Self-Rated Health Among Patients with Coronary Artery Disease Enrolled in a Cardiovascular Risk Reduction Service.

Little is known about the use of the single self-rated health (SRH) status item measuring health-related quality of life among people with coronary artery disease (CAD). The objective of this study was to assess relationships between SRH and recurrent coronary events, mortality, health care utilization, and intermediate clinical outcomes and to assess predictors of fair/poor SRH. A total of 5573 patients enrolled in a comprehensive cardiac risk reduction service managed by clinical pharmacy specialists were evaluated over a 2-year period. Regression modeling explored relationships among variables, modeling SRH separately as an independent and a dependent variable. The 1374 (24.7%) respondents reporting fair/poor SRH differed statistically from 4199 (75.3%) respondents reporting good/very good/excellent SRH in terms of age, sex, ethnicity, number of comorbid conditions, DxCG scores, lifestyle behaviors, blood pressure control, and inpatient and emergency department (ED) utilization. Respondents reporting fair/poor health were more likely to have recurrent major coronary events (MCE), including death. Fair/poor SRH was consistently statistically significant when it was included as a predictor in regression modeling for poor blood pressure control, health care utilization, MCE, and all-cause mortality. Variables associated with fair/poor SRH in regression modeling included females, Hispanic ethnicity, ≥1 baseline ED visit, and DxCG score. Exercising <30 minutes per week was strongly associated with fair/poor SRH. Single-item SRH status may help identify patients with CAD at higher risk of poor blood pressure control, recurrent MCE, and death and those who may benefit from interventions to increase physical activity.

Reduced health care expenditures after enrollment in a collaborative cardiac care service.

STUDY OBJECTIVE: To assess the impact of a collaborative cardiovascular risk reduction service (Collaborative Cardiac Care Service [CCCS]) on total health care expenditures after an incident acute coronary event. DESIGN: Matched, retrospective cohort study. DATA SOURCE: Kaiser Permanente Colorado (KPCO) databases. PATIENTS: Patients who had an incident coronary event between January 1999 and June 2004 and were either enrolled (CCCS group) or never enrolled in the CCCS (No CCCS group). Patients in the CCCS group (628 patients) were matched in a 1:1 ratio to patients in the No CCCS group (628 patients) by Chronic Disease Score (CDS) and total health care expenditures in the 180 days before the index coronary event (baseline). MEASUREMENTS AND MAIN RESULTS: Drug purchases and medical utilization encounters were extracted from the KPCO administrative and claims databases after the incident coronary event until death, KPCO plan termination, 3 years later, or December 31, 2005, whichever came first (follow-up). Expenditure estimates from the plan's decision support system (in 2007 U.S. dollars) were applied to each utilization encounter. A $1/follow-up day cost was applied to all patients in the CCCS group. Expenditures/follow-up day were modeled with adjustment for matching variables, patient characteristics, baseline expenditures, and intracorrelations of matched patients. Patients in the No CCCS group were slightly older and were more likely to be female and have had a myocardial infarction as their incident event compared with those in the CCCS group. During follow-up, there were 12 and 98 cardiac-related deaths and 16 and 188 all-cause deaths for the CCCS and No CCCS groups, respectively; mean and median total health care expenditures/day were $39 and $20, respectively, for the CCCS group, and $108 and $45, respectively, for the No CCCS group (all p<0.001). After adjustment, total health care expenditures for patients in the CCCS group were approximately $60/day ($21,900/yr) lower than those for patients in the No CCCS group (p<0.001; adjusted R(2)=0.29 with log-transformed expenditures). CONCLUSION: The comprehensive and aggressive implementation of secondary cardiac prevention strategies and close monitoring and follow-up of patients with coronary artery disease provided by the CCCS were associated with reduced health care expenditures.

Collaborative cardiac care service: a multidisciplinary approach to caring for patients with coronary artery disease.

