Outcome Indicators for Policy and System Change CONTROLLING HIGH CHOLESTEROL

Transcription

1 Outcme Indicatrs fr Plicy and System Change CONTROLLING HIGH CHOLESTEROL

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3 DRAFT Plicy and System Outcme Indicatrs fr Cntrlling High Chlesterl Divisin fr Heart Disease and Strke Preventin Nvember 2009

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5 Cntents Sectin Page 1. Intrductin Purpse Methds Use Expert Panel Indicatr Rating Tables 9 3. The Science and Indicatr Prfiles 25 Lgic Mdel Bx 1: Healthcare System Changes 27 Lgic Mdel Bx 2: Prvider Changes 42 Lgic Mdel Bx 3: Wrksite Changes 59 Lgic Mdel Bx 4: Cmmunity Changes 72 Lgic Mdel Bx 5: Individual Changes 82 Lgic Mdel Bx 6: Risk Factr Reductin 96 Lgic Mdel Bx 7: Reduced Levels f Chlesterl 115 Lgic Mdel Bx 8: Increased Cntrl f Chlesterl Levels Amng Individuals with High Chlesterl 127 Lgic Mdel Bx 9: Reduced Mrtality and Mrbidity Due t Cardivascular Disease 140 Lgic Mdel Bx 10: Reduced Levels f Disparities in Cardivascular Disease 151 Lgic Mdel Bx 11: Reduced Cst Assciated with High Chlesterl 157 iii

6 Appendices 168 Appendix 1: Lgic Mdel fr Cntrlling High Chlesterl 169 Appendix 2: Data Surce Descriptins iv

7 1. INTRODUCTION 1.1 Purpse The Centers fr Disease Cntrl and Preventin s (CDC s) Divisin fr Heart Disease and Strke Preventin (DHDSP) develped plicy and system utcme indicatrs fr state Heart Disease and Strke Preventin (HDSP) prgrams and partners acrss prgram pririties. Prgram Managers, Evaluatrs, and DHDSP are the primary intended users f the indicatrs and supprting materials. State HDSP prgrams are funded t supprt plicy and system change that will lead imprvements in five pririty areas acrss pririty settings. State wrk fcuses n adults with high bld pressure r high bld chlesterl with emphasis n the healthcare and wrksite settings. Indicatrs are specific, bservable, and measureable characteristics that shw the prgress a prgram is making tward achieving utcmes. This dcument prvides utcme indicatrs fr cntrlling high chlesterl in adults with high chlesterl. Each indicatr includes a scaled rating based n existing science, expert pinin, and state practices. The wrk is intended t assist with prgram planning and evaluatin and: Prvide a slid evidence base fr public health decisin making. Describe utcme indicatrs fr evaluatin f state HDSP prgrams, and suggest apprpriate data surces and measures fr these indicatrs. Encurage states t use valid and reliable measurement methds and cmparable data surces. Help DHDSP determine evaluatin criteria, assess best practices, and prvide cnsistent surveillance and evaluatin technical assistance t states. This indicatr bk includes: A brief summary f the state f the science fr lgic mdel cmpnents and hw it relates t dwnstream cmpnents. A lgic mdel t identify causal pathways acrss the utcme cmpnents. (Appendix 1) Indicatr rating tables that list all f the indicatrs assciated with each cmpnent f the lgic mdel and the synthesized expert reviewer ratings fr each indicatr. Indicatr prfiles that include detailed infrmatin fr each indicatr including example data surces/measures. Data surce descriptins are prvided fr surces related t mre than ne indicatr. (Appendix 2) The data surce descriptins prvide backgrund infrmatin n the surce and where the surce can be lcated. Page 5

8 Sectin 1 Intrductin Thrughut the Cntrlling High Chlesterl Indicatrs bk, the term high chlesterl refers t high bld chlesterl, nt high dietary chlesterl. High bld chlesterl ccurs when there is t much chlesterl in yur bdy and it is depsited in arteries, including thse f the heart, which can lead t narrwing f the arteries and t heart disease. 1.2 Methds The Scial-Eclgical Mdel, first described by McLery, Bibeau, Steckler, & Glanz (1988), prvides a framewrk in which t develp, implement, and evaluate cmprehensive interventins. The mdel describes sciety as intercnnected elements individual, interpersnal, rganizatinal, cmmunity, and scial that affect ne anther. The mdel supprt the premise that in rder t change individual behavir, a cmprehensive interventin shuld cnsider hw all these levels f influence can be addressed t supprt lng-term, healthful lifestyle chices. The Scial-Eclgical Mdel infrmed the lgic mdel fr Cntrlling High Chlesterl and the indicatrs span the dimensins. State Heart Disease and Strke Preventin Prgrams are charged with wrking at the Scietal and Cmmunity levels f the Scial Eclgical Mdel thrugh plicy and systems changes. Because wrking at these higher levels is intended t ultimately impact individual knwledge, awareness, and behavir change, utcmes that reflect these individual-level changes have been included in the Cntrlling High Chlesterl Indicatrs, thugh wrking directly with individuals is nt within the scpe f the HDSP Prgram. The indicatrs were identified thrugh an extensive review f the literature which supprted the develpment f a lgic mdel fr plicy and systems change t cntrl high chlesterl. Each utcme indicatr is nested within a cmpnent f the lgic mdel (Exhibit 1 and Appendix 1). Indicatrs were linked acrss the lgic mdel t dwnstream utcmes based n published findings. The indicatrs were then reviewed and rated by a panel f experts that included state health department managers and epidemilgists, cntent area experts, and CDC experts. Page 6

