- Email: [email protected]
Implementing Quality Assurance Programs in MultiGroup Practices for Treating Hypercholesterolemia in Patients With Coronary Artery Disease
Implementing Quality Assurance Programs in MultiGroup Practices for Treating Hypercholesterolemia in Patients With Coronary Artery Disease Jaime Gerber,
MD
Healthcare reform is driving the development of specialty physician practices into larger regional and national physician networks. These networks arise from the federation of >2 practices that negotiate with managed-care organizations for contracts. Developing cardiovascular networks and establishing and implementing lipid management quality assurance programs into the network are presented in this article. Goals of the lipid management program include enhancing the identification, diagnosis, education, and comprehensive treatment of patients with cardiovascular disease. Utilizing an integrated, coordinated, multidisciplinary approach to lipid management allows the cardiology network to improve patients’ quality of life, reduce longterm costs, and gain a competitive advantage for successful contracting. A network lipid management program involves targeting eligible patients and treating them to a targeted level for low-density lipoprotein (LDL) cholesterol where possible. Among cardiologists, there is a consensus that achieving an LDL cholesterol of <100 mg/dL for patients with pre-existing cardiovascular disease is desirable. Secondary lipid management pro-
gram goals include: (1) collecting, storing, and analyzing patient demographics; (2) implementing programs involving lifestyle modification, smoking cessation, weight control; and (3) measuring clinical and economic outcomes. Convergence of several driving forces in managing hypercholesterolemia provides cardiologists with the ability to improve the process. These forces include: market-consolidated delivery systems, established lipid management guidelines, and employer-initiated policies requiring higher quality care within managed-care organizations. Methods to achieve enhanced treatment effectiveness, patient satisfaction, and control costs are discussed. Utilizing multidisciplinary teams including nurse case managers, clinical pharmacists, dietitians, and physician assistants to achieve lipid level goals and for nutritional counseling is desirable. Developing disease state management programs, treatment algorithms, databases with analytic reports, and process improvement across the network is of paramount importance for future progress and success. Q1997 by Excerpta Medica, Inc. Am J Cardiol 1997;80(8B):57H– 61H
S
tein (LDL) cholesterol levels.2 The demonstrated safety, efficacy, and cost effectiveness of HMG-CoA reductase inhibitor agents along with their exceptional ability to lower LDL cholesterol with a minimum of side effects have made it possible to effect dramatic cholesterol-lowering therapy in large segments of the population.3,4 Opportunities for physicians who are engaged in the management of single or multispecialty networks to develop and implement lipid quality assurance programs are largely a result of these drugs. Such programs will provide the highest quality, most costeffective care to the patient with CAD and hypercholesterolemia. This article reviews the forces driving development of cardiovascular networks and describes the goals and methods used in implementing lipid management programs in these networks.
weeping changes in the healthcare system are forcing a major reorganization in the way medical care is delivered. The development of local, regional, and national physician networks is one important result of healthcare reform. A disease-oriented approach to healthcare delivery, commonly known as disease state management is another. The realm of cardiovascular disease state management in secondary prevention, specifically in the treatment of hypercholesterolemia, is emerging as an area of interest. Substantial decreases in overall mortality, cardiovascular mortality, as well as repeat coronary event rates in hypercholesterolemic coronary artery disease (CAD) patients treated with simvastatin, were demonstrated in the Scandinavian Simvastatin Survival Study (4S).1 This landmark trial firmly established aggressive lipid lowering with hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitor agents (the “statins”) in the CAD patient as a safe and effective treatment strategy. The more recently published Cholesterol and Recurrent Events (CARE) study using pravastatin extended the findings of 4S in a CAD population with lower baseline low-density lipoproFrom Yale University School of Medicine, New Haven, Connecticut. Address for reprints: Jaime Gerber, MD, Cardiology Associates of New Haven, 40 Temple Street, New Haven, Connecticut 06510. ©1997 by Excerpta Medica, Inc. All rights reserved.
BACKGROUND The relation between hypercholesterolemia and atherosclerotic disease is well known.5– 8 Early secondary prevention studies, including the Coronary Drug Project,9 relied on relatively ineffective means of lowering cholesterol—such as bile acid resins and niacin and fibric acid derivatives—and demonstrated modest benefits in lowering LDL cholesterol. More recent angiographic trials, designed to show regres0002-9149/97/$17.00 PII S002-9149(97)00822-9
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sion of atherosclerotic plaques, demonstrated little improvement in mean luminal diameter. However, a substantial reduction in coronary events was recognized in patients treated with aggressive lipid-lowering therapy. The reduction in cardiovascular events was observed irrespective of the method used to lower cholesterol levels.10 –13 The development of statin agents has revolutionized the ability to dramatically lower the serum cholesterol in nearly all patients with hypercholesterolemia with a minimum of adverse reactions. Statin agents offer greater reductions in cholesterol with substantially fewer side effects compared with bile acid resins and niacin and fibric acid derivatives. In addition to their greater efficacy in lowering serum cholesterol levels, the statin agents now enjoy demonstrated long-term safety in widespread clinical use. HMG-CoA reductase inhibitors are extremely well tolerated, with a drug discontinuance rate of approximately 3–15%14,15 due to all side effects. This discontinuance rate compares favorably with other agents such as niacin and fibric acid derivatives and bile acid therapy, with 1-year discontinuance rates of 46%, 37%, and 41%, respectively.15 Cost effectiveness of various secondary prevention strategies has been examined.16 –19 Long-term decreases in mortality and resource utilization due to a decrease in hospitalizations have been demonstrated, resulting in a cost savings to the healthcare system. The cost per life-year saved in the 4S cadre ranged from $3,800 for a 70 year old man with CAD and a total cholesterol of 300 mg/dL to $27,400 for a 35 year old woman with a total cholesterol of 213 mg/dL. Cost savings accrued by statin-treated patients derive from reduced hospital admissions and reduced rates of coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA).16,17 The Second National Cholesterol Education Program–Adult Treatment Panel (NCEP II)20 has recently recommended that a goal LDL cholesterol level of 100 mg/dL be established for all patients with CAD, acknowledging the importance of aggressive cholesterol reduction in these patients. The American Heart Association (AHA) and the American College of Cardiology (ACC) are actively advocating the goal of secondary prevention with their recently published guidelines for secondary prevention.21 Unfortunately, the percentage of patients with hypercholesterolemia and CAD eligible for lipid-lowering therapy who actually receive therapy is approximately 25%.22,23 Numerous reasons have been identified why physicians fail to treat a greater percentage of eligible CAD patients with lipid-lowering agents.24 The establishment of systematic treatment plans for hypercholesterolemia in cardiology networks represents an outstanding opportunity to improve the cardiovascular health of the nation and ultimately reduce overall costs of health care. 58H THE AMERICAN JOURNAL OF CARDIOLOGYT
