Reducing Low-Density Lipoprotein Cholesterol Levels in an Ambulatory Care System

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Abstract
Background: The Cincinnati (Ohio) Department of Veterans Affairs Medical Center Lipid Clinic was established as a collaborative practice to treat patients with substantially elevated serum cholesterol levels referred from the General Internal Medicine Clinic. The Lipid Clinic team (led by a clinical nurse), included a clinical pharmacist, nurse practitioner, dietitian, and clinical psychologist. A consultant cardiologist reviewed all laboratory tests and confirmed therapeutic decisions at a weekly preclinic meeting. Objective: To compare the success of a limited term of treatment in the Lipid Clinic with that of standard physician-based care in the General Internal Medicine Clinic in achieving the goals recommended by the National Cholesterol Education Program I for low-density lipoprotein cholesterol. Methods: A convenience sample of age-matched patients with total cholesterol levels greater than 6.85 mmol/L (265 mg/dL) was selected from each clinic (Lipid Clinic, n=60; General Internal Medicine Clinic, n=60). Fasting lipid profiles were drawn in the free-living state and in the sitting position, and matched by month. Treatment of patients in the Lipid Clinic group consisted of evaluation and treatment of secondary causes of hyperlipidemia, goal setting, and treatment according to the National Cholesterol Education Program I algorithm. Counseling and education were individualized. Outcomes were determined after four visits (12 and 18 months for the Lipid Clinic and General Internal Medicine Clinic groups, respectively). Patients in the two groups had comparable risk factors, including presence of coronary heart disease. Results: After four clinic visits, patients in the Lipid Clinic group were four times more likely to reach a National Cholesterol Education Program I goal of a low-density lipoprotein cholesterol level less than 3.36 mmol/L (130 mg/dL) than were comparable patients in the General Internal Medicine Clinic group (relative risk, 4.1; 95% confidence interval, 1.4 to 12.7;P<.001). Conclusion: These results support multidisciplinary, goal-oriented collaborative practice as an efficacious model of preventive medicine and health care provision. (Arch Intern Med. 1995;155:2330-2335)