Increasing the Detection and Response to Adherence Problems with Cardiovascular Medication in Primary Care through Computerized Drug Management Systems: A Randomized Controlled Trial Clinical and humanistic outcomes of a lipid management program in the community pharmacy setting. Bridging the quality gap in diabetic hyperlipidemia: a practice-based intervention. The Effect of a Disease Management Algorithm and Dedicated Postacute Coronary Syndrome Clinic on Achievement of Guideline Compliance A Randomized Controlled Trial to Provide Adherence Information and Motivational Interviewing to Improve Diabetes and Lipid Control Randomized controlled trial of clinical pharmacy management of patients with type 2 diabetes in an outpatient diabetes clinic in Jordan. Intervention to improve adherence to lipid-lowering medication and lipid-levels in patients with an increased cardiovascular risk. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol: a randomized controlled trial. Computerized community cholesterol control (4C): meeting the challenge of secondary prevention. Examination of lower targets for low-density lipoprotein cholesterol and blood pressure in diabetes--the Stop Atherosclerosis in Native Diabetics Study (SANDS). The Effect of Primary Care Management on Lipids Testing and LDL‐C Control of Elderly Patients With Comorbidities Nurse-run, telephone-based outreach to improve lipids in people with diabetes. Strategies to improve adherence with medications in chronic, ‘silent’ diseases representing high cardiovascular risk Multiple risk intervention trial in high risk hypertensive men: comparison of ultrasound intima-media thickness and clinical outcome during 6 years of follow-up. A long-term nutrition intervention experience: lipid responses and dietary adherence patterns in the Multiple Risk Factor Intervention Trial. Electronic Health Record-Based Patient Identification and Individualized Mailed Outreach for Primary Cardiovascular Disease Prevention: A Cluster Randomized Trial Proactive Pharmaceutical Care Interventions Improve Patients’ Adherence to Lipid-Lowering Medication
Background . Adherence with antihypertensive and lipid-lowering therapy is poor , result ing in an almost 2-fold increase in hospitalization . Treatment side effects , cost , and complexity are common reasons for nonadherence , and physicians are often unaware of these potentially modifiable problems . Objective . To determine if a cardiovascular medication tracking and nonadherence alert system , incorporated into a computerized health record system , would increase drug profile review by primary care physicians , increase the likelihood of therapy change , and improve adherence with antihypertensive and lipid-lowering drugs . Methods . There were 2293 primary care patients prescribed lipid-lowering or antihypertensive drugs who were r and omized to the adherence tracking and alert system or active medication list alone  to determine if the intervention increased drug profile review , changes in cardiovascular drug treatment , and refill adherence in the first 6 months . An intention to treat analysis was conducted using generalized estimating equations to account for clustering within physician . Results . Overall , medication adherence was below 80 % for 36.3 % of patients using lipid-lowering drugs and 40.8 % of patients using antihypertensives at the start of the trial . There was a significant increase in drug profile review in the intervention compared to the control group ( 44.5 % v. 35.5 % ; P < 0.001 ) , a nonsignificant increase in drug discontinuations due to side effects ( 2.3 % v. 2.0 % ; P = 0.61 ) , and a reduction in therapy increases ( 28.5 % v. 29.1 % ; P = 0.86 ) . There was no significant change in refill adherence after 6 months of follow-up . Conclusion . An adherence tracking and alert system increases drug review but not therapy changes or adherence in prevalent users of cardiovascular drug treatment . Targeting incident users where adverse treatment effects are more common and combining adherence tracking and alert tools with motivational interventions provided by multidisciplinary primary care teams may improve the effectiveness of the intervention OBJECTIVES To identify patients at risk for coronary artery disease ( CAD ) through a search of a community pharmacy 's prescription data base , to screen and identify patients with elevated cholesterol and at risk for CAD , to enroll patients in a pharmacist-directed lipid management program , and to evaluate selected clinical and humanistic outcomes . DESIGN R and omized , pretest-posttest control groups . SETTING Independent community pharmacy in a suburban metropolitan area . PATIENTS 51 patients who were not at National Cholesterol Education Program low-density lipoprotein cholesterol ( LDL-C ) or defined triglyceride goals and who met inclusion criteria . INTERVENTION Pharmacist-directed lipid management program . MAIN OUTCOME MEASURES