TABLE I Converging Forces Driving Lipid Management Programs ● Market forces drive consolidation of delivery systems ● Lower morbidity and mortality associated with lowered serum lipids ● AHA/ACC secondary prevention consensus panel established ● Employers demands for improved quality of care in MCOs
CONVERGING FORCES DRIVE DISEASE MANAGEMENT Market consolidation in health care driven by healthcare reimbursement reform continues in earnest across the country. One result of this market consolidation is the formation of physician networks. Such networks arise from the federation of $2 existing practices, which then attempt to negotiate with managed-care organizations for contracts. Convergence of several distinct trends both in the realm of clinical medicine and in the managed-care arena provides the cardiologist with an opportunity to improve the management of the hypercholesterolemic patient as networks develop (Table I). First, the clinical basis for aggressive secondary prevention has been well established by the 4S and CARE investigators.1,2 Pharmacoeconomic data from these 2 studies clearly show that there is a long-term economic benefit to be gained by secondary prevention. In the 4S study for example, hospital admissions for acute ischemic events were decreased by 30% and observed revascularization rates were decreased by 32%. Approximately 6 of 19 expected bypass operations were avoided as a result of treatment in the 4S study.25 In the CARE study, the patients treated with pravastatin underwent CABG or PTCA significantly less often than patients in the placebo group (294 vs 391: p ,0.001).2 As mentioned above, the concurrent joint AHA/ ACC consensus panel on secondary prevention is viewed by many physicians as the standard of care in secondary prevention of the CAD patient.21,26 The increasing demand by employers for higher quality care from managed-care organizations is an additional important development. While substantial cost pressure in the healthcare marketplace continues, a growing awareness of the need for improved quality of care in the managed-care organization marketplace has been recognized. The National Committee for Quality Assurance (NCQA) evaluates healthcare plans according to numerous criteria, which include preventive services.27 These evaluations are available to the public and are likely to be used by business leaders in selecting healthcare plans. Those physician groups and networks that fail to address cost-effectiveness measures to reduce the incidence of cardiovascular events will be at a disadvantage to those who do so. Positioning cardiology services as quality programs therefore will necessarily include effective secondary prevention measures. Future physician reimbursement may increasingly be tied to the performance of preventive program measures such as screening for hypercholesterolemia in appropriate patients. Morrow et al28 reported the
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TABLE II Network Lipid Management Program Goals for Cardiovascular Patients ● Enhancing the identification, diagnosis, education, and comprehensive treatment ● Providing demographic assessment ● Implementing patient management tools ● Measuring outcomes
effectiveness of physician office medical record audits correlated in part to managed-care organization reimbursement as a means to modify physician behavior in this regard. As market consolidation continues, there will be increasing pressure on physicians to form larger networks from pre-existing practices and to implement lipid management programs in a systematic and uniform fashion. Physicians need to be aware of these trends and of the increasing employer interest in quality of healthcare delivery to seize the opportunity to market their services and retain greater autonomy.
GOALS OF NETWORK LIPID MANAGEMENT The objectives of a lipid quality assurance program in a cardiovascular disease network must be to enhance the identification, diagnosis, education, and comprehensive treatment of the patient with CAD (Table II). The program goal would then be to treat all eligible patients to their targeted LDL cholesterol level. This goal assumes agreement among treating cardiologists to achieve a goal LDL cholesterol of ,100 mg/dL for patients with pre-existing CAD. Some cardiologists perceive that cholesterol management is not of major importance for the prevention of atherosclerosis,29 and it is not unusual to identify patients undergoing multiple angioplasties who have not had their lipid status assessed.30 Cardiologists may also not be motivated to treat elevated lipids because lipid management may be viewed as a function of the primary care physician rather than the specialist. Also, since many lipid experts emanate from the field of endocrinology rather than from cardiology, the feeling among some cardiologists is that lipid management is not directly in their purview.24 Despite the NCEP guidelines and the AHA/ACC position papers, the number of eligible post–myocardial infarction patients who are treated with lipidlowering agents is low.31 The screening rate for hypercholesterolemia in the general population approximates 50%, with a considerably suboptimal treatment rate as well.32,33 Increasing the number of CAD patients treated with cholesterol-lowering therapy lowers long-term costs by reducing CAD-associated hospital admissions and revascularization procedures.4 This observed treatment group represents a major opportunity for physicians to improve their quality of care in a fashion that will reduce the cost of health care, and improve the quality and duration of life of their patients. Secondary goals of network lipid management will
include collecting, storing, and analyzing patient demographics, implementing patient management tools such as lifestyle modification and smoking cessation programs, and measurement of clinical costs and outcomes for treated patients (Table II). Utilizing nurse case managers, clinical pharmacists, and physician assistants in a multidisciplinary culture has been shown to be a highly efficient and cost-effective means to institute and monitor lipid-lowering therapy.34,35 In the Kaiser Permanente model of secondary prevention for patients recently hospitalized after acute myocardial infarction, the percentage of patients at or below the NCEP II goal LDL cholesterol cholesterol of 100 mg/dL in the case-managed group was 42% versus 15% in the usual treatment group. At the Cincinnati Veterans Affairs Hospital, patients enrolled in the multidisciplinary lipid program were 4 times more likely to reach their goal cholesterol than were those patients who were managed by their internists in the medical clinic (44% vs 11%, respectively). The Worcester-Area Trial for Counseling in Hyperlipidemia (WATCH) trial of physician nutritional counseling with and without a structured office system for lipid counseling showed the benefit of a standardized environment for in-office lipid treatment education.36 The effectiveness of any treatment delivery system is largely dependent on clearly defining and agreeing upon set organizational goals.
