Cholesterol risk management: a systematic examination of the gap from evidence to practice

Real-World Effectiveness of Lipid-Lowering Therapy in Male and Female Outpatients with Coronary Heart Disease: Relation to Pre-Treatment Low-Density Lipoprotein-Cholesterol, Pre-Treatment Coronary Heart Disease Risk, and other Factors

Background

Determinants of the real-world effectiveness of lipid-lowering therapy have been rarely assessed in an unselected observational coronary heart disease (CHD) community cohort over time.

Design

Randomly drawn patients (n = 605) from randomly drawn practices (n = 62) were retrospectively followed for a median of 3.6 years (1998-2002) on lipid-lowering therapy (98% statins).

Methods

Coronary heart disease population-averaged estimates and variances accounting for repeated measurements within patients were obtained using generalized estimating equations.

Results

Post-treatment low-density lipoprotein-cholesterol (LDL-C) was 124 mg/dl in men and 141 mg/dl in women and was independently associated (all P<0.05) with pre-treatment LDL-C (+ 3.7 mg/dl per 10 mg/dl increment), female sex (+ 14.0 mg/dl), coronary bypass (-9.5 mg/dl), drug-treated diabetes mellitus (-6.8 mg/dl), and era 2002/2001 versus 1999/2000 (- 6.4 mg/dl) in age-adjusted multivariate analyses. Holding pre-treatment LDL-C constant post-treatment LDL-C was associated with pre-treatment Framingham CHD risk in men (- 13.9 mg/dl per doubling of risk), whereas LDL-C control in women resembled that in low-risk men. The likelihood of attaining LDL-C < 100 mg/dl was 0.28 in men and 0.17 in women and was likewise associated with the above factors.

Conclusion

Low-density lipoprotein-cholesterol control remained low despite lipid-lowering therapy across a wide range of pre-treatment LDL-C and pre-treatment CHD risk. Low-density lipoprotein-cholesterol control in women was inferior to that in men, a finding that warrants attention and clarification. Eur J Cardiovasc Prev Rehabil 12:37-45 © 2005 The European Society of Cardiology

Evidence-based goals in LDL-C reduction

The evidence from trials of statin therapy suggests that benefits in cardiovascular disease (CVD) event reduction are proportional to the magnitude of low-density lipoprotein cholesterol (LDL-C) lowering. The lack of a threshold at which LDL-C lowering is not beneficial, in terms of CVD prevention observed in these trials, is supported by epidemiological and genetic studies reporting the cardio-protective effects of lifelong low exposure to atherogenic cholesterol in a graded fashion. Providing that intensive LDL-C lowering is safe, these observations suggest that many individuals even at current LDL-C treatment targets could benefit. Here, we review recent safety and efficacy data from trials of adjunctive therapy, with LDL-C lowering beyond that achieved by statin therapy, and their potential implications for current guideline targets. Finally, the application of current guidance in the context of pre-treatment LDL-C concentration and deployment of statin therapy is also discussed. The number of patients requiring treatment to prevent a CVD event with statin treatment has been shown to differ markedly according to the pre-treatment LDL-C concentration even when absolute CVD risk is similar. It produces more likelihood of benefit when absolute LDL-C reduction is greater which is largely dependent on pre-treatment LDL-C concentration. This also has to be taken in consideration when deploying new agents like proprotein convertase subtilisin/kexin type 9 monoclonal antibodies. Patients with highest LDL-C concentration despite maximum statin and ezetimibe therapy will attain most absolute LDL-C reduction when treated with proprotein convertase subtilisin/kexin type 9 monoclonal antibodies, hence benefit most in term of CVD risk reduction.

A randomized trial of a community-based approach to dyslipidemia management: Pharmacist prescribing to achieve cholesterol targets (RxACT Study)

BACKGROUND

Dyslipidemia is an important risk factor for cardiovascular disease but is suboptimally managed. Pharmacists are accessible primary care professionals and with expanded scopes of practice (including prescribing), could identify and manage patients with dyslipidemia. We sought to evaluate the effect of pharmacist prescribing of dyslipidemia medications on the proportion of participants achieving target LDL-cholesterol (LDL-c) levels.

METHODS

We conducted a randomized controlled trial in 14 community pharmacies in Alberta, Canada. We enrolled adults with uncontrolled dyslipidemia as defined by the 2009 Canadian Dyslipidemia Guidelines. Intervention was pharmacist-directed dyslipidemia care, including assessment of cardiovascular risk, review of LDL-c, prescribing of medications, health behaviour interventions and follow-up every 6 weeks for 6 months. Usual care patients received their lipid results and a pamphlet on cardiovascular disease and usual care from their physician and pharmacist. Primary outcome was the proportion of participants achieving their target LDL-c (<2 mmol/L or ≥50% reduction) at 6 months between groups.

