# Presentation: 489226

## LDL Program

- Medical Management

**Philip E. Johnston, Pharm.D.**

## 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. 

- 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

## A Collaborative Approach

- Physician
- Nurse
- Clinic Assistant
- Data Manager
- Pharmacist
- Patient

## 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

## What are the Evidence-Based Guidelines?

## Update or No Update ?

- 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.

## 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

**Notes:**
Use each quadrant of the diagram to review the steps of the P-D-S-A cycle.  This was introduced at LS1 and the teams should be familiar with it.   

## 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

## Statin Use Guidelines

## Initial Patient Information

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

## Proper 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

**Notes:**
Use each quadrant of the diagram to review the steps of the P-D-S-A cycle.  This was introduced at LS1 and the teams should be familiar with it.   

## Project Process

**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

## 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

## 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

## 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

## Action Results

| New Appointments Made | 20 |
| --- | --- |
| New Prescription Ordered | 59 |
| Lab Drawn | 181 |

## 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

**Notes:**
Use each quadrant of the diagram to review the steps of the P-D-S-A cycle.  This was introduced at LS1 and the teams should be familiar with it.   

## 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) |

## Change in LDL

## Patient Numbers March – October 2006

## 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 **

**Notes:**
Use each quadrant of the diagram to review the steps of the P-D-S-A cycle.  This was introduced at LS1 and the teams should be familiar with it.   

## Effectiveness and Efficiency

** ****Activity can be continued **
** ****Pursue other diseases and other **
** ****Involve other clinics**
** ****Implement New Protocols **
** ****Are Evidence based**
**Are Cost effective**
**$5-10 per patient**
**Outcomes are Measurable**
**Methods are Reproducible**