Early, aggressive lipid management with patient tracking improves outcomes

HMO says program should be transferable to open’ health care models

A program that combines early, aggressive lipid management with a patient tracking and follow-up system has nearly tripled the percentage of patients with coronary artery disease (CAD) who achieve low-density lipoprotein cholesterol levels (LDL-C) lower than 100 mg/dL. And the health maintenance organization (HMO) that implemented the program is betting that it is transferable to a more "open" health care model.

Kaiser Permanente Colorado Region in Aurora initiated this program back in 1998 when cardiologists had concerns that member patients were experiencing recurrent events without having their cholesterol controlled or blood pressure managed, says Kari L. Olson, PharmD, BCPS, a clinical pharmacy specialist with Kaiser’s clinical pharmacy cardiac risk service (CPCRS). "The cardiology department wanted something that would help manage these patients over the long term."

The CPCRS program then was developed with strong support from cardiology, pharmacy, internal medicine, and nursing. "The cardiac risk service is dedicated strictly to managing the secondary prevention population," Olson says.

Currently, Kaiser has 17 clinical pharmacy specialists who directly manage these patients.

How the program works

When patients with CAD come to the hospital, an RN-run team manages them, identifies them in the hospital, and works with the cardiologist and medical group to get patients on appropriate medications, Olson explains. The team also follows the patients through rehabilitation for about three to six months after their event.

Once patients have gone through their rehabilitation program, the team sends them to the cardiac risk service. "Then we, as pharmacists, will continue to follow them over the long term. Our program is geared to outpatient management," she reports.

Some CPCRS patients also are referred directly to the program by their physicians or are identified through administrative queries of computerized coding and billing databases. The CPCRS has screened more than 98% of patients who had "unequivocal" CAD. Unequivocal CAD is defined by the presence of acute myocardial infarction (MI), coronary artery bypass graft surgery, percutaneous coronary intervention with or without stent placement, or unstable angina diagnosed and coded by a cardiologist.

Once the patients are enrolled in the program, all of their relevant medical data are entered into a shared, web-based tracking database. The database is regularly updated electronically with administrative, laboratory, pharmacy, diagnosis/procedure, vital sign, and demographic data. CPCRS staff also manually update data as needed.

The CPCRS pharmacists then contact the patients in the service on a regular basis to review their drug treatments and medication adherence. How often they are contacted depends on their medical status, Olson says. "If patients are controlled — the LDL is where it needs to be and blood pressure is good — we might follow them up on a yearly basis." During that contact, the clinical pharmacy specialists make sure the patients are still taking their medications. The pharmacists do a complete medication review and answer any patient questions.

Patients who do not have their cholesterol controlled will be followed in two to three months, Olson says. "If they are still not controlled, we will recommend dosage changes to whatever medications we see that need to be adjusted. Then we bring them back every two to three months until they are controlled."

Study shows improved outcomes

Kaiser recently published a study that evaluated the impact of the CPCRS on patients enrolled in the program between March 1, 1998, and Oct. 1, 2002. The results were published in the Jan. 10 issue of the Archives of Internal Medicine.

The study included a total of 8,014 patients, who had a mean age of 69.3 years. Almost 70% of these patients were men. They were followed by the service for a mean of 2.3 years — 30% of them for more than three years. At study end, a total of 72.9% of patients achieved an LDL-C level of less than 100 mg/dL, compared with 25.5% at baseline. Of patients receiving medication, most (84.8%) were receiving therapy with statins alone. Almost 12% were receiving combination therapy.

Olson, the lead author of the study, attributes several factors to the program’s success. First, the CPCRS team is aggressive in getting patients on higher-than-normal doses of drugs, particularly statins, she says. For example, patients are given simvastatin 40 mg/day or the same amount of another statin immediately after CAD diagnosis. Lifestyle modification with diet and exercise also is emphasized.

Second, pharmacists, who have the expertise in drugs, drug interactions, and interpretation of medical literature, and know how to counsel patients, run the service, she adds. "Pharmacists are in an excellent position to do something like this because the secondary prevention population and management over the long-term is medication-driven."

Third, the database that houses all of the CAD population allows the pharmacists to track patients and schedule follow-up appointments. "We know exactly when the patients are due for follow-up labs and nobody gets lost to follow-up. It’s a systems-based approach to managing these patients."

The results of the program are real, but Kaiser sometimes is criticized that the results aren’t transferable to the "real world," since Kaiser is a closed model HMO Olson says. The HMO disagrees and is looking at setting up a similar program in Colorado Springs and evaluating the outcomes of those patients.

"Colorado Springs has a Kaiser program, but it is an open model, so patients can go to any physician or any pharmacy. It is more typical of what you would see in the real world," Olson says.

Studies show that real-world practices often fall short of treatment guidelines. For example, less than one-third of patients hospitalized with acute MI are put on lipid-lowering therapy at discharge, the pharmacists say in their research. Only 37% of patients with documented CAD achieve LDL-C levels of less than 100 mg/dL; more than half of patients with CAD stop taking their cholesterol-lowing medication during the first year.

Hospital pharmacists are in an ideal position to help manage these patients, Olson says. The pharmacists can help identify these patients, look at their current treatment in the hospital, and make recommendations to physicians. "The key is to get these patients on appropriate medications, especially when they are having their acute coronary event. At the very least, make sure these patients are on aspirin, the statin drugs, beta-blocker post-MI, and ace inhibitors where appropriate at the time of discharge."

Olson recommends the American Heart Association’s "Get with the Guidelines" program for hospital pharmacists looking for solutions in treating patients with CAD. "Get with the Guidelines program offers [interested] hospital teams the full support and guidance on how to get going," she says. For more information on Get with the Guidelines visit the American Heart Association’s web site at www.americanheart.org.