RESULTS

We enrolled 99 patients with a mean (SD) age of 63 (13) years, 49% male and baseline LDL-c of 3.37 mmol/L (0.98). Proportion of patients achieving LDL-c target was 43% intervention versus 18% control (p = 0.007). Adjusted odds of achieving target LDL-c were 3.3 times higher for the intervention group (p = 0.031), who also achieved greater reduction in LDL-c (1.12 mmol/L, SE = 0.112) versus control (0.42 mmol/L, SE = 0.109), for an adjusted mean difference of 0.546 mmol/L (SE = 0.157), p < 0.001.

CONCLUSION

Pharmacist prescribing resulted in >3-fold more patients achieving target LDL-c levels. This could have major public health implications.

Physician Perceptions of Enhanced Community Pharmacist Care in Cholesterol Management

Objectives:

The Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP) was a randomized controlled trial that demonstrated that community pharmacist intervention improved cholesterol management for patients at high risk for cardiovascular disease. The objective of this sub-study was to describe physician perceptions of the intervention program.

Design:

Surveys were mailed to all physicians contacted as part of the enhanced pharmacist care program within SCRIP. Physician opinions were collected on pharmacist participation in cholesterol management and the impact of the program on patient management and outcomes.

Results:

We received 141 usable surveys from 239 eligible physicians, a response rate of 59%. Of those who responded, 110 (78%) remembered components of the enhanced pharmacist care program, and 77 (55%) were in favour of the pharmacist's recommendations. Of the 110 physicians who recalled the intervention, 27 (25%) agreed that the program improved cholesterol management, and 11 (10%) felt the program had a major effect on patient outcomes; however, only 41 (37%) felt the program was helpful or useful. Written comments reflected opinions that the program duplicates current services and that physicians have reservations about the expanding role of pharmacists. Despite these general comments, similar interventions for other medical conditions were welcomed.

Conclusions:

Physicians had mixed attitudes toward the enhanced pharmacist care program. Despite these opinions, the main results of SCRIP were very positive. Indeed, if the physician opinions of the program had been more positive, the impact might have been even greater. The effectiveness of future programs may be enhanced through improved communication of the program's goals and collaboration of all stakeholders early in the program's implementation.

Role of the Pharmacist in the Management of Dyslipidemia

Dyslipidemia is one of a number of independent risk factors for cardiovascular disease. Numerous large-scale, randomized clinical trials demonstrate the benefit of aggressive lipid-modifying therapy in reducing the mortality and morbidity associated with cardiovascular disease. Despite these data and the wide dissemination of clinical practice guidelines outlining management strategies for patients with dyslipidemia, particularly those at the greatest cardiovascular risk, studies indicate that a significant proportion of patients are not screened, initiated on appropriate therapy, or treated to target lipid levels. Pharmacists, as part of the multidisciplinary team, can play a vital role in assisting in the management of patients with dyslipidemias. This article reviews published studies that have evaluated the pharmacist's role in lipid management, reviews the process for managing a patient with dyslipidemia, and provides suggestions on how pharmacists can become more involved in lipid management.

Ambulatory treatment gaps in patients with ischemic stroke or transient ischemic attack

BACKGROUND

This study evaluated goal attainment for patients with a history of non-cardioembolic ischemic stroke (NCIS) or transient ischemic attack (TIA).

METHODS

A cross-sectional study was conducted in patients aged 18 to 85 years with a history of validated NCIS or TIA. Data collected were demographics, comorbidities, blood pressure (BP), low-density lipoprotein cholesterol (LDL-C) values, and medications within 365 days and most proximal to December 31, 2010. Goal LDL-C and BP were defined as < 100 mg/dL and < 140/90 mm Hg, respectively. Differences in sex and age (< 65 vs ≥ 65 years) were evaluated.

RESULTS

There were 1731 patients evaluated (mean age: 73.6 years; 58% women). Stroke type was NCIS in 51.9% and TIA in 48.1%. The LDL-C and BP were measured in 75.4% and 50.3% of patients, respectively. No difference in LDL-C screening rates existed for sex or age. Men and patients younger than age 65 years were significantly more likely to have BP measured. Overall, LDL-C and BP goals were attained by 48.9% and 43.3% of patients, respectively. Men and patients age 65 years or older were likelier than women and patients younger than age 65 years to attain LDL-C goals (p < 0.01). Men were also likelier than women to attain BP < 140/90 mm Hg (p < 0.01), but more patients younger than age 65 years vs older than age 65 years attained this goal (p < 0.01). Statins and antihypertensives were received by 51.9% and 46.9% of the patients, respectively.