STEPS TO NETWORK SECONDARY PREVENTION DISEASE MANAGEMENT Disease state management is a comprehensive, integrated approach to care and reimbursement based fundamentally on the natural course of a disease with treatment designed to address the illness by maximizing the effectiveness and efficiency of care delivery.37 The development of disease state management programs is in its earliest stages. Many managed-care organizations have begun to develop disease state management programs in the cardiovascular area, recognizing the savings that can be realized from enhanced preventive efforts. These disease state management programs represent a huge opportunity for cardiologists as this marketplace matures. In addition to enhanced physician autonomy, the successful physician group will gain a competitive edge over other groups by leading in the implementation of these programs. Identification of a key physician within each group is essential. This key physician will be an action-oriented individual with a clearly defined role within the network that will allow him to implement specific network-wide activities related to lipid management. Establishing treatment goals and algorithms across the different member groups of the network is critical to successfully implementing lipid treatment programs. Traditional physician education programs (e.g., grand rounds) are a key element of behavioral modification and need to be conducted regularly but do not by themselves greatly influence physician behavior.23 Carefully planned and staged educational A SYMPOSIUM: HEART DISEASE AND HEART FAILURE
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intervention programs (e.g., educational intervention) such as those advocated by Soumerai38 have been shown to be more effective. Presently, there seems to be little doubt among cardiovascular researchers that the NCEP II guidelines should be followed for secondary prevention programs when there is established atherosclerotic disease.26 However, disagreement concerning the suitability of the NCEP II goals for primary prevention is ongoing. The recently published American College of Physicians (ACP) guidelines and the debate surrounding them have further fueled the controversy. Data collection and analysis are vital cornerstones of any healthcare delivery system. Standardized disease-specific outcomes measures that need to be established are mortality, hospital admission and readmission rates, procedure rates, lipid levels, and treatment to goal. Measures of utilization such as hospital length-of-stay, revascularization rates, emergency room visits, and total dollars spent will also need to be tracked to assure the success of any cardiology services network. The network-wide costs associated with these types of data collection and analysis such as computer hardware, software, and personnel are substantial. Interim solutions such as utilizing a data analysis consultant for computer query and storage functions may provide a cost-effective alternative for the startup period of network development. Identification of process improvement measures is integral to ongoing analysis of network efficacy. Standardization of reporting allows comparative analysis across different member groups. Performance of a quality assurance medical record audit is valuable. This will provide a baseline analysis of physician performance and compliance with established guidelines. A pooled analysis of this data will provide a useful benchmark for comparison after lipid treatment programs are established. Identifying patients not at LDL cholesterol level goal will provide a core group of “at risk” patients for enrollment in aggressive treatment programs at the onset of network activity.
ing levels at discharge. There is now good information that admission lipid values are useful, but levels drawn during hospitalization and at discharge are flawed. A recent paper by Brugada et al,39 evaluating lipid levels in patients admitted for coronary artery bypass surgery and myocardial infarction, revealed that cholesterol levels can drop by as much as 100 mg/dL during a hospitalization. Return to baseline occurs at 3– 6 months. The use of discharge lipid values in making therapeutic decisions is inappropriate because they may be low enough so some patients will not be prescribed necessary therapy. However, even if the patient’s values are high enough to institute therapy, the physician may start a patient on a lipidlowering agent and then the patient’s lipid levels will rise, making the patient and physician think therapy is ineffective. I think that this point of using hospital admission lipid levels is something the clinical community is not aware of and probably should be. It is incorporated in the AHA-ACC guidelines on myocardial infarction. Jaime Gerber, MD: In our practice we endeavor to use lipid values determined in the emergency department. Thomas A. Pearson, MD, PhD: Who enters your data into your lipid management software? Dr. Gerber: Data capture is our primary problem. Medical assistants enter data on patients who have procedures in the hospital. Physicians in private practice are unlikely to use a computer database tool for the sake of data collection without a purpose. To make the program indispensable, we have sought ways to incorporate value-added components to our program. One example is the generation of a catheterization report from the data collection form filled out at the time of the procedure and supplemented in the office at the time of data entry. The difficulties with data capture will diminish with the development of the electronic medical record.
CONCLUSIONS
1. Scandinavian Simvastatin Survival Study Group. Randomized trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344:1383–1389. 2. Sacks FM, Pfeffer MA, Moye LA, Rouleau JL, Rutherford JD, Cole TG, Brown L, Warnica JW, Arnold JM, Wun CC, Davis BR, Braunwald E. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators. N Engl J Med 1996;335:1001–1009. 3. The European Study Group. Efficacy and tolerability of simvastatin and pravastatin in patients with primary hypercholesterolemia (multicountry comparative study). Am J Cardiol 1992;70:1281–1286. 4. Perdersen TR, Berg K, Cook TJ, Faergeman O, Haghfelt T, Kjekshus J, Miettinen, Musliner TA, Olsson AG, Pyorala K, Thorgeirsson G, Tobert JA, Wedel H, Wilhelmsen L. Safety and tolerability of cholesterol lowering with simvastatin during 5 years in the Scandinavian simvastatin survival study. Arch Intern Med 1996;156:2085–2092. 5. Stamler J, Wentworth D, Neaton JD. Is relationship between serum cholesterol and risk of premature death from coronary heart disease continuous and graded? Findings in 356,222 primary screenees of the Multiple Risk Factor Intervention Trial (MRFIT). JAMA 1986;256:2823–2828. 6. Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results. II. The relationship of reduction in incidence of coronary heart disease to cholesterol lowering. JAMA 1984;251:365–374. 7. Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results. I. Reduction in incidence of coronary heart disease. JAMA 1984;251:351–364. 8. Castelli WP, Garrison RJ, Wilson PW, Abbott RD, Kalousdian S, Kannel WB.
Forces driving healthcare reform in the United States are the same as those driving the coalescence of physician practice groups into larger physician networks. The concurrent developments in the secondary prevention of coronary events and the demonstration of the economic benefit of these efforts provide the physician with an opportunity to improve patient care, and enhance the marketability of his practice. Implementing lipid treatment and quality assurance programs will be an important part of cardiovascular care as healthcare consolidation continues.
