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Impact of telehealth on the current and future practice of lipidology: a scoping review. J Clin Lipidol 2023; 17:40-54. [PMID: 36577629 PMCID: PMC9757920 DOI: 10.1016/j.jacl.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/15/2022] [Accepted: 12/04/2022] [Indexed: 12/23/2022]
Abstract
Telehealth services have been implemented to deliver care for patients living with many chronic conditions and have expanded greatly during the COVID-19 pandemic. Little is known about the current or future impacts of telehealth on lipid management practices. The PubMed database was searched from inception to June 25, 2021, with the keywords "lipids or cholesterol" and "telehealth," which yielded 376 published articles. Telehealth was defined as a synchronous visit between a patient and clinician that replaced an in-office appointment. Studies that solely used remote monitoring, mobile health technologies, or callbacks of results, were excluded. Articles must have measured lipid values. Review articles and protocol papers were not included. After evaluation, 128 abstracts were included for full text evaluation, with 55 full-text articles eventually included. Of the articles, 29 were randomized clinical trials, 15 were pre-post evaluations, and 11 were other study designs. Telehealth had positive to neutral impacts on lipid management. Reported facilitators include easier implementation of multidisciplinary approaches to care, and utilization of patient-centered programs. Reported barriers to telehealth services include technological barriers, such as various skill levels with technology; systems barriers, such as cost and reimbursement; patient-related barriers, including patient non-adherence; and clinician-related barriers, such as difficulty standardizing care. Clinicians reported improved satisfaction among patients but had mixed feelings regarding their ability to deliver quality care. Telemedicine use to provide care for individuals with lipid conditions has expanded during the COVID-19 pandemic, but more research is needed to determine its potential as a sustainable tool for lipid management.
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Implementation strategies to improve statin utilization in individuals with hypercholesterolemia: a systematic review and meta-analysis. Implement Sci 2021; 16:40. [PMID: 33849601 PMCID: PMC8045284 DOI: 10.1186/s13012-021-01108-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 03/29/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Numerous implementation strategies to improve utilization of statins in patients with hypercholesterolemia have been utilized, with varying degrees of success. The aim of this systematic review is to determine the state of evidence of implementation strategies on the uptake of statins. METHODS AND RESULTS This systematic review identified and categorized implementation strategies, according to the Expert Recommendations for Implementing Change (ERIC) compilation, used in studies to improve statin use. We searched Ovid MEDLINE, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov from inception to October 2018. All included studies were reported in English and had at least one strategy to promote statin uptake that could be categorized using the ERIC compilation. Data extraction was completed independently, in duplicate, and disagreements were resolved by consensus. We extracted LDL-C (concentration and target achievement), statin prescribing, and statin adherence (percentage and target achievement). A total of 258 strategies were used across 86 trials. The median number of strategies used was 3 (SD 2.2, range 1-13). Implementation strategy descriptions often did not include key defining characteristics: temporality was reported in 59%, dose in 52%, affected outcome in 9%, and justification in 6%. Thirty-one trials reported at least 1 of the 3 outcomes of interest: significantly reduced LDL-C (standardized mean difference [SMD] - 0.17, 95% CI - 0.27 to - 0.07, p = 0.0006; odds ratio [OR] 1.33, 95% CI 1.13 to 1.58, p = 0.0008), increased rates of statin prescribing (OR 2.21, 95% CI 1.60 to 3.06, p < 0.0001), and improved statin adherence (SMD 0.13, 95% CI 0.06 to 0.19; p = 0.0002; OR 1.30, 95% CI 1.04 to 1.63, p = 0.023). The number of implementation strategies used per study positively influenced the efficacy outcomes. CONCLUSION Although studies demonstrated improved statin prescribing, statin adherence, and reduced LDL-C, no single strategy or group of strategies consistently improved outcomes. TRIAL REGISTRATION PROSPERO CRD42018114952 .
