Project IMPACT: Hyperlipidemia
Hyperlipidemia refers to an abnormally high amount of lipids (e.g. cholesterol and/or fat) in the blood. Hyperlipidemia is associated with increased risk of coronary artery disease (CAD), the leading cause of death in the United States.2 Reduction in low-density lipoprotein cholesterol (LDL-C) levels has been shown to decrease the number of people who experience heart attacks and death due to CAD.3 Hyperlipidemia is often a comorbidity of hypertension, diabetes, obesity, and sedentary lifestyle, which all contribute to increased risk of heart disease.
View below to learn how Project ImPACT: Hyperlipidemia addressed this issue or read the full manuscript on the project published in JAPhA.
The Background
Initiated in March 1996, Project ImPACT: Hyperlipidemia is the APhA Foundation’s first community pharmacy−based demonstration project.. The project was designed to evaluate the pharmacist’s role in ongoing disease management related to high cholesterol and the impact point-of-care disease monitoring devices in that process. By having real-time cholesterol readings, pharmacists were able to identify which patients had controlled hyperlipidemia and which required dosage adjustments or further counseling about medication adherence.
ImPACT is an acronym for Improving Persistence And Compliance with Therapy. Persistence and compliance are two components of medication adherence.
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Persistence is the act of continuing a medication treatment for the prescribed duration.
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Compliance is the extent to which a patient acts in accordance with the prescribed interval and dose of a dosing regimen
Stated more simply, persistence asks the question, “Has the patient stopped taking a medicine when he should still be on it?”, and compliance asks the question, “When the patient does take the medicine, is it at the right dose and the right time?”
Key Objective:
To demonstrate that pharmacists, working collaboratively with patients and physicians and having immediate access to objective point-of-care patient data, promote patient persistence and compliance with prescribed dyslipidemic therapy that enables patients to achieve their National Cholesterol Education Program (NCEP) goals.
The Participants
Patients enrolled in the project were either newly diagnosed with hyperlipidemia or were already receiving lipid-lowering medications but were poorly controlled (i.e., not yet at target NCEP lipid goal). Patients were identified through referrals from local health care providers, by the project pharmacists, or by patient self-referral. A total of 574 patients enrolled in the project and 397 completed the study period.
26 community pharmacies in 12 states provided care to patients as part of the project. Pharmacy types included independent, chain–professional, chain–grocery store, home health/home infusion, clinic, health maintenance and organization/managed care.
Scroll through the chart below to see the pharmacy information
The Methods
Study Period
Patients were enrolled beginning in March 1996 and final results (listed below) were published in March 2000. The patient care period lasted 24.6 months.
Enrollment
Following referral and eligibility identification, patients provided the necessary personal and general health information that the pharmacist used to assess their CAD risk. An initial fingerstick blood sample was collected by the pharmacist to generate a fasting lipid profile using the Cholestech LDX Analyzer, a point-of-care testing device in the “waived” category under the Clinical Laboratory Improvement Amendments 14. Results were logged into the patient’s clinical activity record.
Innovation
After the initial visit and consultation with the pharmacist, patients were asked to make follow-up visits every month for the first 3 months and quarterly thereafter. During these visits, pharmacists employed the APhA Foundation’s Process of Care to engage in collaborative care with the patient and other members of the health care team. The collaborative care framework for the Project ImPACT model includes:
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Establishing a process for the seamless flow of patient care data between and among patients, pharmacists, and physicians.
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Use of point-of-care testing technology to obtain timely, objective information about the patient’s progress in a community practice setting.
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Organizing methods for pharmacists to document, interpret, and report their lipid management interventions.
At each visit, pharmacists used the Cholestech LDX Analyzer to obtain a real-time cholesterol reading that allowed the pharmacist to evaluate the level of hyperlipidemia control. Pharmacist-provided education was tailored to address adherence issues and lifestyle modifications that could improve control. As patients became actively involved in their therapy, treatment plans, and goal setting, physicians were kept informed about clinical progress in these areas:
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Cholesterol test results
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Condition
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CAD risk
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NCEP goal achievement
Pharmacists made recommendations to physicians as appropriate to optimize medication dosages. The routine monitoring and appointments with the pharmacist created accountability for each patient to become more active self-managers of their high cholesterol.
Payment for Pharmacists’ Services
In the late 1990s, pharmacists were not routinely paid for the clinical services they provided. However within Project ImPACT: Hyperlipidemia, some pharmacies were able to receive compensation for the high level services they provided.
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The average assigned value per visit with the pharmacist was $55, which was broken down as $28 for counseling services and $27 for lipid profiles.
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Of the 232 patients who were asked for payment, 174 (75%) paid an average of $35 per visit.
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Of the 121 third party payers billed for services, 64 (53%) paid an average of $30 for each visit billed. Of these 64 payers, 30 paid for counseling services and 53 paid for lipid profiles (some paid for both).
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Two project sites secured contracts with managed care organizations to deliver services to health plan beneficiaries, one under a fee-for-service arrangement and the other under capitation.
The Results
The evaluable population consisted of of 397 patients.
Clinical Outcomes:
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93.6% of patients achieved medication persistence, defined as continuing with therapy for the duration of the project (24.6 monhts).
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90.1% of patients achieved medication compliance, defined here as missing less than 5 doses of medicine between each refill.
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62.5% of patients achieved the NCEP goal for lipid control
Pharmacist Job Satisfaction Outcomes:
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88.5% of pharmacists were very satisfied with their professional role and 11.5% were satisfied (100% satisfaction).
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84.6% of pharmacists were very satisfied with their relationship with patients and 15.4% were satisfied (100% satisfaction).
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19.2% of pharmacists were very satisfied with their relationship with physicians, and 46.2% were satisfied (65.4% satisfaction). Another 30.8% were “neutral”.
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Pharmacists perceived that 53.8% of their patients were “very satisfied” and 46.2% were “satisfied” with the services provided (100% satisfaction).