CONCLUSION

Although attaining guideline-recommended goals for LDL-C and BP may present challenges, future research should focus on innovative methods to help patients attain optimal treatment goals.

The burden and management of dyslipidemia: practical issues

The objective of this study is to describe briefly the burden of dyslipidemia, and to discuss and present strategies for health professionals to improve dyslipidemia management, based on a review of selected literature focusing on interventions for dyslipidemia treatment adherence. Despite the availability of effective lifestyle and pharmaceutical therapies for dyslipidemias, they continue to present a significant economic burden in the United States. Adherence to evidence-based guidelines for the treatment of dyslipidemias is unsatisfactory. The reasons for medication nonadherence are complex and specific to each patient. The lack of progress in achieving optimal lipid targets is caused by many factors: patient (medication adherence, cost of medication, literacy), medication (adverse effects, complexity of regimen), provider (lack of adherence to evidence-based practice guidelines, poor communication), and the US healthcare system (being focused on acute care rather than prevention, lack of continuity of care, general lack of use of an electronic health record). Combined interventions that target each part of the system have been effective in improving treatment adherence and achieving lipid goals. Patients, providers, pharmacists, and employers all play a role in management of dyslipidemia. No single approach will solve the complex issue of improving dyslipidemia management. The required lifestyle changes are known and effective medications are available. The challenge is for all interested parties-including nurses, nurse practitioners, doctors, pharmacists, other health care professionals, employers, and health plans-to help patients achieve behavioral changes.

Predicting intentions to use research evidence for carpal tunnel syndrome treatment decisions among certified hand therapists

INTRODUCTION

Research evidence is not routinely used for clinical decisions among rehabilitation practitioners. The purpose of this study was to model the predictors of intention to use research evidence for carpal tunnel syndrome (CTS) clinical decisions among certified hand therapists (CHTs).

METHODS

A total of 308 American CHTs (M age = 46 years, SD = 8.1, M clinical experience = 21 years, SD = 8.2) completed a validated mail survey measuring the variables of intention, attitudes, subjective norms, self-efficacy, workload, and autonomy. Structural equation modeling was used to test the overall model and estimate the direct and indirect relationships of study variables on intention.

RESULTS

The model demonstrated excellent overall fit and explained 52% of the variance in intention. The direct significant predictors of intention were attitudes (β = 0.43) and subjective norms (β = 0.34) (Ps = 0.00). Self-efficacy and workload did not directly significantly predict intention (Ps = 0.82/0.09, respectively). Workload and autonomy did not indirectly significantly predict intention (Ps = 0.82/0.07, respectively). Neither did workload significantly predict attitudes (P = 0.06). There were no direct or indirect effects of autonomy, self-efficacy, or workload on the intention to use research evidence. However, autonomy significantly predicted self-efficacy (β = 0.36, P = 0.00).

CONCLUSIONS

Intention to use research evidence in clinical practice is a complex yet predictable phenomenon. Attitudes and subjective norm were identified as significant predictors of intention. Workload, autonomy and self-efficacy did not directly or indirectly effect intentions for research use. Altering subjective norms and managing attitudes about research are recommended as key factors for increasing the use of research evidence for clinical decisions among CHTs.

Collaborative cardiac care service: a multidisciplinary approach to caring for patients with coronary artery disease

BACKGROUND

Coronary artery disease (CAD) remains the leading cause of death in the US. In 1996, Kaiser Permanente of Colorado (KPCO) developed the Collaborative Cardiac Care Service (CCCS) with the goal of improving the health of patients with CAD.

DESCRIPTION

CCCS consists of a nursing team (the KP Cardiac Rehabilitation program) and a pharmacy team (the Clinical Pharmacy Cardiac Risk Service). CCCS works collaboratively with patients, primary care physicians, cardiologists, and other health care professionals to coordinate proven cardiac risk reduction strategies for patients with CAD. Activities such as lifestyle modification, medication initiation and adjustment, patient education, laboratory monitoring, and management of adverse events are all coordinated through CCCS. The CCCS uses an electronic medical record and patient-tracking software to document all interactions with patients, track patient appointments, and collect data for evaluation of both short- and long-term outcomes.

OUTCOMES

The CCCS currently follows over 12,000 patients with CAD. The CCCS has demonstrated improvement in surrogate outcomes including: cholesterol screening (55% to 96.3%), the proportion of patients with a goal of low-density lipoprotein cholesterol (LDL-c) <100 mg/dL (22% to 76.9%), and has reduced the average LDL-c to 78.3 mg/dL for the CAD population it follows. The CCCS has shown a reduction in all-cause mortality associated with CAD by 76% in the patients followed by the service. Patient and physician satisfaction have been high with CCCS.