9 Sectin 1 Intrductin Exhibit 1 Cntrlling High Chlesterl Lgic Mdel Shrt-term Outcmes Intermediate Outcmes Lng-term Outcmes Inputs Activities Bx 1 Healthcare System Changes: Adherence Efficiency Plicies/Prtcls/Tls Bx 6 Risk Factr Reductin Thrugh Lifestyle and Therapeutic Interventin Bx 9 Reduced Mrtality and Mrbidity Due t Heart Disease and Strke Outputs Bx 2 Prvider Changes: Awareness Adherence t Guidelines Bx 3 Wrkplace Changes: Plicies/Prtcls/Tls Envirnmental Changes Bx 4 Cmmunity Changes: Envirnmental Changes Plicy/legislative Changes Bx 5 Individual Changes: Awareness Knwledge Bx 7 Reduced Levels f Hig h Chlesterl Bx 8 Increased Cntrl f Chlesterl Levels Amng Individuals with High Chlesterl Bx 10 Reduced Levels f Disparities in Heart Disease and Strke Bx 11 Reduced Csts Assciated with Heart Disease and Strke: Individual Healthcare Emplyer Scietal Cntextual Factrs Sci- ecnmic and demgraphic characteristics f the target ppulatin Participating rganizatins plicies and practices Healthcare industry practice trends and plicies Partnerships amng patients, prviders, healthcare rganizatins, and wrksites Page 7

10 Sectin 1 Intrductin 1.3 Use The utcme indicatrs are intended t assist in planning and utcme evaluatin f heart disease and strke preventin activities. T facilitate use, the indicatrs and supprting materials have been written t allw flexibility t tailr measurement t the specific strategies and needs f prgrams. State HDSP prgrams may use the indicatrs t supprt the develpment f an evaluatin plan as described in Evaluatin Guide: Develping an Evaluatin Plan published by the CDC Divisin fr Heart Disease and Strke Preventin, State Heart Disease and Strke Preventin Prgram and available at The HDSP Evaluatin Guide identifies eight steps in develping an evaluatin plan: 1. Develp evaluatin questins (what d yu want t knw?). 2. Determine indicatrs (what will yu measure? what type f data will yu need t answer the evaluatin questin?). 3. Identify data surces (where can yu find these data?). 4. Determine the data cllectin methd (hw will yu gather the data?). 5. Specify the time frame fr data cllectin (when will yu cllect the data?). 6. Plan the data analysis (hw will data be analyzed and interpreted?). 7. Cmmunicate results (with whm and hw will results be shared?). 8. Designate staff respnsibility (wh will versee the cmpletin f this evaluatin?). State HDSP prgrams can use the lgic mdel, indicatr ratings and prfiles t select a set f utcme indicatrs t include in their evaluatin plan: Lgic mdel bx summaries prvide a very brief verview summarizing the state f the science fr the given utcme cmpnent and identify hw it relates t dwnstream cmpnents. As HDSP prgrams cnsider evaluatin needs, reviewing this infrmatin will identify critical causal pathways acrss the utcme cmpnents that shuld be measured. Once these causal pathways are identified, HDSP prgrams may want t select ne r mre indicatrs frm each identified utcme cmpnent t ensure a strng evaluatin plan. Indicatr rating tables list all f the indicatrs assciated with the utcme cmpnent f the lgic mdel and the synthesized expert reviewer ratings fr each indicatr by criterin. HDSP prgrams may want t select criteria mst suited t the cntext f the prgram and mst imprtant t stakehlders. Once Page 8

11 Sectin 1 Intrductin the criteria are selected, prgrams can use this infrmatin t help select relevant utcme indicatrs. Indicatr prfiles include detailed infrmatin fr each indicatr including ptential data surces and hw t measure indicatrs. This infrmatin may prvide a starting pint fr addressing Step 3 in the Evaluatin Plan develpment, Identify data surces. HDSP prgrams, hwever, will need t carefully cnsider a number f relevant issues befre final selectin f measures can ccur, including at what level data shuld be cllected; whether the data surce t be used is valid, reliable, and feasible given the cntext; and the peridicity f data cllectin. 2. EXPERT PANEL INDICATOR RATING TABLES The rating table lists the indicatrs, by lgic mdel bx, and summarizes the expert panel ratings fr each indicatr. The indicatrs were rated n criteria that describe five imprtant characteristics f a gd indicatr and verall quality f the indicatr. Availability f an existing data surce was nt a criterin fr selectin f the indicatrs r a rated criterin. Rating tables can be used t quickly review the indicatrs t identify thse with specific criteria, fr example, indicatrs with the highest scientific validity r as a quick reference t review all the indicatrs and their relatinships. The criteria are: Overall quality a summary rating that reflects expert reviewer pinin f the verall quality f the indicatr. Resurces needed rating f the amunt f funds, time, and effrt needed t cllect reliable and precise data n the indicatr and t analyze primary r secndary data. The value dentes a qualitative rating f the resurces rather than a specific amunt r range f csts. Strength f the scientific evidence extent t which expert reviewers believe that the literature supprts the use f the indicatr fr HDSP prgram evaluatin; the assumptin that implementing interventins t mdify an upstream indicatr will result in measurable dwnstream effect. Face validity expert reviewer estimatin f the extent t which judgments abut and measurement f the indicatr wuld appear valid and relevant t plicy makers and ther decisin makers wh use the results f an evaluatin t justify their cntinued supprt. Utility extent t which expert reviewers believe that the indicatr wuld help t answer key HDSP prgram evaluatin questins. Cnfrmity with accepted practice expert reviewer pinin f the degree t which use f the indicatr is cnsistent with currently accepted HDSP practice. Page 9