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Clinical Outcomes of Telephone Service for Patients on Warfarin: A Systematic Review and Meta-Analysis. Telemed J E Health 2020; 26:1507-1521. [PMID: 32213010 DOI: 10.1089/tmj.2019.0268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective: To evaluate clinical outcomes of telephone-based service for patients on warfarin. Methods: Five bibliographic databases and gray literature were searched for articles that reported the effects of telephone interventions provided to patients using warfarin compared with those receiving usual clinic-based care. Mean difference (MD) and relative risk (RR) were used to calculate the effects of telephone intervention on time in therapeutic range (TTR) and visit in range (VIR), respectively. Adverse events (AEs) were pooled and reported as incidence rate ratios. Results: A total of 1,840 articles were examined. Eight articles involving 8,087 subjects were included in the quantitative synthesis. The pooled estimates from seven studies showed no difference on TTR between the telephone service group and the usual care group (MD 2.30; 95% confidence interval [CI] -3.56 to 8.16). In addition, VIR in the telephone service group was not different from the usual care group (RR 1.22, 95% CI 0.87-1.71). Moreover, patients in telephone service groups appeared to have a lower incidence of AEs compared with usual care groups. Discussion: Telephone-based service could be considered as an alternative anticoagulant management. However, owing to a lack of evidence from well-designed studies, further high-quality randomized control trials are warranted.
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Impact of ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) Telemedicine Randomized Controlled Trial on Diabetes Optimal Care Outcomes in Patients with Type 2 Diabetes. J Acad Nutr Diet 2019; 119:585-598. [DOI: 10.1016/j.jand.2018.11.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 11/07/2018] [Accepted: 11/13/2018] [Indexed: 10/27/2022]
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Interactive voice response technology for symptom monitoring and as an adjunct to the treatment of chronic pain. Transl Behav Med 2013; 2:93-101. [PMID: 22448205 PMCID: PMC3291819 DOI: 10.1007/s13142-012-0115-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Chronic pain is a medical condition that severely decreases the quality of life for those who struggle to cope with it. Interactive voice response (IVR) technology has the ability to track symptoms and disease progression, to investigate the relationships between symptom patterns and clinical outcomes, to assess the efficacy of ongoing treatments, and to directly serve as an adjunct to therapeutic treatment for chronic pain. While many approaches exist toward the management of chronic pain, all have their pitfalls and none work universally. Cognitive behavioral therapy (CBT) is one approach that has been shown to be fairly effective, and therapeutic interactive voice response technology provides a convenient and easy-to-use means of extending the therapeutic gains of CBT long after patients have discontinued clinical visitations. This review summarizes the advantages and disadvantages of IVR technology, provides evidence for the efficacy of the method in monitoring and managing chronic pain, and addresses potential future directions that the technology may take as a therapeutic intervention in its own right.
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Reducing cardiovascular disease risk in medically underserved urban and rural communities. Am Heart J 2011; 161:351-9. [PMID: 21315219 DOI: 10.1016/j.ahj.2010.11.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Accepted: 11/07/2010] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The aim of this study is to evaluate methods for lowering cardiovascular disease (CVD) risk in asymptomatic urban and rural underserved subjects. BACKGROUND Medically underserved populations are at increased CVD risk, and systems to lower CVD risk are needed. Nurse management (NM) and telemedicine (T) systems may provide low-cost solutions for this care. METHODS We randomized 465 subjects without overt CVD, with Framingham CVD risk >10% to NM with 4 visits over 1 year, or NM plus T to facilitate weight, blood pressure (BP), and physical activity reporting. The study goal was to reduce CVD risk by 5%. RESULTS Three hundred eighty-eight subjects completed the study. Cardiovascular disease risk fell by ≥ 5% in 32% of the NM group and 26% of the T group (P, nonsignificant). In hyperlipidemic subjects, total cholesterol decreased (NM -21.9 ± 39.4, T -22.7 ± 41.3 mg/dL) significantly. In subjects with grade II hypertension (systolic BP ≥ 160 mm Hg, 24% of subjects), both NM and T groups had a similar BP response (average study BP: NM 147.4 ± 17.5, T 145.3. ± 18.4, P is nonsignificant), and for those with grade I hypertension (37% of subjects), T had a lower average study BP compared to NM (NM 140.4 ± 16.9, T 134.6 ± 15.0, P = .058). In subjects at high risk (Framingham score ≥ 20%), risk fell 6.0% ± 9.9%; in subjects at intermediate risk (Framingham score ≥ 10, < 20), risk fell 1.3% ± 4.5% (P < .001 compared to high-risk subjects). Medication adherence was similar in both high- and intermediate-risk subjects. CONCLUSIONS In 2 underserved populations, CVD risk was reduced by a nurse intervention; T did not add to the risk improvement. Reductions in BP and blood lipids occurred in both high- and intermediate-risk subjects with greatest reductions noted in the high-risk subjects. Frequent communication using a nurse intervention contributes to improved CVD risk in asymptomatic, underserved subjects with increased CVD risk. Telemedicine did not change the effectiveness of the nurse intervention.