Clinical outcome measures included total cholesterol , LDL-C , high-density lipoprotein cholesterol ( HDL-C ) , and triglyceride levels ; achievement of LDL-C goal ; and risk factor prediction scores . Humanistic outcome measures included patient satisfaction with pharmaceutical care and patient knowledge of hyperlipidemia . RESULTS LDL-C was decreased in the pharmacist intervention group ( n = 25 ) , compared with an increase in the control group at study end . HDL-C levels increased and triglyceride levels decreased in both groups . Of treatment group patients , 32 % achieved their cholesterol goals , compared with 15 % of control group patients . Risk factor prediction scores improved in the treatment group and worsened in the control group . The treatment group 's hyperlipidemia knowledge scores improved significantly from pretest to posttest . Both treatment and control group patient satisfaction scores for the pharmacist investigator were favorable at study end . CONCLUSION Both treatment and control patients benefited from participating in this study . Patients enrolled in the lipid management program made greater improvements in their knowledge of hyperlipidemia , risk factor scores , and cholesterol levels PURPOSE Dyslipidemia treatment dramatically decreases coronary heart disease risk in diabetes , yet only a minority of these patients are screened or achieve optimal low-density lipoprotein ( LDL ) cholesterol levels . Our aim was to increase the percentage of diabetic patients in whom lipid management was achieved through electronic and direct educational detailing . METHODS The study cohort comprised 884 diabetic patients at 12 primary care practice s. Practice sites were r and omized to one of three intervention groups : electronic educational detailing , direct ( face-to-face ) educational detailing , or control . Direct and electronic detailing were performed over a 12-month period . All sites were notified of our goal to enhance lipid testing among diabetic patients . Chart abstract ion was performed 15 months after the start of the intervention . For the entire population ( n=884 ) , the proportion of patients with lipid testing was calculated , and changes from pre- to postintervention were compared across groups . We compared pre- and postintervention LDL-cholesterol changes between groups using least square means to account for site variation . RESULTS Favorable provider actions increased significantly with the intervention ( + 22 % compared with + 6 % in controls , P=.01 ) . By logistic regression , electronic detailing increased the likelihood of lipid testing ( odds ratio 3.0 , confidence interval 1.6 - 5.7 ) , as did direct detailing ( odds ratio 1.8 , confidence interval 0.9 - 3.7 ) in patients with no preintervention LDL test ( n=432 ) . Lipid testing tended to increase to a greater extent at intervention sites ( + 23 % for the combination of electronic and direct detailing vs + 11 % for controls , P=.06 ) . CONCLUSIONS Brief educational detailing either through direct or electronic communication favorably impacts provider behavior regarding dyslipidemia care for diabetic patients Background The application of disease management algorithms by physician extenders has been shown to improve therapeutic adherence in selected population s. It is unknown whether this strategy would improve adherence to secondary prevention goals after acute coronary syndromes ( ACSs ) in a largely indigent county hospital setting . Methods Patients admitted for ACS were r and omized at the time of discharge to usual follow-up care versus the same care with the addition of a physician extender visit . Physician extender visits were conducted according to a treatment algorithm based on contemporary practice guidelines . Groups were compared using the primary end point of achievement of low-density lipoprotein treatment goals at 3 months after discharge and achievement of additional evidence -based practice goals . Results One hundred forty consecutive patients were r and omized . A similar proportion of patients returned for study follow-up in both groups at 3 months ( 54 [79%]/68 in the usual care group vs 57 [79%]/72 in the intervention group ; P = 0.97 ) . Among those completing the 3-month visit , a low-density lipoprotein cholesterol level less than 100 mg/dL was achieved in 37 ( 69 % ) of the usual care patients compared with 35 ( 57 % ) of those in the intervention group ( P = 0.43 ) . There was no statistical difference in implementation of therapeutic lifestyle changes ( smoking cessation , cardiac rehabilitation , or exercise ) between groups . Prescription rates of evidence -based therapeutics at 3 months were similar in both groups . Conclusion The implementation of a post-ACS clinic run by a physician extender applying a disease management algorithm did not measurably improve adherence to evidence -based secondary prevention treatment goals . Despite initially high rates