CONCLUSION

The CCCS coordinates many aspects of cardiac risk reduction care resulting in excellent continuity of care. The CCCS has continued to grow and expand the number of patients enrolled by using innovative strategies and technology and has resulted in excellent care and improved outcomes of the CAD population at KPCO.

Interventions encouraging the use of systematic reviews in clinical decision-making: a systematic review

BACKGROUND

Systematic reviews have the potential to inform clinical decisions, yet little is known about the impact of interventions on increasing the use of systematic reviews in clinical decision-making.

PURPOSE

To systematically review the evidence on the impact of interventions for seeking, appraising, and applying evidence from systematic reviews in decision-making by clinicians.

DATA SOURCES

Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and LISA were searched from the earliest date available until July 2009.

STUDY SELECTION AND DATA EXTRACTION

Two independent reviewers selected studies for inclusion if the intervention intended to increase seeking, appraising, or applying evidence from systematic reviews by a clinician. Information about the study population, features of each intervention, methods used to measure the use of systematic reviews and those used to measure professional performance or health care outcomes, existence and use of statistical tests, study outcomes, and comparative data were extracted.

DATA SYNTHESIS

A total of 8,104 titles and abstracts were reviewed, leading to retrieval of 189 full-text articles for assessment; five of these studies met all inclusion criteria. All five studies reported on professional performance behavior; none reported on patient health outcomes. One study reported positive outcomes in improving preventive care. Three studies focused on obstetrical care, with two reporting no impact on professional practice change, and one study reporting increases in the use of prophylactic oxytocin and episiotomy. One study found no improvement in the sealant rate of newly erupted molars among dentists in Scotland.

LIMITATIONS

The small number of studies available for examination indicates the difficulty in summarizing and identifying key aspects in successful strategies that encourage clinicians to use systematic reviews in decision-making. Other concerns lay in selective reporting and lack of blinding during data collection.

CONCLUSIONS

The limited empirical data render the strength of evidence weak for the effectiveness and types of interventions that encourage clinicians to use systematic reviews in clinical decision making.

The association between achieving low-density lipoprotein cholesterol (LDL-C) goal and statin treatment in an employee population

Statin medications are recommended for patients who have not achieved low-density lipoprotein cholesterol (LDL-C) goals through lifestyle modifications. The objective of this retrospective observational study was to examine statin medication usage patterns and the relationship with LDL-C goal levels (according to Adult Treatment Panel III guidelines) among a cohort of employees of a major financial services corporation. From 1995 to 2004, a total of 1607 executives participated in a periodic health examination program. An index date was assigned for each study participant (date of their exam) and statin medication usage was determined from the pharmacy claims database for 365 days before the index date. Patients were identified as adherent to statins if the medication possession ratio was > or =80%. In all, 150 (9.3%) executives filled at least 1 statin prescription in the 365 days prior to their exam. A total of 102 statin users (68%) were adherent to statin medication. Among all executives who received statin treatment, 70% (odds ratio [OR] = 2.30, 95% confidence interval [CI] = 1.82, 2.90) achieved near-optimal (<130 mg/dL) and 30% (OR = 1.78, 95% CI = 1.15, 2.76) achieved optimal (<100 mg/dL) LDL-C goals, which is significantly higher than the rates among statin nonusers (55% and 21%). Adherent statin users were more likely to achieve recommended near-optimal LDL-C goals compared to statin nonusers (overall P = 0.002; adherent: OR = 2.75, 95% CI = 1.662, 4.550), while nonadherent statin users were more likely to achieve the optimal goal compared to statin nonusers (OR = 2.223; CI = 1.145, 4.313). Statin usage was associated with improvements in LDL-C goal attainment among executives who participated in a periodic health examination. Appropriate statin medication adherence should be encouraged in working populations in order to achieve LDL-C goals.

Barriers to the implementation of practice guidelines in managing patients with nonvariceal upper gastrointestinal bleeding: A qualitative approach

BACKGROUND/OBJECTIVE

Guidelines for the management of patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) are inconsistently applied by health care providers, potentially resulting in suboptimal care and patient outcomes. A needs assessment was performed to assess health care providers' barriers to the implementation of these guidelines in Canada.

METHODS

Semistructured telephone interviews were conducted by trained research personnel with 22 selectively sampled health care professionals actively treating and managing NVUGIB patients, including emergency room physicians (ER), intensivists (ICU), gastroenterologists (GI), gastroenterology nurses and hospital administrators. Participants were chosen from a representative sample of six Canadian community- and academic-based hospitals that participated in a national Canadian audit on the management of NVUGIB.