QUESTIONS AND ANSWERS Nanette K. Wenger, MD: Physicians should be using admission lipid levels, preferably emergency room levels, in evaluating the need for lipid-lowering therapy. Physicians should be discouraged from measur60H THE AMERICAN JOURNAL OF CARDIOLOGYT
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Incidence of coronary heart disease and lipoprotein cholesterol levels. The Framingham Study. JAMA 1986;256:2835–2838. 9. Anonymous. Clofibrate and niacin in coronary heart disease. JAMA 1975;231: 360 –381. 10. Carlson LA, Rosenhamer G. Reduction of mortality in the Stockholm Ischaemic Heart Disease Secondary Prevention Study by combined treatment with clofibrate and nicotinic acid. Acta Med Scand 1988;223:405– 418. 11. Blankenhorn DH, Azen SP, Kramsch DM, Mack WJ, Cashin-Hemphill L, Hodis HN, DeBoer LW, Mahrer PR, Masteller MJ, Vailas LI. Coronary angiographic changes with lovastatin therapy. The Monitored Atherosclerosis Regression Study (MARS). The MARS Research Group. Ann Intern Med 1993;119: 969 –976. 12. Ornish D, Brown SE, Scherwitz LW, Billings JH, Armstrong WT, Ports TA, McLanahan SM, Kirkeeide RL, Brand RJ, Gould KL. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet 1990;336:129 – 133. 13. Brown G, Albers JJ, Fisher LD, Schaefer SM, Lin JT, Kaplan C, Zhao XQ, Bisson BD, Fitzpatrick VF, Dodge HT. Regression of coronary artery disease as a result of intensive lipid-lowering therapy in men with high levels of apolipoprotein B. N Engl J Med 1990;323:1289 –1298. 14. Bradford RH, Shear CL, Chremos AN, Dujovne C, Downton M, Franklin FA, Gould AL, Hesney M, Higgins J, Hurley DP. Expanded Clinical Evaluation of Lovastatin (EXCEL) study results. I. Efficacy in modifying plasma lipoproteins and adverse event profile in 8245 patients with moderate hypercholesterolemia [see comments]. Arch Intern Med 1991;151:43– 49. 15. Andrade SE, Walker AM, Gottlieb LK, Hollenberg NK, Testa MA, Saperia GM, Platt R. Discontinuation of antihyperlipidemic drugs— do rates reported in clinical trials reflect rates in primary care settings? N Engl J Med 1995;332:1125– 1131. 16. Ashraf T, Hay JW, Pitt B, Wittels E, Crouse J, Davidson M, Furberg CD, Radican L. Cost-effectiveness of pravastatin in secondary prevention of coronary artery disease. Am J Cardiol 1996;78:409 – 414. 17. Goldman L, Weinstein MC, Goldman PA, Williams LW. Cost-effectiveness of HMG-CoA reductase inhibition for primary and secondary prevention of coronary heart disease. JAMA 1991;265:1145–1151. 18. Hamilton VH, Racicot FE, Zowall H, Coupal L, Grover SA. The costeffectiveness of HMG-CoA reductase inhibitors to prevent coronary heart disease. Estimating the benefits of increasing HDL-C [see comments]. JAMA 1995; 273:1032–1038. 19. Johannesson M, Jonsson B, Kjekshus J, Olsson AG, Pedersen TR, Wedel H. Cost effectiveness of simvastatin treatment to lower cholesterol levels in patients with coronary heart disease. Scandinavian Simvastatin Survival Study Group. N Engl J Med 1997;336:332–336. 20. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in adults. Summary of the second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA 1993;269:3015–3023. 21. Pearson T, Rapaport E, Criqui M, Furberg C, Fuster V, Hiratzka L, Little W, Ockene I, Williams G. Optimal risk factor management in the patient after coronary revascularization. A statement for healthcare professionals from an American Heart Association Writing Group. Circulation 1994;90:3125–3133.
22. Marketing Research Counselors, Inc.(1992). 23. Browner WS, Baron RB, Solkowitz S, Adler LJ, Gullion DS. Physician
management of hypercholesterolemia. A randomized trial of continuing medical education. West J Med 1994;161:572–578. 24. Roberts WC. Getting cardiologists interested in lipids. (Editorial.) Am J Cardiol 1993;72:744 –745. 25. Pedersen TR, Kjekshus J, Berg K, Olsson AG, Wilhelmsen L, Wedel H, Pyorala K, Miettinen T, Haghfelt T, Faergeman O, Thorgeirsson G, Jonsson B, Schwartz JS. Cholesterol lowering and the use of healthcare resources. Results of the Scandinavian Simvastatin Survival Study. Circulation 1996;93:1796 –1802. 26. Smith SC, Jr., Blair SN, Criqui MH, Fletcher GF, Fuster V, Gersh BJ, Gotto AM, Gould KL, Greenland P, Grundy SM. Preventing heart attack and death in patients with coronary disease. Circulation 1995;92:2– 4. 27. National Committee for Quality Assurance Health Plan Employer Data and Information Set, Version 3.0.(1996). 28. Morrow RW, Gooding AD, Clark C. Improving physicians’ preventive health care behavior through peer review and financial incentives. Arch Fam Med 1995;4:165–169. 29. Schucker B, Wittes JT, Cutler JA, Bailey K, Mackintosh DR, Gordon DJ, Haines CM, Mattson ME, Goor RS, Rifkind BM. Change in physician perspective on cholesterol and heart disease. Results from two national surveys. JAMA 1987;258:3521–3526. 30. Marques V, Bowser S, Hendricks J, Ruffner R. Treatment of hypercholesterolemia in patients undergoing multiple coronary angioplasties. Rev Port Cardiol 1996;15:787–791,771–772. 31. Cohen MV, Byrne MJ, Levine B, Gutowski T, Adelson R. Low rate of treatment of hypercholesterolemia by cardiologists in patients with suspected and proven coronary artery disease. Circulation 1991;83:1294 –1304. 32. Hyman DJ, Maibach EW, Flora JA, Fortmann SP. Cholesterol treatment practices of primary care physicians. Public Health Rep 1992;107:441– 448. 33. Schectman JM, Elinsky EG, Bartman BA. Primary care clinician compliance with cholesterol treatment guidelines. J Gen Intern Med 1991;6:121–125. 34. DeBusk RF, Miller NH, Superko HR, Dennis CA, Thomas RJ, Lew HT, Berger WE, 3rd, Heller RS, Rompf J, Gee D. A case-management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med 1994;120:721–729. 35. Shaffer J, Wexler LF. Reducing low-density lipoprotein cholesterol levels in an ambulatory care system. Results of a multidisciplinary collaborative practice lipid clinic compared with traditional physician-based care. Arch Intern Med 1995;155:2330 –2335. 36. Ockene IS, Hebert JR, Ockene JK, Merriam PA, Hurley TG, Saperia GM. Effect of training and a structured office practice on physician-delivered nutrition counseling: the Worcester-Area Trial for Counseling in Hyperlipidemia (WATCH). Am J Prev Med 1996;12:252–258. 37. Zitter M. Product Management Today, February 1995;10 –16. 38. Soumerai, SB, Avorn, J. Principles of educational outreach (“academic detailing”) to improve clinical decision making. JAMA 1990;263:549 –556. 39. Brugada R, Wenger NK, Jacobson TA, Clark WS, Cotsonis G, Iglesias A. Changes in plasma cholesterol levels after hospitalization for acute coronary events. Cardiology 1996;87:194 –199.
