3050 — Multidisciplinary Service Utilization and Cholesterol Guideline Implementation for Patients with Coronary Disease or Diabetes

Wu W (Providence VAMC), Jiang L (Providence VAMC), Pirraglia P (Providence VAMC), O'Toole T (Providence VAMC), Friedmann P (Providence VAMC)

Objectives:
Given the multiple disciplines and providers involved in cardiac risk reduction in the VHA, we evaluated whether setting of ambulatory service use was related to achievement of LDL cholesterol targets in a high-risk patient population with diabetes (DM) and/or coronary artery disease (CAD).

Methods:
We extracted computerized medical records of 3611 patients with DM, CAD or both who had used hospital and/or ambulatory care services at the Providence VAMC during fiscal year 2004. Adherence to VHA Dyslipidemia Guidelines was defined as the presence of an LDL measurement < 100 mg/dL within 12 months (or total cholesterol/HDL ratio < =4.9 if LDL was unavailable). We characterized service use as patient visit to any of the following ambulatory settings: nutrition, physical therapy, diabetes education, primary-care-based general pharmacist (medication compliance, depression, pain, and cardiac-risk management), and cardiology-based dedicated cardiac-risk management pharmacist. We examined the relationship between setting of service use and adherence to cholesterol guidelines; multivariate logistic regression controlled for demographics, socioeconomic and comorbid conditions, use of specialty clinics, clinic site (CBOC vs. hospital), and clinic allocation.

Results:
The analytic sample included 1925 patients with DM alone, 1089 patients with CAD alone, and 597 with both DM and CAD. There were 910 patients seen in nutrition, 26 patients in physical therapy, 67 in diabetes education, 417 in general pharmacy clinic, and 121 in dedicated cardiac-risk management pharmacy clinic. LDL cholesterol was measured in 76.63% (2767) patients, of whom 64.08% (1772) had a value < 100 mg/dL. Overall cholesterol guideline adherence was 55.75%, with an interquartile range of 53.46%-56.36% at the clinic level. Only dedicated cardiac-risk management pharmacy clinic predicted cholesterol guideline adherence (OR 1.62, 95%CI 1.08, 2.43) after adjustment for other significant predictors that included cardiology clinic visits (OR 1.53, 95%CI 1.26, 1.85), comorbidities (hypertension, hypercholesterolemia, DM, DM-CAD), blood pressure, and hemoglobin A1c levels.

Implications:
Dedicated cardiac-risk management pharmacist clinics are associated with cholesterol guideline adherence in high-risk patients with CAD or DM, suggesting that these clinics provide an effective setting for lipid management.

Impacts:
These results may guide VHA decisions regarding care organization and resource allocation to achieve effective lipid management and cardiac risk reduction.