of evidence -based treatment at discharge , adherence with follow-up appointments and sustained implementation of evidence -based therapies remains a significant challenge in this high-risk cohort Purpose The purpose of this study was to assess whether providing medication adherence information with or without motivational interviewing improves diabetes and lipid control . Methods Study participants were adult members of a health system in southeast Michigan , were using both oral diabetes and lipid-lowering medications , and had glycated hemoglobin ( A1C ) or low-density lipoprotein cholesterol ( LDL-C ) levels not at goal . Participants were r and omly assigned to receive usual care ( UC ) , n = 567 ; have medication adherence information ( AI ) provided to their physician , n = 569 ; or have AI and receive motivational interviewing ( MI ) though trained staff ( AI + MI ) , n = 556 . Primary outcomes were A1C and LDL-C levels at 18 months post r and omization . Results Primary outcomes were not significantly different between patients in the AI or AI + MI study arms when compared with UC . Similarly , neither oral diabetes nor lipid-lowering medication adherence was significantly different between groups . Patient participation in the AI + MI arm was low and limit the interpretation of the study results , but post hoc analysis of the AI + MI study arm showed that the number of MI  sessions received was positively associated with only oral diabetes medication adherence . Conclusion Neither AI nor MI significantly improved diabetes and lipid control when compared with UC . Moreover , patient participation appeared to be a particular barrier for MI BACKGROUND Glycemic goals ( hemoglobin A1c < 7 % ) are often not achieved in patients with type 2 diabetes despite the availability of many effective treatments and the documented benefits of glycemic control in the reduction of long-term microvascular and macrovascular complications . Several studies have established the important positive effects of pharmacist-led management on achieving glycemic control and other clinical outcomes in patients with diabetes . Diabetes prevalence and mortality are increasing rapidly in Jordan . Nevertheless , clinical pharmacists in Jordan do not typically provide pharmaceutical care ; instead , the principal responsibilities of pharmacists in Jordan are dispensing and marketing of medical products to physicians . OBJECTIVE To assess the primary clinical outcome of glycemic control ( A1c ) and secondary outcomes , including blood pressure , lipid values , self-reported medication adherence , and self-care activities for patients with type 2 diabetes in an outpatient diabetes clinic r and omly assigned to either usual care or a pharmacist-led pharmaceutical care intervention program . METHODS Patients with type 2 diabetes attending an outpatient diabetes clinic of a large teaching hospital were recruited over a 4-month period from January through April 2011 and r and omly assigned to intervention and usual care groups using the Minim software technique . The intervention group at baseline received face-to-face objective -directed education from a clinical pharmacist about type 2 diabetes , prescription medications , and necessary lifestyle changes , followed by 8 weekly telephone follow-up calls to discuss and review the prescribed treatment plan and to resolve any patient concerns . The primary outcome measure was glycemic control ( A1c ) , and secondary measures included systolic and diastolic blood pressure , complete lipid profile ( i.e. , total cholesterol , low-density lipoprotein cholesterol [ LDL-C ] , high-density lipoprotein cholesterol [ HDL-C ] , serum triglycerides ) , and self-reported medication adherence ( 4-item Morisky Scale ) and self-care activities ( Summary of Diabetes Self-Care Activities question naire ) . Data were collected at baseline and at 6 months follow-up . Changes from baseline to follow-up were calculated for biomarker values , and between-group differences in the change amounts were tested using the t test for independent sample s. A P value of < 0.05 was considered statistically significant . RESULTS A total of 77 of 85 patients ( 90.6 % ) r and omly assigned to the intervention group and 79 of 86 patients ( 91.9 % ) assigned to usual care had baseline and 6-month follow-up values . Compared with baseline values , patients in the intervention group had a mean reduction of 0.8 % in A1c versus a mean increase of 0.1 % from baseline in the usual care group ( P = 0.019 ) . The intervention group compared with the usual care group had small but statistically significant improvements in the secondary measures of fasting blood glucose , systolic and diastolic blood pressure , total cholesterol , LDL-C , serum triglycerides , self-reported medication adherence , and self-care activities . Between-group differences in changes in the secondary measures of HDL-C and body mass index were not significant . CONCLUSIONS Patients with type 2 diabetes who received pharmacist-led pharmaceutical care in an outpatient diabetes clinic experienced reduction in A1c at 6 months compared with essentially no change in the usual care group . Six of 8 secondary biomarkers were improved in the intervention group compared with usual care Low levels of statin adherence may compromise treatment outcomes . The aim of this study was to investigate whether nurse-led cardiovascular risk-factor counseling could improve statin adherence and lipid levels without increasing patients ' anxiety .  