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MD
Healthcare reform is driving the development of specialty physician practices into larger regional and national physician networks. These networks arise from the federation of >2 practices that negotiate with managed-care organizations for contracts. Developing cardiovascular networks and establishing and implementing lipid management quality assurance programs into the network are presented in this article. Goals of the lipid management program include enhancing the identification, diagnosis, education, and comprehensive treatment of patients with cardiovascular disease. Utilizing an integrated, coordinated, multidisciplinary approach to lipid management allows the cardiology network to improve patients’ quality of life, reduce longterm costs, and gain a competitive advantage for successful contracting. A network lipid management program involves targeting eligible patients and treating them to a targeted level for low-density lipoprotein (LDL) cholesterol where possible. Among cardiologists, there is a consensus that achieving an LDL cholesterol of <100 mg/dL for patients with pre-existing cardiovascular disease is desirable. Secondary lipid management pro-
gram goals include: (1) collecting, storing, and analyzing patient demographics; (2) implementing programs involving lifestyle modification, smoking cessation, weight control; and (3) measuring clinical and economic outcomes. Convergence of several driving forces in managing hypercholesterolemia provides cardiologists with the ability to improve the process. These forces include: market-consolidated delivery systems, established lipid management guidelines, and employer-initiated policies requiring higher quality care within managed-care organizations. Methods to achieve enhanced treatment effectiveness, patient satisfaction, and control costs are discussed. Utilizing multidisciplinary teams including nurse case managers, clinical pharmacists, dietitians, and physician assistants to achieve lipid level goals and for nutritional counseling is desirable. Developing disease state management programs, treatment algorithms, databases with analytic reports, and process improvement across the network is of paramount importance for future progress and success. Q1997 by Excerpta Medica, Inc. Am J Cardiol 1997;80(8B):57H– 61H
S
tein (LDL) cholesterol levels.2 The demonstrated safety, efficacy, and cost effectiveness of HMG-CoA reductase inhibitor agents along with their exceptional ability to lower LDL cholesterol with a minimum of side effects have made it possible to effect dramatic cholesterol-lowering therapy in large segments of the population.3,4 Opportunities for physicians who are engaged in the management of single or multispecialty networks to develop and implement lipid quality assurance programs are largely a result of these drugs. Such programs will provide the highest quality, most costeffective care to the patient with CAD and hypercholesterolemia. This article reviews the forces driving development of cardiovascular networks and describes the goals and methods used in implementing lipid management programs in these networks.
weeping changes in the healthcare system are forcing a major reorganization in the way medical care is delivered. The development of local, regional, and national physician networks is one important result of healthcare reform. A disease-oriented approach to healthcare delivery, commonly known as disease state management is another. The realm of cardiovascular disease state management in secondary prevention, specifically in the treatment of hypercholesterolemia, is emerging as an area of interest. Substantial decreases in overall mortality, cardiovascular mortality, as well as repeat coronary event rates in hypercholesterolemic coronary artery disease (CAD) patients treated with simvastatin, were demonstrated in the Scandinavian Simvastatin Survival Study (4S).1 This landmark trial firmly established aggressive lipid lowering with hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitor agents (the “statins”) in the CAD patient as a safe and effective treatment strategy. The more recently published Cholesterol and Recurrent Events (CARE) study using pravastatin extended the findings of 4S in a CAD population with lower baseline low-density lipoproFrom Yale University School of Medicine, New Haven, Connecticut. Address for reprints: Jaime Gerber, MD, Cardiology Associates of New Haven, 40 Temple Street, New Haven, Connecticut 06510. ©1997 by Excerpta Medica, Inc. All rights reserved.
BACKGROUND The relation between hypercholesterolemia and atherosclerotic disease is well known.5– 8 Early secondary prevention studies, including the Coronary Drug Project,9 relied on relatively ineffective means of lowering cholesterol—such as bile acid resins and niacin and fibric acid derivatives—and demonstrated modest benefits in lowering LDL cholesterol. More recent angiographic trials, designed to show regres0002-9149/97/$17.00 PII S002-9149(97)00822-9
57H
sion of atherosclerotic plaques, demonstrated little improvement in mean luminal diameter. However, a substantial reduction in coronary events was recognized in patients treated with aggressive lipid-lowering therapy. The reduction in cardiovascular events was observed irrespective of the method used to lower cholesterol levels.10 –13 The development of statin agents has revolutionized the ability to dramatically lower the serum cholesterol in nearly all patients with hypercholesterolemia with a minimum of adverse reactions. Statin agents offer greater reductions in cholesterol with substantially fewer side effects compared with bile acid resins and niacin and fibric acid derivatives. In addition to their greater efficacy in lowering serum cholesterol levels, the statin agents now enjoy demonstrated long-term safety in widespread clinical use. HMG-CoA reductase inhibitors are extremely well tolerated, with a drug discontinuance rate of approximately 3–15%14,15 due to all side effects. This discontinuance rate compares favorably with other agents such as niacin and fibric acid derivatives and bile acid therapy, with 1-year discontinuance rates of 46%, 37%, and 41%, respectively.15 Cost effectiveness of various secondary prevention strategies has been examined.16 –19 Long-term decreases in mortality and resource utilization due to a decrease in hospitalizations have been demonstrated, resulting in a cost savings to the healthcare system. The cost per life-year saved in the 4S cadre ranged from $3,800 for a 70 year old man with CAD and a total cholesterol of 300 mg/dL to $27,400 for a 35 year old woman with a total cholesterol of 213 mg/dL. Cost savings accrued by statin-treated patients derive from reduced hospital admissions and reduced rates of coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA).16,17 The Second National Cholesterol Education Program–Adult Treatment Panel (NCEP II)20 has recently recommended that a goal LDL cholesterol level of 100 mg/dL be established for all patients with CAD, acknowledging the importance of aggressive cholesterol reduction in these patients. The American Heart Association (AHA) and the American College of Cardiology (ACC) are actively advocating the goal of secondary prevention with their recently published guidelines for secondary prevention.21 Unfortunately, the percentage of patients with hypercholesterolemia and CAD eligible for lipid-lowering therapy who actually receive therapy is approximately 25%.22,23 Numerous reasons have been identified why physicians fail to treat a greater percentage of eligible CAD patients with lipid-lowering agents.24 The establishment of systematic treatment plans for hypercholesterolemia in cardiology networks represents an outstanding opportunity to improve the cardiovascular health of the nation and ultimately reduce overall costs of health care. 58H THE AMERICAN JOURNAL OF CARDIOLOGYT