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American Dietetic Association revised standards of practice and standards of professional performance for registered Dietitians (generalist, specialty, and advanced) in diabetes care. ACTA ACUST UNITED AC 2011; 111:156-166.e1-27. [PMID: 21185979 DOI: 10.1016/j.jada.2010.10.053] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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A secondary prevention lipid clinic reaches low-density lipoprotein cholesterol goals more often than usual cardiology care with coronary heart disease. J Clin Lipidol 2010; 4:46-52. [DOI: 10.1016/j.jacl.2009.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Revised: 12/01/2009] [Accepted: 12/03/2009] [Indexed: 11/19/2022]
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Statins and coronary artery bypass graft surgery: preoperative and postoperative efficacy and safety. Expert Opin Drug Saf 2009; 8:559-71. [DOI: 10.1517/14740330903188413] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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[Cardiologists opinion on the situation of the secondary prevention of ischemic heart disease in Spain]. Med Clin (Barc) 2009; 132:599-602. [PMID: 19409296 DOI: 10.1016/j.medcli.2008.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 09/18/2008] [Indexed: 10/20/2022]
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Effect of an educational program (PEGASE) on cardiovascular risk in hypercholesterolaemic patients. Cardiovasc Drugs Ther 2008; 22:495-505. [PMID: 18830810 DOI: 10.1007/s10557-008-6137-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Accepted: 09/04/2008] [Indexed: 01/10/2023]
Abstract
BACKGROUND Many studies have demonstrated a gap between guidelines for the prevention of cardiovascular disease (CVD) and their implementation in clinical practice. AIM The PEGASE education program has been devised with an aim to improve the management of patients at high risk of CVD. METHODS In a multicentre study carried out from 2001-2004 in France, 96 participating physicians were randomized into a "trained" group, which included 398 "educated" patients, and a "non-trained" group, which included 242 "non-educated" patients. Educated patients received six hospital-based educational sessions, four collective and two individual. Framingham score, smoking, lipid levels, glycaemia, blood pressure, dietary intake and drug compliance, as well as quality of life, were evaluated at baseline (M0) and 6 months (M6). The primary endpoint of the study was the efficacy of the PEGASE program in reducing global CVD risk in high-risk patients. RESULTS The Framingham score was calculated for 473 patients. The Framingham score improved significantly at M6 vs M0 in the educated group (13.0 +/- 8.21 vs 13.6 +/- 8.48, d = -0.658, p = 0.016), but not in the non-educated group (12.5 +/- 8.19 vs 12.4 +/- 7.81, d = +0.064, p = 0.836); the mean change between the two groups did not reach significance. Quality of life, LDL-c level and diet scores improved in the "educated" group only. CONCLUSIONS The PEGASE education program improved risk factors for CVD, although global assessment by Framingham score was not significantly different between groups. This program, aimed at meeting needs and expectations of patients and physicians, was easily implemented in all hospital centres.
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Design of a nurse-run, telephone-based intervention to improve lipids in diabetics. Contemp Clin Trials 2008; 29:809-16. [DOI: 10.1016/j.cct.2008.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Revised: 05/23/2008] [Accepted: 05/30/2008] [Indexed: 10/22/2022]
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Effects of an enhanced secondary prevention program for patients with heart disease: a prospective randomized trial. Can J Cardiol 2007; 23:1066-72. [PMID: 17985009 PMCID: PMC2651931 DOI: 10.1016/s0828-282x(07)70875-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2005] [Accepted: 08/23/2007] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Secondary prevention medications in cardiac patients improve outcomes. However, prescription rates for these drugs and long-term adherence are suboptimal. OBJECTIVE To determine whether an enhanced secondary prevention program improves outcomes. METHODS Hospitalized patients with indications for secondary prevention medications were randomly assigned to either usual care or an intervention arm, in which an intensive program was used to optimize prescription rates and long-term adherence. Follow-up was 19 months. RESULTS A total of 2643 patients were randomly assigned in the study; 1342 patients were assigned to usual care and 1301 patients were assigned to the intervention arm. Prescription rates were near optimal except for lipid-lowering medications. Rehospitalization rates per 100 patients were 136.2 and 132.6 over 19 months in the usual care and intervention groups, respectively (P=0.59). Total days in hospital per patient were similar (10.9 days in the usual care group versus 10.2 days in the intervention group; P not significant). Crude mortality was 6.2% and 5.5% in the usual care and intervention groups, respectively, with no significant difference (P=0.15) in overall survival. Post hoc analysis suggested that after the study team became experienced, days in hospital per patient were reduced by the program (11.1+/-0.91 and 8.9+/-0.61 in the usual care and intervention groups, respectively; P<0.05). CONCLUSIONS The intervention program failed to improve outcomes in the present study. One explanation for these results is the near optimal physician compliance with guidelines in both groups. It is also possible that a substantial learning curve for the staff was involved, as suggested by the reduction in total days in hospital in the intervention patients during the second part of the study.