RESULTS

Participants reported substantive gaps in the implementation of NVUGIB guidelines that included the following: lack of knowledge of the specifics of the NVUGIB guidelines (ER, ICU, nurses); limited belief in the value of guidelines, especially in areas where evidence is lacking (ER, ICU); limited belief in the value of available tools to support implementation of guidelines (GI); lack of knowledge of the roles and responsibilities of health care professions and disciplines, and lack of effective collaboration skills (ER, ICU and GI); variability of knowledge and skills of health care professionals within professions (eg, variability of nurses' knowledge and skills in endoscopic procedures); and perceived overuse of intravenous proton pump inhibitor treatment, with limited concern regarding cost or side effect implications (all participants).

CONCLUSIONS

In the present study population, ER, ICU and nurses did not adhere to NVUGIB guidelines because they were neither aware of nor familiar with them, whereas the GI lack of adherence to NVUGIB guidelines was influenced more by attitudinal and contextual barriers. These findings can guide the design of multifaceted educational and behavioural interventions when attempting to effectively disseminate existing guidelines, and for guideline implementation into practice.

Increase in lipid-lowering treatment rates among TRICARE beneficiaries: a population-based study

PURPOSE

To evaluate the use of lipid-lowering treatment (LLT) among patients at risk for cardiovascular disease (CVD) in the US Military Health System (MHS).

METHODS

The study examined healthcare service and prescription records among beneficiaries > or =18 years for calendar years 2002, 2004, and 2006. Patients were categorized based on cardiovascular (CV) risk, with exposure to LLT defined as one or more prescriptions for lipid-lowering medication. Logistic regression models estimated odds of treatment in 2004 and 2006 relative to 2002 after adjustment for age, gender, and CV risk.

RESULTS

The yearly unadjusted population prevalence of LLT increased from 9.3% in 2002 to 14.7% in 2006. Among subjects with the highest CV risk, established coronary artery disease (CAD) or peripheral vascular disease (PVD), those receiving LLT increased from 55% in 2002 to 65% in 2006 (adjusted OR = 1.50, 95% CI 1.48, 1.52, p < 0.00). Treatment rates among diabetic patients with no coded CAD or PVD showed the largest relative increase from 47% in 2002 to 66% in 2006 (adjusted OR = 2.30, 95% CI 2.26, 2.332, p < 0.00). LLT growth was lowest among those with only 1 coded CV risk factor (adjusted OR = 1.32, 95% CI 1.31, 1.34, p < 0.00).

CONCLUSIONS

The MHS experienced a significant increase in LLT among patients at greatest risk for cardiovascular disease. However, treatment may still be underutilized as approximately one-third of high-risk patients did not receive lipid-lowering medication.

Lipid testing among patients beginning statin therapy in general practice in the United Kingdom

OBJECTIVES

To determine the frequency of lipid testing and to identify the factors predictive of lipid-testing frequency over a 1-year period in patients beginning statin treatment.

METHODS

Retrospective cohort study performed using the UK General Practice Research Database. The patients were selected if they were > or = 35 years of age, received first-ever statin between January 2000 and December 2004, had at least one total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), or triglyceride (TG) test conducted in the 1-year period before statin initiation, and had at least 1 year of follow-up data. The main outcome measures were TC, HDL-C, and TG testing frequencies in the year after initiating statins. Poisson regression was used to assess baseline factors associated with testing frequency for each lipid.

RESULTS

In the year after initiating statins, the patients received a mean (+/-SD) of 1.3 (+/-1.0) TC tests, 0.9 (+/-1.0) HDL-C tests, and 0.9 (+/-1.0) TG tests; however, 22.7%, 44.3%, and 39.1% of the patients did not receive any TC, HDL-C, and TG tests, respectively. In multivariate analyses, a high coronary heart disease (CHD) risk (odds ratio [OR] 1.04; 95% confidence interval [CI] 1.01-1.07) and elevated baseline TC (> or = 6.2 vs. < 5.0 mmol/L; OR 1.12; 95% CI 1.06-1.18) were significantly associated with greater TC testing frequency.

CONCLUSIONS

High risk of CHD and elevated baseline TC were associated with greater rates of TC testing in the year after statin initiation. Lack of TC testing in approximately one in five patients, and infrequent HDL-C and TG testing may be barriers to comprehensive lipid management.

Clinical pharmacy cardiac risk service for managing patients with coronary artery disease in a health maintenance organization

PURPOSE

A clinical pharmacy service for managing the treatment of coronary artery disease in a health maintenance organization is described.

