- Email: [email protected]
It takes more than patient education to reach low-density lipoprotein cholesterol goals
Editorial
It takes more than patient education to reach lowdensity lipoprotein cholesterol goals Eva M. Kline-Rogers, MS, RN, and Kim A. Eagle, MD Ann Arbor, Mich
See related article on page 522.
The benefits of cholesterol-lowering therapy in patients with known coronary artery disease have been well documented.1–3 The National Cholesterol Education Program’s (NCEP) updated clinical guidelines for cholesterol management suggest intensive management of low-density lipoprotein (LDL) cholesterol in persons with established coronary artery disease and recommend more intensive LDL-lowering therapy in patients who are at high risk.4 For patients with known coronary heart disease, the current guidelines suggest treatment to an LDL cholesterol level ⱕ100 mg/dL. Recently, data from the Heart Protection Study suggests that lowering LDL cholesterol below current NCEP guidelines is associated with cardiovascular risk reduction, even in traditionally high-risk groups such as women and elderly patients, in whom the benefits of cholesterol-lowering have previously been debated.5 The Reinforcing Education About Cholesterol (REACH) trial was designed to evaluate the impact of a nurse-based education intervention on the ability to achieve an LDL cholesterol level ⱕ100 mg/dL at 1 year in patients who had recently been hospitalized and had documented evidence of coronary artery disease. The unique contribution of this trial was its goal of testing the additional independent benefit of an educational intervention to standard care; the decision to initiate or titrate lipid medications was at the discretion of each patient’s physician. This report is timely and relevant, because most of our inpatient and outpatient interventions include patient education as a core element. On the basis of work by Wagner et al,6 the theory that patient empowerment plays a vital role in successful management of chronic illnesses was the basis for the intervention arm of the protocol. In the REACH trial, the nurse-based educational intervention did not increase compliance with NCEP-recommended guidelines. In the intervention group, 70.2% of the patients versus 67.4% of pa-
From the Division of Cardiology, University of Michigan Health System, Ann Arbor, Mich. Reprint requests: Eva M. Kline-Rogers, MS, RN, Dominos Farms/Lobby B/MCORRP, 24 Frank Lloyd Wright Dr, Ann Arbor, MI 48106. Am Heart J 2004;147:381–2. 0002-8703/$ - see front matter © 2004, Elsevier Inc. All rights reserved. doi:10.1016/j.ahj.2003.10.012
tients in the control group (P ⫽ .46) reached target LDL cholesterol levels at 1 year (ⱕ100 mg/dL). Patients in the intervention group had improved knowledge of appropriate lipid targets, but this did not result in increased adherence. Although disappointing, these results emphasize several issues. First, increased knowledge does not necessarily translate into achievement of pharmacologic goals in this population of patients. Educational interventions in patients with asymptomatic illnesses (like hypercholesterolemia) may be much less effective than similar interventions in patients with symptomatic illnesses. For instance, the authors point out that a similar educational intervention was successful in a study of 88 patients with symptomatic heart failure.7 Educational interventions have also been shown to be effective in reducing glucose levels in patients with diabetes mellitus,8 but again, in this circumstance, patients may sense hyperglycemia symptoms, be monitoring glycemia with daily glucose measures, or both. Management of hypertension presents similar challenges to hypercholesterolemia in attempting to achieve adequate control in an illness that usually has no symptoms. Second, the recent Lescol Intervention Prevention Study (LIPS)9 demonstrated that cholesterollowering therapy initiated in the hospital for patients who had undergone a recent coronary intervention resulted in a significant risk reduction in subsequent fatal and non-fatal coronary events, which supports early initiation of statin therapy in patients after intervention. In another trial designed to achieve established goals for LDL cholesterol in patients participating in cardiac rehabilitation after an acute coronary event, specially trained nurses were able to attain results similar to those reached by preventive cardiologists, with the initiation of drug therapy (primarily a statin drug) being the strongest predictor of achieving an LDL cholesterol level ⱕ100 mg/dL.10 In this instance, education was just 1 aspect of a multidimensional program that provided the appropriate medications and lifestyle targets and monitored patient adherence. Recent quality improvement initiatives, like the American College of Cardiology’s Guidelines Applied in Practice (GAP) and the American Heart Association’s Get With the Guidelines (GWTG) program, have been successful in increasing the percentage of patients with acute coronary syndromes who are discharged on appropriate evidence-based therapies, including choles-
382 Kline-Rogers and Eagle
terol-lowering therapy.11 Much of this benefit is correlated to the use of standardized care tools that emphasize the initiation of evidence-based therapies in eligible patients and active involvement of the patient, nurse, and physician. Dissemination and integration of the NCEP guidelines into ambulatory practices is equally, if not more, important. Application of a GAPlike intervention in the ambulatory setting would include processes that identify barriers to proper implementation of treatment and titration of therapies with proven interventions for overcoming these barriers. Incorporation of simple pocket cards with titration algorithms into standard orders and office notes would assist busy caregivers in making appropriate changes. This may be facilitated with electronic care tools. Getting patients to achieve recommended cholesterol levels will truly take a concerted team approach, linking inpatient to outpatient care and involving all members of the care triangle, including the patient, nurse, and/or physician. Only when all health care team members are aware of national guidelines and are accountable for implementing evidence-based therapy will the benefits of current knowledge be fully realized.