TABLE I Converging Forces Driving Lipid Management Programs ● Market forces drive consolidation of delivery systems ● Lower morbidity and mortality associated with lowered serum lipids ● AHA/ACC secondary prevention consensus panel established ● Employers demands for improved quality of care in MCOs
CONVERGING FORCES DRIVE DISEASE MANAGEMENT Market consolidation in health care driven by healthcare reimbursement reform continues in earnest across the country. One result of this market consolidation is the formation of physician networks. Such networks arise from the federation of $2 existing practices, which then attempt to negotiate with managed-care organizations for contracts. Convergence of several distinct trends both in the realm of clinical medicine and in the managed-care arena provides the cardiologist with an opportunity to improve the management of the hypercholesterolemic patient as networks develop (Table I). First, the clinical basis for aggressive secondary prevention has been well established by the 4S and CARE investigators.1,2 Pharmacoeconomic data from these 2 studies clearly show that there is a long-term economic benefit to be gained by secondary prevention. In the 4S study for example, hospital admissions for acute ischemic events were decreased by 30% and observed revascularization rates were decreased by 32%. Approximately 6 of 19 expected bypass operations were avoided as a result of treatment in the 4S study.25 In the CARE study, the patients treated with pravastatin underwent CABG or PTCA significantly less often than patients in the placebo group (294 vs 391: p ,0.001).2 As mentioned above, the concurrent joint AHA/ ACC consensus panel on secondary prevention is viewed by many physicians as the standard of care in secondary prevention of the CAD patient.21,26 The increasing demand by employers for higher quality care from managed-care organizations is an additional important development. While substantial cost pressure in the healthcare marketplace continues, a growing awareness of the need for improved quality of care in the managed-care organization marketplace has been recognized. The National Committee for Quality Assurance (NCQA) evaluates healthcare plans according to numerous criteria, which include preventive services.27 These evaluations are available to the public and are likely to be used by business leaders in selecting healthcare plans. Those physician groups and networks that fail to address cost-effectiveness measures to reduce the incidence of cardiovascular events will be at a disadvantage to those who do so. Positioning cardiology services as quality programs therefore will necessarily include effective secondary prevention measures. Future physician reimbursement may increasingly be tied to the performance of preventive program measures such as screening for hypercholesterolemia in appropriate patients. Morrow et al28 reported the
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TABLE II Network Lipid Management Program Goals for Cardiovascular Patients ● Enhancing the identification, diagnosis, education, and comprehensive treatment ● Providing demographic assessment ● Implementing patient management tools ● Measuring outcomes
effectiveness of physician office medical record audits correlated in part to managed-care organization reimbursement as a means to modify physician behavior in this regard. As market consolidation continues, there will be increasing pressure on physicians to form larger networks from pre-existing practices and to implement lipid management programs in a systematic and uniform fashion. Physicians need to be aware of these trends and of the increasing employer interest in quality of healthcare delivery to seize the opportunity to market their services and retain greater autonomy.
GOALS OF NETWORK LIPID MANAGEMENT The objectives of a lipid quality assurance program in a cardiovascular disease network must be to enhance the identification, diagnosis, education, and comprehensive treatment of the patient with CAD (Table II). The program goal would then be to treat all eligible patients to their targeted LDL cholesterol level. This goal assumes agreement among treating cardiologists to achieve a goal LDL cholesterol of ,100 mg/dL for patients with pre-existing CAD. Some cardiologists perceive that cholesterol management is not of major importance for the prevention of atherosclerosis,29 and it is not unusual to identify patients undergoing multiple angioplasties who have not had their lipid status assessed.30 Cardiologists may also not be motivated to treat elevated lipids because lipid management may be viewed as a function of the primary care physician rather than the specialist. Also, since many lipid experts emanate from the field of endocrinology rather than from cardiology, the feeling among some cardiologists is that lipid management is not directly in their purview.24 Despite the NCEP guidelines and the AHA/ACC position papers, the number of eligible post–myocardial infarction patients who are treated with lipidlowering agents is low.31 The screening rate for hypercholesterolemia in the general population approximates 50%, with a considerably suboptimal treatment rate as well.32,33 Increasing the number of CAD patients treated with cholesterol-lowering therapy lowers long-term costs by reducing CAD-associated hospital admissions and revascularization procedures.4 This observed treatment group represents a major opportunity for physicians to improve their quality of care in a fashion that will reduce the cost of health care, and improve the quality and duration of life of their patients. Secondary goals of network lipid management will
include collecting, storing, and analyzing patient demographics, implementing patient management tools such as lifestyle modification and smoking cessation programs, and measurement of clinical costs and outcomes for treated patients (Table II). Utilizing nurse case managers, clinical pharmacists, and physician assistants in a multidisciplinary culture has been shown to be a highly efficient and cost-effective means to institute and monitor lipid-lowering therapy.34,35 In the Kaiser Permanente model of secondary prevention for patients recently hospitalized after acute myocardial infarction, the percentage of patients at or below the NCEP II goal LDL cholesterol cholesterol of 100 mg/dL in the case-managed group was 42% versus 15% in the usual treatment group. At the Cincinnati Veterans Affairs Hospital, patients enrolled in the multidisciplinary lipid program were 4 times more likely to reach their goal cholesterol than were those patients who were managed by their internists in the medical clinic (44% vs 11%, respectively). The Worcester-Area Trial for Counseling in Hyperlipidemia (WATCH) trial of physician nutritional counseling with and without a structured office system for lipid counseling showed the benefit of a standardized environment for in-office lipid treatment education.36 The effectiveness of any treatment delivery system is largely dependent on clearly defining and agreeing upon set organizational goals.