SUMMARY

Despite the proven benefits of aggressive risk factor modification for patients with coronary artery disease (CAD), there remains a treatment gap between consensus- and evidence-based recommendations and their application in patient care. In 1998, Kaiser Permanente of Colorado developed the Clinical Pharmacy Cardiac Risk Service (CPCRS) to focus on the long-term management of patients with CAD to improve clinical outcomes. The primary goals of the CPCRS are to increase the number of CAD patients on lipid-lowering therapy, manage medications shown to decrease the risk of future CAD-related events, assist in the monitoring and control of other diseases that increase cardiovascular risk, provide patient education and recommendations for nonpharmacologic therapy, and act as a CAD information resource for physicians and other health care providers. Using an electronic medical record and tracking database, the service works in close collaboration with primary care physicians, cardiologists, cardiac rehabilitation nurses, and other health care providers to reduce cardiac risk in the CAD population. Particular attention is given to dyslipidemia, blood pressure, diabetes mellitus, and tobacco cessation. Treatment with evidence-based regimens is initiated and adjusted as necessary. Over 11,000 patients are currently being followed by the CPCRS.

CONCLUSION

A clinical pharmacy service in a large health maintenance organization provides cardiac risk reduction for patients with CAD and helps close treatment gaps that may exist for these patients.

Continuing education, guideline implementation, and the emerging transdisciplinary field of knowledge translation

This article discusses continuing education and the implementation of clinical practice guidelines or best evidence, quality improvement, and patient safety. Continuing education focuses on the perspective of the adult learner and is guided by well-established educational principles. In contrast, guideline implementation and related concepts borrow from the fields of quality improvement and patient safety and from health services research. Relative to the question of improved clinical outcomes, both to some extent afford only partial understanding of a complex issue. Knowledge translation (KT) is a transformative concept that links the best elements of both broad fields and, in particular, adds educational elements to the work of health services researchers and others. Interdisciplinary in the extreme, KT is explored in some detail: its major elements (information, facilitation, context, the clinician-learner, among others) considered as variables in an equation leading to knowledge uptake and improved health care outcomes and an improved functioning health care system.

Kaiser Permanente Colorado Region Pharmacy Department: Innovative Leader in Pharmacy Practice

OBJECTIVE

To describe innovative programs within the Kaiser Permanente Pharmacy Department in the Colorado Region.

SETTING

One of eight regions of the nation's largest nonprofit health maintenance organization.

PRACTICE DESCRIPTION

The pharmacy department comprises two services, Clinical Pharmacy Services and Pharmacy Operations/Support Services, which are integrated to provide comprehensive care.

PRACTICE INNOVATION

Within Clinical Pharmacy Services, the Primary Care Clinical Pharmacy Services team works alongside physicians to provide integrated patient care. The Centralized Clinical Pharmacy Service teams manage large groups of patients effectively and efficiently. The Clinical Pharmacy Specialty staff and the Disease State Management clinical pharmacy specialists provide focused drug therapy expertise.

MAIN OUTCOME MEASURES

Clinical and economic outcomes; recognition by national organizations.

RESULTS

Technological innovations are used within Pharmacy Operations/Support Services to increase pharmacists' time for patient care activities. The use of technology by the Pharmacy Automated Refill Center and the implementation of ScriptPro in the medical office pharmacies decrease dispensing demands by processing large volumes of prescriptions. Workflow in the medical office pharmacies has also been reengineered to increase efficiency. Various programs have been developed by the Pharmacy Information Technology Service to support patient care initiatives. Benchmark clinical and economic outcomes have been demonstrated. Positive outcomes have also resulted in quality and safety awards and captured the attention of national pharmacy and medical organizations.

CONCLUSION

The Colorado Region Pharmacy Department has been recognized as a leader in pharmacy practice through the development of innovative services that provide exceptional patient care.

An Assessment of Patient Knowledge and Awareness of Issues Surrounding Cholesterol Risk Management

Background:

A lack of patient understanding and awareness of issues surrounding cholesterol risk management may be one reason that a significant number of patients receiving cholesterol-lowering therapy do not achieve optimal cholesterol levels. This study was conducted to assess patients' knowledge and awareness of issues surrounding cholesterol risk management.

Methods:

Community pharmacists within the Edmonton, Alberta, area were identified and asked to recruit patients within their practice who had been receiving cholesterol-lowering therapy for a minimum of six weeks. A 32-question telephone survey was developed and used as the instrument to assess patient knowledge and awareness. All surveys were conducted by the same individual, and data analysis was primarily descriptive.

Results:

Seventeen community pharmacies recruited 136 potential subjects over an eight-week period. Surveys were conducted with 105 (77%) of the eligible subjects. Of those surveyed, 37% identified elevated cholesterol as a risk factor for heart disease. While the majority of respondents felt it important to know their cholesterol targets (82%) and their specific levels (91%), only 23% and 29% of respondents indicated that they knew their high-density lipoprotein cholesterol and low-density lipoprotein cholesterol levels, respectively. Gaps in knowledge with respect to cholesterol-lowering therapy also existed.

