Impact of Pharmacy-Led Dyslipidemia Interventions on Medication Safety and Therapeutic Failure Patients

Major Joseph G. Weaver, Captain Tamy Leung, Rhonda Mangione, Judy McManus, and Patrick Air Force Base Pharmacy Staff

45th Medical Support Squadron

Patrick Air Force Base, Florida

Rationale and Objectives

Medication safety is a national imperative that warrants pharmacy leadership on strategies and interventions to prevent errors. Our practice setting at the Department of Defense (DoD) is in a challenging position to thwart prescribing errors since a large proportion of military retirees obtain prescriptions from providers not on the base. Efforts to improve medication safety require extensive efforts to reach out to prescribers in the community, patients, and other ancillary healthcare providers servicing DoD patients. In January of 2002, Medication Safety parameters focusing on prescribing errors and subsequent patient outcomes was identified as a top priority for the Department of Pharmacy. To demonstrate pharmacy impact on patient outcomes, we focused our efforts on a costly and the most prevalent disease state, cardiovascular illness.

Initial steps included establishing a baseline for standards of care both among internal providers and community physicians. Over the next 6-months, 6,421 dyslipidemia patients were identified as therapeutic failures, defined as patients not at LDL goal. A review was subsequently conducted on 527 of these patients. Findings revealed 57.3% were under-treated or non-adherent to therapy, 31.7% were on a sub-therapeutic dose, and 20% required a more potent therapy based upon the DoD Pharmacoeconomic Center guidelines on therapeutic failures. The barrier analysis included evaluation of unsafe combination regimens according to FDA labeling. In this medication safety analysis, 14.7% of patients were on unsafe combination regimens and almost all (96.4%) doses that far exceeded the safety limit. A pharmacoeconomic analysis revealed a high potential for cost-avoidance through optimization of care and outcomes.

Having identified barriers to care and medication safety issues pertaining to prescribing, the goal was to partner with community providers to implement a process that would facilitate close patient follow-up, increased access to medications, and improved communication. Ultimately, we would work with on base and off-base (community) providers to get as many of the 6000+ patients currently not at their cholesterol goals and 15% with potential serious drug interactions under control.

Description of the program

The strategies outlined by pharmacy were multiple. Pharmacy first collaborated with the local DoD P&T Committee to highlight services that could be initiated and utilized to improve care for community physicians and patients. A pharmacist-run patient education/polypharmacy clinic was newly developed. The team felt that this would be a good venue to support medication access issues and patient non-adherence to medications. Furthermore, close pharmacy-provider interaction on base led to the initial stages of development of a lipid clinic, including recruitment of a dedicated clinical pharmacist. The lipid clinic would be a service available to both on-base providers and community physicians. Until the lipid clinic was implemented, the patient education/polypharmacy clinic would serve as the primary communication means for external, community providers requesting non-formulary drugs as well as referrals to the clinic.

Internal mechanisms to thwart potentially dangerous drug interactions were also in place. The protocol relied heavily on the pharmacy technician identifying these interactions with use of the host pharmacy computer system. Since FDA labeling changes for unsafe combination regimens with simvastatin, the Department of Defense’s preferred statin, were just released, all pharmacists were educated on how to deal with such interactions. When calling physicians, pharmacists were provided with guidelines on recommendations for therapeutic alternatives, including access to non-formulary agents if needed.

The physician and external healthcare providers awareness campaign included a series of three educational programs all led by the Chief of Pharmacy and presented throughout the community. These programs entailed dissemination of baseline results, discussing medication access issues, highlighting pharmacy services and interventions (ie, polypharmacy and lipid clinics), and mechanisms to access such clinics to enable easier provider-pharmacy communication. The partnership with community physicians on medication access issues entailed such physicians contact the polypharmacy clinic to refer patients back to the base to have a non-formulary medication considered and dispensed if appropriate. Programs reaching out to community providers also included cardiovascular updates surrounding dyslipidemia by a well-known, community cardiologist. Key to the success of the program was the partnership with the pharmaceutical industry. Industry assisted with the “promotion” of the service to the off-base providers and with the analysis of the data. In fact, industry was indispensable in that they “marketed” the clinic to off base providers during their normal “detailing” visits. The Chief of Medical Services at the facility pledged his support to the community providers to assist in providing them the “tools” to provide the care our beneficiaries deserve.

Results/Conclusion

Approximately 6-months after the interventions, a re-evaluation of therapeutic failure patients was conducted. This included 310 patients of the original 527 baseline review patients with available LDL values documented through the base computer systems. Results demonstrated a statistically significant reduction in LDL value of 37.87 mg/dL (25.5%) for all patients. Such statistically significant reductions were noted even among patient subgroups in the CHD/CHD-risk equivalent and multiple risk factor categories. LDL reductions amounted to 33.6 mg/dL (24.4%) for CHD/CHD risk equivalent patients, and 41.05 mg/dL (26.1%) among patients in the multiple risk factor category. Overall, 68.6% of patients were now at LDL goal, compared to 0% from the previous review.

The re-evaluation demonstrated 97.5% of those previously classified as nonadherent or undertreated as having received a prescription for a lipid-lowering agent on base within the six-month study period. Suboptimal dosing was corrected in almost half of the identified patients from the baseline study as having lack of dose titration. For drug interactions, 67% of those identified from the previous review had medication changes reflecting safer regimens. Finally, appropriate therapeutic selection was noted for those patients requiring more aggressive LDL lowering, an increase of 10.6% in atorvastatin utilization versus 31.6% of the candidates outlined in the baseline review.

This project has set the standard for collaboration between the Department of Defense, the Pharmaceutical Industry and the community providers to improve the health of our common beneficiaries. Improved medication access to a restricted agent was also demonstrated, highlighting the success of pharmacy-provider communications. Overall, the Pharmacy-led team efforts demonstrated great success at improving cholesterol management and medication safety.