Cardiometabolic syndrome Group of metabolic disturbances

1. Use of a Clinical Dashboard to Improve Cardiometabolic Syndrome MonitoringKristina Ward, Pharm.D., BCPSPharmacy Service, Northern California Health Care System (NCHCS) Multi-dimensional Data Abstract Objective Interventions Results • Identify patients taking antipsychotic medications who are not appropriately monitored for cardiometabolic syndrome • Contact patients and order necessary lab tests • Evaluate changes in cardiometabolic syndrome monitoring rate to determine clinical pharmacy intervention effect Patient selection Cardiometabolic Monitoring Dashboard • BACKGROUND:VA Northern California Health Care System uses a clinical dashboard to identify patients prescribed antipsychotics and determine if they are being appropriately monitored for cardiometabolic syndrome. Clinical pharmacists have recently been added to the staff in the behavioral health clinics at the Martinez and Mather campuses and have been tasked with improving cardiometabolic monitoring rates. • The VA follows monitoring guidelines established by the American Diabetes Association and the American Psychiatric Association: • Personal/Family history: baseline and annually • Weight/body mass index (BMI): baseline, 4 weeks, 8 weeks, 12 weeks, quarterly • Waist circumference: baseline, annually • Blood pressure: baseline, 12 weeks, annually • Fasting plasma glucose (FPG): baseline, 12 weeks, annually • Fasting lipid panel (FLP): baseline, 12 weeks, annually • OBJECTIVE: Use the clinical dashboard to identify and contact patients requiring follow up for cardiometabolic monitoring to meet performance measure goals for monitoring rates. Evaluate changes in dashboard results to determine effect of clinical pharmacy interventions. • METHODS: The clinical dashboard was used to create a list of all patients prescribed antipsychotic medications. This list was exported to Microsoft Excel and included the most recent date and value of each of the following cardiometabolic parameters: blood pressure (BP), BMI, glucose, HgbA1c, triglycerides (TG) and HDL cholesterol. Cells with dates that were greater than one year in the past and cells with values above the predefined goals were highlighted to easily identify patients requiring monitoring or follow up for management of cardiometabolic syndrome. • Using this list, the clinical pharmacist manually reviewed patients with monitoring parameters greater than one year old and contacted them via telephone or letter requesting that they have fasting blood work drawn at their local clinic or come into clinic to have their BP or weight checked. The patient was then contacted by the clinical pharmacist via telephone to review the lab results and discuss any possible lifestyle or medication changes that may be needed to help them reach the goals. • RESULTS/DISCUSSION: All cardiometabolic syndrome monitoring performance measure goals were met at the Martinez site following intervention from the clinical pharmacist. Pre-intervention data was not captured, but the impact can be seen when comparing this with data from another site within the Northern California Health Care System which did not have a clinical pharmacist working on this measure. • CONCLUSION: Use of a clinical dashboard and intervention from a clinical pharmacist in the mental health clinic had a large impact on the rate of cardiometabolic syndrome monitoring. • Active antipsychotic prescription • Overdue monitoring for one or more cardiometabolic parameters Martinez VA Clinic 5/09/2011 Clinical Pharmacist Intervention Patient Contact Methods • Communicate need for cardiometabolic syndrome monitoring • Telephone calls • Lab reminder letters VISN 21 Clinical Data Warehouse SQL Server 2008 Daily Extraction and Transformation Follow-up RDW • Clinical pharmacist telephones patients • Discuss lab results • Evaluate cause for abnormal values • Educate about cardiometabolic syndrome, lifestyle modifications, and medication management • Refer to dietician, if appropriate and desired • Change medication therapy • Initiate per scope of practice • Forward recommendations to primary care provider • Schedule follow-up labs as needed • Mail letters with lab results if unable to reach patients by phone VISTA SQL Server 2008 Fairfield VA Clinic 5/09/2011 No Clinical Pharmacist Intervention Background SharePoint • Cardiometabolic syndrome • Group of metabolic disturbances • Increased atherosclerotic cardiovascular disease risk • Predisposed to develop diabetes • Guideline development • World Health Organization (1998) • Adult Treatment Panel III (2001) • International Diabetes Federation (2005) • VA cardiometabolic syndrome diagnostic criteria (at least 3 of 5 of the following): • BMI ≥ 30 kg/m2 • BP ≥ 130/85 mmHg • Fasting glucose ≥ 100 mg/dLand HgbA1c ≥ 5.7% • TG ≥ 150 mg/dL • HDL ≤ 40 mg/dL (male) or ≤ 50 mg/dL (female) • Increased incidence in patients with major mental illness • Unhealthy lifestyle and genetic factors • Growing evidence that antipsychotic pharmacotherapy is risk factor • American Diabetes Association and American Psychiatric Association Consensus Monitoring Guidelines • Personal / family history: baseline and annually • Weight / BMI: baseline, 4 weeks, 8 weeks, 12 weeks, quarterly • Waist circumference: baseline, annually • Blood pressure: baseline, 12 weeks, annually • Fasting plasma glucose (FPG): baseline, 12 weeks, annually • Fasting lipid panel (FLP): baseline, 12 weeks, annually Performance Point VISN 21 Mental Health Dashboard SQL Server Reporting Service Conclusions • Cardiometabolic monitoring rates: • Meet performance measure standards with clinical pharmacy care • Remain below goal without clinical pharmacy support References and Acknowledgements • M Hasnain, WVR Vieweg, SK Fredrickson, M Beatty-Brooks, A Fernandez, AK Pandurangi, Clinical monitoring and management in patients receiving atypical antipsychotic medications, Primary Care Diabetes 3 (2009) 5-15. • Special thanks to Amy Furman, Pharm.D., VISN 21 PBM Data Manager; Joy Meier, Pharm.D., VISN 21 Data Mart Manager; Wafa Samara, Pharm.D., Divisional Pharmacy Manager; Sarah Popish, Pharm.D., BCPP