Patients with indications for statin therapy for primary or secondary prevention of cardiovascular disease were r and omly assigned to receive routine care or extended care ( EC ) at baseline and at months 3 , 9 , and 18 . Patients in the EC group received a personalized risk-factor passport , showing modifiable and unmodifiable individual risk factors and a graphical presentation of their calculated absolute 10-year cardiovascular disease risk as well as the target risk that could be reached if all modifiable risk factors were optimally treated . Lipid levels were assessed at each visit . Carotid intima-media thickness was measured at baseline and at month 18 . Adherence , anxiety , quality of life , symptoms , and smoking status were assessed using a self-administered question naire at each visit . A total of 201 patients were included in the study .  Statin adherence was significantly higher ( p < 0.01 ) and anxiety was significantly lower ( p < 0.01 ) in the EC group than in the routine care group . Low-density lipoprotein cholesterol was statistically significantly lower in the EC group than in the routine group ( 2.66 vs 3.00 mmol/L , respectively , p = 0.024 ) in primary prevention patients only . Intima-media thickness improved significantly from baseline ( p < 0.01 ) in all patients , irrespective of group assignment . In conclusion , cardiovascular risk-factor counseling result ed in improved lipid profiles in primary prevention patients and higher levels of adherence to statins and lower levels of anxiety in all patients CONTEXT Poor medication adherence diminishes the health benefits of pharmacotherapies . Elderly patients with coronary risk factors frequently require treatment with multiple medications , placing them at increased risk for nonadherence . OBJECTIVE To test the efficacy of a comprehensive pharmacy care program to improve medication adherence and its associated effects on blood pressure ( BP ) and low-density lipoprotein cholesterol ( LDL-C ) . DESIGN , SETTING , AND PATIENTS A multiphase , prospect i ve study with an observational phase and a r and omized controlled trial conducted at the Walter Reed Army Medical Center of 200 community-based patients aged 65 years or older taking at least 4 chronic medications . The study was conducted from June 2004 to August 2006 . INTERVENTION After a 2-month run-in phase ( measurement of baseline adherence , BP , and LDL-C ) , patients entered a 6-month intervention phase ( st and ardized medication education , regular follow-up by pharmacists , and medications dispensed in time-specific packs ) . Following the intervention phase , patients were r and omized to continued pharmacy care vs usual care for an additional 6 months . MAIN OUTCOME MEASURES Primary end point of the observation phase was change in the proportion of pills taken vs baseline ; secondary end points were the associated changes in BP and LDL-C. Primary end point of the r and omization phase was the between-group comparison of medication persistence . RESULTS A total of 200 elderly patients ( 77.1 % men ; mean [ SD ] age , 78 [ 8.3 ] years ) , taking a mean ( SD ) of 9 ( 3 ) chronic medications were enrolled . Coronary risk factors included drug-treated hypertension in 184 patients ( 91.5 % ) and drug-treated hyperlipidemia in 162 ( 80.6 % ) . Mean ( SD ) baseline medication adherence was 61.2 % ( 13.5 % ) . After 6 months of intervention , medication adherence increased to 96.9 % ( 5.2 % ; P<.001 ) and was associated with significant improvements in systolic BP ( 133.2 [ 14.9 ] to 129.9 [ 16.0 ] mm Hg ; P = .02 ) and LDL-C ( 91.7 [ 26.1 ] to 86.8 [ 23.4 ] mg/dL ; P = .001 ) . Six months after r and omization , the persistence of medication adherence decreased to 69.1 % ( 16.4 % ) among those patients assigned to usual care , whereas it was sustained at 95.5 % ( 7.7 % ) in pharmacy care ( P<.001 ) . This was associated with significant reductions in systolic BP in the pharmacy care group ( -6.9 mm Hg ; 95 % CI , -10.7 to -3.1 mm Hg ) vs the usual care group ( -1.0 mm Hg ; 95 % CI , -5.9 to 3.9 mm Hg ; P = .04 ) , but no significant between-group differences in LDL-C levels or reductions . CONCLUSIONS A pharmacy care program led to increases in medication adherence , medication persistence , and clinical ly meaningful reductions in BP , whereas discontinuation of the program