WINTER 2009
PREVENTIVE CARDIOLOGY
CLINICAL STUDY
Maintenance of Cardiovascular Risk Goals in Veterans With Diabetes After Discharge from a Cardiovascular Risk Reduction Clinic Paul A. Pirraglia, MD, MPH;1,2 Tracey H. Taveira, PharmD;1,3 Lisa B. Cohen, PharmD;1,3 Andrea Dooley, PharmD;1,3 Wen-Chih Wu, MD1,2
The authors evaluated maintenance of achieved cardiovascular risk control after discharge from a pharmacist-coordinated cardiovascular risk reduction clinic. Using data from 2001 to 2004 divided by financial quarters (ie, 3-month periods), the authors performed survival analysis of diabetic patients who had attained at least one cardiovascular risk goal in the clinic. Mean times to failure were 7.10.21 quarters for hemoglobin A1c, 7.60.29 quarters for low-density lipoprotein cholesterol (LDL-C), and 2.50.24 quarters for systolic blood pressure (SBP). Body mass index predicted glycemic control failure (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.01–1.15; P=.02), insulin use predicted LDL-C control failure (HR, 3.08; 95% CI, 1.15–8.22; P=.03), and baseline SBP predicted SBP control failure (HR, 1.02; 95% CI, 1.01–1.03; P=.0003). The authors found good durability of effect for most cardiovascular risk targets. Worse control at entry predicted failure after successful attainment of a cardiovascular goal. More sustained attention or booster interventions for patients with worse control at entry may be necessary. Prev Cardiol. 2009;12:3–8.
2009 Wiley Periodicals, Inc.
From the Systems, Outcomes, and Quality in Chronic Disease and Rehabilitation (SOQCR) Program, Providence VA Medical Center, Providence, RI;1 the Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI;2 and the College of Pharmacy, University of Rhode Island, Kingston, RI3 Address for correspondence: Paul A. Pirraglia, MD, MPH, Providence VA Medical Center, 830 Chalkstone Avenue, Building T32, Providence, RI 02908-4799 E-mail:
[email protected] Manuscript received March 28, 2008; revised August 6, 2008; accepted August 28, 2008
doi: 10.1111/j.1751-7141.2008.00017.x
D
iabetes, hypertension, and dyslipidemia are chronic diseases that are difficult to treat with respect to attaining target goals and maintaining the effects of the treatment. Obstacles to maintain adherence to target goals exist at different levels. At the patient level, there is a lack of disease knowledge and mistrust of the treatment.1–3 At the provider level, the physician who prescribes the medication does not have sufficient time to provide education, frequent follow-up visits, and behavioral counseling to ensure adherence to the medical regimen and the necessary lifestyle modifications.4–6 Specialized clinics and interventions help to improve national guideline adherence in cardiovascular (CV) risk control such as lowering of blood pressure (BP), glycemia, or serum lipid levels.7–9 Patients are typically discharged from specialized clinics when specific target goals are met. Little is known, however, about the maintenance of the adherence to CV risk factors after discharge from such clinics. The Cardiovascular Risk Reduction Clinic (CRRC) is a pharmacist-coordinated clinic at the Providence VA Medical Center in Rhode Island designed to treat the 4 traditional CV risk factors (diabetes, dyslipidemia, hypertension, and smoking) to attain goals set forth by the national guidelines for patients with diabetes or documented CV disease. Patients are discharged from the CRRC when guideline-recommended goals for hemoglobin A1c (HbA1c), low-density lipoprotein cholesterol (LDL-C), BP, and smoking are achieved or mostly achieved. The effectiveness of this program in attaining these goals has been demonstrated.10 The purpose of this study is to evaluate the maintenance of the achieved goals of 3 CV risk factors 2 to 3 years after discharge from the CRRC.
3
4
PREVENTIVE CARDIOLOGY
METHODS Design We performed a survival analysis on an observational cohort. The CRRC The details of the CRRC intervention have been previously published.10 Briefly, clinical pharmacists, following national VA guidelines and under the supervision of a physician cardiologist, simultaneously address hyperglycemia, dyslipidemia, hypertension, and smoking in patients with coronary artery disease (CAD) or diabetes using both motivational interviewing and aggressive medication up-titration techniques. In order to be accepted into this clinic, the patient must have demonstrated poor control in at least one area of CV risk and have been referred by their primary care provider. Diabetic patients were discharged from the CRRC when therapeutic goals of HbA1c