References 1. Scandanavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344:1383–9.
American Heart Journal March 2004
2. Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996;335:1001–9. 3. Streja L, Packard CJ, Shepherd J, et al. Factors affecting lowdensity lipoprotein and high-density lipoprotein cholesterol response to pravastatin in the West of Scotland Coronary Prevention Study (WOSCOPS). Am J Cardiol 2002;90:731– 6. 4. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 2001;285:2486 –97. 5. MRC/BHF Heart Protection study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomized placebocontrolled trial. Lancet 2002;360:7–22. 6. Wagner EH. The role of patient care teams in chronic disease management. BMJ 2000;320:569 –72. 7. Krumholtz HM, Amatruda J, Smith GL, et al. Randomized trial of an education and support intervention to prevent readmission of patients with heart failure. J Am Coll Cardiol 2002;39:83–9. 8. Annaswamy R, Gomes H, Beard JO, et al. A randomized trial comparing intensive and passive education in patients with diabetes mellitus. Arch Intern Med 2002;162:1301– 4. 9. Serruys PW, deFeyter P, Macaya C, et al. Fluvastatin for prevention of cardiac events following successful first percutaneous coronary intervention: a randomized controlled trial. JAMA 2002;287: 3215–22. 10. Allison TG, Squires RW, Johnson BD, et al. Achieving National Cholesterol Education Program goals for low-density lipoprotein cholesterol in cardiac patients: importance of diet, exercise, weight control, and drug therapy. Mayo Clin Proc 1999;74:466 –73. 11. Mehta RH, Montoye CK, Gallogly M, et al. Improving quality of care for acute myocardial infarction: the Guidelines Applied in Practice (GAP) initiative. JAMA 2002;287:1269 –76.
It takes more than patient education to reach lowdensity lipoprotein cholesterol goals Eva M. Kline-Rogers, MS, RN, and Kim A. Eagle, MD Ann Arbor, Mich
See related article on page 522.
The benefits of cholesterol-lowering therapy in patients with known coronary artery disease have been well documented.1–3 The National Cholesterol Education Program’s (NCEP) updated clinical guidelines for cholesterol management suggest intensive management of low-density lipoprotein (LDL) cholesterol in persons with established coronary artery disease and recommend more intensive LDL-lowering therapy in patients who are at high risk.4 For patients with known coronary heart disease, the current guidelines suggest treatment to an LDL cholesterol level ⱕ100 mg/dL. Recently, data from the Heart Protection Study suggests that lowering LDL cholesterol below current NCEP guidelines is associated with cardiovascular risk reduction, even in traditionally high-risk groups such as women and elderly patients, in whom the benefits of cholesterol-lowering have previously been debated.5 The Reinforcing Education About Cholesterol (REACH) trial was designed to evaluate the impact of a nurse-based education intervention on the ability to achieve an LDL cholesterol level ⱕ100 mg/dL at 1 year in patients who had recently been hospitalized and had documented evidence of coronary artery disease. The unique contribution of this trial was its goal of testing the additional independent benefit of an educational intervention to standard care; the decision to initiate or titrate lipid medications was at the discretion of each patient’s physician. This report is timely and relevant, because most of our inpatient and outpatient interventions include patient education as a core element. On the basis of work by Wagner et al,6 the theory that patient empowerment plays a vital role in successful management of chronic illnesses was the basis for the intervention arm of the protocol. In the REACH trial, the nurse-based educational intervention did not increase compliance with NCEP-recommended guidelines. In the intervention group, 70.2% of the patients versus 67.4% of pa-
From the Division of Cardiology, University of Michigan Health System, Ann Arbor, Mich. Reprint requests: Eva M. Kline-Rogers, MS, RN, Dominos Farms/Lobby B/MCORRP, 24 Frank Lloyd Wright Dr, Ann Arbor, MI 48106. Am Heart J 2004;147:381–2. 0002-8703/$ - see front matter © 2004, Elsevier Inc. All rights reserved. doi:10.1016/j.ahj.2003.10.012