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Abstract
A variety of approaches can provide cardiac patients with needed follow-up care. However, with the explosion of telehealth capabilities, clinicians are more ready to explore other methods to integrate the use of telehealth devices into the delivery of effective nursing interventions. This article summarizes the development of a symptom management intervention for coronary artery bypass graft patients using the Health Buddy to deliver a nursing intervention in the early recovery period after hospital discharge. Considerations used to design the symptom management intervention and selection of this telehealth modality are discussed. This overview can help clinicians and researchers gain perspective on how to evaluate telehealth modalities to aid in the delivery of interventions for cardiac and other clinical populations.
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Achievement of optimal combined lipid values in a managed care setting: Is a new treatment paradigm needed? Clin Ther 2007; 29:196-209. [PMID: 17379061 DOI: 10.1016/j.clinthera.2007.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND Published guidelines suggest the management of high-density lipoprotein cholesterol (HDL-C) and triglyceride (TG) values after the low-density lipoprotein cholesterol (LDL-C) goal is achieved. OBJECTIVE This study evaluated the attainment of optimal combined lipid values (LDL-C, HDL-C, and TGs) and associated therapy over time. METHODS This retrospective cohort analysis was conducted among managed-care patients who had a baseline lipid panel taken between October 1, 1999, and September 30, 2000; were naive to lipid therapy; and had plan eligibility for at least 12 months before and 12 to 36 months after the baseline lipid values. Patients were categorized as elevated-risk primary prevention (ERP) or as coronary heart disease (CHD) and CHD risk equivalents (CHD-RE). The attainment of optimal combined lipid values was assessed at baseline and quarterly thereafter. Associations between lipid values and the use of lipid-altering therapy were assessed using multivariate logistic regression. RESULTS A total of 30,348 patients were monitored for a mean (SD) duration of 27 (8) months. Mean (SD) age was 66 (12) years and 55% (16,549/30,348) were men; 43% (13,059/30,348) were categorized as ERP and 57% (17,289/30,348) as CHD-RE. Combined lipid values were optimal in 14% (4167/30,348),18% (5508/30,348), and 22% (2936/13,100) of patients at baseline, 12 months, and 36 months, respectively. After 36 months, 78% (10,164/13,100) of patients did not attain optimal combined lipid values. Lipid therapy, primarily statin monotherapy (87% [7992/ 92251), was prescribed in 30% (9225/30,348) of patients. After 36 months, 34% (4492/13,100) of patients had isolated elevated LDL-C and 20% (2588/13,100) had non-optimal HDL-C and/or TGs. Lipid therapy was associated with the attainment of optimal combined values for LDL-C and TGs (both, P < 0.05), but not for HDL-C. Because the study was retrospective, causality cannot be determined. CONCLUSIONS Based on the results of this study, use of combination lipid therapy and targeted therapy aimed at the specific lipid abnormalities may increase the attainment of optimal lipid parameters.