12 Sectin 2 Indicatr Rating Tables Indicatr Name and Number Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Prprtin f healthcare systems with plicies that identify LDL chlesterl as the primary target f lipidlwering therapy Prprtin f healthcare systems with electrnic medical recrds apprpriate fr treating patients with high chlesterl Prevalence f specialized chrnic care clinics with a fcus n high chlesterl $$ $$ $$ Prprtin f healthcare systems with treatment algrithms that incrprate recmmendatins f current evidence-based chlesterl guidelines $$ Number f quality imprvement initiatives t increase practitiner adherence t current evidence-based chlesterl guidelines $$ Page 10

13 Sectin 2 Indicatr Rating Tables Indicatr Name and Number Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Prprtin f healthcare systems with plicies t fllw up with patients tested fr high chlesterl $$ Prprtin f healthcare systems with plicies t increase patient adherence t high chlesterl treatment (including lifestyle mdificatin and pharmaclgic cmpnents) Dentes lw agreement amng reviewers, defined as less than 75% f valid ratings being within tw pints f the median fr verall quality f the indicatr. $$ Page 11

14 Sectin 2 Indicatr Rating Tables Indicatr Name and Number Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Prprtin f prviders wh rder bld chlesterl tests accrding t current evidence-based guidelines $$ Prprtin f prviders wh classify LDL, HDL, and ttal chlesterl accrding t current evidence-based guidelines $$$ Prprtin f prviders wh dcument majr cardivascular risk factrs nted in current evidencebased chlesterl guidelines $$ Prprtin f prviders wh increase mnitring and shifts in medicatin fr patients unable t achieve chlesterl treatment gals $$$ Prprtin f prviders wh fllw current evidencebased guideline algrithms fr pharmaclgic therapies t treat high chlesterl $$$ Page 12

15 Sectin 2 Indicatr Rating Tables Indicatr Name and Number Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Prprtin f patients with high chlesterl wh receive prvider-initiated recmmendatin and fllwup f therapeutic lifestyle mdificatins Prprtin f prviders wh cunsel patients with high chlesterl n hw t take prescribed medicines $$ $$$ Prprtin f prviders wh wrk with patients t identify chlesterl self management gals $$$ Dentes lw agreement amng expert reviewers. Less than 75% f valid ratings are within ne pint f the median fr this criterin. Dentes lw agreement amng expert reviewers. Less than 75% f valid ratings are within tw pints f the median fr verall quality f the indicatr. Page 13

16 Sectin 2 Indicatr Rating Tables Indicatr Name and Number Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Prprtin f wrksites with emplyer payment fr services t cntrl high chlesterl Prprtin f wrksites that ffer behaviral appraches fr emplyees t cntrl high chlesterl Prprtin f wrksites that prvide health risk assessments that include high chlesterl mnitring Prprtin f wrksites with envirnmental supprts t cntrl high chlesterl $$ $$ $$ $$ Dentes lw agreement amng expert reviewers. Less than 75% f valid ratings are within tw pints f the median fr verall quality f the indicatr. Page 14

17 Sectin 2 Indicatr Rating Tables Indicatr Name and Number Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Number f legislative plicies t supprt therapeutic lifestyle behavirs fr cntrlling high chlesterl Number f cmmunity interventins t cntrl high chlesterl $ $$ Number f cmmunity envirnmental supprts t cntrl high chlesterl $$ Prprtin f cmmunitybased rganizatins that are linked t health care and public health systems t supprt cntrl f high chlesterl $$$ Page 15

18 Sectin 2 Indicatr Rating Tables Indicatr Name and Number Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Prprtin f adults wh knw their chlesterl level(s) $$ Prprtin f adults wh have had their chlesterl checked within the previus five years Degree f disparity in knwledge f the risks f high chlesterl between general and pririty ppulatins Prprtin f adults wh knw which therapeutic lifestyle behavir changes are assciated with cntrlling high chlesterl Prprtin f adults wh are aware f their persnal risk assciated with high chlesterl Average annual ut-fpcket patient csts fr prescriptin medicatin fr the treatment f high chlesterl $$ $$ $$ $$ $$$ Page 16

19 Sectin 2 Indicatr Rating Tables Indicatr Name and Number Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Average annual ut-fpcket csts assciated with therapeutic lifestyle mdificatin fr the treatment f high chlesterl $$$ Dentes lw agreement amng expert reviewers. Less than 75% f valid ratings are within tw pints f the median fr verall quality f the indicatr. Page 17

20 Sectin 2 Indicatr Rating Tables Indicatr Name and Number Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Prprtin f adults wh fllw a recmmended diet t reduce their high chlesterl $$ Prprtin f adults with high chlesterl wh participate regularly in physical activity Prevalence f besity amng adults with high chlesterl $$ $$ Smking prevalence amng adults with high chlesterl $$ Prprtin f smkers with high chlesterl wh have made a quit attempt using prven cessatin methds Degree f disparity in risk factrs fr high chlesterl between general and pririty ppulatins $$ $$ Page 18

21 Sectin 2 Indicatr Rating Tables Indicatr Name and Number Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Prprtin f adults with high chlesterl wh adhere t chlesterl-lwering medicatin regimens $$ Degree f disparity in adherence t chlesterllwering medicatin regimens between general and pririty ppulatins $$ Dentes lw agreement amng expert reviewers. Less than 75% f valid ratings are within ne pint f the median fr this criterin. Page 19