tients in the control group (P ⫽ .46) reached target LDL cholesterol levels at 1 year (ⱕ100 mg/dL). Patients in the intervention group had improved knowledge of appropriate lipid targets, but this did not result in increased adherence. Although disappointing, these results emphasize several issues. First, increased knowledge does not necessarily translate into achievement of pharmacologic goals in this population of patients. Educational interventions in patients with asymptomatic illnesses (like hypercholesterolemia) may be much less effective than similar interventions in patients with symptomatic illnesses. For instance, the authors point out that a similar educational intervention was successful in a study of 88 patients with symptomatic heart failure.7 Educational interventions have also been shown to be effective in reducing glucose levels in patients with diabetes mellitus,8 but again, in this circumstance, patients may sense hyperglycemia symptoms, be monitoring glycemia with daily glucose measures, or both. Management of hypertension presents similar challenges to hypercholesterolemia in attempting to achieve adequate control in an illness that usually has no symptoms. Second, the recent Lescol Intervention Prevention Study (LIPS)9 demonstrated that cholesterollowering therapy initiated in the hospital for patients who had undergone a recent coronary intervention resulted in a significant risk reduction in subsequent fatal and non-fatal coronary events, which supports early initiation of statin therapy in patients after intervention. In another trial designed to achieve established goals for LDL cholesterol in patients participating in cardiac rehabilitation after an acute coronary event, specially trained nurses were able to attain results similar to those reached by preventive cardiologists, with the initiation of drug therapy (primarily a statin drug) being the strongest predictor of achieving an LDL cholesterol level ⱕ100 mg/dL.10 In this instance, education was just 1 aspect of a multidimensional program that provided the appropriate medications and lifestyle targets and monitored patient adherence. Recent quality improvement initiatives, like the American College of Cardiology’s Guidelines Applied in Practice (GAP) and the American Heart Association’s Get With the Guidelines (GWTG) program, have been successful in increasing the percentage of patients with acute coronary syndromes who are discharged on appropriate evidence-based therapies, including choles-
382 Kline-Rogers and Eagle
terol-lowering therapy.11 Much of this benefit is correlated to the use of standardized care tools that emphasize the initiation of evidence-based therapies in eligible patients and active involvement of the patient, nurse, and physician. Dissemination and integration of the NCEP guidelines into ambulatory practices is equally, if not more, important. Application of a GAPlike intervention in the ambulatory setting would include processes that identify barriers to proper implementation of treatment and titration of therapies with proven interventions for overcoming these barriers. Incorporation of simple pocket cards with titration algorithms into standard orders and office notes would assist busy caregivers in making appropriate changes. This may be facilitated with electronic care tools. Getting patients to achieve recommended cholesterol levels will truly take a concerted team approach, linking inpatient to outpatient care and involving all members of the care triangle, including the patient, nurse, and/or physician. Only when all health care team members are aware of national guidelines and are accountable for implementing evidence-based therapy will the benefits of current knowledge be fully realized.
References 1. Scandanavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344:1383–9.
American Heart Journal March 2004
2. Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996;335:1001–9. 3. Streja L, Packard CJ, Shepherd J, et al. Factors affecting lowdensity lipoprotein and high-density lipoprotein cholesterol response to pravastatin in the West of Scotland Coronary Prevention Study (WOSCOPS). Am J Cardiol 2002;90:731– 6. 4. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 2001;285:2486 –97. 5. MRC/BHF Heart Protection study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomized placebocontrolled trial. Lancet 2002;360:7–22. 6. Wagner EH. The role of patient care teams in chronic disease management. BMJ 2000;320:569 –72. 7. Krumholtz HM, Amatruda J, Smith GL, et al. Randomized trial of an education and support intervention to prevent readmission of patients with heart failure. J Am Coll Cardiol 2002;39:83–9. 8. Annaswamy R, Gomes H, Beard JO, et al. A randomized trial comparing intensive and passive education in patients with diabetes mellitus. Arch Intern Med 2002;162:1301– 4. 9. Serruys PW, deFeyter P, Macaya C, et al. Fluvastatin for prevention of cardiac events following successful first percutaneous coronary intervention: a randomized controlled trial. JAMA 2002;287: 3215–22. 10. Allison TG, Squires RW, Johnson BD, et al. Achieving National Cholesterol Education Program goals for low-density lipoprotein cholesterol in cardiac patients: importance of diet, exercise, weight control, and drug therapy. Mayo Clin Proc 1999;74:466 –73. 11. Mehta RH, Montoye CK, Gallogly M, et al. Improving quality of care for acute myocardial infarction: the Guidelines Applied in Practice (GAP) initiative. JAMA 2002;287:1269 –76.