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Effectiveness of telephone counselling by a pharmacist in reducing mortality in patients receiving polypharmacy: randomised controlled trial. BMJ 2006; 333:522. [PMID: 16916809 PMCID: PMC1562472 DOI: 10.1136/bmj.38905.447118.2f] [Citation(s) in RCA: 155] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the effects of compliance and periodic telephone counselling by a pharmacist on mortality in patients receiving polypharmacy. DESIGN Two year randomised controlled trial. SETTING Hospital medical clinic. PARTICIPANTS 502 of 1011 patients receiving five or more drugs for chronic disease found to be non-compliant at the screening visit were invited for randomisation to either the telephone counselling group (n = 219) or control group (n = 223) at enrollment 12-16 weeks later. MAIN OUTCOME MEASURES Primary outcome was all cause mortality in randomised patients. Associations between compliance and mortality in the entire cohort of 1011 patients were also examined. Patients were defined as compliant with a drug if they took 80-120% of the prescribed daily dose. To calculate a compliance score for the whole treatment regimen, the number of drugs that the patient was fully compliant with was divided by the total number of prescribed drugs and expressed as a percentage. Only patients who complied with all recommended drugs were considered compliant (100% score). RESULTS 60 of the 502 eligible patients defaulted and only 442 patients were randomised. After two years, 31 (52%) of the defaulters had died, 38 (17%) of the control group had died, and 25 (11%) of the intervention group had died. After adjustment for confounders, telephone counselling was associated with a 41% reduction in the risk of death (relative risk 0.59, 95% confidence interval 0.35 to 0.97; P = 0.039). The number needed to treat to prevent one death at two years was 16. Other predictors included old age, living alone, rate of admission to hospital, compliance score, number of drugs for chronic disease, and non-treatment with lipid lowering drugs at screening visit. In the cohort of 1011 patients, the adjusted relative risk for death was 1.61 (1.05 to 2.48; P = 0.029) and 2.87 (1.80 to 2.57; P < 0.001) in patients with compliance scores of 34-66% and 0-33%, respectively, compared with those who had a compliance score of 67% or more. CONCLUSION In patients receiving polypharmacy, poor compliance was associated with increased mortality. Periodic telephone counselling by a pharmacist improved compliance and reduced mortality. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number Register: SRCTN48076318.
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Cholesterol management: targeting a lower low-density lipoprotein cholesterol concentration increases adult treatment panel-III goal attainment. Am J Cardiol 2006; 97:1667-9. [PMID: 16728235 DOI: 10.1016/j.amjcard.2005.12.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2005] [Revised: 12/20/2005] [Accepted: 12/20/2005] [Indexed: 11/21/2022]
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An Assessment of Patient Knowledge and Awareness of Issues Surrounding Cholesterol Risk Management. Can Pharm J (Ott) 2005. [DOI: 10.1177/171516350513800805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: A lack of patient understanding and awareness of issues surrounding cholesterol risk management may be one reason that a significant number of patients receiving cholesterol-lowering therapy do not achieve optimal cholesterol levels. This study was conducted to assess patients' knowledge and awareness of issues surrounding cholesterol risk management. Methods: Community pharmacists within the Edmonton, Alberta, area were identified and asked to recruit patients within their practice who had been receiving cholesterol-lowering therapy for a minimum of six weeks. A 32-question telephone survey was developed and used as the instrument to assess patient knowledge and awareness. All surveys were conducted by the same individual, and data analysis was primarily descriptive. Results: Seventeen community pharmacies recruited 136 potential subjects over an eight-week period. Surveys were conducted with 105 (77%) of the eligible subjects. Of those surveyed, 37% identified elevated cholesterol as a risk factor for heart disease. While the majority of respondents felt it important to know their cholesterol targets (82%) and their specific levels (91%), only 23% and 29% of respondents indicated that they knew their high-density lipoprotein cholesterol and low-density lipoprotein cholesterol levels, respectively. Gaps in knowledge with respect to cholesterol-lowering therapy also existed. Conclusions: The results of this survey indicate gaps in patient knowledge of various issues surrounding cholesterol risk management. Pharmacists are in an excellent position to provide better education to patients about cholesterol levels and cardiovascular disease risk management. Further research is required to determine whether improved patient knowledge leads to improved clinical outcomes.