22 Sectin 2 Indicatr Rating Tables Indicatr Name and Number Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Average LDL chlesterl level amng adults with high chlesterl $$ Average HDL chlesterl level amng adults with high chlesterl $$ Average triglyceride level amng adults with high chlesterl $$ Average ttal chlesterl level amng adults with high chlesterl $$ Dentes lw agreement amng expert reviewers. Less than 75% f valid ratings are within ne pint f the median fr this criterin. Dentes lw agreement amng expert reviewers. Less than 75% f valid ratings are within tw pints f the median fr verall quality f the indicatr. Page 20

23 Sectin 2 - Indicatr Rating Tables Indicatr Name and Number Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Prprtin f adults diagnsed with high chlesterl wh have LDL chlesterl at r belw gal as defined by current evidencebased guidelines $$ Prprtin f adults diagnsed with high chlesterl wh have HDL chlesterl at r abve gal as defined by current evidencebased guidelines $$ Prprtin f adults diagnsed with high chlesterl wh have Nn-HDL chlesterl at r belw gal as defined by current evidencebased guidelines $$ Prprtin f adults diagnsed with high chlesterl wh have ttal chlesterl level at r belw gal as defined by current evidence-based guidelines $$ Degree f disparity in high LDL chlesterl cntrl between general and pririty ppulatins $$ Page 21

24 Sectin 2 - Indicatr Rating Tables Indicatr Name and Number Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Prprtin f adults with high chlesterl wh have an elevated 10-year cardivascular risk Prprtin f adults with high chlesterl wh have pr quality f life Prevalence f nnfatal cardivascular events assciated with high chlesterl $$ $$$ $$ Death rate due t cardivascular disease assciated with high chlesterl Dentes lw agreement amng expert reviewers. Less than 75% f valid ratings are within tw pints f the median fr verall quality f the indicatr. $$ Page 22

25 Sectin 2 Indicatr Rating Tables Indicatr Name and Number Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Degree f disparity in cardivascular mrbidity assciated with high chlesterl between general and pririty ppulatins Degree f disparity in cardivascular mrtality assciated with high chlesterl between general and pririty ppulatins $$ $$ Page 23

26 Sectin 2 Indicatr Rating Tables Indicatr Name and Number Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Average annual emplyer csts attributable t high chlesterl and related health utcmes Average annual utpatient csts attributable t high chlesterl and related health utcmes Average annual inpatient csts attributable t high chlesterl and related health utcmes Average annual emergency department csts attributable t high chlesterl and related health utcmes $$$ $$$ $$$ $$$ Page 24

27 3. THE SCIENCE AND INDICATOR PROFILES Indicatrs are rganized and presented by shrt-term, intermediate, and lng-term lgic mdel bx. Fr each lgic mdel bx, a brief summary f the science supprting the indicatrs is prvided fllwed by a prfile f each indicatr. The indicatr prfiles prvide detailed infrmatin abut each indicatr. The prfiles include: Rating Summary ratings prvided by the expert reviewers. The symbls used crrespnd t median reviewer ratings fr each criterin. Indicatr Name and Number Each indicatr has been assigned a unique three-part number. The first number identifies the pririty area (2 = Cntrlling High Chlesterl) The secnd number identifies the utcme cmpnent f the lgic mdel The third number identifies the specific indicatr within the cmpnent (Figure 1) Pririty Area The title f the pririty area. Lgic Mdel Cmpnent The title f the assciated utcme cmpnent. What t Measure A descriptin f what t measure when emplying the indicatr fr utcme evaluatin. Why This Indicatr is Useful A brief ratinale statement is prvided fr using the indicatr as a measure f the utcme cmpnent. Hw t Measure Example data surces, surveys, r methdlgies fr cllecting infrmatin relevant t the indicatr are prvided. Althugh sme f the prpsed data surces/measures are able t prvide pertinent infrmatin at the state level, thers are nt. Additinally, depending n the cntext and scpe f state strategies, evaluatin f state prgram activities may require using a given measure r data cllectin methdlgy in a mre targeted way, fr example, within a single cunty r healthcare system. The example data surces, surveys, and measures infrmatin is prvided as an initial suggestin. Appendix 2, Data Surce Descriptins, has descriptins f each data surce r survey listed. Ppulatin Grup The ppulatin grup fr which data relevant t the indicatr are mst cmmnly cllected, if applicable. Page 25

28 Cmments Additinal infrmatin pertinent t measuring the indicatr and/r t the example data surce. At times, suggestins regarding cllecting, analyzing, and reprting data are nted. Other Infrmatin As needed, illustrative examples f elements included under the pertinent indicatr. References A small subset f citatins relevant t the indicatr. Figure 1 Indicatr Number Designatin Pririty Area 1 = Cntrlling High Bld Pressure 2 = Cntrlling High Chlesterl Specific Indicatr within the Lgic Mdel Bx Lgic Mdel Bx 1 = Healthcare System Changes 2 = Prvider Changes 3 = Wrkplace Changes 4 = Cmmunity Changes 5 = Individual Changes 6 = Risk Factr Reductin 7 = Reduced Levels f High Chlesterl 8 = Increased Cntrl f Chlesterl Levels 9 = Reduced Mrbidity and Mrtality 10= Reduced Levels f Disparities 11= Reduced Csts The abve example is the first indicatr in Bx 1 f the lgic mdel utcmes fr Cntrlling High Chlesterl, Healthcare System Changes. Page 26

