LDL Control Causal Tree
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- Ralph Atkins
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1 LDL Control Causal Tree This material was prepared by HealthInsight, the Medicare Quality Innovation Network Quality Improvement Organization for Nevada, New Mexico, Oregon Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW B
2 Heart Disease (LDL Cholesterol) A Patient aware of LDL B Patient unaware LDL elevated A1 Patient untreated A2 Patient treated A2.1 Patient at goal A2.2 Patient not at goal A2.2.1 Inaccurate LDL measurement A2.2.2 Low patient adherence (therapy) A2.2.2 Resistant LDL (tough disease genetic) A2.2.3 Side effects cannot tolerate therapy A2.2.4 Suboptimal prescription regimen A2.2.5 Therapeutic inertia
3 B Patient Unaware LDL Elevated B1 No contact with health care system ( probability) B2 Office visit but LDL not taken B3 Heart disease not diagnosed ( probability) B1.1 No insurance or low income B1.2 Low patient priority (no symptoms) B1.3 No regular patient contact with system (e.g., regular physicals)
4 B2 Office Visit but LDL Not Taken B2.1 Nurse/MA/provider plans to take but B2.2 No system reminder B2.3 Patient know or remind B2.4Nurse/MA/ provider know to do LDL test B2.5 Patient not fasting B2.1.1 Equipment Failure B2.1.2 Nurse/MA/provider busy B Equipment not working B Equipment not checked regularly B2.1.3 Nurse/MA/provider distracted B Equipment not available B Not enough equipment B2.1.4 Nurse/MA forgets B Patient prompt B2.4.1 No order from provider B2.4.2 Incomplete training B System prompt (human or electronic)
5 B3 Patient not Diagnosed ( Probability) B3.1 Documentation of diagnosis not available during encounter B3.2 High LDL documented, but not evident to provider B3.1.1 Chart/lab unavailable (lost, misplaced, EHR down, or no lab interface) B3.1.2 LDL not taken (see branch B2) B3.2.1 Provider does not review or flag B3.2.2 Patient prompt B3.2.3 System prompt (human or electronic) B Provider intends to review LDL results but (forgets) B Provider s process does not include LDL review B Result tagged as high cannot calculate LDL B Provider trust result B High reading not flagged by nurse/ma B EHR does not flag
6 A1 Patient Untreated, Diagnosed with Heart Disease A1.1.1 Younger, male A1.1 Inadequate access A1.1.2 Hispanic A1.2 Low priority condition for patient (no symptoms, no urgency, patient does not want to be seen) A1.1.3 Low income A1.1.4 No insurance A1.3 Provider distracted by separate acute episode A1.3.1 Patient prompt A1.3.2 System does not prompt (human or electronic) A1.4 New baseline needed old LDL lab not trusted
7 A2.2.2 Low Patient Adherence (Therapy) A Patient does not comply A Provider initiating failure A Provider detect correct (see therapeutic inertia branch) A Prescription A Lifestyle (diet/ physical activity) A Alcoholism A Co morbidities comm attention A Mental health A Mental health meds override effects of LDL meds A Dementia /or depression A Only sees mental health doctor
8 A Prescription A No visible symptoms with meds A Dislikes side effects pursue A Cost of prescription high no insurance or limited formulary A No provider feedback/ reinforcement A Does not know to refill prescription A Lack of education as to why prescription needed A System does not detect no fills, refills, feedback A Insurance A Pharmacy A EHR
9 A Lifestyle (Diet/Physical Activity) A Too difficult to change lifestyle A Say they have changed but have not A Changed but not at goal failure to see why medication needed A Does not underst what elevated LDL is /or importance A Family. friends not supportive A Fat reduced foods not available A Time constraints A No provider feedback (failure to reinforce) A Cultural issues A Language barriers A Insufficient or no patient education A Insurance cover education
10 A2.2.5 Therapeutic Inertia A Provider does not detect correct A Patient initiate dialogue or prompt A System (electronic or human) prompt A Competing dems/ limited time A Ineffective feedback response when LDL goal not met A Unclear role communication patient sees more than one provider A Soft clinical reasoning ( probability) A Failure to modify treatment plan A Guidelines not followed A No patient follow up A No team care (failure to delegate) A More urgent concerns ( probability) A Failure to detect non adherence A Guidelines changed, practice did not A Not familiar with guidelines A Feels that risks of prescription outweigh benefits
11 A Soft Clinical Reasoning A Satisfied with patient s current results/progress A Does not believe LDL is important A Prefers behavioral to medicinal Intervention A Does not trust lab result A Fail to set goal, dose appropriately
12 A Failure to Modify Treatment Plan A Treatment plan not activated A No plan for treatment A Treatment plan not adequate A Implemented Provider has plan but does not activate yet A Provider has activated a partial plan (see not adequate ) A Wait see A Wants to address other issues first A Patient concerns A Other A Lifestyle (education) A First round medications (education/monitoring) A Second round medications (education/monitoring) A Inadequate clinical systems to support plan
13 A No Patient Follow up A Patient overdue A Provider have a practice of following up (no system, not team, not EHR or sees as patient responsibility) A No system follow up (feedback loop) A Patient is told to follow up with provider A Provider has a practice of following up but A Busy A Forgets A Chart unavailable (lost/misplaced/ EHR down) A Chart flags/ prompts/registries fail A Patient intends to schedule appointment but A Patient schedules appointment but LDL not addressed A Patient intend to schedule (See A2.2.2 branch) A Busy A Forgets A Transportation is a challenge
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