Conclusions:

The results of this survey indicate gaps in patient knowledge of various issues surrounding cholesterol risk management. Pharmacists are in an excellent position to provide better education to patients about cholesterol levels and cardiovascular disease risk management. Further research is required to determine whether improved patient knowledge leads to improved clinical outcomes.

Relationship between major depression and high serum cholesterol in Japanese men

Although it has been argued that those with lower levels of serum cholesterol are likely to be depressive, the findings are inconsistent. The present study attempted to clarify the relationship between major depression and serum total cholesterol in a working population. Subjects were 987 Japanese men working at an institute, aged 20 to 64 years. In addition to blood examinations and physical measurements, clinical structured interviews of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) were used to detect major depression. The prevalence of major depression was higher in the hypercholesterolemics (serum total cholesterol levels > or = 5.69 mmol/liter) than in the normocholesterolemics (3.10-5.69 mmol/liter) (6.1% vs 1.8%, p < 0.05). Notably, there was no case with major depression among the hypocholesterolemics (< 3.10 mmol/liter). Through a multiple regression analysis, serum total cholesterol levels were positively predicted by the following four variables: major depression, age, body mass index, and skipping breakfast (all p < 0.01). Concerning those diagnosed with major depression, serum total cholesterol levels remained higher in the following year (p < 0.05), comparing to those without such diagnosis. Therefore, depression is associated with higher serum cholesterol levels in a population of Japanese male workers. The irregularity of eating behavior may be one of the factors mediating high serum cholesterol levels and major depression.

Impact of medication adherence on hospitalization risk and healthcare cost

OBJECTIVE

The objective of this study was to evaluate the impact of medication adherence on healthcare utilization and cost for 4 chronic conditions that are major drivers of drug spending: diabetes, hypertension, hypercholesterolemia, and congestive heart failure.

RESEARCH DESIGN

The authors conducted a retrospective cohort observation of patients who were continuously enrolled in medical and prescription benefit plans from June 1997 through May 1999. Patients were identified for disease-specific analysis based on claims for outpatient, emergency room, or inpatient services during the first 12 months of the study. Using an integrated analysis of administrative claims data, medical and drug utilization were measured during the 12-month period after patient identification. Medication adherence was defined by days' supply of maintenance medications for each condition.

PATIENTS

The study consisted of a population-based sample of 137,277 patients under age 65.

MEASURES

Disease-related and all-cause medical costs, drug costs, and hospitalization risk were measured. Using regression analysis, these measures were modeled at varying levels of medication adherence.

RESULTS

For diabetes and hypercholesterolemia, a high level of medication adherence was associated with lower disease-related medical costs. For these conditions, higher medication costs were more than offset by medical cost reductions, producing a net reduction in overall healthcare costs. For diabetes, hypercholesterolemia, and hypertension, cost offsets were observed for all-cause medical costs at high levels of medication adherence. For all 4 conditions, hospitalization rates were significantly lower for patients with high medication adherence.

CONCLUSIONS

For some chronic conditions, increased drug utilization can provide a net economic return when it is driven by improved adherence with guidelines-based therapy.

National trends in statin use by coronary heart disease risk category

BACKGROUND

Only limited research tracks United States trends in the use of statins recorded during outpatient visits, particularly use by patients at moderate to high cardiovascular risk.

METHODS AND FINDINGS

Data collected between 1992 and 2002 in two federally administered surveys provided national estimates of statin use among ambulatory patients, stratified by coronary heart disease risk based on risk factor counting and clinical diagnoses. Statin use grew from 47% of all lipid-lowering medications in 1992 to 87% in 2002, with atorvastatin being the leading medication in 2002. Statin use by patients with hyperlipidemia, as recorded by the number of patient visits, increased significantly from 9% of patient visits in 1992 to 49% in 2000 but then declined to 36% in 2002. Absolute increases in the rate of statin use were greatest for high-risk patients, from 4% of patient visits in 1992 to 19% in 2002. Use among moderate-risk patients increased from 2% of patient visits in 1992 to 14% in 1999 but showed no continued growth subsequently. In 2002, 1 y after the release of the Adult Treatment Panel III recommendations, treatment gaps in statin use were detected for more than 50% of outpatient visits by moderate- and high-risk patients with reported hyperlipidemia. Lower statin use was independently associated with younger patient age, female gender, African American race (versus non-Hispanic white), and non-cardiologist care.