29 LOGIC MODEL BOX 1: Healthcare System Changes Healthcare system interventins have been fund t be effective in imprving detectin and cntrl f high bld chlesterl and imprving adherence t treatment regimens r practice guidelines. Chlesterl-reductin interventins in healthcare settings deliver prgrams fr specific ppulatins, such as patients at risk fr cardivascular disease, thrugh rganizatin-fcused (i.e., changing the plicies r guidelines within an institutin), prvider-fcused (i.e., changing physician practices), and/r patient-fcused effrts (i.e., influencing individual behavir change). Healthcare systems include multiple prvider entities including hspitals, lng-term care facilities, ther institutinal prviders and prgrams, physician practices, and/r rganizatins with insurance functins (such as managed care rganizatins). The Third Reprt f the Natinal Chlesterl Educatin Prgram (NCEP) Expert Panel n Detectin, Evaluatin, and Treatment f High Bld Chlesterl in Adults (Adult Treatment Panel III), 2001 ffers clinical guidelines fr care. Effrts t facilitate applicatin f these guidelines in clinical practice serve t imprve the quality f care and enhance preventin f heart disease and strke. The high chlesterl cntrl indicatrs presented here have been strngly influenced by the Adult Treatment Panel III (ATP III) guidelines. Evidence suggests that patients wh d nt achieve ATP III chlesterl gals are at significantly higher risk fr cardivascular events (Stanek et al., 2007). Therefre, it is critical that healthcare systems wrk t ensure adherence t evidence-based clinical guidelines. Examples f rganizatin-fcused interventins t prmte adherence t guidelines include: (1) implementing plicies that identify LDL chlesterl as a primary target; (2) utilizing cmputerized systems fr patient management; (3) implementing lifestyle mdificatin prgrams within healthcare settings; and (4) establishing clinics specific t disease management and preventin (Bijlani et al., 2005; Brwn & Cfer, 2000; Kinn et al., 2001; McLed et al., 2005; Pujia, 2002; Rbinsn et al., 2000). Cmputerized system supprts have been widely used in healthcare settings fr imprved service delivery. Specifically, cmputerized prtcls in healthcare settings have been shwn t imprve adherence t treatment regimens amng patients and imprve chlesterl cntrl (Schectman, Wlff, Byrd, Hiatt, & Hartz, 1996; Shaffer & Wexler, 1995). There is bth direct and indirect evidence that the use f electrnic medical recrd systems is assciated with imprvement in high chlesterl management thrugh imprvement in health infrmatin exchange amng patients, prviders, and healthcare systems (Kinn et al., 2001; Lester, Grant, Barnett, & Chueh, 2006). Additinally, lipid management interventins delivered thrugh specialized clinics have successfully helped individuals reach individual LDL-lwering gals (Brwn & Cfer, 2000). These interventins entail a three- Page 27

30 prnged apprach including a predefined system referring patients t effective treatments; patient supprt t achieve individualized gals; and prvider feedback n patient perfrmance. The shrt-term utcme indicatrs fr cntrlling high chlesterl in the healthcare setting are: Prprtin f healthcare systems with plicies that identify LDL chlesterl as the primary target f lipid-lwering therapy Prprtin f healthcare systems with electrnic medical recrds apprpriate fr treating patients with high chlesterl Prevalence f specialized chrnic care clinics with a fcus n high chlesterl Prprtin f healthcare systems with treatment algrithms that incrprate recmmendatins f current evidence-based chlesterl guidelines Number f quality imprvement initiatives t increase practitiner adherence t current evidence-based chlesterl guidelines Prprtin f healthcare systems with plicies t fllw up with patients tested fr high chlesterl Prprtin f healthcare systems with plicies t increase patient adherence t high chlesterl treatment (including lifestyle mdificatin and pharmaclgic cmpnents) References Bijlani RL, Vempati RP, Yadav RK, Ray RB, Gupta V, Sharma R, et al. A brief but cmprehensive lifestyle educatin prgram based n yga reduces risk factrs fr cardivascular disease and diabetes mellitus. Jurnal f Alternative and Cmplementary Medicine 2005;11(2): Brwn AS, Cfer LA. Lipid management in a private cardilgy practice (the Midwest Heart experience). American Jurnal f Cardilgy 2000;85:18A 22A. Kinn JW, O Tle MF, Rwley SM, Marek JC, Bufalin VJ, Brwn AS. Effectiveness f the electrnic medical recrd in chlesterl management in patients with crnary artery disease (Virtual Lipid Clinic). American Jurnal f Cardilgy 2001;88: Lester WT, Grant RW, Barnett GO, Chueh HC. Randmized cntrlled trial f an infrmaticsbased interventin t increase statin prescriptin fr secndary preventin f crnary disease. Jurnal f General Internal Medicine 2006;21(1): McLed AL, Brks L, Taylr V, Wylie A, Currie PF, Dewhurst NG. Nn-attendance at secndary preventin clinics: the effect n lipid management. Scttish Medical Jurnal 2005;50(2): Pujia A. A hspital-based netwrk fr hyperlipidaemia management and cardivascular disease preventin. Nutritin, Metablism & Cardivascular Diseases 2002;12(4): Page 28

31 Rbinsn JG, Cnry C, Wickemeyer WJ. A nvel telephne-based system fr management f secndary preventin t a lw-density lipprtein chlesterl < r = 100 mg/dl. American Jurnal f Cardilgy 2000;85(3): Schectman G, Wlff N, Byrd JC, Hiatt JG, Hartz A. Physician extenders fr cst-effective management f hyperchlesterlemia. Jurnal f General Internal Medicine 1996;11(5): Shaffer J, Wexler LF. Reducing lw-density lipprtein chlesterl levels in an ambulatry care system. Results f a multidisciplinary cllabrative practice lipid clinic cmpared with traditinal physician-based care. Archives f Internal Medicine 1995;155(21): Stanek EJ, Sarawate C, Willey VJ, Charland SL, Cziraky MJ. Risk f cardivascular events in patients at ptimal values fr cmbined lipid parameters. Current Medical Research and Opinin 2007 Mar;23(3): Page 29