was associated with decreased medication adherence and persistence . TRIAL REGISTRATION clinical trials.gov Identifier : BACKGROUND Dyslipidemia remains underdiagnosed and undertreated in patients with coronary artery disease . The Computer-based Clinical Decision Support System provides an opportunity t close these gaps . OBJECTIVES To study the impact of computerized intervention on secondary prevention of CAD . METHODS The CDSS was programmed to automatically detect patients with CAD and to evaluate the availability of an up date d  lipoprotein profile  and treatment with lipid-lowering drugs . The program produced automatic computer-generated monitoring and treatment recommendations . Adjusted primary clinics were r and omly assigned to intervention ( n=56 ) or st and ard care arms ( n=56 ) . Reminders were mailed to the primary medical teams in the intervention arm every 4 months updating them with current lipid levels and recommendations for further treatment . Compliance and lipid levels were monitored . The study group comprised all patients with CAD who were alive at least 3 months after hospitalization . RESULTS Follow-up was available for 7448 patients ( median 19.8 months , range 6 - 36 months ) . Overall , 51.7 % of patients were adequately screened , and 55.7 % of patients were compliant with treatment to lower lipid level . In patients with initial low density lipoprotein  > 120 mg/dl , a significant decrease in LDL levels was observed in both arms , but was more pronounced in the intervention arm : 121.9 + /- 34.2 vs. 124.3 + /- 34.6 mg/dl ( P < 0.02 ) . A significantly lower rate of cardiac rehospitalizations was documented in patients who were adequately treated with lipid-lowering drugs , 37 % vs. 40.9 % ( P < 0.001 ) . CONCLUSIONS This initial assessment of our data represent a real-world snapshot where physicians and CAD patients often do not adhere to clinical guidelines , presenting a major obstacle to implementing effective secondary prevention . Our automatic computerized reminders system substantially facilitates adherence to guidelines and supports wide-range implementation Diabetes incidence is increasing rapidly in the United States . Diabetes increases the risk for cardiovascular disease , the major cause of death in diabetic individuals . The conventional cardiovascular risk factors of hyperlipidemia and hypertension worsen diabetic vascular disease . Treatment targets for low-density lipoprotein cholesterol ( LDL-C ) and blood pressure in diabetic individuals are being debated . The S AND S is a r and omized , open-label , 3-year trial to examine the effects of aggressive LDL-C ( goal < 70 mg/dL ) and blood pressure ( BP ) ( goal < 115/75 mm Hg ) reduction versus the st and ard goals of < 100 mg/dL for LDL-C and < 130/85 mm Hg for BP .  Five hundred forty-nine American-Indian men and women > 40 years old with type 2 diabetes were r and omized to 1 of 2 groups . Lipids and BP are managed using Food and Drug Administration-approved medications in an algorithmic approach . The presence and progression of atherosclerosis are evaluated by carotid ultrasonography ; echocardiography assesses cardiac function . The primary end point is the composite outcome of change in carotid artery intimal medial thickness and fatal/nonfatal cardiovascular events . These outcomes are combined by using a ranked analysis for carotid thickness and assigning a " worst rank " for a cardiovascular event . Secondary end points include carotid plaque score , left ventricular geometry and function , serum C-reactive protein , and safety measures . Unique aspects of the study design and analysis plan involve the use of a composite outcome and changes during the trial of LDL-C treatment goals for participants with baseline or incident cardiovascular disease in the conventional group because of changes in the st and ard of care . Study results will further underst and ing of the effects of aggressive risk factor reduction on atherosclerosis burden and cardiac function in diabetic individuals in US population s and will help determine optimal LDL-C and BP treatment goals for diabetic patients Purpose This article presents results of a r and omized clinical trial evaluating the effectiveness of the Medicare Coordinated Care Demonstration , Illinois site , on selected clinical outcomes over 36 months . Primary Practice Setting s Interdisciplinary teams , located at primary care practice s , provided case and disease management services to 999 patients . Results  Intervention group patients had higher lipids-testing rates during the first 2 years than control  group patients . Once tested , more than 80 % of patients in both groups were retested in subsequent years . There were no differences in the percentage of intervention group patients who were in low-density lipoprotein cholesterol ( LDL-C ) control at program entry and at the end of 36 months as compared with control group patients ( maintained control ) . However , a higher percentage of intervention group patients who were not in the LDL-C control at baseline were in control after 36 months as compared with control group patients ( achieved control ) . Implication s for Case Management Practice This study suggests that physician — nurse case management team care has the potential to augment the effectiveness of primary care by increasing adherence to testing protocol s among elderly patients with multiple chronic illnesses , but this effect diminishes over time as guidelines are adopted into general practice . It suggests that LDL-C therapeutic control can be improved through increased lipids testing and the use of lipid-lowering medications . The results also indicate that care management strategies targeting more intensive patients versus less intensive patients are cost-effective strategies that can be exp and ed beyond lipids testing and control to other clinical health status measures BACKGROUND There is a need for r and omized , prospect i ve trials of case management interventions with re source utilization analyses . OBJECTIVES To determine whether algorithm-driven telephone care by nurses improves lipid control in patients with diabetes . DESIGN Prospect i ve , r and omized , controlled trial . PARTICIPANTS Adults with diabetes at a federally funded community health center were r and omly assigned to intervention ( n = 381 ) or usual-care ( n = 381 ) groups . INTERVENTIONS Nurses independently initiated and titrated lipid therapy and promoted behavioral change through motivational interviewing and self-management techniques . Other parameters of diabetes care were addressed based on time constraints . MAIN MEASURES The primary outcome was the proportion of patients with a low-density lipoprotein ( LDL ) less than 100 mg/dL. Secondary outcomes included the number of hospital admissions , total hospital charges per patient , and the proportion of patients meeting other lipid , glycemic , and blood pressure guidelines . KEY RESULTS The percent of patients with an LDL < 100 mg/dL increased from 52.0 % to 58.5 % in the intervention group and decreased from 55.6 % to 46.7 % in the control group ( P < .01 ) . Average cost per patient to the healthcare system was less for the intervention group ( $ 6600 vs $ 9033 , P = .03 ) . Intervention patients trended toward fewer hospital admissions ( P = .06 ) . The intervention did not affect glycemic and blood pressure outcomes . CONCLUSIONS Nurses can improve lipid control in patients with diabetes in a primarily indigent population through telephone care using moderately complex algorithms , but a more targeted approach is warranted . Telephone-based outreach may decrease re source utilization , but more study is needed Given the burden of illness related to diabetes , hypertension and dyslipidemia , it is very important to achieve glycemic control , optimal blood pressure and low-density lipoprotein cholesterol ( LDL-C ) in order to avoid severe long-term complications . Patients ’ adherence with , and persistence to , the treatment regimen is a critical factor in achieving this goal . Medication taking behavior in these chronic , nonsymptomatic ( ‘ silent ’ ) diseases is generally low , although a wide range of results have been reported . The literature has shown that nonadherence to medications is a multidimensional phenomenon ; relating factors can be grouped into the following categories : health system related , social/economic , condition-related , therapy-related and patient-related factors . Although several interventions exist to improve patients ’ medication-taking behavior , none appear to be clearly superior to others . The key steps to improve adherence are to identify individual barriers and to develop patient-specific self-management plans to overcome them ( called ‘ patient-centric ’ approach ) . When developing intervention strategies one should always remember that ‘ one size does not fit all ’ . Well design ed ( but not r and omized ) , observational studies ( for example , patient registries ) may be required with sufficient follow-up periods and multiple adherence measurements in order to advance the field OBJECTIVES The objective was to analyse whether a favourable change in risk factors , caused by a comprehensive risk factor modification programme , affected intima-media thickness ( IMT ) in the common carotid artery , and whether any such change was associated with a change in cardiovascular events during a 6-year follow-up . DESIGN Patients were r and omized 1 : 1 to special intervention or usual care .  