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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

Reducing Low-Density Lipoprotein Cholesterol Levels in an Ambulatory Care System: Results of a... Abstract Background: The Cincinnati (Ohio) Department of Veterans Affairs Medical Center Lipid Clinic was established as a collaborative practice to treat patients with substantially elevated serum cholesterol levels referred from the General Internal Medicine Clinic. The Lipid Clinic team (led by a clinical nurse), included a clinical pharmacist, nurse practitioner, dietitian, and clinical psychologist. A consultant cardiologist reviewed all laboratory tests and confirmed therapeutic decisions at a weekly preclinic meeting. Objective: To compare the success of a limited term of treatment in the Lipid Clinic with that of standard physician-based care in the General Internal Medicine Clinic in achieving the goals recommended by the National Cholesterol Education Program I for low-density lipoprotein cholesterol. Methods: A convenience sample of age-matched patients with total cholesterol levels greater than 6.85 mmol/L (265 mg/dL) was selected from each clinic (Lipid Clinic, n=60; General Internal Medicine Clinic, n=60). Fasting lipid profiles were drawn in the free-living state and in the sitting position, and matched by month. Treatment of patients in the Lipid Clinic group consisted of evaluation and treatment of secondary causes of hyperlipidemia, goal setting, and treatment according to the National Cholesterol Education Program I algorithm. Counseling and education were individualized. Outcomes were determined after four visits (12 and 18 months for the Lipid Clinic and General Internal Medicine Clinic groups, respectively). Patients in the two groups had comparable risk factors, including presence of coronary heart disease. Results: After four clinic visits, patients in the Lipid Clinic group were four times more likely to reach a National Cholesterol Education Program I goal of a low-density lipoprotein cholesterol level less than 3.36 mmol/L (130 mg/dL) than were comparable patients in the General Internal Medicine Clinic group (relative risk, 4.1; 95% confidence interval, 1.4 to 12.7; P<.001). Conclusion: These results support multidisciplinary, goal-oriented collaborative practice as an efficacious model of preventive medicine and health care provision.(Arch Intern Med. 1995;155:2330-2335) References 1. The Expert Panel. Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Arch Intern Med . 1988;148:36-69.Crossref 2. Durrington PN. Secondary hyperlipidemia. Br Med Bull . 1990;46:1005-1024. 3. Mogadam M, Ahmed SW, Mensch AH, Godwin MD. Within-person fluctuations of serum cholesterol and lipoproteins. Arch Intern Med . 1990;150:1645-1648.Crossref 4. Friedwald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem . 1972;18:499-502. 5. Veterans Administration Department of Medicine and Surgery. Use of Cholesterol-Lowering Drugs . Cincinnati, Ohio: Dept of Veterans Affairs Medical Center; November 28, 1988. Circular 10-88-145. 6. Veterans Administration Department of Medicine and Surgery. Cardiovascular Risk Factors Clinics Program . Cincinnati, Ohio: Dept of Veterans Affairs Medical Center; May 17, 1989. Clinical Affairs Letter IL 11-89-06. 7. Moran MB, Naughton BJ, Hughes SL. Elderly veterans at risk for nutrition-related cardiovascular disease. J Am Diet Assoc . 1992;92:863-865. 8. Richlie DG, Winters S, Prochazka AV. Dyslipidemia in veterans: multiple risk factors may break the bank. Arch Intern Med . 1991;151:1433-1436.Crossref 9. Gemson DH, Sloan RP, Messeri P, Goldberg IJ. A public health model for cardiovascular risk reduction: impact of cholesterol screening with brief nonphysician counseling. Arch Intern Med . 1990;150:985-989.Crossref 10. Hyman DJ, Flora JA, Reynolds KD, Johannsson MB, Farquhar JW. The impact of public cholesterol screening on diet, general well-being, and physician referral. Am J Prev Med . 1991;7:268-272. 11. Waters D, Lesperance J. Regression of coronary atherosclerosis: an achievable goal? review of results from recent trials. Am J Med . 1991;91( (suppl 1B) ):1B-7S.Crossref 12. Kane JP, Malloy MJ, Ports TA, Phillips NR, Diethl JC, Havel RJ. Regression of coronary atherosclerosis during treatment of familial hypercholesterolemia with combined drug regimens. JAMA . 1990;264:3007-3012.Crossref 13. Brown GB, Albers JJ, Fisher LD, et al. 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.Crossref 14. Giles WH, Anda RF, Jones DH, Serdula MK, Merritt RK, DeStefano F. Recent trends in the identification and treatment of high blood cholesterol by physicians: progress and missed opportunities. JAMA . 1993;269:1133-1138.Crossref 15. Rosser WW, Palmer WH. Dissemination of guidelines on cholesterol: effect on patterns of practice of general practitioners and family physicians in Ontario: Ontario Task Force on the Use and Provision of Medical Services. Can Fam Phys . 1993;39:280-284. 16. Levine MA, Grossman RS, Darden PM, et al. Dietary counseling of hypercholesterolemic patients by internal medicine residents. J Gen Intern Med . 1992; 7:511-516.Crossref 17. Maiman LA, Greenland P, Hildreth NG, Cox C. Patterns of physicians' treatments for referral patients from public screening. Am J Prev Med . 1991;7: 273-279. 18. Fix KW, Oberman A. Barriers to following national cholesterol educational program guidelines: an appraisal of poor physician compliance. Arch Intern Med . 1992;152:2385-2387.Crossref 19. Watson JE. The National Cholesterol Education Program: the role of nursing. Cardiovasc Nurs . 1988;24:13-18. 20. Watson JE. Nutritional intervention in hyperlipidemia. Prog Cardiovasc Nurs . 1989;4:131-137. 21. Guido BA, Mocogni F. Hypercholesterolemia as a cardiovascular risk factor: nursing implications. Crit Care Nurs Q . 1989;12:73-91.Crossref 22. Heubsch JA. Educational and behavioral strategies for successful cholesterol management. J Cardiovasc Nurs . 1991;5:44-54.Crossref 23. Wolfson B, Neidlinger SH. Nurse entrepreneurship opportunities in acute care hospitals. Nurs Econ . 1991;9:40-43. 24. Memmer MK. Hypercholesterolemia: prevention and control. Prog Cardiovasc Nurs . 1989;4:40-48. 25. LaRosa JH. An update from the national cholesterol education program: implications for nurses. J Cardiovasc Nurs . 1991;5:1-9.Crossref 26. Shively M, Fitzsimmons L, Verderber A. Research connections: treating hyperlipidemia. J Cardiovasc Nurs . 1991;5:55-57.Crossref 27. Finney CP. Measurement issues in cholesterol screening: an overview for nurses. J Cardiovasc Nurs . 1991;5:10-22.Crossref 28. Jewell D, Hope J. Evaluation of a nurse-run hypertension clinic in general practice. Practitioner . 1988:232:484-487. 29. Bradshaw C, Spencer J. Nurse-run diabetic clinics in general practice. Diabet Med . 1990;7:572-573.Crossref 30. Seabrook GR, Karp D, Schmitt DD, Bandyk DF, Towne JB. An outpatient anticoagulation protocol managed by a vascular nurse-clinician. Am J Surg . 1990; 160:501-505.Crossref 31. DeBusk RF, Miller NH, Superko HR, et al. A case management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med . 1994;120:721-729.Crossref 32. Blair TP, Bryant J, Bocuzzi S. Treatment of hypercholesterolemia by a clinical nurse using a stepped-care protocol in a nonvolunteer population. Arch Intern Med . 1988;148:1046-1048.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

