Patient and Provider Satisfaction With a Pharmacist-managed Lipid Clinic
Patient and Provider Satisfaction With a Pharmacist-managed Lipid Clinic
Purpose: Patient and provider satisfaction with a pharmacist-managed lipid clinic in a Veterans Affairs medical center were assessed.
Methods: All patients at Louis Stokes Cleveland Veterans Affairs Medical Center who were referred to a pharmacist-managed lipid clinic for drug therapy management were mailed a questionnaire addressing overall satisfaction with care provided by the lipid clinic. Chart reviews were performed for patients completing the questionnaire to ascertain lipid-lowering medications used, changes in serum cholesterol levels, and achievement of low-density-lipoprotein (LDL) cholesterol goal. Health care providers referring patients to the lipid clinic were sent an anonymous electronic questionnaire to assess provider satisfaction with the clinic. Responses to the questionnaire were rated on a Likert scale (strongly agree, somewhat agree, neutral, somewhat disagree, strongly disagree). A paired t test was used to assess the percent change in lipid values, and chi-square analysis was used to evaluate the achievement of each patient's LDL cholesterol goal.
Results: Surveys were sent to 224 patients and 104 providers. A total of 105 patients (47%) and 49 providers (47%) completed the questionnaire. Most patients and providers expressed satisfaction with the clinic, with 91.4% of patients and 87.8% of providers indicating that they were strongly or somewhat satisfied with the care provided by the pharmacist-managed clinic. Attainment rates of goal LDL cholesterol levels increased from 8.6% at baseline to 53.3% at discharge or the most recent measurement (p < 0.001).
Conclusion: Most patients and providers were satisfied with the services provided by the pharmacist-managed lipid clinic. The clinic helped improve patients' LDL cholesterol, total cholesterol, and triglyceride levels.
Cardiovascular disease (CVD) remains the leading cause of mortality in the United States, accounting for nearly 40% of deaths each year. It is responsible for approximately 910,000 deaths annually, at an estimated cost of $403 billion in 2006. Dyslipidemia, including elevated levels of low-density lipoprotein (LDL), is one of the major risk factors associated with the development of CVD. Over half of American adults, an estimated 107 million, have total cholesterol concentrations of ≥200 mg/dL. Nearly 95 million Americans have LDL cholesterol values of ≥130 mg/dL.
Reduction of serum cholesterol is a commonly accepted surrogate end-point for reducing CVD risk. A 10% decrease in total cholesterol levels may result in a 30% reduction in the incidence of coronary heart disease. Numerous clinical trials have also displayed a correlation between lower LDL cholesterol levels and decreased cardiovascular events and mortality. Moreover, an analysis of pooled data from clinical trials evaluating LDL-cholesterol-lowering therapy suggests that a 30-mg/dL reduction in LDL cholesterol reduces the rate of coronary heart disease events by approximately 30%.
The National Cholesterol Education Program (NCEP) published the Adult Treatment Panel III guidelines for the management of dyslipidemia in 2001. LDL cholesterol was the primary target identified by these guidelines. The LDL cholesterol goal for patients at greatest risk for cardiovascular events (i.e., those with established CVD or diabetes) is <100 mg/dL, while individuals at moderate risk (having two or more cardiovascular risk factors) should aim for an LDL cholesterol concentration of <130 mg/dL. The LDL cholesterol goal for low-risk persons (having zero or one risk factor) is <160 mg/dL. Recent literature suggests a more intensive LDL cholesterol goal of <70 mg/dL for patients at very high risk for cardiovascular events. These patients have CVD plus one of the following: (1) multiple major risk factors (especially diabetes), (2) severe and poorly controlled risk factors (especially continued cigarette smoking), (3) multiple risk factors for metabolic syndrome (especially a triglyceride value of ≥200 mg/dL plus a non-high-density-lipoprotein [HDL] cholesterol concentration of ≥130 mg/dL with a low HDL cholesterol value [<40 mg/dL]), and (4) acute coronary syndrome. Because these data had not yet been published during the time period studied, an LDL cholesterol goal of <100 mg/dL was used for those at highest risk of cardiovascular events, as this was the standard of care at that time.