SETTING Hypertension Unit at university hospital . SUBJECTS A total of 164 patients were r and omized . Inclusion criteria were male , aged 50 - 72 years ( at r and omization ) and one or more of the following : Serum cholesterol level > 6.5 mmol L(-1 ) , smoking or diabetes mellitus . All patients were prescribed antihypertensive treatment since many years . In 142 men good quality ultrasound recording of the common carotid IMT were achieved at baseline , 119 were re-examined after 3.3 years , and 97 patients were available for examination after mean follow-up time of 6.2 years . Cardiovascular events were available for all r and omized patients . INTERVENTIONS The nonpharmacological special intervention programme was based on one information meeting followed by five weekly 2-h sessions with participation of patients and spouses . The diet recommendations were similar to established guidelines . Overweight patients were instructed to lose weight , and diabetic patients were systematic ally taught self-monitoring of blood glucose . Smokers were invited to a smoking cessation programme with five weekly meetings . Follow-up visits were thereafter scheduled every 6 months . Lipid lowering drugs were recommended in the intervention group if the treatment goals using nonpharmacological measures were not achieved . Patients in the usual care group were told to quit smoking and to lower their consumption of fat and glucose . Antihypertensive treatment ( i.e. , selection of drugs ) was on purpose kept similar in the two groups . MAIN OUTCOME MEASURES The IMT of the common carotid artery as measured by ultrasound . Cardiovascular events during follow-up . RESULTS Significant net reductions were seen for serum cholesterol , triglycerides , fasting glucose and smoking . No difference in change in IMT was observed during follow-up between the two r and omization groups . The explanation was that patients with positive plaque status at baseline had a much larger increase in IMT over time than patients with negative plaque status , and that patients with positive plaque status more often survived and were available for re-examination after 6 years in the intervention group than in the usual care group .  Total mortality was lower in the intervention group , compared with the usual care group , 13 and 29 % , respectively ( P=0.028 ) . CONCLUSIONS In high risk population s , long-term studies with surrogate endpoints may be misleading because of missing data in patients where a large increase in IMT would have been observed , had they been re-examined . Another important conclusion from our study was that the gloomy prognosis for this patient category may be improved by a dedicated risk factor intervention programme . The improved prognosis was observed mainly in those patients at highest risk judged from history of cardiovascular disease or positive ultrasound plaque status at baseline Nutrition counselors in the Multiple Risk Factor Intervention Trial ( MRFIT ) were able to help middle-aged men who were at high risk for coronary heart disease change their dietary habits , maintain those changes over time , and decrease their serum cholesterol levels . Most of a 7.5 % mean serum cholesterol reduction achieved after 6 years of nutrition intervention occurred during the first year of the trial and was thereafter sustained . Total cholesterol and low-density lipoprotein cholesterol fraction decreases indicated improvement in terms of coronary heart disease risk . The food record rating , a numerical , semi- objective adherence technique that assesses a 3-day food record with respect to lipid-lowering potential , was used throughout the trial to measure adherence to recommended food patterns . Participants with lower food record rating scores , which indicate better adherence , demonstrated greater reductions in serum total cholesterol , plasma total cholesterol , and low-density lipoprotein fraction cholesterol determinations on a group basis . Subjective evaluations of the suitability of home and working environments , evidence of deviation from the MRFIT food patterns , and overall nutrition program motivation also showed that as ratings in each category became more favorable , lower food record rating scores and greater blood lipid reductions were consistently observed . The subgroup of participants who were non-smokers and not hypertensive demonstrated greater lipid responses and better dietary adherence . Continued smoking and antihypertensive medications appeared to adversely influence dietary adherence and /or lipid reductions . The MRFIT experience , however , demonstrated for the first time that dietary changes and blood lipid reductions can be achieved after the initial intervention effect , despite a continued emphasis on high blood pressure management and smoking cessation ABSTRACT BACKGROUND Many individuals at higher risk for cardiovascular disease ( CVD ) do not receive recommended treatments . Prior interventions using personalized risk information to promote prevention did not test clinic-wide effectiveness . OBJECTIVE AND DESIGN To perform a 9-month cluster-r and omized trial , comparing a strategy of electronic health record-based identification of patients with increased CVD risk and individualized mailed outreach to usual