Rehring Thomas F, Stolcpart Ryan S, Sandhoff Brian G, Merenich John A, Hollis H Whitton
Department of Vascular Surgery, Colorado Permanente Medical Group, University of Colorado Health Sciences Center, Denver, CO 80205, USA.
J Vasc Surg. 2006 Jun;43(6):1205-10. doi: 10.1016/j.jvs.2006.02.019.
Our group and others have previously established that patients with peripheral artery disease (PAD) are significantly undertreated with respect to overall cardiovascular risk factor management, despite national guidelines to the contrary. In an effort to maximize risk factor control in our patients with PAD, we established a pharmacist-managed, physician-monitored algorithmic approach to the outpatient management of lipids in patients with PAD. The purpose of this study was to determine the effect of this service on lipid screening and control in patients with PAD.
We analyzed the records of patients treated at a large, group-model, not-for-profit regional managed care system serving approximately 405,000 members. An electronic medical record provided full examination, laboratory, and pharmacy data for all patients. Pharmacy data were analyzed to determine prescriptions for lipid-lowering agents. Lipid control was assessed through fasting lipid data. Patients with validated PAD and the absence of clinical coronary artery disease (CAD) were offered the service between May 2003 and September 2004 and followed up for a minimum of 6 months.
We administratively identified 5159 active patients with a diagnosis of PAD. Of these, 1075 could be validated with a noninvasive arterial study. The exclusion of 384 patients with a diagnosis of CAD resulted in a cohort of 691 patients. Of these, 90 patients were enrolled in the lipid service (study group), and 601 received standard care. Mean follow-up was 17.1 months. Screening fasting lipid profiles were found in 95.6% (86/90) of patients in the study group and only 66.9% (402/601) of the standard care patients (P < .0001). Low-density lipoprotein cholesterol (LDL-C) control was improved in the pharmacist-managed group, with 79.1% (68/86) achieving an LDL-C of less than 100 mg/dL in comparison to the standard care group (54.8% [219/400]; P < .0001). An LDL-C value of more than 130 mg/dL was noted in 1.2% and 14.0% (56/400) in the treatment and control groups, respectively (P < .001). Statin use was present in 51.9% (312/601) of the control group patients and 84.4% (76/90) of the pharmacist-managed group (P < .001).
Despite national consensus of PAD as a CAD equivalent, patients are currently undertreated with regard to atherosclerotic risk factor modification. Initiation of a pharmacist-managed, physician-monitored lipid service provides improved compliance with national guidelines.
我们团队及其他研究人员此前已证实，尽管有国家指南的要求，但外周动脉疾病（PAD）患者在整体心血管危险因素管理方面的治疗仍显著不足。为了最大限度地控制我们PAD患者的危险因素，我们建立了一种由药剂师管理、医生监督的算法方法，用于PAD患者门诊血脂管理。本研究的目的是确定该服务对PAD患者血脂筛查和控制的影响。
我们分析了在一个大型、集团模式、非营利性区域管理式医疗系统接受治疗的患者记录，该系统服务约405,000名成员。电子病历提供了所有患者的全面检查、实验室和药房数据。分析药房数据以确定降脂药物的处方。通过空腹血脂数据评估血脂控制情况。2003年5月至2004年9月期间，为确诊为PAD且无临床冠状动脉疾病（CAD）的患者提供该服务，并进行至少6个月的随访。
我们通过管理手段确定了5159名诊断为PAD的活跃患者。其中，1075名患者可通过无创动脉研究得到证实。排除384名诊断为CAD的患者后，得到691名患者队列。其中，90名患者纳入血脂服务组（研究组），601名患者接受标准治疗。平均随访时间为17.1个月。研究组95.6%（86/90）的患者进行了空腹血脂筛查，而标准治疗组仅为66.9%（402/601）（P <.0001）。药剂师管理组的低密度脂蛋白胆固醇（LDL-C）控制得到改善，79.1%（68/86）的患者LDL-C低于100 mg/dL，而标准治疗组为54.8%（219/400）（P <.0001）。治疗组和对照组LDL-C值大于130 mg/dL的患者分别为1.2%和14.0%（56/400）（P <.001）。对照组51.9%（312/601）的患者使用了他汀类药物，药剂师管理组为84.4%（76/90）（P <.001）。
尽管国家已达成共识，将PAD视为等同于CAD的疾病，但目前患者在动脉粥样硬化危险因素改善方面的治疗仍不足。启动由药剂师管理、医生监督的血脂服务可提高对国家指南的依从性。
