Date of Award

Fall 11-27-2023

Document Type

Scholarly Project

Degree Name

Doctor of Nursing Practice (DNP)

First Advisor

Hilary Morgan, PhD, CNM, CNE

Second Advisor

Marfe Hutson, DNP, ACNP-BC, CWON-AP


Practice Problem: Cardiovascular disease continues to be the leading cause of mortality globally. Often, healthcare providers fail to follow evidence-based guidelines in their practice.

PICOT: In high cardiac-risk, adult patients with low-density lipoprotein cholesterol (LDL-C) levels greater than 70 milligram/deciliter (mg/dl) despite being on a maximum tolerated dose of statin (P), what was the effect of a provider flagging system to initiate ezetimibe (I) compared to standard care (C) on increasing the utilization of ezetimibe according to the 2018 American Heart Association (AHA) guidelines (O) within 8 weeks (T)?

Evidence: An extensive evidence literature review supported the use of a flagging system to improve clinician adherence to AHA (2018) guidelines and to increase the use of guideline-recommended treatments such as statins and ezetimibe in clinical practice.

Intervention: A flagging tool was implemented to prompt primary care providers to initiate ezetimibe on high-cardiac risk patients with an LDL-C level greater than 70 mg/dl despite being on high-dose statin medication.

Outcome: The project achieved clinical significance with a 24% increase in the ezetimibe prescription rate. Of the 23 patients whose providers were manually flagged, six were started on ezetimibe. Overall, the project resulted in a 14% increase in the prescription rate compared to the planned goal of 10%. The results of the test were statistically significant based on the alpha value of .05 and p-value of .032.

Conclusion: The manual flagging tool used in this project was successful. However, its implementation as an electronic flagging tool in the future will require the expertise and cooperation of stakeholders, such as informatics specialists, pharmacists, registered nurses, and clinicians, and the guidance and support of primary care leadership.


Scholarly project submitted to the University of St. Augustine for Health Sciences in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice.

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