Despite the available evidence promoting the importance of LDL cholesterol reduction, there remains a significant gap between published guidelines and clinical practice. The Lipid Treatment Assessment Project, a large-scale trial designed to evaluate the achievement of LDL cholesterol goals, found that only 38% of patients achieved their individual NCEP-specified LDL cholesterol goals. Even more astounding, only 18% of patients at highest risk (those with established CVD) achieved their goals.
Pharmacist-managed lipid clinics are one strategy to increase patients' attainment of LDL cholesterol goals. Several studies have found improved lipid management, including attainment of LDL cholesterol goals, with pharmacist-managed clinics compared with control groups managed by primary care physicians. The success of the pharmacist-managed clinics was attributed to increasing patient education and providing more intensive lipid monitoring. Little attention has focused on patient and provider satisfaction with these pharmacist-managed lipid clinics and how their satisfaction relates to an objective measure of clinical care. The existing data primarily describe patient satisfaction and indicate a high level of satisfaction with pharmacist-managed lipid clinics. Simultaneous patient and provider satisfaction with lipid services and the effectiveness of these services on the achievement of LDL cholesterol goals has not been fully evaluated.
The Louis Stokes Cleveland Veterans Affairs Medical Center (LSCVAMC) established a pharmacist- managed lipid clinic in October 2003 to improve the management of dyslipidemia. The clinic is primarily telephone based, with face-to-face sessions occurring only when requested by patients. Patients with complicated dyslipidemia are referred to the clinic by their health care provider. There are three types of consultations that may be requested: nonformulary drug requests, drug therapy recommendations, and lipid therapy management. The clinic is staffed by one clinical pharmacy specialist who conducts telephone interviews with the patients and is responsible for the prescribing and monitoring of lipid-lowering agents. Information on diet and exercise modification is also provided to all patients by the pharmacist.
The primary objective of this study was to assess patient and provider satisfaction with the newly established pharmacist-managed lipid clinic. The secondary objectives were to determine the percent change in lipid levels and the percentage of patients achieving their LDL cholesterol goals.
Abstract and Introduction
Abstract
Purpose: Patient and provider satisfaction with a pharmacist-managed lipid clinic in a Veterans Affairs medical center were assessed.
Methods: All patients at Louis Stokes Cleveland Veterans Affairs Medical Center who were referred to a pharmacist-managed lipid clinic for drug therapy management were mailed a questionnaire addressing overall satisfaction with care provided by the lipid clinic. Chart reviews were performed for patients completing the questionnaire to ascertain lipid-lowering medications used, changes in serum cholesterol levels, and achievement of low-density-lipoprotein (LDL) cholesterol goal. Health care providers referring patients to the lipid clinic were sent an anonymous electronic questionnaire to assess provider satisfaction with the clinic. Responses to the questionnaire were rated on a Likert scale (strongly agree, somewhat agree, neutral, somewhat disagree, strongly disagree). A paired t test was used to assess the percent change in lipid values, and chi-square analysis was used to evaluate the achievement of each patient's LDL cholesterol goal.
Results: Surveys were sent to 224 patients and 104 providers. A total of 105 patients (47%) and 49 providers (47%) completed the questionnaire. Most patients and providers expressed satisfaction with the clinic, with 91.4% of patients and 87.8% of providers indicating that they were strongly or somewhat satisfied with the care provided by the pharmacist-managed clinic. Attainment rates of goal LDL cholesterol levels increased from 8.6% at baseline to 53.3% at discharge or the most recent measurement (p < 0.001).
Conclusion: Most patients and providers were satisfied with the services provided by the pharmacist-managed lipid clinic. The clinic helped improve patients' LDL cholesterol, total cholesterol, and triglyceride levels.
Introduction
Cardiovascular disease (CVD) remains the leading cause of mortality in the United States, accounting for nearly 40% of deaths each year. It is responsible for approximately 910,000 deaths annually, at an estimated cost of $403 billion in 2006. Dyslipidemia, including elevated levels of low-density lipoprotein (LDL), is one of the major risk factors associated with the development of CVD. Over half of American adults, an estimated 107 million, have total cholesterol concentrations of ≥200 mg/dL. Nearly 95 million Americans have LDL cholesterol values of ≥130 mg/dL.
