1. LDL Program Medical Management Philip E. Johnston, Pharm.D.

2. Disease Management 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

3. A Collaborative Approach Physician Physician Nurse Nurse Clinic Assistant Clinic Assistant Data Manager Data Manager Pharmacist Pharmacist Patient Patient

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

5. What are the Evidence-Based Guidelines?

6. Update or No Update ? The trials support these facts: The trials support these facts: ATP III treatment goal of low-density lipoprotein cholesterol (LDL-C) remains <100 mg/dL 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. Patients with diabetes are in the high-risk category and benefit from lowering of LDL. Older persons benefit from lowering of LDL-C Older persons benefit from lowering of LDL-C A major recommendation for modifications is the following: 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 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.

7. The PDSA Cycle ActPlan StudyDo 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

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

10. Statin Use Guidelines

11. Initial Patient Information Patients between 101 and 105 24 Patients to be assessed 120 Number at Goal 0 Average LDL 126.7

12. Proper Medications for Patients

13. The PDSA Cycle Act Plan StudyDo 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

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

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 Total136 NOTE: Patients may be counted more than once

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

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

18. Action Results New Appointments Made 20 New Prescription Ordered 59 Lab Drawn 181

19. The PDSA Cycle Act Plan StudyDo 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

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)

21. Change in LDL

22. Patient Numbers March – October 2006

23. The PDSA Cycle Act Plan StudyDo 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

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