Lipid-lowering drug therapy significantly reduces the risk of recurrent coronary and cerebrovascular events in high-risk patients with coronary artery disease. Unfortunately, fewer than one half of these patients receive lipid-lowering drug therapy and, of those who do, only 10 percent achieve the National Cholesterol Education Program (NCEP) target low-density lipoprotein (LDL) cholesterol level of 100 mg per dL (2.60 mmol per L) or less. Robinson and associates describe a telephone-based, dietitian-managed, computerized tracking (TDCT) system to streamline patient management with the goal of increasing the percentage of patients who achieve the NCEP target LDL cholesterol level.
Patients from a large private cardiology practice who were discharged from the hospital following a coronary event were included in the analysis. At discharge, most of the patients were given a statin to lower LDL cholesterol, and all were entered into the TDCT system. Three months after patient entry, the program generated a laboratory test request for a fasting lipid panel and a serum glutamicpyruvic transaminase level to be obtained through the patient's physician's office. Results of the laboratory studies were then sent to the TDCT system for entry. Nonresponders were sent reminders after one month, and those who still did not respond after the first reminder received up to two telephone calls and a letter.
After the results of the laboratory studies were entered into the system, a dietitian called the patient to review the results and discuss issues such as weight, diet and exercise. All patients received advice on lifestyle modification. The dietitian's management algorithm allowed for patients to be given a maximum dosage of 40 mg of simvastatin or 40 mg of atorvastatin in an attempt to achieve the NCEP target LDL cholesterol level. Patients who exceeded the parameters of the dietitian's management algorithm were reviewed by the physicians for follow-up recommendations and treatment. Standardized correspondence about lipid values, and lifestyle and medication recommendations were sent to the primary care physician.
Patients with a diagnosis of coronary heart disease or peripheral vascular disease were tracked for a period of approximately one year, and data were compared with an earlier baseline period when the TDCT system was not available. Mean lipid values significantly improved during the study period, with mean total cholesterol levels decreasing 10 percent, triglyceride levels declining 3 percent, LDL levels decreasing 11 percent and high-density lipoprotein levels increasing 26 percent. In addition, the proportion of patients who achieved the NCEP target LDL level almost doubled, to 61 percent. Unfortunately, the drop-out rate was 30 percent at one year, and although this rate is lower than the 50 percent lack of patient follow-up occurring previously after one year, the high rate of drop out was of concern.
The authors conclude that the TDCT approach to patient tracking was successful in increasing the percentage of patients who achieved the NCEP target LDL cholesterol level for secondary prevention of cardiovascular events. Further investigation is still needed to evaluate the costs and benefits of this type of patient management system.