LDL Program Medical Management

Toolkit for Implementing the Chronic Care Model in an Academic Environment

On October 12, 2006, Philip E. Johnson, Pharm.D., made a presentation during the Academic Chronic Care Collaborative (ACCC) site visit to Vanderbilt University Medical Center, entitled LDL Program Medical Management.

This is the text version of Dr. Johnson's slide presentation. Select to access the PowerPoint Version [ - 468.5 KB]

Slide 1

LDL Program Medical Management

Philip E. Johnson, Pharm.D.

Vanderbilt University Medical Center

Slide 2

Disease Management

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

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

Slide 3

A Collaborative Approach

• Physician.
• Nurse.
• Clinic Assistant.
• Data Manager.
• Pharmacist.
• Patient.

Slide 4

Focus—Hyperlipidemia

• Background—ATP III Guidelines.
• Focused Patients—Adult APCC patients with hyperlipidemia likely to be responsive to oral therapy.
• Concept—Agree on a treatment protocol by type rather than specific medication.
• Goals—
• • Goal of 100 per ATP III Guidelines.
  • Consensus of faculty by March 1.
  • Conduct patient interventions March 15-October 15.

Slide 5

What are the Evidence-Based Guidelines?

Slide 6

• The trials support these facts:
  • ATP III treatment goal of low-density lipoprotein cholesterol (LDL-C) remains <100 mg/dL.
  • Patients with diabetes are in the high-risk category and benefit from lowering of LDL.
  • Older persons benefit from lowering of LDL-C.
• A major recommendation for modifications is the following:
  • In high-risk persons, the recommended LDL-C goal is <100 mg/dL, but when risk is very high, an LDL-C goal of <70 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.

Slide 7

The Plan-Do-Study-Act (PDSA) Cycle—Plan

• Use ATP III Guidelines.
• Improve LDL monitoring.
• Focus on optimal LDL control.
• Apply life style changes.
• Utilize medication.

Slide 8

The Plan

• Learn ATP III Guidelines.
• Identified 120 patients with LDL over 100.
• Base LDL value within one year.
• Evaluate history of the patient.
• Eliminate terminal patients.
• Collect baseline information.

Slide 9

Screenshot of a computerized dashboard for a patient with diabetes. It has the patient's name, birthday, and other patient information. It shows blood pressure rate, Hgba1c rate, LDL cholesterol, Ur Microalb rate, and whether the patient has an ACEI/ARB, foot exam, and is self-managing aspects of care.

Screenshot also shows information on medications ad adverse and allergic drug reactions.

Slide 10

Flowchart outlining Statin Use Guidelines

LDL greater than 100 mg/dl: If no, then: LDL, HDL, and TG should be measured annually. If yes, then: Is LDL greater than 130 mg/dl?

If no, then: Make lifestyle modifications to reach LDL goal less than 100 mg/dl. Recheck in three months. Is LDL greater than 100 mg/dl after three months of lifestyle modifications? If no, then: Continue lifestyle modifications and recheck every 6 months. If yes, then: Initiate statin therapy along with lifestyle modifications. Does patient tolerate statin without liver enzyme elevation? If no, then: Refer to physician for alternative treatment.

If yes, then: Continue statin modifications and recheck every 6 months. Is LDL greater than 100 mg/dl after six months? If no, then: Continue and recheck annually. If yes, then: Consider increasing dose or consulting physician for alternative.

Slide 11

Initial Patient Information

Patient between 101 and 105: 24
Patients to be assessed: 120
Number at Goal: 0
Average LDL: 126.7

Slide 12

Proper Medications for Patients

Click icon to add content

Slide 13

The PDSA Cycle—Do

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

Slide 14

Project Process

• Review medical record and determine therapy recommendation.
• Inform PCP of plan.
• Wait on answers.
• Act on or amend the plan.
• Call and advise patient.
• Send patient letter.
• Prepare lab sheet.
• Send education.
• Call a new prescription.
• Follow up.
• Medical Record Updates.

Slide 15

Interaction with PCP

Recommendations with a yes response: 128
Recommendations with a partial yes response: 2
Recommendations with a no response: 5
Recommendations with an alternative response: 1
Total: 136

Note: Patients may be counted more than once.

Slide 16

Actions Agreed Upon

Patients Receiving Calls: 105
Patients Receiving Letters: 33
Other (saw with PCP): 3
Patients Receiving Call and Letter: 2
Total Actions: 143

Note: Patients may be counted more than once.

Slide 17

Actions Initiated

Plans Developed: 120
Information Given: 107
New Drug Dose: 46
New Drug Started: 45
Drug Refills: 2
New Lab Ordered: 201

Note: Patients may be counted more than once.

Slide 18

Action Results

New Appointments Made: 20
New Prescription Ordered: 59
Lab Drawn: 181

Slide 19

The PDSA Cycle—Study

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

Slide 20

Action Results

Percent of Recommendations Accepted: 94.1%
Time in Days to Receive PCP Response: 0.68 (0-9)
Time in Days to Complete New Plan: 2.45 (0-24)

Slide 21

Change in LDL

Line graph showing LDL rate on the left and time span on the bottom (ranging from when the program began, through March, April, May, June, July, August, September, and October). The line shows the LDL rate starting at 125 and remaining there until April. It then drops to below 120 in June and July, and below 115 in August and dropping just above 110 in September and October.

Slide 22

Patient Numbers

March-October 2006

A line graph showing the total number patients on the left and time span on the bottom (ranging from when the program began, through March, April, May, June, July, August, September, and October).

The top line indicates that the number of patients began at 120 and dropped below 120 in April and dropped slightly again in July where it held steady through October.

The bottom line indicates the number of patients at goal over the same period. Beginning at zero before March, the number steadily increases to 20 in June and continues rising steadily until it reaches over 40 in September and October.

Slide 23

The PDSA Cycle—Act

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

Slide 24

Effectiveness and Efficiency

• Activity can be continued.
• Pursue other diseases.
• Involve other clinics.
• Implement new protocols.
• Are evidence based.
• Are cost effective ($5-10 per patient).
• Outcomes are measurable.
• Methods are reproducible.

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