17: REFLECTIVE RESPONSE 2 ■ 413the newly approved agents (i.e., proprotein convertase subtilisin/ kexin type 9 or PCSK9
inhibitors) affect the inflammatory biomarkers, and what are their effects on progres-
sion of atherosclerosis? All these questions and many others should be addressed by
doctorally prepared APNs in collaboration with other specialists in other disciplines.
The professional identity of the doctorally prepared APN should be flourished
in the area of evidence appraisal and guidelines development. Doctorally prepared
APNs will be equipped to appraise the evidence. In the area of cardiovascular preven-
tion, there are numerous randomized controlled trials (RCTs) being performed. The
American College of Cardiology (ACC) and the American Heart Association (AHA)
released in 2013 a set of recommendations to reduce atherosclerotic cardiovascular risk
in adults (Stone et al., 2013). These recommendations were set forth by an expert panel
from the medical field who reviewed high- quality evidence such as RCTs. The DNP pro-
gram will prepare the APNs not only to understand and apply the evidence behind our
practice but to be part of the expert panel that sets forth the national guidelines pertain-
ing to our practice in this field.
The doctoral prepared APN will also be expected to possess a set of skills in the
area of health policy development pertaining to the APN’s field of practice. It has been
demonstrated through many state initiatives that policy change is a staggering way to
enhance public health (Centers of Disease Control and Prevention [CDC], 2013, 2014).
Therefore, unlike the counterargument that governing one’s health is an individual’s
responsibility, doctorally prepared APNs are expected to induce policy changes that
positively impact their specialty practices. Policy changes are greatly needed in the field
of cardiovascular prevention. The soaring costs of CVD expected to reach $275 billion
in 2030 are not reflective of preventive costs but purely short- and long- term costs of
CVD (Heidenreich et al., 2011). Policy changes are needed in the area of insurance cov-
erage for cardiovascular risk assessment testing. Numerous studies demonstrated that
a substantial percentage of individuals diagnosed with CVD and heart attacks did not
qualify (before the cardiovascular event) for long- term preventive treatments due to
lack of major risk factors (Nasir et al., 2012; Ridker, Buring, Rifai, & Cook, 2007; Wilson
et al., 2008). Therefore, individualizing one’s risk by evaluating for subclinical athero-
sclerosis (presence of atherosclerosis in the absence of clinical symptoms) is predictive
of CVD and cardiovascular events and is the recommended testing measure, which
unfortunately comes with an out- of- pocket cost and not covered by private or govern-
mental insurance agencies (Blaha et al., 2009; Budoff et al., 2007; Detrano et al., 2008;
Sarwar et al., 2010). The only exception was with the Texas Heart Attack Prevention
Bill that was passed in 2009 and mandated insurance companies to cover the costs of
computer tomography (CT) scan for the heart that measures coronary artery calcifica-
tion scores and/ or ultrasonography for the neck vessels (carotid arteries) that measures
vessel thickness and evaluate for the presence of atherosclerosis (Beller, 2009). Inducing
policy change at this level is a function expected from doctorally prepared APN while
collaborating at the interdisciplinary and interprofessional levels.
In summary, I described within this response a few concrete examples of the con-
tinuously growing role of the doctorally prepared APN. Through interdisciplinary
and interprofessional collaboration, doctorally prepared APNs are capable of inducing
many of the much- needed changes in our complex and expensive health care system.
When reflecting on your role in your specialized area of practice, do that with com-
plete freedom. As Aristotle described freedom being the cause of itself (Liberum est quod
Causa sui est), or in other words, freedom calls for knowing self and the truth/ value
within self. It is imperative to use this freedom in order to envision and design your role
in this profession and the unlimited potential that this role has to improve the health