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

Archives of Internal Medicine , Volume 155 (21) – Nov 27, 1995

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Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1995.00430210080012
Publisher site
See Article on Publisher Site

Abstract

Abstract Background: The Cincinnati (Ohio) Department of Veterans Affairs Medical Center Lipid Clinic was established as a collaborative practice to treat patients with substantially elevated serum cholesterol levels referred from the General Internal Medicine Clinic. The Lipid Clinic team (led by a clinical nurse), included a clinical pharmacist, nurse practitioner, dietitian, and clinical psychologist. A consultant cardiologist reviewed all laboratory tests and confirmed therapeutic decisions at a weekly preclinic meeting. Objective: To compare the success of a limited term of treatment in the Lipid Clinic with that of standard physician-based care in the General Internal Medicine Clinic in achieving the goals recommended by the National Cholesterol Education Program I for low-density lipoprotein cholesterol. Methods: A convenience sample of age-matched patients with total cholesterol levels greater than 6.85 mmol/L (265 mg/dL) was selected from each clinic (Lipid Clinic, n=60; General Internal Medicine Clinic, n=60). Fasting lipid profiles were drawn in the free-living state and in the sitting position, and matched by month. Treatment of patients in the Lipid Clinic group consisted of evaluation and treatment of secondary causes of hyperlipidemia, goal setting, and treatment according to the National Cholesterol Education Program I algorithm. Counseling and education were individualized. Outcomes were determined after four visits (12 and 18 months for the Lipid Clinic and General Internal Medicine Clinic groups, respectively). Patients in the two groups had comparable risk factors, including presence of coronary heart disease. Results: After four clinic visits, patients in the Lipid Clinic group were four times more likely to reach a National Cholesterol Education Program I goal of a low-density lipoprotein cholesterol level less than 3.36 mmol/L (130 mg/dL) than were comparable patients in the General Internal Medicine Clinic group (relative risk, 4.1; 95% confidence interval, 1.4 to 12.7; P<.001). Conclusion: These results support multidisciplinary, goal-oriented collaborative practice as an efficacious model of preventive medicine and health care provision.(Arch Intern Med. 1995;155:2330-2335) References 1. The Expert Panel. Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Arch Intern Med . 1988;148:36-69.Crossref 2. Durrington PN. Secondary hyperlipidemia. Br Med Bull . 1990;46:1005-1024. 3. Mogadam M, Ahmed SW, Mensch AH, Godwin MD. Within-person fluctuations of serum cholesterol and lipoproteins. Arch Intern Med . 1990;150:1645-1648.Crossref 4. Friedwald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem . 1972;18:499-502. 5. Veterans Administration Department of Medicine and Surgery. Use of Cholesterol-Lowering Drugs . Cincinnati, Ohio: Dept of Veterans Affairs Medical Center; November 28, 1988. Circular 10-88-145. 6. Veterans Administration Department of Medicine and Surgery. Cardiovascular Risk Factors Clinics Program . Cincinnati, Ohio: Dept of Veterans Affairs Medical Center; May 17, 1989. Clinical Affairs Letter IL 11-89-06. 7. Moran MB, Naughton BJ, Hughes SL. Elderly veterans at risk for nutrition-related cardiovascular disease. J Am Diet Assoc . 1992;92:863-865. 8. Richlie DG, Winters S, Prochazka AV. Dyslipidemia in veterans: multiple risk factors may break the bank. Arch Intern Med . 