Reducing Low-Density Lipoprotein Cholesterol Levels in an Ambulatory Care System

Shaffer, Judy

doi:10.1001/archinte.1995.00430210080012

Cited by 70 publications

(17 citation statements)

References 20 publications

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“…One effective model tested in clinical trials of hypertension, diabetes mellitus, congestive heart failure, cigarette cessation, and hyperlipidemia, is the use of non-physician health care providers guided by treatment algorithms and physician supervision (Haskell et al, 1994;Lasater, 1996;Mundinger et al, 2000;Schectman et al, 1996;Schultz & Sheps, 1994;Shaffer & Wexler, 1995;Taylor et al, 1990;Weinberger et al, 1995). The current study was an attempt to apply the results of such trials to a 'real world' setting in order to evaluate its costs, applicability, acceptability (to both patients and physicians) and clinical effectiveness.…”

Section: Discussionmentioning

confidence: 99%

Physician–nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients' perception of care

Litaker

Mion

Planavsky

et al. 2003

Journal of Interprofessional Care

221

244

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Increasing demand to deliver and document therapeutic and preventive care sharpens the need for disease management strategies that accomplish these goals efficiently while preserving quality of care. The purpose of this study was to compare selected outcomes for a new chronic disease management program involving a nurse practitioner - physician team with those of an existing model of care. One hundred fifty-seven patients with hypertension and diabetes mellitus were randomly assigned to their primary care physician and a nurse practitioner or their primary care physician alone. Costs for personnel directly involved in patient management, calculated from hourly rates and encounter time with patients, and pre- and post-study glycosylated hemoglobin (HbA(1c)), high-density lipoprotein cholesterol (HDL-c), satisfaction with care and health-related quality of life (HRQoL) were assessed. Although 1-year costs for personnel were higher in the team-treated group, participants experienced significant improvements in mean HbA(1c) ( - 0.7%, p = 0.02) and HDL-c ( + 2.6 mg dL( - 1), p = 0.02). Additionally, satisfaction with care improved significantly for team-treated subjects in several sub-scales whereas the mean change over time in HRQoL did not differ significantly between groups. This study demonstrates the value of a complementary team approach to chronic disease management in improving patient-derived and clinical outcomes at modest incremental costs.

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Section: Discussionmentioning

confidence: 99%

Physician–nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients' perception of care

Litaker

Mion

Planavsky

et al. 2003

Journal of Interprofessional Care

221

244

View full text Add to dashboard Cite

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“…Others have also demonstrated the superiority of a pharmacist interaction over other modes of intervention including computer‐generated feedback to physicians 12 . In an observational study, Shaffer and Wexler previously reported on the development of a referral lipid clinic team led by a clinical nurse, which included a clinical pharmacist, a nurse practitioner, dietitian, and clinical psychologist 13 . A consulting cardiologist reviewed all laboratory tests and therapeutic decisions at a weekly preclinic meeting.…”

Section: Discussionmentioning

confidence: 99%

The Physician and Pharmacist Team An Effective Approach to Cholesterol Reduction

et al. 1997

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OBJECTIVE:To assess the effect of a program that encourages teamwork between physicians and pharmacists on attempts to lower total cholesterol levels and to meet recommended goals proposed by the National Cholesterol Education Program (NCEP). DESIGN:A single-blind, randomized, controlled trial lasting 6 months.SETTING: An ambulatory primary care center. PATIENTS:A sample of 94 patients with total cholesterol levels of 240 mg/dL (6.2 mmol/L) or higher. INTERVENTION:Equal numbers of patients were randomly assigned to a control arm in which standard medical care was received and an intervention arm which implemented close interaction between physicians and pharmacists. MEASUREMENTS AND MAIN RESULTS:Absolute change in total cholesterol levels from baseline values and the percentage of patients who achieved an NCEP goal after 6 months of intervention were determined. The rate of success in achieving NCEP goals in the intervention arm was double the rate in the control arm (43% vs 21%, p Ͻ .05). Total cholesterol levels in the intervention arm declined 44 ؎ 47 mg/dL (1.1 ؎ 1.2 mmol/L) versus 13 ؎ 51 mg/dL (0.3 ؎ 1.3 mmol/L) in the control arm ( p Ͻ .01). The effect of intervention on reducing total cholesterol levels was similar for men and women and did not appear to be altered by age. The effect of intervention was greatest in patients with coronary heart disease ( p Ͻ .01) followed by those without disease but with two or more coronary heart disease risk factors ( p Ͻ .05). An effect of intervention was absent in patients without coronary heart disease and with fewer than two risk factors. CONCLUSIONS:Attempts to lower total cholesterol levels and achieve NCEP goals are likely to be more successful when combined with programs that include teamwork between physicians and pharmacists. Some programs, however, may be more successful for high-risk patients, for whom it is often easier to provide more aggressive therapies. Although altering adverse lipid profiles in lower-risk patients may be difficult, achieving optimal cholesterol levels could have an important impact on preventing movement to higher risk strata.KEY WORDS: total cholesterol; low density lipoprotein cholesterol; hypercholesterolemia; National Cholesterol Education Program; coronary heart disease, risk factor. J GEN INTERN MED 1997;12:158-164.urrent National Cholesterol Education Program (NCEP) guidelines use coronary heart disease and related risk factors to assist in providing recommendations for the treatment of hypercholesterolemia and to determine the goals that should be reached in order to minimize the risk of new or recurrent coronary episodes. 1 Using these guidelines, it is estimated that 52 million Americans would be candidates for dietary therapy and as many as 12.7 million would be candidates for cholesterollowering medication. 2 These numbers and the implications from the NCEP guidelines suggest that the success in achieving NCEP goals could have a major impact on reducing the risk of morbidity and mortality from coronary heart disease. 3,4...