CONCLUSION

Despite notable improvements in the past decade, clinical practice fails to institute recommended statin therapy during many ambulatory visits of patients at moderate-to-high cardiovascular risk. Innovative approaches are needed to promote appropriate, more aggressive statin use for eligible patients.

Long-Term Impact of a Community Pharmacist Intervention on Cholesterol Levels in Patients at High Risk for Cardiovascular Events: Extended Follow-up of the Second Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP-plus)

STUDY OBJECTIVE

To determine the effect of a community pharmacist intervention in patients at high risk for coronary heart disease on low-density lipoprotein cholesterol (LDL) levels 1 year after completion of the Second Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP- plus ).

METHODS

Patients who completed the original study were invited to make a single return visit to their community pharmacy so that the pharmacist could measure their fasting LDL level using a point-of-care device. The primary outcome was change in LDL level from the 6-month (final) visit to the extended follow-up evaluation.

RESULTS

Of the 359 patients who completed the original 6-month visit, data were collected for 162 (45%) patients. The mean +/- SD LDL level at completion of the original study was 107.9 +/- 33.6 mg/dl (2.79 +/- 0.96 mmol/L) (an increase of 2.7 mg/dl [0.07 mmol/L], 95% confidence interval -19.3-7.3 [-0.5-0.19]). Sixty-one (38%) patients were at the target LDL level (< 96.7 mg/dl [< 2.50 mmol/L]).

CONCLUSION

The LDL reduction was maintained 1 year after completion of the extended follow-up. Since most patients were still not at the target LDL level, this finding suggests that continuing intervention is necessary to help patients reach this target.

Population implications of changes in lipid management in patients with coronary heart disease

Pharmacologic treatment and goal attainment rates from published literature indicate that lipid management has generally improved for patients with coronary heart disease. The population implications of these changes in lipid management are examined, suggesting that the challenge of lipid management may be shifting from a problem of no treatment to one of undertreatment.

Development and validation of the hyperlipidemia: attitudes and beliefs in treatment (HABIT) survey for physicians

INTRODUCTION

Many patients treated with lipid-lowering medications in clinical practice do not achieve targeted National Cholesterol Education Program (NCEP) goals for low-density lipoprotein cholesterol (LDL-C), despite the proven efficacy of these medications. Understanding physician attitudes and beliefs about treating patients to goal may be useful in improving patient care and ensuring that all patients receive the benefits of treatments shown to be optimal in clinical trials.

OBJECTIVE

To develop a theoretically based, and statistically reliable and valid survey instrument for measuring the attitudes and beliefs of physicians toward hyperlipidemia and its treatment, including treatment of patients to goal. To determine whether the attitudes measured were associated with physician intentions to treat patients to LDL-C goal.

METHODS

We assessed the reliability of the instrument through an examination of the internal consistency and factor structure of the constructs. Validity was assessed through zero-order correlations among the constructs and the relationship between the constructs and an intent to treat to goal case study.

RESULTS

Internal consistency scores for the 8 constructs ranged from 0.48 to 0.75. Factor loadings indicated that the individual items belonged to their respective constructs, as hypothesized. The predictive validity of the instrument was demonstrated by significant relationships between 5 of the 8 attitudinal constructs and an intent to treat to goal case study.

CONCLUSIONS

The HABIT physician survey is the first validated instrument covering a broad set of attitudes about the treatment of hyperlipidemia that are both theoretically and empirically linked to physician intent to treat to NCEP LDL-C goal.

Improving cardiovascular health in postmenopausal women by addressing medication adherence issues

OBJECTIVE

To review medication adherence issues that relate to managing cardiovascular health in postmenopausal women and to explore strategies pharmacists can use to improve outcomes by identifying and resolving adherence problems.

DATA SOURCES

Published articles identified through MEDLINE using the search terms adherence, compliance, cardiovascular, and menopause. Additional articles and data were identified from the bibliographies of the retrieved articles and from Web sites and reports from the National Council on Patient Information and Education, North American Menopause Society, American College of Obstetricians and Gynecologists, and American Heart Association.

DATA SYNTHESIS

Cardiovascular disease is the leading killer of women, a fact many women do not recognize. Although effective pharmacologic treatments for managing risk factors for cardiovascular disease have been developed, these therapies are underprescribed, and patient adherence to them is often poor. Efforts to increase postmenopausal women's awareness of cardiovascular disease and the efficacy of therapeutic regimens can help improve such patients' adherence to these lifesaving treatments.

CONCLUSION

As one of the most accessible health care professionals, pharmacists are well positioned to provide counseling about the importance of medication adherence, help measure and optimize outcomes from medication use, and help patients find objective and authoritative sources of information about their conditions. By working with postmenopausal women to enhance their adherence, pharmacists can help them improve their cardiovascular health.