Role of aggressive LDL reduction in patients with coronary heart disease.

The aim of the present study was to integrate research evidence with the care of the patient with coronary heart disease (CHD) and place into perspective the importance of intensive statin therapy. We reviewed five major trials and select related post hoc analyses that examined the beneficial effects from intensive low-density lipoprotein (LDL) reduction on combined morbidity and mortality end points in patients with stabilized CHD and those with recent acute coronary syndrome.Accumulating evidence since the publication of the pivotal Heart Protection Study and Adult Treatment Panel III supports a more intensive LDL reduction than that recommended in the 2004 Adult Treatment Panel III update. An LDL reduction of 49% from baseline in statin-naïve patients with stable CHD or a 41% to 44% reduction in LDL from postadmission values in patients with acute coronary syndrome improves composite morbidity and mortality end points.Current evidence suggests that a more intensive LDL reduction of approximately 45% to 50% from a patient's baseline in acute and stable CHD is warranted. The decrease in recurrent events associated with the use of statin regimens that can achieve this degree of reduction in LDL may offer a financial incentive for managed care healthcare systems; however, statin therapy should be selected upon careful consideration of both dose and agent.

Increasing rural patient access using clinical pharmacy specialist providers: Successful practice integration within the Department of Veterans Affairs.

PURPOSE: Access to care is a critical issue facing healthcare and affects patients living in rural and underserved areas more significantly. This led the Department of Veterans Affairs (VA) to launch a project that leveraged the expertise of the clinical pharmacy specialist (CPS) provider, embedding 180 CPS providers into primary care, mental health, and pain management across the nation. METHODS: This multidimensional project resulted in hiring 111 CPS providers in primary care, 40 CPS providers in mental health, and 35 CPS providers in pain management to serve rural veterans' needs. From October 2017 to March 2020, CPS providers provided direct patient care to 213,477 veterans within 606,987 visits. This was an average of 43,000 additional visits each quarter to support comprehensive medication management services, demonstrating an additional 219,823 visits in fiscal year 2018 and 232,030 visits in fiscal year 2019. Over the course of the project, the team provided mentorship to 164 CPS providers, performed consultative visits at 27 VA facilities, and trained 180 CPS providers in educational boot camps. CONCLUSION: VA funding of rural health initiatives adding CPS providers to primary care, mental health, and pain teams has resulted in positive measures of comprehensive medication management, interdisciplinary team satisfaction, facility leadership acceptance, and multiple positive outcomes.

Evaluation of the Impact of a Pharmacist-Led Telehealth Clinic on Diabetes-Related Goals of Therapy in a Veteran Population.

OBJECTIVES: Telemedicine has been offered as a way to ensure that all patients, including those who live in rural areas, have access to the same health care. This study was performed to evaluate the benefit of a real-time, clinic-based video telehealth (Clinical Video Telehealth [CVT]) program and the impact of a pharmacist-led CVT clinic for chronic disease state management. The primary objective was to evaluate changes from baseline values, in veterans referred by primary care providers to this clinic. METHODS: This was a single-center, prospective, pre-post pilot study that also included a post-patient satisfaction survey. The study was conducted at the Tennessee Valley Healthcare System, which is composed of two medical centers and 12 community-based outpatient clinics (CBOCs) located away from the two main facilities. Fifteen clinical pharmacy specialists (CPSs)-seven at the two main facilities and eight at the CBOCs-provide disease state management clinical pharmacy services. One of the seven CPSs at the main facilities works via telemedicine and provides services to the CBOCs where on-site clinical pharmacy services did not exist. The primary outcomes were changes from baseline in A1C, LDL level, systolic blood pressure, and diastolic blood pressure after 6 months of CVT services by the CPS. Secondary outcomes were the percentages of patients meeting American Diabetes Association treatment goals for hemoglobin A1c (A1C), low-density lipoprotein level, and blood pressure, both individually and in combination after attending a pharmacist-led CVT program; the level of patient satisfaction with pharmacists' care and with CVT as a method of receiving chronic disease management, specifically for diabetes; and medication additions or changes made by the pharmacist. RESULTS: Twenty-six patients completed the 6-month evaluation. A significant decrease in A1C of 2% from baseline was observed (p=0.0002), and the percentage of patients meeting goal A1C significantly increased from 0% at baseline to 38% at 6 months (p=0.0007). Overall patient satisfaction scores were also high, with a median score 39.5 (interquartile range 36-40) of a maximum score of 40. CONCLUSION: Six months of CVT clinic attendance significantly improved A1C values and the overall percentage of patients meeting their goal A1C values in this veteran population. In addition, patient satisfaction scores also indicated a high level of satisfaction with the pharmacist-led CVT service.