1991;151:1433-1436.Crossref 9. Gemson DH, Sloan RP, Messeri P, Goldberg IJ. A public health model for cardiovascular risk reduction: impact of cholesterol screening with brief nonphysician counseling. Arch Intern Med . 1990;150:985-989.Crossref 10. Hyman DJ, Flora JA, Reynolds KD, Johannsson MB, Farquhar JW. The impact of public cholesterol screening on diet, general well-being, and physician referral. Am J Prev Med . 1991;7:268-272. 11. Waters D, Lesperance J. Regression of coronary atherosclerosis: an achievable goal? review of results from recent trials. Am J Med . 1991;91( (suppl 1B) ):1B-7S.Crossref 12. Kane JP, Malloy MJ, Ports TA, Phillips NR, Diethl JC, Havel RJ. Regression of coronary atherosclerosis during treatment of familial hypercholesterolemia with combined drug regimens. JAMA . 1990;264:3007-3012.Crossref 13. Brown GB, Albers JJ, Fisher LD, et al. 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.Crossref 14. Giles WH, Anda RF, Jones DH, Serdula MK, Merritt RK, DeStefano F. Recent trends in the identification and treatment of high blood cholesterol by physicians: progress and missed opportunities. JAMA . 1993;269:1133-1138.Crossref 15. Rosser WW, Palmer WH. Dissemination of guidelines on cholesterol: effect on patterns of practice of general practitioners and family physicians in Ontario: Ontario Task Force on the Use and Provision of Medical Services. Can Fam Phys . 1993;39:280-284. 16. Levine MA, Grossman RS, Darden PM, et al. Dietary counseling of hypercholesterolemic patients by internal medicine residents. J Gen Intern Med . 1992; 7:511-516.Crossref 17. Maiman LA, Greenland P, Hildreth NG, Cox C. Patterns of physicians' treatments for referral patients from public screening. Am J Prev Med . 1991;7: 273-279. 18. Fix KW, Oberman A. Barriers to following national cholesterol educational program guidelines: an appraisal of poor physician compliance. Arch Intern Med . 1992;152:2385-2387.Crossref 19. Watson JE. The National Cholesterol Education Program: the role of nursing. Cardiovasc Nurs . 1988;24:13-18. 20. Watson JE. Nutritional intervention in hyperlipidemia. Prog Cardiovasc Nurs . 1989;4:131-137. 21. Guido BA, Mocogni F. Hypercholesterolemia as a cardiovascular risk factor: nursing implications. Crit Care Nurs Q . 1989;12:73-91.Crossref 22. Heubsch JA. Educational and behavioral strategies for successful cholesterol management. J Cardiovasc Nurs . 1991;5:44-54.Crossref 23. Wolfson B, Neidlinger SH. Nurse entrepreneurship opportunities in acute care hospitals. Nurs Econ . 1991;9:40-43. 24. Memmer MK. Hypercholesterolemia: prevention and control. Prog Cardiovasc Nurs . 1989;4:40-48. 25. LaRosa JH. An update from the national cholesterol education program: implications for nurses. J Cardiovasc Nurs . 1991;5:1-9.Crossref 26. Shively M, Fitzsimmons L, Verderber A. Research connections: treating hyperlipidemia. J Cardiovasc Nurs . 1991;5:55-57.Crossref 27. Finney CP. Measurement issues in cholesterol screening: an overview for nurses. J Cardiovasc Nurs . 1991;5:10-22.Crossref 28. Jewell D, Hope J. Evaluation of a nurse-run hypertension clinic in general practice. Practitioner . 1988:232:484-487. 29. Bradshaw C, Spencer J. Nurse-run diabetic clinics in general practice. Diabet Med . 1990;7:572-573.Crossref 30. Seabrook GR, Karp D, Schmitt DD, Bandyk DF, Towne JB. An outpatient anticoagulation protocol managed by a vascular nurse-clinician. Am J Surg . 1990; 160:501-505.Crossref 31. DeBusk RF, Miller NH, Superko HR, et al. A case management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med . 1994;120:721-729.Crossref 32. Blair TP, Bryant J, Bocuzzi S. Treatment of hypercholesterolemia by a clinical nurse using a stepped-care protocol in a nonvolunteer population. Arch Intern Med . 1988;148:1046-1048.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Nov 27, 1995

References