32 Prpsed Indicatr Prprtin f healthcare systems with plicies that identify LDL chlesterl as the primary target f lipid-lwering therapy (2.1.1) Rating $$ Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Pririty Area Lgic Mdel Cmpnent What t Measure Cntrlling High Chlesterl Shrt-term Outcmes Bx 1 Healthcare System Changes: Adherence, Efficiency, Plicies/Prtcls/Tls Prprtin f healthcare systems with plicies that fcus clinical effrts n LDL chlesterl as the primary target f lipid-lwering therapy. Why This Indicatr is Useful Elevated LDL chlesterl is a majr cause f cardivascular heart disease (Executive Summary f the Third Reprt f the NCEP, 2001). Several studies have shwn that lwering LDL chlesterl can significantly reduce the risk f crnary heart disease (Olssn, 2006). A greater percentage f patients f healthcare clinics that rutinely dcument LDL chlesterl level (71%) met their LDL gals than did patients f healthcare systems less likely t dcument patients LDL-chlesterl level (11%) (Brwn & Cfer, 2000). Hw t Measure TO BE DETERMINED Ppulatin Grup Healthcare systems Cmments Evaluatrs may want t assess whether the healthcare system has existing plicies related t LDL chlesterl as the primary target f lipid-lwering therapy. Evaluatrs may als chse t gather data n the size and demgraphics f the ppulatin affected by the relevant plicies. Other Infrmatin If applying the indicatr within a single healthcare system, the indicatr will simply dente the presence r absence f the given plicy. References Brwn AS, Cfer LA. Lipid management in a private cardilgy practice (the Midwest Heart experience). American Jurnal f Cardilgy. 2000;85:18A 22A. Executive Summary f The Third Reprt f The Natinal Chlesterl Educatin Prgram (NCEP) Expert Panel n Detectin, Evaluatin, And Treatment f High Bld Chlesterl In Adults (Adult Treatment Page 30

33 Panel III). JAMA May 16;285(19): Glassberg H, Rader DJ. Management f lipids in the preventin f cardivascular events. Annual Review f Medicine 2008;59: Review. Olssn AG. Are lwer levels f lw-density lipprtein chlesterl beneficial? A review f recent data. Current Athersclersis Reprts 2006;8(5): Review. Page 31

34 Prpsed Indicatr Prprtin f healthcare systems with electrnic medical recrds apprpriate fr treating patients with high chlesterl (2.1.2) Rating $$ Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Pririty Area Cntrlling High Chlesterl Lgic Mdel Cmpnent Shrt-term Outcmes Bx 1 Healthcare System Changes: Adherence, Efficiency, Plicies/Prtcls/Tls What t Measure Prprtin f healthcare systems that use medical recrds and related decisin prmpts t enhance the prvisin f high chlesterl care accrding t clinical guidelines. Why This Indicatr is Useful Effective use f infrmatin and medical technlgy is ne f the strategies the Institute f Medicine (2001) recmmended t imprve the quality f care in the United States. Use f electrnic medical recrds (EMR) has been shwn t significantly increase LDL dcumentatin, the number f patients n lipid-lwering medicatins, and the incidence f patients achieving LDL levels f <100 mg/dl (Kinn et al., 2001). Furthermre, flagging patients wh may be candidates fr chlesterl treatment can significantly increase statin prescriptins (Lester et al., 2006; Whitley et al., 2006). Hw t Measure TO BE DETERMINED Ppulatin Grup Cmments Healthcare systems In additin t tracking care prvided t patients with high chlesterl, evaluatrs may als want t determine whether healthcare systems are using electrnic medical recrds t track patient health utcmes. EMRs with the fllwing cmpnents shuld be cunted: Decisin supprt cmpnents Alerts Electrnic prescriptins Page 32

35 Other Infrmatin If applying the indicatr within a single healthcare system, the indicatr will simply dente the presence r absence f the given plicy. References Kinn JW, O'Tle MF, Rwley SM, Marek JC, Bufalin VJ, Brwn AS. Effectiveness f the electrnic medical recrd in chlesterl management in patients with crnary artery disease (Virtual Lipid Clinic). American Jurnal f Cardilgy 2001;88(2):163 5, A5. Lester WT, Grant RW, Barnett GO, Chueh HC. Randmized cntrlled trial f an infrmatics-based interventin t increase statin prescriptin fr secndary preventin f crnary disease. Randmized cntrlled trial f an infrmatics-based interventin t increase statin prescriptin fr secndary preventin f crnary disease. Jurnal f General Internal Medicine 2006 Jan;21(1):22 9. Whitley HP, Ferm JD, Chumney EC. 5-year evaluatin f electrnic medical recrd flag alerts fr patients warranting secndary preventin f crnary heart disease. Pharmactherapy 2006;26(5): Page 33

36 Prpsed Indicatr Prevalence f specialized chrnic care clinics with a fcus n high chlesterl (2.1.3) Rating $$ Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Pririty Area Cntrlling High Chlesterl Lgic Mdel Cmpnent Shrt-term Outcmes Bx 1 Healthcare System Changes: Adherence, Efficiency, Plicies/Prtcls/Tls What t Measure Prprtin f healthcare systems with specialized chrnic care clinics that address high chlesterl. Specific elements f these clinics are prvided in Cmments belw. Why This Indicatr is Useful Evidence shws that specialized clinics (e.g., specialty cardivascular risk reductin clinics (CRRC), pharmacist-managed r nurse-managed lipid clinics) can achieve better chlesterl-related utcmes than ther types f care (e.g., enhanced primary care, VA Medical Centers) (Becker et al., 1998; Mazzlini et al., 2008; Pearsn et al., 2008). Others have fund that lipid clinics reduced waiting times, led t imprved lipid results, and imprved fllw-up, all f which were sustained ver time (Stuart & Smellie, 2005). Hw t Measure TO BE DETERMINED Ppulatin Grup Healthcare systems Cmments Specialized clinics are typified by a fcus n facilitating mre frequent cntact with patients and prviding patient educatin t enhance adherence t imprve the cntrl f high chlesterl. HDSP state prgrams are encuraged t partner with ther chrnic disease prgrams such as Diabetes Preventin and Cntrl prgrams t increase the prevalence f chrnic care clinics. Page 34

