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.
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