care . PARTICIPANTS Patients of participating physicians with a Framingham Risk Score of at least 5 % , low-density lipoprotein (LDL)-cholesterol level above guideline threshold for drug treatment , and not prescribed a lipid-lowering medication were included in the intention-to-treat analysis .INTERVENTION Patients of physicians r and omized to the intervention group were mailed individualized CVD risk messages that described benefits of using a statin ( and controlling hypertension or quitting smoking when relevant).MAIN MEASURES The primary outcome was occurrence of a LDL-cholesterol level , repeated in routine practice , that was at least 30 mg/dl lower than prior . A secondary outcome was lipid-lowering drug prescribing . Clinical trials.gov identifier : NCT01286311.KEY RESULTS Fourteen physicians with 218 patients were r and omized to intervention , and 15 physicians with 217 patients to control . The mean patient age was 60.7 years and 77 % were male . There was no difference in the primary outcome ( 11.0 % vs. 11.1 % , OR 0.99 , 95 % CI 0.56–1.74 , P = 0.96 ) , but intervention group patients were twice as likely to receive a prescription for lipid-lowering medication ( 11.9 % , vs. 6.0 % , OR 2.13 , 95 % CI 1.05–4.32 , p = 0.038 ) . In post hoc analysis with extended follow-up to 18 months , the primary outcome occurred more often in the intervention group ( 22.5 % vs. 16.1 % , OR 1.59 , 95 % CI 1.05–2.41 , P = 0.029 ) . CONCLUSIONS In this effectiveness trial , individualized mailed CVD risk messages increased the frequency of new lipid-lowering drug prescriptions , but we observed no difference in proportions lowering LDL-cholesterol after 9 months . With longer follow-up , the intervention ’s effect on LDL-cholesterol levels was apparent Bachground : Lipid-lowering drugs are effective preventive medication for patients at risk of cardiovascular complications . However , medication adherence is suboptimal , thereby decreasing therapy effectiveness . Pharmaceutical care interventions may increase therapy adherence . Objective : To assess the effect of a proactive pharmaceutical care intervention program , Medication Monitoring and Optimization ( MeMO ) , on therapy discontinuation and adherence with lipid-lowering drugs as well as patients ’ satisfaction with the intervention program . Methods : This prospect i ve intervention study included 1002 patients initiating lipid-lowering drug therapy from 9 Dutch community pharmacies . In the intervention group ( n = 500 ) , the MeMO program was used , comprising continuous monitoring of patients ’ adherence to lipid-lowering drugs and personal counseling with nonadherent patients . The intervention group was compared with a historical reference group ( n = 502 ) receiving usual care . Outcomes were therapy discontinuation and adherence . Results : Discontinuation rates with lipid lowering drugs in the first year after drug initiation were 13.6 % for the intervention group and 25.9 % in the usual care group ; continued but non-adherent use was 3.2 % and 7.6 % in these groups . Patients in the MeMO program had a decreased risk to discontinue medication of 51 % ( 95 % confidence interval : 34%-63 % ) . Results were not affected by potential confounders . Patient satisfaction with MeMO was very high ; one quarter of patients mentioned that they only received information about their medication from their pharmacy . Conclusions : Improving adherence to lipid lowering drugs can be achieved by a proactive pharmaceutical care program . Pharmacists can contribute to optimal use of chronic medication , which is likely to reduce healthcare costs
There was mixed evidence that provider-level computerized decision support improves outcomes .
There was more evidence in support of patient-level tools that provide connectivity to the healthcare system , as well as system-level interventions that involve data base monitoring and outreach by central ized care teams .
R and omized controlled trials show wide variability in the effects of HIT on lipid management outcomes .
Evidence suggests that multilevel HIT approaches that target not only providers but include patients and systems approaches will be needed to improve lipid treatment , adherence and quality
BACKGROUND Large gaps in lipid treatment and medication adherence persist in high-risk out patients in the United States .
Health information technology ( HIT ) is being applied to close quality gaps in chronic illness care , but its utility for lipid management has not been widely studied .
OBJECTIVE To perform a qualitative review of the impact of HIT interventions on lipid management processes of care ( screening or testing ; drug initiation , titration or adherence ; or referrals ) or clinical outcomes ( percent at low density lipoprotein cholesterol goal ; absolute lipid levels ; absolute risk scores ; or cardiac hospitalizations ) in out patients with coronary heart disease or at increased risk .