37 Other Infrmatin If applying the indicatr within a single healthcare system, the indicatr will simply dente the presence r absence f the specialized chrnic care clinic. References Becker DM, Raquen JV, Yk RM, Kral BG, Blumenthal RS, My TF, Bezirdjian PJ, Becker LC. Nurse-mediated chlesterl management cmpared with enhanced primary care in siblings f individuals with premature crnary disease. Archives f Internal Medicine 1998;158: Mazzlini TA, Irns BK, Schell EC, Seifert CF. Lipid levels and use f lipidlwering medicatins fr patients in pharmacist-managed lipid clinics versus usual care in 2 VA Medical Centers. Jurnal f Managed Care Pharmacy 2005,11(9): Pearsn GJ, Olsn KL, Panich NE, Majumdar SR, Tsuyuki RT, Gilchrist DM, Damani A, Francis GA. Maintenance f imprved lipid levels fllwing attendance at a cardivascular risk reductin clinic: a 10- year experience. Vascular Health and Risk Management 2008;4(5): Stuart W, Smellie A. D we need lipid clinics? Shifting the balance between secndary and primary care. Annals f Clinical Bichemistry 2005;42(Pt 6): Dentes lw agreement amng expert reviewers. Less than 75% f valid ratings are within tw pints f the median fr verall quality f the indicatr. Page 35

38 Prpsed Indicatr Prprtin f healthcare systems with treatment algrithms that incrprate recmmendatins f current evidence-based chlesterl guidelines (2.1.4) Rating $$ Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Pririty Area Lgic Mdel Cmpnent What t Measure Cntrlling High Chlesterl Shrt-term Outcmes Bx 1 Healthcare System Changes: Adherence, Efficiency, Plicies/Prtcls/Tls Prprtin f healthcare systems with plicies fr the use f treatment algrithms that incrprate recmmendatins f the ATP III guidelines. Why This Indicatr is Useful Guidelines fr crnary heart disease risk assessment can be useful in early identificatin and treatment f thse at risk. In a study cmparing different guidelines, it was shwn that ATP III guidelines predicted higher levels f risk than ther guidelines (e.g., revised Sheffield table, Munster Heart Study calculatr) (Bredl et al., 2003). Furthermre, the ATP III guidelines have been shwn t be a cst-effective primary preventin strategy fr lipid-lwering (Pletcher et al., 2009). Hw t Measure TO BE DETERMINED Ppulatin Grup Healthcare systems Other Infrmatin If applying the indicatr within a single healthcare system, the indicatr will simply dente the presence r absence f the given plicy. References Bredl UC, Geiss HC, Parhfer KG. Cmparisn f current guidelines fr primary preventin f crnary heart disease: risk assessment and lipid-lwering therapy. Jurnal f General Internal Medicine 2003;18(3): Pletcher MJ, Lazar L, Bibbins-Dming K, Mran A, Rdndi N, Cxsn P, Lightwd J, Williams L, Gldman L. Cmparing impact and csteffectiveness f primary preventin strategies fr lipid-lwering. Annals f Internal Medicine 2009;150(4): Page 36

39 Prpsed Indicatr Number f quality imprvement initiatives t increase practitiner adherence t current evidence-based chlesterl guidelines (2.1.5) Rating $$ Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Pririty Area Lgic Mdel Cmpnent What t Measure High Chlesterl Cntrl Shrt-term Outcmes Bx 1 Healthcare System Changes: Adherence, Efficiency, Plicies/Prtcls/Tls Number f quality imprvement initiatives implemented by healthcare systems that prvide targeted, intensive supprt fr guideline cmpliance as well as review f practitiner adherence t treatment guidelines. Why This Indicatr is Useful Quality imprvement initiatives t increase practitiner adherence t ATP III guidelines can imprve cardivascular disease preventin services, including increases in the patients n lipid-lwering therapy, cnsistent dcumentatin f chlesterl levels, and increases f patients meeting their LDL gal (Brwn et al., 2000; McBride et al., 2000; Stams et al., 2001). Hw t Measure TO BE DETERMINED Ppulatin Grup Healthcare systems References Brwn AS, Cfer LA. Lipid management in a private cardilgy practice (the Midwest Heart experience). American Jurnal f Cardilgy 2000;85:18A 22A. McBride P, Underbakke G, Plane MB, Massth K, Brwn RL, Slberg LI, Ellis L, Schrtt HG, Smith K, Swansn T, Spencer E, Pfeifer G, Knx A. Imprving preventin systems in primary care practices: the Health Educatin and Research Trial (HEART). Jurnal f Family Practice 2000;49: Stams TD, Shaltni H, Girard SA, Parill JE, Calvin JE. Effectiveness f chart prmpts t imprve physician cmpliance with the Natinal Chlesterl Educatin Prgram guidelines. American Jurnal f Cardilgy 2001;88: Dentes lw agreement amng expert reviewers. Less than 75% f valid ratings are within tw pints f the median fr verall quality f the indicatr. Page 37