Reduction of serum cholesterol is a commonly accepted surrogate end-point for reducing CVD risk. A 10% decrease in total cholesterol levels may result in a 30% reduction in the incidence of coronary heart disease. Numerous clinical trials have also displayed a correlation between lower LDL cholesterol levels and decreased cardiovascular events and mortality. Moreover, an analysis of pooled data from clinical trials evaluating LDL-cholesterol-lowering therapy suggests that a 30-mg/dL reduction in LDL cholesterol reduces the rate of coronary heart disease events by approximately 30%.
The National Cholesterol Education Program (NCEP) published the Adult Treatment Panel III guidelines for the management of dyslipidemia in 2001. LDL cholesterol was the primary target identified by these guidelines. The LDL cholesterol goal for patients at greatest risk for cardiovascular events (i.e., those with established CVD or diabetes) is <100 mg/dL, while individuals at moderate risk (having two or more cardiovascular risk factors) should aim for an LDL cholesterol concentration of <130 mg/dL. The LDL cholesterol goal for low-risk persons (having zero or one risk factor) is <160 mg/dL. Recent literature suggests a more intensive LDL cholesterol goal of <70 mg/dL for patients at very high risk for cardiovascular events. These patients have CVD plus one of the following: (1) multiple major risk factors (especially diabetes), (2) severe and poorly controlled risk factors (especially continued cigarette smoking), (3) multiple risk factors for metabolic syndrome (especially a triglyceride value of ≥200 mg/dL plus a non-high-density-lipoprotein [HDL] cholesterol concentration of ≥130 mg/dL with a low HDL cholesterol value [<40 mg/dL]), and (4) acute coronary syndrome. Because these data had not yet been published during the time period studied, an LDL cholesterol goal of <100 mg/dL was used for those at highest risk of cardiovascular events, as this was the standard of care at that time.
Despite the available evidence promoting the importance of LDL cholesterol reduction, there remains a significant gap between published guidelines and clinical practice. The Lipid Treatment Assessment Project, a large-scale trial designed to evaluate the achievement of LDL cholesterol goals, found that only 38% of patients achieved their individual NCEP-specified LDL cholesterol goals. Even more astounding, only 18% of patients at highest risk (those with established CVD) achieved their goals.
Pharmacist-managed lipid clinics are one strategy to increase patients' attainment of LDL cholesterol goals. Several studies have found improved lipid management, including attainment of LDL cholesterol goals, with pharmacist-managed clinics compared with control groups managed by primary care physicians. The success of the pharmacist-managed clinics was attributed to increasing patient education and providing more intensive lipid monitoring. Little attention has focused on patient and provider satisfaction with these pharmacist-managed lipid clinics and how their satisfaction relates to an objective measure of clinical care. The existing data primarily describe patient satisfaction and indicate a high level of satisfaction with pharmacist-managed lipid clinics. Simultaneous patient and provider satisfaction with lipid services and the effectiveness of these services on the achievement of LDL cholesterol goals has not been fully evaluated.
The Louis Stokes Cleveland Veterans Affairs Medical Center (LSCVAMC) established a pharmacist- managed lipid clinic in October 2003 to improve the management of dyslipidemia. The clinic is primarily telephone based, with face-to-face sessions occurring only when requested by patients. Patients with complicated dyslipidemia are referred to the clinic by their health care provider. There are three types of consultations that may be requested: nonformulary drug requests, drug therapy recommendations, and lipid therapy management. The clinic is staffed by one clinical pharmacy specialist who conducts telephone interviews with the patients and is responsible for the prescribing and monitoring of lipid-lowering agents. Information on diet and exercise modification is also provided to all patients by the pharmacist.
The primary objective of this study was to assess patient and provider satisfaction with the newly established pharmacist-managed lipid clinic. The secondary objectives were to determine the percent change in lipid levels and the percentage of patients achieving their LDL cholesterol goals.
