed in conjunction the cholesterol guidelines for ASCVD Risk Calculation and prescribing.

21 21 Fact Sheets You might also use fact sheets that provide information about the chances of heart attack, stroke, or cardiovascular death events without aspirin over 10 years, with aspirin over 10 years, and then compare the benefit of aspirin over 10 years with the harms.

22 22 Hearth Health Now! Dashboard And, finally, we ll direct you to our Heart Health Now dashboard where you can get a population level view of ASCVD risk for your patients and whether or not they re on aspirin or need aspirin prescribing.

23 23 For additional questions and resources For additional questions and resources related to aspirin, see our website at

24 24 Is Aspirin Right for Your Practice? So, I leave you with a question, Are you ready to implement a program on aspirin in your practice?

25 25 Deciding about Aspirin and Your Practice In deciding about aspirin in your practice, ask yourself, is your goal to improve aspirin decisionmaking in use? Could you use some additional help with identifying the best approach to aspirin in practice? Or in figuring out how to most efficiently approach aspirin decision making and use? If you answered, Yes to any of these questions, talk to your practice facilitator about aspirin.

26 26 Putting the Approach into Action Because they can help putting the approach into action.

27 27 Putting this Approach into Action Putting aspirin prescribing into action requires addressing aspirin decision-making and use in both individuals and populations.

28 28 Addressing Individuals Addressing aspirin in individuals, we could return to our case. So consider a 65 year old white man in good health. He has no diabetes, non-smoker, blood pressure 139 / 82. His total cholesterol is 220 mg/dl; HDL 41 mg/dl; LDL 145 mg/dl. TO MAKE A DECISION ABOUT ASPIRIN: You calculate his ASCVD risk, which is 17% over 10 years, using one of the available calculators. Given his age, you determine aspirin has marginal potential value. While the absolute benefits of aspirin increase with age, so do the absolute harms, making it a close-call. You then engage him in shared decision- making and support his decision to either start aspirin or not.

29 29 Addressing Populations As he leaves your office, he returns to the population of your patients, and he mentions that he doesn t know if his brother-in-law is on aspirin. So you need a way to address populations, too. To monitor and support aspirin decision-making in populations of patients, you can use the Heart Health Now dashboard. Engage practice facilitators to: redesign teams and clinic workflows to monitor and track aspirin prescribing, use, and adherence. You can investigate how to share decisions about aspirin with patients who currently aren t in the office. Or how to bill for aspirin counseling.

30 30 Together we can renew our commitment And hopefully you can celebrate your successes, because together we can renew our commitment and get to Heart Health Now!

31 32 Congratulations

32 33 The Evidence Team 34 The Evidence Team