LDL ProgramLDL ProgramMedical Medical

ManagementManagement

Philip E. Johnston, Pharm.D.

Disease ManagementDisease Management a strategy of delivering health care services a strategy of delivering health care services

using using interdisciplinary interdisciplinary clinical teams, clinical teams, continuous analysis of relevant continuous analysis of relevant datadata, and , and cost-effective technology to improve the cost-effective technology to improve the health health outcomes outcomes of patients with specific of patients with specific diseases. It includes diseases. It includes self-care self-care management management techniques, techniques, patient educationpatient education, and provider , and provider training. Disease management provides training. Disease management provides individualized care plans based on clinical individualized care plans based on clinical guidelinesguidelines to manage individuals with to manage individuals with treatable treatable chronic diseaseschronic diseases. .

Medicaid Disease Management and Health Outcomes - sponsored by National Pharmaceutical Council

A Collaborative ApproachA Collaborative Approach

PhysicianPhysician NurseNurse Clinic AssistantClinic Assistant Data ManagerData Manager PharmacistPharmacist PatientPatient

FOCUS - FOCUS - HyperlipidemiaHyperlipidemia BackgroundBackground – ATP III Guidelines – ATP III Guidelines Focused PatientsFocused Patients – Adult APCC patients with – Adult APCC patients with

hyperlipidemia likely to be responsive to oral hyperlipidemia likely to be responsive to oral therapytherapy

ConceptConcept – Agree on a treatment protocol by – Agree on a treatment protocol by type rather than specific medicationtype rather than specific medication

GoalsGoals – – Goal of 100 per ATP III GuidelinesGoal of 100 per ATP III Guidelines Consensus of faculty by March 1Consensus of faculty by March 1 Conduct patient interventions March 15 – October 15Conduct patient interventions March 15 – October 15

What are the Evidence-Based What are the Evidence-Based Guidelines?Guidelines?

Update or No Update ?Update or No Update ? The trials support these facts:The trials support these facts:

ATP III treatment ATP III treatment goal of low-density lipoproteingoal of low-density lipoprotein cholesterol (LDL-C) remains cholesterol (LDL-C) remains <100 mg/dL<100 mg/dL

Patients with diabetesPatients with diabetes are in the high-risk category are in the high-risk category and benefit from lowering of LDL. and benefit from lowering of LDL.

Older personsOlder persons benefit from lowering of LDL-C benefit from lowering of LDL-C

A major recommendation for modifications is the A major recommendation for modifications is the following: following: In high-risk personsIn high-risk persons, the recommended LDL-C goal is , the recommended LDL-C goal is

<100 mg/dL, but when risk is very high, an LDL-C <100 mg/dL, but when risk is very high, an LDL-C goal of goal of <70<70 mg/dL is a therapeutic option mg/dL is a therapeutic option

Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT, Hunninghake DB, Pasternak RC, Smith SC Jr, Stone NJ; National Heart, Lung, and Blood Institute; American College of Cardiology Foundation; American Heart Association. Implications of recent clinical trials for the National Cholesterol

Education Program Adult Treatment Panel III guidelines. Circulation. 2004 Aug 10;110(6):763.

The PDSA Cycle

Act Plan

Study Do

Use ATP III Guidelines

Improve LDL monitoring

Focus on optimal LDL control

Apply life style changes

Utilize medication

Recommend plan to PCP Pharmacist handles changes Evaluate from 3/06 to 10/06

Number of interventions Percent accepted Time to decisions New interventions Number at goal Is this effective Are physicians accepting

Activity can be continued For other diseases and other Begin in other clinics Protocols can be implemented For other chronic needs

The PlanThe Plan

Learn ATP III GuidelinesLearn ATP III Guidelines Identified 120 patients with LDL over 100Identified 120 patients with LDL over 100 Base LDL value within one yearBase LDL value within one year Evaluate history of the patientEvaluate history of the patient Eliminate terminal patientsEliminate terminal patients Collect baseline informationCollect baseline information

Statin Use Statin Use GuidelinesGuidelines

LDL > 100 mg/dl

LDL> 130 mg/dl

LDL, HDL, and TG should be measured

annually

Initiate statin therapy along with lifestyle

modifications.

Lifestyle modifications* to reach LDL goal < 100mg/dl.

Recheck in 3 months.

LDL > 100 mg/dl after 3 months of lifestyle

modifications

Continue lifestyle modifications and

recheck every 6 months.

No

Yes

No

Yes

Patient tolerates statin without liver enzyme elevation

No

Refer to physician for alternative treatment

No

Yes

LDL > 100 mg/dl after 6 months

Consider increasing dose

or consulting physician for alternative

Continue and recheck annually

No

Yes

Yes

Continue statin modifications and recheck every 6

months.