BACKGROUND: Coronary artery disease (CAD) remains the leading cause of death in the US. In 1996, Kaiser Permanente of Colorado (KPCO) developed the Collaborative Cardiac Care Service (CCCS) with the goal of improving the health of patients with CAD. DESCRIPTION: CCCS consists of a nursing team (the KP Cardiac Rehabilitation program) and a pharmacy team (the Clinical Pharmacy Cardiac Risk Service). CCCS works collaboratively with patients, primary care physicians, cardiologists, and other health care professionals to coordinate proven cardiac risk reduction strategies for patients with CAD. Activities such as lifestyle modification, medication initiation and adjustment, patient education, laboratory monitoring, and management of adverse events are all coordinated through CCCS. The CCCS uses an electronic medical record and patient-tracking software to document all interactions with patients, track patient appointments, and collect data for evaluation of both short- and long-term outcomes. OUTCOMES: The CCCS currently follows over 12,000 patients with CAD. The CCCS has demonstrated improvement in surrogate outcomes including: cholesterol screening (55% to 96.3%), the proportion of patients with a goal of low-density lipoprotein cholesterol (LDL-c) <100 mg/dL (22% to 76.9%), and has reduced the average LDL-c to 78.3 mg/dL for the CAD population it follows. The CCCS has shown a reduction in all-cause mortality associated with CAD by 76% in the patients followed by the service. Patient and physician satisfaction have been high with CCCS. CONCLUSION: The CCCS coordinates many aspects of cardiac risk reduction care resulting in excellent continuity of care. The CCCS has continued to grow and expand the number of patients enrolled by using innovative strategies and technology and has resulted in excellent care and improved outcomes of the CAD population at KPCO.

Clinical pharmacy cardiac risk service for managing patients with coronary artery disease in a health maintenance organization.

PURPOSE: A clinical pharmacy service for managing the treatment of coronary artery disease in a health maintenance organization is described. SUMMARY: Despite the proven benefits of aggressive risk factor modification for patients with coronary artery disease (CAD), there remains a treatment gap between consensus- and evidence-based recommendations and their application in patient care. In 1998, Kaiser Permanente of Colorado developed the Clinical Pharmacy Cardiac Risk Service (CPCRS) to focus on the long-term management of patients with CAD to improve clinical outcomes. The primary goals of the CPCRS are to increase the number of CAD patients on lipid-lowering therapy, manage medications shown to decrease the risk of future CAD-related events, assist in the monitoring and control of other diseases that increase cardiovascular risk, provide patient education and recommendations for nonpharmacologic therapy, and act as a CAD information resource for physicians and other health care providers. Using an electronic medical record and tracking database, the service works in close collaboration with primary care physicians, cardiologists, cardiac rehabilitation nurses, and other health care providers to reduce cardiac risk in the CAD population. Particular attention is given to dyslipidemia, blood pressure, diabetes mellitus, and tobacco cessation. Treatment with evidence-based regimens is initiated and adjusted as necessary. Over 11,000 patients are currently being followed by the CPCRS. CONCLUSION: A clinical pharmacy service in a large health maintenance organization provides cardiac risk reduction for patients with CAD and helps close treatment gaps that may exist for these patients.

Effect of a clinical pharmacy service on lipid control in patients with peripheral arterial disease.

