Clinical Review

Efficacy of Patient Aligned Care Team Pharmacist Services in Reaching Diabetes and Hyperlipidemia Treatment Goals

Fed Pract. 2015 November;32(11):42-47

References

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Discussion

The results of this analysis suggest a positive impact of CPSs on the care of veterans within VAIHCS, consistent with previous literature. The strengths of this study include a true measure of pharmacist intervention via an extended length of enrollment and regular CPS  follow-up visits. Additionally, this was a multicenter design across numerous sites within VAIHCS. The variety of sites showed the impact of differing prescribing practice or consulting habits among CPSs and their associated PACT providers. Subjects were analyzed only if they received a prescription for antihyperlipidemic or antidiabetic medications. This exclusion allowed the analysis to focus on CPS medication adjustment skills.

Limitations

This analysis is limited by its retrospective design and the reliance on chart reviews to collect data. As a retrospective analysis, a direct causality between CPS intervention and change in endpoints cannot be determined. Retrospective chart reviews are also subject to both bias and influence from confounding variables due to inability to establish blinding. One confounding variable not assessed was the impact of ancillary PACT members on subject outcomes. Therapeutic lifestyle changes implemented by registered dietitians could have confounded A_1c and lipid profile improvements throughout the course of the analysis.

A specific limitation for hyperlipidemia included an early exclusion for meeting LDL-C goal before 3 months. After the completion of several chart reviews, it was determined that many of these patients required rapid or minimal medication adjustment to meet their therapeutic goals. The major limitation for T2DM included a small sample size. This limitation was partially due to the establishment of hyperlipidemia services before T2DM services within VAIHCS DSM clinics. Due to earlier establishment, hyperlipidemia management was better recognized, and consults for this disease were more prevalent. Sample size was also limited for T2DM due to the nature of the chart review and the original data attainment. The review of both diseases was limited due to some subjects not acquiring laboratory values within the predefined collection periods. In some cases, useful data outside the collection interval could not be used.

Although CPSs produced significant reductions in LDL-C, TG, and TC, their ability to provide more impactful results was likely limited due to enrollment for statin intolerance. Some studies indicated the incidence of statin intolerance to be about 5% to 10% of the general population.²² However, in this analysis, 17.1% of patients who did not meet LDL-C goal had some history of or current statin intolerance. Despite this high degree of intolerance, CPS management was still able to effectively improve lipid profiles but to a less significant degree.

A final point to consider is the design of the analysis before the release of the American College of Cardiology/American Heart Association (ACC/AHA) 2013 cholesterol guidelines.23 Target LDL-C reduction is no longer considered the most appropriate management technique for reducing the risk of atherosclerotic cardiovascular disease (ASCVD). However, the hyperlipidemia endpoints in this analysis were directly related to NCEP-ATP III recommendations. The current guidelines focus on the intensity of statin therapy for patients with ASCVD or elevated risk for ASCVD. With the release of this new guideline, a poststudy analysis was completed to apply the new information to previous practice in  VAIHCS DSM clinics. Many subjects were already meeting their statin intensity goal without further intervention. In fact, 46.3% of subjects were meeting their goal at the time of primary endpoint collection. Between the  release of the new clinical guideline and February 2014, another  14.6% of subjects had changed therapy and were meeting their statin-intensity goal, with or without pharmacist intervention. Another 17.1% of patients had statin intolerance that may have limited their ability to reach their statin-intensity goal. The remaining 22% of subjects (without statin intolerance) did not have any adjustments in hyperlipidemia profiles since the release of the updated guideline; these patients were scheduled to be contacted as a result of this analysis. Further review of patients meeting LDL-C goal at primary endpoint collection would also be beneficial to ensure appropriate management per current ACC/AHA 2013 guidelines.  

Conclusion

Pharmacists were able to produce significant improvements in LDL-C and A_1c profiles despite the confounding factors mentioned previously. With further analysis, VAIHCS may demonstrate efficacy in other CPS services and have greater potential to expand its services.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
This quality improvement analysis was performed to improve patient care at the VAIHCS, Danville, IL. It was reviewed by the VHA education department, privacy officer, information security officer, and VAIHCS leadership and was determined to meet guidelines for nonresearch, which is exempt from IRB review. As a quality improvement project, these data are not generalizable.