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“…Studies evaluating the effectiveness of these specialty clinics have demonstrated significant improvements in lowering LDL-C levels, achieving lipid targets, and reducing other cardiac risk factors compared to usual care (Shaffer and Wexler 1995; Harris et al 1998; Wilson et al 1999; Yates et al 2001; Gavish et al 2002; Koren and Hunninghake 2004; Olson et al 2005). While the evidence clearly demonstrates that specialty cardiovascular risk reduction or lipid clinics are very effective in managing patients with dyslipidemias and other risks for CVD, all published evaluations of these practices have focused on the outcomes achieved while the patients are managed within the clinic.…”

Section: Discussionmentioning

confidence: 99%

“…A number of studies have evaluated the effectiveness of these specialty clinics. Compared to management by primary care physicians or specialists in other nonlipid clinics, patients who are managed in CRRC or lipid clinics have lower LDL-C levels and are more likely to achieve their lipid targets (Shaffer and Wexler 1995; Harris et al 1998; Wilson et al 1999; Yates et al 2001; Gavish et al 2002; Koren and Hunninghake 2004; Olson et al 2005). Additional evidence demonstrates that patients referred to a CRRC were also able to achieve significant improvements in other cardiovascular (CV) risk factors, such as blood pressure and glycemic control (Olson et al 2005).…”

Section: Introductionmentioning

confidence: 99%

Maintenance of improved lipid levels following attendance at a cardiovascular risk reduction clinic: a 10-year experience

Pearson¹,

Olson²,

Panich³

et al. 2008

VHRM

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Background:Specialty cardiovascular risk reduction clinics (CRRC) increase the proportion of patients attaining recommended lipid targets; however, it is not known if the benefits are sustained after discharge. We evaluated the impact of a CRRC on lipid levels and assessed the long-term effect of a CRRC in maintaining improved lipid levels following discharge.Methods:The medical records of consecutive dyslipidemic patients discharged ×6 months from a tertiary hospital CRRC from January 1991 to January 2001 were retrospectively reviewed. The primary outcome was the change in patients’ lipid levels between the final CRRC visit and the most recent primary care follow-up. A worst-case analysis was conducted to evaluate the potential impact of the patients in whom the follow-up lipid profiles post-discharge from the CRRC were not obtained.Results:Within the CRRC (median follow-up = 1.28 years in 1064 patients), we observed statistically significant improvements in all lipid parameters. In the 411 patients for whom post-discharge lipid profiles were available (median follow-up = 2.41 years), there were no significant differences observed in low-density lipoprotein-cholesterol, total cholesterol (TC), or triglycerides since CRRC discharge; however, there were small improvements in high-density lipoprotein-cholesterol (HDL-C) and TC:HDL ratio (p < 0.05 for both). The unadjusted worst-case analysis (653 patients with no follow-up lipid profiles) demonstrated statistically significant worsening of all lipid parameters between CRRC discharge and the most recent follow-up. However, when the change in lipid parameters between the baseline and the most recent follow-up was assessed in this analysis, the changes in all lipid parameters were significantly improved (p < 0.05).Conclusions:This study demonstrates that a CRRC can improve lipid levels and suggests that these benefits are sustained once patients are returned to the care of their primary physician.

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Reducing Low-Density Lipoprotein Cholesterol Levels in an Ambulatory Care System

Abstract: These results support multidisciplinary, goal-oriented collaborative practice as an efficacious model of preventive medicine and health care provision.

Cited by 70 publications

References 20 publications

Physician–nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients' perception of care

Physician–nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients' perception of care

The Physician and Pharmacist Team An Effective Approach to Cholesterol Reduction

Maintenance of improved lipid levels following attendance at a cardiovascular risk reduction clinic: a 10-year experience

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