OBJECTIVE: Our group and others have previously established that patients with peripheral artery disease (PAD) are significantly undertreated with respect to overall cardiovascular risk factor management, despite national guidelines to the contrary. In an effort to maximize risk factor control in our patients with PAD, we established a pharmacist-managed, physician-monitored algorithmic approach to the outpatient management of lipids in patients with PAD. The purpose of this study was to determine the effect of this service on lipid screening and control in patients with PAD. METHODS: We analyzed the records of patients treated at a large, group-model, not-for-profit regional managed care system serving approximately 405,000 members. An electronic medical record provided full examination, laboratory, and pharmacy data for all patients. Pharmacy data were analyzed to determine prescriptions for lipid-lowering agents. Lipid control was assessed through fasting lipid data. Patients with validated PAD and the absence of clinical coronary artery disease (CAD) were offered the service between May 2003 and September 2004 and followed up for a minimum of 6 months. RESULTS: We administratively identified 5159 active patients with a diagnosis of PAD. Of these, 1075 could be validated with a noninvasive arterial study. The exclusion of 384 patients with a diagnosis of CAD resulted in a cohort of 691 patients. Of these, 90 patients were enrolled in the lipid service (study group), and 601 received standard care. Mean follow-up was 17.1 months. Screening fasting lipid profiles were found in 95.6% (86/90) of patients in the study group and only 66.9% (402/601) of the standard care patients (P < .0001). Low-density lipoprotein cholesterol (LDL-C) control was improved in the pharmacist-managed group, with 79.1% (68/86) achieving an LDL-C of less than 100 mg/dL in comparison to the standard care group (54.8% [219/400]; P < .0001). An LDL-C value of more than 130 mg/dL was noted in 1.2% and 14.0% (56/400) in the treatment and control groups, respectively (P < .001). Statin use was present in 51.9% (312/601) of the control group patients and 84.4% (76/90) of the pharmacist-managed group (P < .001). CONCLUSIONS: Despite national consensus of PAD as a CAD equivalent, patients are currently undertreated with regard to atherosclerotic risk factor modification. Initiation of a pharmacist-managed, physician-monitored lipid service provides improved compliance with national guidelines.

Evaluation of cases of severe statin-related transaminitis within a large health maintenance organization.

PURPOSE: To describe the rate, potential causes, symptoms, time to onset, and time to resolution of severe transaminitis associated with increased 3-hydroxy-3-methylglutaryl coenzyme reductase inhibitor ("statin") usage in a large group model health maintenance organization. SUBJECTS AND METHODS: Health plan members 18 years of age and older, not receiving chemotherapy, who had received at least 1 statin prescription between January 1, 1997, and December 31, 2001 were eligible. All eligible patients with an alanine aminotransferase greater than 10 times the upper limit of normal at any time during the study period were identified using computerized laboratory records. Medical records were subsequently reviewed in order to determine whether the elevation was attributable to statin therapy. RESULTS: Alanine aminotransferase had never been measured in 2334 of 25334 (9%) of eligible patients. In the remaining 23000 patients, 62 (0.3%) were identified with an alanine aminotransferase greater than 10 times the upper limit of normal during the 5-year study period. Of these, 17 (0.1% of 23000 patients) had severe transaminitis deemed directly attributable to statin use. All except 4 of these 17 cases were associated with drug interactions. In 16 cases, transaminitis resolved upon statin discontinuation. CONCLUSIONS: In the observed study sample, statin-related severe transaminitis occurred infrequently. These findings support less frequent liver enzyme monitoring for most patients on statins. Continued monitoring remains warranted for patients on concomitant medications or those with comorbid conditions.

Atherosclerotic risk factor control in patients with peripheral arterial disease.

BACKGROUND: The presence of peripheral arterial disease (PAD), even in the absence of overt coronary artery disease (CAD), confers the same relative risk of death from a cardiovascular cause as in patients with a previous cardiovascular event. Current guidelines recommend atherosclerotic risk factor-reduction strategies in PAD patients identical to those in patients with a recent coronary event. The purpose of this study was to determine the status of atherosclerotic risk factor control in patients with PAD. METHODS: We analyzed the records of patients treated at 2 regional clinics serving 92,940 individuals. Full examination, laboratory, and pharmacy data were available for all patients. Pharmacy data were analyzed to determine prescriptions for beta-blocker therapy, angiotensin-converting enzyme inhibitors, and lipid-lowering agents. Lipid control was assessed through fasting lipid data. Glycemic control in diabetics was evaluated by using hemoglobin A 1c levels. RESULTS: We administratively identified 2839 patients with a diagnosis of PAD. The exclusion of 1106 patients with a diagnosis of CAD or validated not to have PAD resulted in a cohort of 1733 patients. Of these, 33.1% (574/1733) were currently receiving beta-blockers, 28.9% (500/1733) were receiving an angiotensin-converting enzyme inhibitor, and 31.3% (543/1733) were receiving a statin. Most patients (92%; 1594/1733) had a recent blood pressure recorded. However, 56% (893/1594) had a systolic blood pressure of 130 mm Hg or higher, 45.5% (726/1594) had a diastolic blood pressure of 80 mm Hg or higher, and 13.6% (217/1594) had a diastolic blood pressure of 90 mm Hg or higher. Screening fasting lipid profiles were found in 62.6% (1085/1733) of patients, 56% (508/912) had a low-density lipoprotein of 100 mg/dL or higher, and 21% (187/912) had a value of more than 130 mg/dL. In patients with diabetes, a hemoglobin A 1c level of 7.0% or higher was found in 54.2% (198/365) of patients. CONCLUSIONS: Despite national consensus of PAD as a CAD equivalent, patients are currently undertreated with regard to atherosclerotic risk factor modification. Until broader recognition of this disease process exists, vascular surgeons must continue to champion medical as well as surgical treatments for these patients.

