Pharmacists start clinics to help reduce lipid levels
Heart disease kills more adults in the United States than any other disease. One largely preventable risk factor of heart disease is high cholesterol.
Cameron C. Lindsey, PharmD, clinical pharmacist at the Veterans Affairs (VA) Medical Center in Kansas City, MO, tells Drug Utilization Review that pharmacist-run lipid clinics can make a significant difference for patients with hypercholesterolemia. In 1998, as a pharmacy practice resident, Lindsey wrote the protocol that the Kansas City VA outpatient lipid clinic now uses.
"There was an obvious need for such a service to patients," Lindsey says. "We had more than 3,000 patients on statins or some other lipid-lowering agent. The majority of statin patients were on simvastatin, and many were on subtherapeutic doses, typically less than 20 mg. Paying for medications that are subtherapeutic is a waste of patient, physician, and health care time and money. Pharmacists were ready to step up to bat and take the lead in helping assure that patients reached lipid goals set by their physicians."
Participating from a distance
Patients involved in the lipid clinic at this VA hospital have labs drawn and visit the clinical pharmacist every six to eight weeks until they reach their target lipid levels. Labs include a fasting lipid panel and liver function tests and can be performed outside the VA for patients who live a great distance from the hospital. The pharmacist visit is conducted by phone for those patients.
"It sometimes hinders the exchange of information between pharmacist and patient, but patients appreciate the flexibility in this type of appointment and probably continue to be part of the program because they are able to participate from a distance," says Lindsey.
During their visits with patients, pharmacists help patients achieve lipid goals by evaluating individual labs, diet and exercise habits, compliance with medications, and comorbid disease states. Pharmacists then titrate patient drug doses when necessary and sometimes change drug selection based on evaluation of patients at each visit in order to help them reach their goals.
"The protocol allows us to titrate drug dose," she says. "We also take into account other disease states that could affect lipid levels and are able to order labs for patients. Once patients reach their goals, they come back at six months and a year for further monitoring. Patient counseling is an important part of the program. Pharmacists are able to teach patients the importance of being compliant with their regimens. We also counsel on potential side effects of the drugs and which signs and symptoms the patients should watch for."
Although rhabdomyolysis is a concern as a side effect of HMG-CoA reductase inhibitor use, Lindsey has not yet seen it in any of the patients at her institution.
She says pharmacists should be part of a larger group of doctors treating patients. "Although pharmacists do a fine job with patient care when they’re the only ones interacting with the patient, the team approach is more desirable, when it’s possible," she says. "Patients can really benefit from the skills and counsel of dietitians, behavior modifiers, and psychologists, too. It’s all part of the treatment."
Lindsey says the lipid-monitoring program is based on the lipid goals set forth in the National Cholesterol Education Program (NCEP) guidelines, with a strong focus on low-density lipoprotein cholesterol (LDL) levels. "With our population at the VA, the majority of patients have a positive history of coronary heart disease [CHD] and, therefore, should have LDL levels less than 100 mg/dL. That’s the toughest of the LDL goals to reach, but the lipid clinic helps them stay on top of their levels and encourages them to be compliant with diet, exercise, and medications," she says.
Mike Eastin, clinical pharmacist and coordinator of the lipid-monitoring program at the Kansas City VA tells DUR about its advantages. "Benefits to patients include reduced cholesterol levels and reduced risk of coronary heart disease," he says. "They are more successful at reaching their goals; it’s easier for them than if they weren’t in the program. They see that someone cares and is monitoring their health. Regular physician appointments might be spread out further, so the interaction with us in between those visits helps patients reach their goals more readily.
"Benefits to the hospital include easing physician workload by taking on the monitoring ourselves," he says. "Long-term, both the patient and the hospital benefit from prevention of heart attacks and hospitalizations. We also help decrease the number of adverse events through monitoring and counseling. All of this saves the hospital money. In addition, it’s cost-effective to have pharmacists interacting with patients and improving their treatment results through lipid clinics. Many of the lipid-lowering drugs they take are expensive. If the system is going to pay for these agents, patients should derive maximum benefit from their use.
"Benefits to pharmacists include a better relationship with physicians and patients. Working in the clinic allows us to put our knowledge and patient care to practice and, I believe, makes us better professionals and better people," he says. "We’re still not reimbursed for our pharmacy services to lipid clinic. Billing doesn’t recognize pharmacists as providers outside of the warfarin clinic, even though we prevent long-term adverse events, catch drug interactions, and prevent hospitalizations. Our work in lipid clinic should add to the arsenal of reasons for pharmacist reimbursement from third-party payers, although if we keep doing it for free, why should they want to pay us?"
The obstacles in running the lipid clinic are few but can be important. "The first obstacle we sometimes have to overcome," Eastin says, "is getting patients to recognize the necessity for coming to clinic. Some patients are very religious about it, but others reason that if they’re not in pain, then it’s not a problem. Another obstacle is that many of our patients continue to drink, smoke, and lead sedentary lives. Drug compliance, while still sometimes a problem, is less of a problem than is compliance with lifestyle modification." Exercise is a key part of patient treatment. Any type of regular aerobic exercise (e.g., walking, running, swimming, biking) will increase HDL cholesterol levels and decrease triglycerides and may lower LDL levels, too.
"In starting a lipid clinic, it’s important to start by establishing the need for it, and then ensuring physician buy-in," advises Eastin. "You want providers — whether physicians or nurse practitioners — to agree that you and the program should be there. You don’t want them to feel like you’re stepping on their toes. The provider base should be glad you’re there."
"Having one pharmacist designated to run it is the main resource needed in establishing a lipid clinic," adds Lindsey. Pharmacy students and residents also can help run the clinic, she says. "That’s a win-win situation. Students and residents help meet staffing needs, and the experience of the clinic broadens and deepens their education.
Sources
Cameron C. Lindsey, PharmD, Mike Eastin, RPh, Veterans Affairs Medical Center, Kansas City, MO. Telephone: (816) 861-4700.
Get in at the beginning
"Lab access is another critical part of a lipid clinic, whether it’s at your facility or some place where patients can show for appointments," she says. "Either way, the pharmacist must have ready and timely access to the results of the tests. Then, a physician-approved protocol can provide the pharmacist with the authority to titrate drug therapy and write prescription orders. You also need the physical space to meet with and evaluate patients, and a computer for inputting notes."
Lindsey says pharmacists are fortunate in the VA system to have ready access to computers complete with physicians’ notes and lab data. Patients have access to an education center and computers where they can surf the Internet for further information. Physicians are just up the hall if needed for consultation, and dietitians, endocrinologists, and others are just a phone call away.
"Lipid clinics can be set up in different ways. Ours operates on a consultant basis," says Lindsey. That is, physicians refer patients — either those newly diagnosed with hypercholesterolemia or those who have been difficult to manage and who have not met lipid goals — to the clinic for close monitoring and titration of medication. The positive side of this method is that we usually get in at the beginning of a patient’s therapy, and patients typically reach their goals quickly."
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