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Abstract
STUDY OBJECTIVES To objectively compare the results of a collaborative approach using pharmacists with the results of usual care for achieving a low-density lipoprotein cholesterol (LDL) goal of 100 mg/dl or less in outpatients with documented coronary heart disease (CHD) who are not at goal, and to document the effect on LDL after removal of such a collaborative model from the study population. DESIGN Prospective, multiclinic, controlled study. SETTING Four clinics of a 19-clinic staff model health maintenance organization in Minneapolis and St. Paul, Minnesota. Two clinics treated the intervention patients, two the controls; one clinic for each group was suburban, and one for each was urban. PATIENTS Four hundred eighty-one patients aged 18 years or older with CHD and whose LDL levels were not at goal. INTERVENTION Clinical pharmacists implemented the physician-approved care plan for each intervention patient; activities included managing lipid-lowering drug therapy and educating patients on cardiovascular risk reduction. MEASUREMENTS AND MAIN RESULTS Primary outcomes were changes in LDL level and the proportion of patients achieving goal LDL in the intervention versus the usual care (control) group. Secondary outcomes were the sustainability of the impact observed up to 18 months after discontinuation of the intervention. Mean+/-SD baseline LDL levels were 131+/-28 and 131+/-26 mg/dl (p=NS) for the intervention and control groups, respectively. After a mean of 6.5 months follow-up, 107 (72%) patients in the intervention group and 61 (18%) patients in the control group had attained their LDL goal (p<0.001). Mean LDL levels were reduced by 35.6 mg/dl (27.5%) and 6.7 mg/dl (4.6%) in the intervention and control groups, respectively (p<0.001). When the active program was discontinued, results of the 18-month follow-up indicated that 85 (65%) intervention patients remained at goal compared with 96 (42%) controls (p<0.001). CONCLUSION This trial provides quantitative evidence to support the effectiveness of the collaborative approach as an intervention to optimize management of patients with CHD whose LDL levels are not at goal; this approach is specifically called for in the executive summary of the National Cholesterol Education Program Adult Treatment Panel III. Furthermore, this study documents both the magnitude and sustainability of the impact collaborative care models can have in managed care environments.
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Abstract
STUDY OBJECTIVE To evaluate the cost of a pharmacist-directed intervention that prompts physicians to treat hypercholesterolemia more aggressively in patients with coronary heart disease (CHD). METHODS Health care resource use and CHD outcomes were evaluated for 612 patients with CHD followed for 2 years after an index hospitalization for an ischemic event. After discharge, the physicians of 309 patients who had been admitted from January 1--March 31, 1999, were contacted by telephone and mail concerning lipid profiles and statin therapy. These patients were the intervention group. Controls were 303 patients admitted from October 1--December 31, 1998; their physicians were not contacted. Costs of the physician-prompting intervention, clinic visits, laboratory tests, statin drugs, and CHD outcomes were compared between these two patient groups. RESULTS The number of clinic visits, laboratory tests, and statins prescribed was significantly greater for the intervention group versus the controls. A significantly higher percentage of patients in the intervention group (55%) than in the control group (18%) achieved their National Cholesterol Education Program target low-density lipoprotein cholesterol level and had significantly better CHD outcomes. The cost of the physician-prompting intervention (pharmacist salaries, postage, telephone calls) was $102,941. For patients in the intervention and control groups, respectively, the cost of statin therapy was $352,365 and $200,087, the cost of clinic visits and laboratory tests $48,097 and $27,367, and the cost of coronary heart disease outcomes, such as myocardial infarction, coronary artery bypass graft, percutaneous transluminal and coronary angioplasty, $1,073,495 and $1,741,220. The total cost was $1,576,898 and $1,968,674, respectively, for patients in the intervention and control groups. Net savings was $1394/patient over the 2-year period. CONCLUSION A relatively simple physician-prompting intervention involving patients with CHD significantly improved the use of lipid testing and statin therapy. Improved use of statins was associated with better CHD outcomes. As a result, the physician-prompting intervention was associated with cost savings. This intervention should be implemented for patients with CHD discharged after hospitalization for an ischemic event.