Low myopathy rates associated with statins as monotherapy or combination therapy with interacting drugs in a group model health maintenance organization.

STUDY OBJECTIVE: Because the risk for myopathy increases when 3-hydroxy-3-methylglutaryl coenzyme A inhibitors (statins) are used with other agents known to inhibit cytochrome P450 3A4 in patients with dyslipidemia, we sought to quantify this risk in a diverse, real-world sample of patients receiving statin therapy. DESIGN: Retrospective chart review. SETTING: Kaiser Permanente Colorado (KPCO), a group model health maintenance organization with approximately 360,000 members. PATIENTS: Four hundred sixty-eight patients who were identified as having a diagnosis of myopathy over a 4-year period using KPCO computerized data systems. MEASUREMENTS AND MAIN RESULTS: Medical records were reviewed to confirm myopathy cases associated with statin therapy. Of the 468 patients, 61 had received statin therapy before their diagnosis, and 41 (67%) of these patients had confirmed myopathy (documented creatine kinase level>or=1000 IU/L). The prevalence of myopathy was 0.12% with statin monotherapy and 0.22% with statins in combination with interacting drugs. Only 17 of the 41 (41%) patients had confirmed myopathy with no other plausible clinical explanation, such as a muscle injury. Increased risk of myopathy associated with statin therapy in combination with interacting drugs approached statistical significance (p=0.052) but was of minimal clinical significance. CONCLUSION: The prevalence of confirmed myopathy in patients receiving statin therapy is low (<1%). Combining statin therapy with interacting drugs (e.g., fibrates) was not associated with a clinically important increase in the prevalence of myopathy. The risk of developing myopathy during statin therapy is outweighed by the benefits derived from the therapeutic effects of the therapy.

Lipid management in patients with coronary artery disease by a clinical pharmacy service in a group model health maintenance organization.

BACKGROUND: Published data indicate that there is a significant treatment gap between the evidence for and the implementation of lipid-lowering therapy and that recidivism is as high as 60% at 1 year. The aim of this study is to examine the impact of a clinical pharmacy cardiac risk service (CPCRS) on lipid screening, control, and treatment outcomes. METHODS: A computer-generated list of all patients with documented coronary artery disease, enrolled in a CPCRS between March 1, 1998, and October 1, 2002, and followed up for a minimum of 6 months was obtained. Outcome measures were the percentage of patients with up-to-date lipid screening results and the percentage achieving low-density lipoprotein cholesterol (LDL-C) goals at enrollment in CPCRS and at study end. RESULTS: A total of 8014 patients (mean age, 69.3 years; 69.8% men) met the entry criteria. The mean duration of follow-up was 2.3 years. Most patients (97.3%) had up-to-date lipid screening results at study end compared with 66.9% of patients at baseline. At study end, a total of 72.9% of patients achieved a LDL-C level of less than 100 mg/dL (<2.6 mmol/L) compared with 25.5% at baseline. The mean +/- SD LDL-C level for the cohort at study end was 89 +/- 24 mg/dL (2.3 +/- 0.6 mmol/L). Of patients receiving medication, most (84.8%) were receiving therapy with statins alone, whereas 11.7% were receiving combination therapy. CONCLUSIONS: A CPCRS working in conjunction with a patient-tracking system can achieve improved lipid results in a large and inclusive cohort of patients with coronary artery disease. Our approach is unique in that the results were sustainable and demonstrate reduced recidivism.