LDL-C Goals Using Team-Based Care

The American Academy of Family Physicians, along with 6 other medical associations, has endorsed the framework of practice design known as the patient-centered medical home (PCMH). Included in the Patient Protection and Affordable Care Act of 2010, the PCMH is a component of changes needed to influence healthcare quality, access, continuity, and cost impact in the United States. As part of healthcare reform efforts, primary care practices can qualify for financial incentives to effectively adopt health information technologies (HITs) and otherwise redesign processes of care. Whereas there are specific directions in the PCMH framework for practices to adopt a certified electronic medical record (EMR) and to create registry-like capabilities, the guidance available to help practices make decisions regarding changes in processes of care following the implementation of HIT is less specific, according to researchers. Practices need to redesign care processes to delegate the right work to the right team member at the right time to provide the most effective outcomes at the lowest cost. Researchers recently conducted a study to evaluate the incremental impact of team-based care in the context of a fully implemented and adopted EMR and disease registry in a community-based primary care setting. They reported study results in Archives of Internal Medicine [2011;171(16):1480-1486]. The study focused on cholesterol management in patients with diabetes mellitus (DM) based on the prevalence of DM, available treatment options, poor disease control, and the impact of DM on cardiovascular disease profile. Study design was a 2-year prospective, cluster randomized controlled trial conducted within the Providence Primary Care Research Network (PPCRN) in Oregon. During the study period, PPCRN included 16 clinics where approximately 110 internal medicine and family practice physicians cared for 182,534 patients. Direct patient care services and patient consultations are provided by clinical pharmacists for patients with chronic conditions. All of the clinics in the network utilized Centricity EMR to facilitate and document patient care activities; in addition, physicians, pharmacists, and staff had access to a Web-based disease management software system. Patients were included in the study if they were ≥18 years of age and had an International Classification of Diseases, Ninth Revision diagnosis code for DM. Exclusion criteria included lack of medical chart activity (office visit, prescription refill, or telephone contact) within the past 3 years. The study included 2 arms: clinics were randomly assigned in a 1:2 intervention-to-control schedule. The primary outcome measure was the proportion of patients in each arm achieving a target low-density lipoprotein cholesterol (LDL-C) level of ≤100 mg/dL. In the control arm, the clinics had access to the CareManager disease management program utilized by the network. The intervention clinics also had access to the HIT resources, as well as use of a physician-pharmacist team-based approach for outcome of cholesterol level in patients with DM. The approach was enabled by the EMR that allowed for remote access to patients’ medical records and electronic communication between the physician and the pharmacist. The researchers evaluated patients with DM who were cared for at 9 clinics by 68 physicians; the study included 23 physicians treating 2069 patients in the intervention arm and 45 physicians treating 4160 patients in the control arm. At the 24-month follow-up, 78% of patients in the intervention arm achieved their target LDL-C level compared with 50% of patients in the control arm (P=.003); the mean LDL-C level was 12 mg/dL lower in the intervention arm compared with the control arm (P<.001). In addition, LDL-C testing was significantly higher in the intervention arm compared with the control arm. Patients in the intervention arm were 15% more likely than those in the control arm to receive a prescription for a lipid-lowering medication (P=.008). In conclusion, the researchers said, “physician-pharmacist team-based care resulted in considerably improved LDL-C levels and goal attainment among patients with DM.… The active nature of the control arm bolsters confidence that the model of physician-pharmacist team-based care represents an effective quality improvement strategy that remains relevant with advancing health information technology and evolving healthcare strategies aimed at improving management of chronic illness.”