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Clinical trial of an educational intervention to achieve recommended cholesterol levels in patients with coronary artery disease. Am Heart J 2004; 147:522-8. [PMID: 14999204 DOI: 10.1016/j.ahj.2003.06.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite national efforts to improve cholesterol management for patients with coronary artery disease, many patients are not reaching recommended cholesterol target levels. We sought to determine whether a nurse-based educational intervention, designed to educate patients with confirmed coronary artery disease about personal low-density lipoprotein (LDL) cholesterol target levels and encourage partnership with physicians, could increase adherence with National Cholesterol Education Program target levels (LDL cholesterol level < or =100 mg/dL). METHODS Patients hospitalized with confirmed coronary artery disease were randomized to undergo a nurse-based educational intervention (375 patients) or usual care (381 patients) for a 12-month period after hospitalization. The primary outcome was the proportion of patients at the LDL cholesterol target level 1 year after hospitalization. The secondary outcome was the proportion of patients with accurate knowledge of LDL cholesterol target levels. RESULTS The groups were similar at baseline in demographic and clinical characteristics, percent at LDL cholesterol target level (43.9% and 41.1%, respectively), and percent with knowledge of LDL cholesterol target levels (both 5%). The proportion of patients at LDL cholesterol target levels at 1 year did not differ between the intervention (70.2%) and usual care group (67.4%, P =.46). At the conclusion of the trial, patient knowledge about LDL cholesterol target level was higher for the intervention group than the usual care group (19.6% and 6.7%, respectively, P =.001), but this was not associated with improved cholesterol management. CONCLUSIONS Our nurse-based educational intervention did not result in a significant increase in the proportion of patients who reached target LDL cholesterol levels 1 year after hospitalization. Although the intervention improved patient knowledge of LDL cholesterol target levels, overall rates of LDL cholesterol knowledge remained low, and it was not associated with improved cholesterol management.
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Programa de intervención para mejorar la prevención secundaria del infarto de miocardio. Resultados del estudio PRESENTE (PREvención SEcuNdaria TEmprana). Rev Esp Cardiol 2004. [DOI: 10.1016/s0300-8932(04)77077-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Multiple studies have demonstrated disappointingly low rates of persistence with therapies recommended to reduce cardiovascular risk. Non face-to-face communication has been employed as a strategy to increase the rate of adherence with both pharmacologic and lifestyle modification risk-reduction measures. In addition to the impact on adherence, these interventions have the potential to affect intermediate measures, such as increased access to care, increased patient satisfaction, and decreased resource utilization. Improvement in clinical outcomes is the ultimate measure of success of this intervention.
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Comparison of effectiveness and safety of simvastatin in patients <75 versus > or =75 years of age with coronary, cerebral, or peripheral arterial disease. Am J Cardiol 2002; 90:994-5. [PMID: 12398969 DOI: 10.1016/s0002-9149(02)02676-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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High-soluble-fiber foods in conjunction with a telephone-based, personalized behavior change support service result in favorable changes in lipids and lifestyles after 7 weeks. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION 2002; 102:503-10. [PMID: 11985406 DOI: 10.1016/s0002-8223(02)90116-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate whether an intervention of foods high in soluble fiber from psyllium and/or oats plus a telephone-based, personalized behavior change support service improves serum lipids and elicits cholesterol-managing lifestyle changes vs usual care. DESIGN 7-week randomized, controlled intervention. SUBJECTS/SETTING 150 moderately hypercholesterolemic men and women, age range 25 to 70 years. INTERVENTION The intervention group consumed 4 servings/day of high-fiber foods and had weekly telephone conversations with a personal coach who offered support and guidance in making lifestyle changes consistent with the National Cholesterol Education Program's (NCEP) cholesterol-lowering guidelines. The usual care group received a handout describing the NCEP Step-1 diet. MAIN OUTCOME MEASURES Serum lipids and lipoproteins and self-reported lifestyle changes. STATISTICAL ANALYSES For physiologic and dietary changes, mixed linear models for repeated measures were applied. Models were simplified using analysis of covariance where age in years was the covariate. Traditional general linear models were used to assess lifestyle changes. RESULTS In the intervention group total cholesterol (TC) decreased 5.6%, low-density lipoprotein (LDL) cholesterol 7.1%, LDL/high-density lipoprotein (HDL) cholesterol ratio 5.6%, and triglycerides (TG) 14.2% (P<.0167); decreases in TC and LDL were significantly different from the usual care group. In the usual care group TC decreased 1.9%, LDL 1.2%, LDL/HDL 1.9%, and TG 4.4% (all not significant). The intervention group also reported an increase in their knowledge, ability, and confidence to make cholesterol-managing diet and exercise changes compared with the usual care group (P<.05). The intervention group had a greater decrease in energy intake from saturated fat (-1.6%) and increase in soluble fiber intake (7.3%) than the usual care group (P<.05). The intervention group reported an increase in exercise vs the usual care group (P<.05). Both intervention and control groups had a minimal reduction (<1%) in body weight compared with baseline (P<.0167). APPLICATIONS/CONCLUSIONS A 7-week intervention that includes both functional foods and individualized, interactive support for behavior change could be an effective model for dietitians to use with patients at risk for CVD, pending results of long-term studies.
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