Sandhoff Brian G, Kuca Susan, Rasmussen Jon, Merenich John A
Perm J. 2008 Summer;12(3):4-11. doi: 10.7812/TPP/08-007.
Coronary artery disease (CAD) remains the leading cause of death in the US. In 1996, Kaiser Permanente of Colorado (KPCO) developed the Collaborative Cardiac Care Service (CCCS) with the goal of improving the health of patients with CAD.
CCCS consists of a nursing team (the KP Cardiac Rehabilitation program) and a pharmacy team (the Clinical Pharmacy Cardiac Risk Service). CCCS works collaboratively with patients, primary care physicians, cardiologists, and other health care professionals to coordinate proven cardiac risk reduction strategies for patients with CAD. Activities such as lifestyle modification, medication initiation and adjustment, patient education, laboratory monitoring, and management of adverse events are all coordinated through CCCS. The CCCS uses an electronic medical record and patient-tracking software to document all interactions with patients, track patient appointments, and collect data for evaluation of both short- and long-term outcomes.
The CCCS currently follows over 12,000 patients with CAD. The CCCS has demonstrated improvement in surrogate outcomes including: cholesterol screening (55% to 96.3%), the proportion of patients with a goal of low-density lipoprotein cholesterol (LDL-c) <100 mg/dL (22% to 76.9%), and has reduced the average LDL-c to 78.3 mg/dL for the CAD population it follows. The CCCS has shown a reduction in all-cause mortality associated with CAD by 76% in the patients followed by the service. Patient and physician satisfaction have been high with CCCS.
The CCCS coordinates many aspects of cardiac risk reduction care resulting in excellent continuity of care. The CCCS has continued to grow and expand the number of patients enrolled by using innovative strategies and technology and has resulted in excellent care and improved outcomes of the CAD population at KPCO.
冠状动脉疾病（CAD）仍然是美国的主要死因。1996年，科罗拉多州凯撒医疗集团（KPCO）开发了协作心脏护理服务（CCCS），目标是改善CAD患者的健康状况。
CCCS由一个护理团队（KP心脏康复项目）和一个药学团队（临床药学心脏风险服务）组成。CCCS与患者、初级保健医生、心脏病专家及其他医疗专业人员合作，为CAD患者协调经证实有效的降低心脏风险策略。诸如生活方式改变、药物起始和调整、患者教育、实验室监测以及不良事件管理等活动均通过CCCS进行协调。CCCS使用电子病历和患者跟踪软件记录与患者的所有互动、跟踪患者预约，并收集数据以评估短期和长期结果。
CCCS目前跟踪超过12000名CAD患者。CCCS已在替代指标方面取得改善，包括：胆固醇筛查（从55%提高到96.3%）、低密度脂蛋白胆固醇（LDL-c）目标值<100mg/dL的患者比例（从22%提高到76.9%），并且其跟踪的CAD人群的平均LDL-c已降至78.3mg/dL。CCCS所跟踪的患者中，与CAD相关的全因死亡率降低了76%。患者和医生对CCCS的满意度很高。
CCCS协调了降低心脏风险护理的许多方面，从而实现了出色的护理连续性。CCCS通过使用创新策略和技术持续发展并扩大了登记患者数量，在KPCO实现了对CAD人群的优质护理并改善了治疗结果。