STEPS TO NETWORK SECONDARY PREVENTION DISEASE MANAGEMENT Disease state management is a comprehensive, integrated approach to care and reimbursement based fundamentally on the natural course of a disease with treatment designed to address the illness by maximizing the effectiveness and efficiency of care delivery.37 The development of disease state management programs is in its earliest stages. Many managed-care organizations have begun to develop disease state management programs in the cardiovascular area, recognizing the savings that can be realized from enhanced preventive efforts. These disease state management programs represent a huge opportunity for cardiologists as this marketplace matures. In addition to enhanced physician autonomy, the successful physician group will gain a competitive edge over other groups by leading in the implementation of these programs. Identification of a key physician within each group is essential. This key physician will be an action-oriented individual with a clearly defined role within the network that will allow him to implement specific network-wide activities related to lipid management. Establishing treatment goals and algorithms across the different member groups of the network is critical to successfully implementing lipid treatment programs. Traditional physician education programs (e.g., grand rounds) are a key element of behavioral modification and need to be conducted regularly but do not by themselves greatly influence physician behavior.23 Carefully planned and staged educational A SYMPOSIUM: HEART DISEASE AND HEART FAILURE
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intervention programs (e.g., educational intervention) such as those advocated by Soumerai38 have been shown to be more effective. Presently, there seems to be little doubt among cardiovascular researchers that the NCEP II guidelines should be followed for secondary prevention programs when there is established atherosclerotic disease.26 However, disagreement concerning the suitability of the NCEP II goals for primary prevention is ongoing. The recently published American College of Physicians (ACP) guidelines and the debate surrounding them have further fueled the controversy. Data collection and analysis are vital cornerstones of any healthcare delivery system. Standardized disease-specific outcomes measures that need to be established are mortality, hospital admission and readmission rates, procedure rates, lipid levels, and treatment to goal. Measures of utilization such as hospital length-of-stay, revascularization rates, emergency room visits, and total dollars spent will also need to be tracked to assure the success of any cardiology services network. The network-wide costs associated with these types of data collection and analysis such as computer hardware, software, and personnel are substantial. Interim solutions such as utilizing a data analysis consultant for computer query and storage functions may provide a cost-effective alternative for the startup period of network development. Identification of process improvement measures is integral to ongoing analysis of network efficacy. Standardization of reporting allows comparative analysis across different member groups. Performance of a quality assurance medical record audit is valuable. This will provide a baseline analysis of physician performance and compliance with established guidelines. A pooled analysis of this data will provide a useful benchmark for comparison after lipid treatment programs are established. Identifying patients not at LDL cholesterol level goal will provide a core group of “at risk” patients for enrollment in aggressive treatment programs at the onset of network activity.
ing levels at discharge. There is now good information that admission lipid values are useful, but levels drawn during hospitalization and at discharge are flawed. A recent paper by Brugada et al,39 evaluating lipid levels in patients admitted for coronary artery bypass surgery and myocardial infarction, revealed that cholesterol levels can drop by as much as 100 mg/dL during a hospitalization. Return to baseline occurs at 3– 6 months. The use of discharge lipid values in making therapeutic decisions is inappropriate because they may be low enough so some patients will not be prescribed necessary therapy. However, even if the patient’s values are high enough to institute therapy, the physician may start a patient on a lipidlowering agent and then the patient’s lipid levels will rise, making the patient and physician think therapy is ineffective. I think that this point of using hospital admission lipid levels is something the clinical community is not aware of and probably should be. It is incorporated in the AHA-ACC guidelines on myocardial infarction. Jaime Gerber, MD: In our practice we endeavor to use lipid values determined in the emergency department. Thomas A. Pearson, MD, PhD: Who enters your data into your lipid management software? Dr. Gerber: Data capture is our primary problem. Medical assistants enter data on patients who have procedures in the hospital. Physicians in private practice are unlikely to use a computer database tool for the sake of data collection without a purpose. To make the program indispensable, we have sought ways to incorporate value-added components to our program. One example is the generation of a catheterization report from the data collection form filled out at the time of the procedure and supplemented in the office at the time of data entry. The difficulties with data capture will diminish with the development of the electronic medical record.
CONCLUSIONS
1. Scandinavian Simvastatin Survival Study Group. Randomized trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344:1383–1389. 2. Sacks FM, Pfeffer MA, Moye LA, Rouleau JL, Rutherford JD, Cole TG, Brown L, Warnica JW, Arnold JM, Wun CC, Davis BR, Braunwald E. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators. N Engl J Med 1996;335:1001–1009. 3. The European Study Group. Efficacy and tolerability of simvastatin and pravastatin in patients with primary hypercholesterolemia (multicountry comparative study). Am J Cardiol 1992;70:1281–1286. 4. Perdersen TR, Berg K, Cook TJ, Faergeman O, Haghfelt T, Kjekshus J, Miettinen, Musliner TA, Olsson AG, Pyorala K, Thorgeirsson G, Tobert JA, Wedel H, Wilhelmsen L. Safety and tolerability of cholesterol lowering with simvastatin during 5 years in the Scandinavian simvastatin survival study. Arch Intern Med 1996;156:2085–2092. 5. Stamler J, Wentworth D, Neaton JD. Is relationship between serum cholesterol and risk of premature death from coronary heart disease continuous and graded? Findings in 356,222 primary screenees of the Multiple Risk Factor Intervention Trial (MRFIT). JAMA 1986;256:2823–2828. 6. Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results. II. The relationship of reduction in incidence of coronary heart disease to cholesterol lowering. JAMA 1984;251:365–374. 7. Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results. I. Reduction in incidence of coronary heart disease. JAMA 1984;251:351–364. 8. Castelli WP, Garrison RJ, Wilson PW, Abbott RD, Kalousdian S, Kannel WB.
Forces driving healthcare reform in the United States are the same as those driving the coalescence of physician practice groups into larger physician networks. The concurrent developments in the secondary prevention of coronary events and the demonstration of the economic benefit of these efforts provide the physician with an opportunity to improve patient care, and enhance the marketability of his practice. Implementing lipid treatment and quality assurance programs will be an important part of cardiovascular care as healthcare consolidation continues.
