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 B1 16 03
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
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)
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 B2.1.1.1 Equipment not working B2.1.1.1.1 Equipment not checked regularly B2.1.3 Nurse/MA/provider distracted B2.1.1.2 Equipment not available B2.1.1.2.1 Not enough equipment B2.1.4 Nurse/MA forgets B2.4.1.1 Patient prompt B2.4.1 No order from provider B2.4.2 Incomplete training B2.4.1.2 System prompt (human or electronic)
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) B3.2.1.1 Provider intends to review LDL results but (forgets) B3.2.1.2 Provider s process does not include LDL review B3.2.1.3 Result tagged as high cannot calculate LDL B3.2.1.4 Provider trust result B3.2.3.1 High reading not flagged by nurse/ma B3.2.3.2 EHR does not flag
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
A2.2.2 Low Patient Adherence (Therapy) A2.2.2.1 Patient does not comply A2.2.2.2 Provider initiating failure A2.2.2.3 Provider detect correct (see therapeutic inertia branch) A2.2.2.1.1 Prescription A2.2.2.1.2 Lifestyle (diet/ physical activity) A2.2.2.1.3 Alcoholism A2.2.2.1.4 Co morbidities comm attention A2.2.2.1.5 Mental health A2.2.2.1.5.1 Mental health meds override effects of LDL meds A2.2.2.1.5.2 Dementia /or depression A2.2.2.1.5.3 Only sees mental health doctor
A2.2.2.1.1 Prescription A2.2.2.1.1.1 No visible symptoms with meds A2.2.2.1.1.2 Dislikes side effects pursue A2.2.2.1.1.3 Cost of prescription high no insurance or limited formulary A2.2.2.1.1.5 No provider feedback/ reinforcement A2.2.2.1.1.6 Does not know to refill prescription A2.2.2.1.1.7 Lack of education as to why prescription needed A2.2.2.1.1.4 System does not detect no fills, refills, feedback A2.2.2.1.1.4.1 Insurance A2.2.2.1.1.4.2 Pharmacy A2.2.2.1.1.4.3 EHR
A2.2.2.1.2 Lifestyle (Diet/Physical Activity) A2.2.2.1.2.1 Too difficult to change lifestyle A2.2.2.1.2.2 Say they have changed but have not A2.2.2.1.2.3 Changed but not at goal failure to see why medication needed A2.2.2.1.2.4 Does not underst what elevated LDL is /or importance A2.2.2.1.2.1.1 Family. friends not supportive A2.2.2.1.2.1.2 Fat reduced foods not available A2.2.2.1.2.1.3 Time constraints A2.2.2.1.2.1.4 No provider feedback (failure to reinforce) A2.2.2.1.2.1.5 Cultural issues A2.2.2.1.2.4.1 Language barriers A2.2.2.1.2.4.2 Insufficient or no patient education A2.2.2.1.2.4.3 Insurance cover education
A2.2.5 Therapeutic Inertia A2.2.5.1 Provider does not detect correct A2.2.5.2 Patient initiate dialogue or prompt A2.2.5.3 System (electronic or human) prompt A2.2.5.1.1 Competing dems/ limited time A2.2.5.1.2 Ineffective feedback response when LDL goal not met A2.2.5.1.3 Unclear role communication patient sees more than one provider A2.2.5.1.4 Soft clinical reasoning ( probability) A2.2.5.1.2.1 Failure to modify treatment plan A2.2.5.1.2.2 Guidelines not followed A2.2.5.1.2.3 No patient follow up A2.2.5.1.1.1 No team care (failure to delegate) A2.2.5.1.1.2 More urgent concerns ( probability) A2.2.5.1.1.3 Failure to detect non adherence A2.2.5.1.2.2.1 Guidelines changed, practice did not A2.2.5.1.2.2.2 Not familiar with guidelines A2.2.5.1.2.2.3 Feels that risks of prescription outweigh benefits
A2.2.5.1.4 Soft Clinical Reasoning A2.2.5.1.4.1 Satisfied with patient s current results/progress A2.2.5.1.4.2 Does not believe LDL is important A2.2.5.1.4.3 Prefers behavioral to medicinal Intervention A2.2.5.1.4.4 Does not trust lab result A2.2.5.1.4.5 Fail to set goal, dose appropriately
A2.2.5.1.2.1 Failure to Modify Treatment Plan A2.2.5.1.2.1.1 Treatment plan not activated A2.2.5.1.2.1.2 No plan for treatment A2.2.5.1.2.1.3 Treatment plan not adequate A2.2.5.1.2.1.4 Implemented 2.2.5.1.2.1.1.1 Provider has plan but does not activate yet A2.2.5.1.2.1.1.2 Provider has activated a partial plan (see not adequate ) A2.2.5.1.2.1.1.1.1 Wait see A2.2.5.1.2.1.1.1.2 Wants to address other issues first A2.2.5.1.2.1.2.1 Patient concerns A2.2.5.1.2.1.2.2 Other A2.2.5.1.2.1.3.1 Lifestyle (education) A2.2.5.1.2.1.3.2 First round medications (education/monitoring) A2.2.5.1.2.1.3.3 Second round medications (education/monitoring) A2.2.5.1.2.1.3.4 Inadequate clinical systems to support plan
A2.2.5.1.2.3 No Patient Follow up A2.2.5.1.2.3.1 Patient overdue A2.2.5.1.2.3.2 Provider have a practice of following up (no system, not team, not EHR or sees as patient responsibility) A2.2.5.1.2.3.3 No system follow up (feedback loop) A2.2.5.1.2.3.1.1 Patient is told to follow up with provider A2.2.5.1.2.3.1.1.1 Provider has a practice of following up but A2.2.5.1.2.3.1.1.1.1 Busy A2.2.5.1.2.3.1.1.1.2 Forgets A2.2.5.1.2.3.1.1.1.3 Chart unavailable (lost/misplaced/ EHR down) A2.2.5.1.2.3.1.1.1.4 Chart flags/ prompts/registries fail A2.2.5.1.2.3.1.1.1 Patient intends to schedule appointment but A2.2.5.1.2.3.1.1.2 Patient schedules appointment but LDL not addressed A2.2.5.1.2.3.1.1.3 Patient intend to schedule (See A2.2.2 branch) A2.2.5.1.2.3.1.1.1.1 Busy A2.2.5.1.2.3.1.1.1.2 Forgets A2.2.5.1.2.3.1.1.1.3 Transportation is a challenge