Initial Patient InformationInitial Patient Information

Patients between 101 and 105 Patients between 101 and 105 2424

Patients to be assessedPatients to be assessed 120120

Number at GoalNumber at Goal 00

Average LDLAverage LDL 126.7126.7

Proper Medications for PatientsProper Medications for Patients

The PDSA Cycle

Act Plan

Study Do

Use ATP III Guidelines

Improve LDL monitoring

Focus on optimal LDL control

Apply life style changes

Utilize medication

Recommend plan to PCP Pharmacist handles changes Evaluate from 3/06 to 9/06

Number of interventions Percent accepted Time to decisions New interventions Number at goal Is this effective Are physicians accepting

Activity can be continued For other diseases and other Begin in other clinics Protocols can be implemented For other chronic needs

Project ProcessProject Process

Review Medical Record and

Determine TherapyRecommendation Inform PCP of Plan

Wait on Answers

Act on or amend the plan

Call and advise patientSend patient letterPrepare lab sheetSend education

Call a new prescriptionFollow up

Medical Record Updates

Interaction with PCPInteraction with PCPRecommendations with a yes Recommendations with a yes responseresponse

128128

Recommendations with a partial yes Recommendations with a partial yes responseresponse

22

Recommendations with a no responseRecommendations with a no response 55

Recommendations with an alternative Recommendations with an alternative responseresponse

11

TotalTotal 136136NOTE: Patients may be counted more than once

Actions Agreed UponActions Agreed Upon

Patients Receiving CallsPatients Receiving Calls 105105

Patients Receiving LettersPatients Receiving Letters 3333

Other – (saw with PCP)Other – (saw with PCP) 33

Patients Receiving Call and Patients Receiving Call and LetterLetter

22

Total ActionsTotal Actions 143143

NOTE: Patients may be counted more than once

Actions InitiatedActions InitiatedPlans DevelopedPlans Developed 120120

Information GivenInformation Given 107107

New Drug DoseNew Drug Dose 4646

New Drug StartedNew Drug Started 4545

Drug Refills Drug Refills 22

New Lab OrderedNew Lab Ordered 201201

NOTE: Patients may be counted more than once

Action ResultsAction Results

New Appointments MadeNew Appointments Made 2020

New Prescription OrderedNew Prescription Ordered 5959

Lab DrawnLab Drawn 181181

The PDSA Cycle

Act Plan

Study Do

Use ATP III Guidelines

Improve LDL monitoring

Focus on optimal LDL control

Apply life style changes

Utilize medication

Review patients records Recommend plan to PCP Pharmacist handles changes Evaluate from 3/06 to 9/06

Number of interventions Percent accepted Time to decisions New interventions Number at goal Is this effective Are physicians accepting

Activity can be continued For other diseases and other Begin in other clinics Protocols can be implemented For other chronic needs

Action ResultsAction Results

Percent of Recommendations Percent of Recommendations AcceptedAccepted

94.1%94.1%

Time in Days to Receive PCP Time in Days to Receive PCP ResponseResponse

0.68 (0-9)0.68 (0-9)

Time in Days to Complete New Time in Days to Complete New PlanPlan

2.45 (0-24)2.45 (0-24)

Change in LDLChange in LDL

100

105

110

115

120

125

130

Initial Mar Apr May Jun Jul Aug Sep Oct

Patient Numbers Patient Numbers March – October 2006March – October 2006

0

20

40

60

80

100

120

140

Initial Mar Apr May Jun Jul Aug Sep Oct

Total Pts Number at Goal

The PDSA Cycle

Act Plan

Study Do

Use ATP III Guidelines

Improve LDL monitoring

Focus on optimal LDL control

Apply life style changes

Utilize medication

Review patients records Recommend plan to PCP Pharmacist handles changes Evaluate from 3/06 to 9/06

Number of interventions Percent accepted Time to decisions New interventions Number at goal Is this effective Are physicians accepting

Activity can be continued For other diseases and other Begin in other clinics Protocols can be implemented

Effectiveness and EfficiencyEffectiveness and Efficiency

Activity can be continued Activity can be continued Pursue other diseases and other Pursue other diseases and other Involve other clinicsInvolve other clinics Implement New Protocols Implement New Protocols Are Evidence basedAre Evidence based Are Cost effectiveAre Cost effective

$5-10 per patient$5-10 per patient Outcomes are MeasurableOutcomes are Measurable Methods are ReproducibleMethods are Reproducible