QUESTIONS AND ANSWERS Nanette K. Wenger, MD: Physicians should be using admission lipid levels, preferably emergency room levels, in evaluating the need for lipid-lowering therapy. Physicians should be discouraged from measur60H THE AMERICAN JOURNAL OF CARDIOLOGYT
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Incidence of coronary heart disease and lipoprotein cholesterol levels. The Framingham Study. JAMA 1986;256:2835–2838. 9. Anonymous. Clofibrate and niacin in coronary heart disease. JAMA 1975;231: 360 –381. 10. Carlson LA, Rosenhamer G. Reduction of mortality in the Stockholm Ischaemic Heart Disease Secondary Prevention Study by combined treatment with clofibrate and nicotinic acid. Acta Med Scand 1988;223:405– 418. 11. Blankenhorn DH, Azen SP, Kramsch DM, Mack WJ, Cashin-Hemphill L, Hodis HN, DeBoer LW, Mahrer PR, Masteller MJ, Vailas LI. Coronary angiographic changes with lovastatin therapy. The Monitored Atherosclerosis Regression Study (MARS). The MARS Research Group. Ann Intern Med 1993;119: 969 –976. 12. Ornish D, Brown SE, Scherwitz LW, Billings JH, Armstrong WT, Ports TA, McLanahan SM, Kirkeeide RL, Brand RJ, Gould KL. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet 1990;336:129 – 133. 13. Brown G, Albers JJ, Fisher LD, Schaefer SM, Lin JT, Kaplan C, Zhao XQ, Bisson BD, Fitzpatrick VF, Dodge HT. Regression of coronary artery disease as a result of intensive lipid-lowering therapy in men with high levels of apolipoprotein B. N Engl J Med 1990;323:1289 –1298. 14. Bradford RH, Shear CL, Chremos AN, Dujovne C, Downton M, Franklin FA, Gould AL, Hesney M, Higgins J, Hurley DP. Expanded Clinical Evaluation of Lovastatin (EXCEL) study results. I. Efficacy in modifying plasma lipoproteins and adverse event profile in 8245 patients with moderate hypercholesterolemia [see comments]. Arch Intern Med 1991;151:43– 49. 15. Andrade SE, Walker AM, Gottlieb LK, Hollenberg NK, Testa MA, Saperia GM, Platt R. Discontinuation of antihyperlipidemic drugs— do rates reported in clinical trials reflect rates in primary care settings? N Engl J Med 1995;332:1125– 1131. 16. Ashraf T, Hay JW, Pitt B, Wittels E, Crouse J, Davidson M, Furberg CD, Radican L. Cost-effectiveness of pravastatin in secondary prevention of coronary artery disease. Am J Cardiol 1996;78:409 – 414. 17. Goldman L, Weinstein MC, Goldman PA, Williams LW. Cost-effectiveness of HMG-CoA reductase inhibition for primary and secondary prevention of coronary heart disease. JAMA 1991;265:1145–1151. 18. Hamilton VH, Racicot FE, Zowall H, Coupal L, Grover SA. The costeffectiveness of HMG-CoA reductase inhibitors to prevent coronary heart disease. Estimating the benefits of increasing HDL-C [see comments]. JAMA 1995; 273:1032–1038. 19. Johannesson M, Jonsson B, Kjekshus J, Olsson AG, Pedersen TR, Wedel H. Cost effectiveness of simvastatin treatment to lower cholesterol levels in patients with coronary heart disease. Scandinavian Simvastatin Survival Study Group. N Engl J Med 1997;336:332–336. 20. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in adults. Summary of the second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA 1993;269:3015–3023. 21. Pearson T, Rapaport E, Criqui M, Furberg C, Fuster V, Hiratzka L, Little W, Ockene I, Williams G. Optimal risk factor management in the patient after coronary revascularization. A statement for healthcare professionals from an American Heart Association Writing Group. Circulation 1994;90:3125–3133.
22. Marketing Research Counselors, Inc.(1992). 23. Browner WS, Baron RB, Solkowitz S, Adler LJ, Gullion DS. Physician
management of hypercholesterolemia. A randomized trial of continuing medical education. West J Med 1994;161:572–578. 24. Roberts WC. Getting cardiologists interested in lipids. (Editorial.) Am J Cardiol 1993;72:744 –745. 25. Pedersen TR, Kjekshus J, Berg K, Olsson AG, Wilhelmsen L, Wedel H, Pyorala K, Miettinen T, Haghfelt T, Faergeman O, Thorgeirsson G, Jonsson B, Schwartz JS. Cholesterol lowering and the use of healthcare resources. Results of the Scandinavian Simvastatin Survival Study. Circulation 1996;93:1796 –1802. 26. Smith SC, Jr., Blair SN, Criqui MH, Fletcher GF, Fuster V, Gersh BJ, Gotto AM, Gould KL, Greenland P, Grundy SM. Preventing heart attack and death in patients with coronary disease. Circulation 1995;92:2– 4. 27. National Committee for Quality Assurance Health Plan Employer Data and Information Set, Version 3.0.(1996). 28. Morrow RW, Gooding AD, Clark C. Improving physicians’ preventive health care behavior through peer review and financial incentives. Arch Fam Med 1995;4:165–169. 29. Schucker B, Wittes JT, Cutler JA, Bailey K, Mackintosh DR, Gordon DJ, Haines CM, Mattson ME, Goor RS, Rifkind BM. Change in physician perspective on cholesterol and heart disease. Results from two national surveys. JAMA 1987;258:3521–3526. 30. Marques V, Bowser S, Hendricks J, Ruffner R. Treatment of hypercholesterolemia in patients undergoing multiple coronary angioplasties. Rev Port Cardiol 1996;15:787–791,771–772. 31. Cohen MV, Byrne MJ, Levine B, Gutowski T, Adelson R. Low rate of treatment of hypercholesterolemia by cardiologists in patients with suspected and proven coronary artery disease. Circulation 1991;83:1294 –1304. 32. Hyman DJ, Maibach EW, Flora JA, Fortmann SP. Cholesterol treatment practices of primary care physicians. Public Health Rep 1992;107:441– 448. 33. Schectman JM, Elinsky EG, Bartman BA. Primary care clinician compliance with cholesterol treatment guidelines. J Gen Intern Med 1991;6:121–125. 34. DeBusk RF, Miller NH, Superko HR, Dennis CA, Thomas RJ, Lew HT, Berger WE, 3rd, Heller RS, Rompf J, Gee D. A case-management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med 1994;120:721–729. 35. Shaffer J, Wexler LF. Reducing low-density lipoprotein cholesterol levels in an ambulatory care system. Results of a multidisciplinary collaborative practice lipid clinic compared with traditional physician-based care. Arch Intern Med 1995;155:2330 –2335. 36. Ockene IS, Hebert JR, Ockene JK, Merriam PA, Hurley TG, Saperia GM. Effect of training and a structured office practice on physician-delivered nutrition counseling: the Worcester-Area Trial for Counseling in Hyperlipidemia (WATCH). Am J Prev Med 1996;12:252–258. 37. Zitter M. Product Management Today, February 1995;10 –16. 38. Soumerai, SB, Avorn, J. Principles of educational outreach (“academic detailing”) to improve clinical decision making. JAMA 1990;263:549 –556. 39. Brugada R, Wenger NK, Jacobson TA, Clark WS, Cotsonis G, Iglesias A. Changes in plasma cholesterol levels after hospitalization for acute coronary events. Cardiology 1996;87:194 –199.
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