40 Prpsed Indicatr Prprtin f healthcare systems with plicies t fllw up with patients tested fr high chlesterl (2.1.6) Rating $$ Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Pririty Area Cntrlling High Chlesterl Lgic Mdel Cmpnent Shrt-term Outcmes Bx 1 Healthcare System Changes: Adherence, Efficiency, Plicies/Prtcls/Tls What t Measure Prprtin f healthcare systems with plicies that include infrmatin abut type, timing, and intensity f fllw up with patients tested fr high chlesterl. Why This Indicatr is Useful ATP III guidelines recmmend fllw-up with patients t prmte healthy lifestyle mdificatins and adherence t pharmaceutical therapies (Executive Summary f the Third Reprt f NECP, 2001). Letters t patients and their general practitiners have been shwn t be effective in imprving the use f lipid lwering medicatins in primary preventin and increasing cnsultatin rates fr secndary preventin (Atthbari et al., 2004; Feder et al., 1999). Hw t Measure TO BE DETERMINED Ppulatin Grup Healthcare systems Other Infrmatin If applying the indicatr within a single healthcare system, the indicatr will simply dente the presence r absence f the given plicy. The Institute fr Healthcare Imprvement s Cntinuing Care Clinic (CCC) Handbk is a step-by-step guide t establishing mre efficient patient visits. The Handbk recmmends: At rutine intervals abut ne mnth befre their first scheduled CCC, mail a letter f intrductin abut the CCC t the selected patients t determine their interest in participatin. Review patients medical recrds and determine clinical pririties. Page 38

41 Using the scheduling template, lay ut each patient schedule f care fr the visit. Cmplete individual patient schedules and mail t patient alng with cnfirmatin letter. Be sure patient receives cnfirmatin f CCC visit 2 weeks ahead f the visit day s that he r she can visit the lab t have requested bld wrk dne as needed. Order lab wrk and send lab requisitins t apprpriate lab facility as needed. Call patients 1 week prir t visit day t remind abut schedules and lab wrk. References Atthbari J, Mnster TB, de Jng PE, Jng-van den Berg LT. The effect f hypertensin and hyperchlesterlemia screening with subsequent interventin letter n the use f bld pressure and lipid lwering drugs. British Jurnal f Clinical Pharmaclgy 2004;57: Executive Summary f The Third Reprt f The Natinal Chlesterl Educatin Prgram (NCEP) Expert Panel n Detectin, Evaluatin, And Treatment f High Bld Chlesterl In Adults (Adult Treatment Panel III). JAMA 2001;285(19): Feder G, Griffiths C, Eldridge S, Spence M. Effect f pstal prmpts t patients and general practitiners n the quality f primary care after a crnary event (POST): Randmised cntrlled trial. BMJ 1999;318(7197): Dentes lw agreement amng expert reviewers. Less than 75% f valid ratings are within tw pints f the median fr verall quality f the indicatr. Page 39

42 Prpsed Indicatr Prprtin f healthcare systems with plicies t increase patient adherence t high chlesterl treatment (including lifestyle mdificatin and pharmaclgic cmpnents) (2.1.7) Rating $$ Overall Quality Resurces Needed Scientific Evidence Face Validity Utility Accepted Practice lw high better Pririty Area Cntrlling High Chlesterl Lgic Mdel Cmpnent Shrt-term Outcmes Bx 1 Healthcare System Changes: Adherence, Efficiency, Plicies/Prtcls/Tls What t Measure Prprtin f healthcare systems with plicies in place intended t increase patient adherence t high chlesterl treatment. These may include infrmatin abut the type, timing, and intensity f fllw up with patients screened fr high chlesterl t increase patient adherence t high chlesterl treatment. Specific elements fr evaluatin are prvided in Cmments belw. Why This Indicatr is Useful Adherence t high chlesterl treatment is imperative t reducing LDL chlesterl levels amng thse at risk fr crnary heart disease. Pharmaceutical care services and lifestyle mdificatin advice have been shwn t imprve adherence rates. Fr example, ne study fund that utilizing pharmacists in cllabratin with patients and physicians can lead t greater levels f adherence, resulting in mre successful management f lipid levels (Bluml et al., 2000; Lee et al., 2006). A study by Rbinsn et al. (2000) fund that a telephne-based cmputerized system that included lifestyle mdificatin infrmatin resulted in lwer levels f LDL chlesterl amng participants. Hw t Measure TO BE DETERMINED Ppulatin Grup Healthcare systems Cmments Evaluatrs may want t assess whether the healthcare system has existing plicies related t the use f electrnic medicatin mnitring equipment and pharmacy care prgrams t increase medicatin adherence Page 40

43 as well as systems t prmpt prvider inquiry int adherence t recmmended lifestyle medicatin activities. Evaluatrs may als chse t gather data n the size and demgraphics f the ppulatin effected by the relevant plicies. Other Infrmatin If applying the indicatr within a single healthcare system, the indicatr will simply dente the presence r absence f the given plicy. References Bluml BM, McKenney JM, Cziraky MJ. Pharmaceutical care services and results in Prject ImPACT: hyperlipidemia. Jurnal f the American Pharmacists Assciatin 2000;40: Lee JK, Grace KA, Taylr AJ. Effect f a pharmacy care prgram n medicatin adherence and persistence, bld pressure, and lwdensity lipprtein chlesterl: A randmized cntrlled trial. JAMA 2006;296(21): Epub 2006 Nv 13. Rbinsn JG, Cnry C, Wickemeyer WJ. A nvel telephne-based system fr management f secndary preventin t a lw-density lipprtein chlesterl 100 mg/dl. American Jurnal f Cardilgy 2000;85: Dentes lw agreement amng expert reviewers. Less than 75% f valid ratings are within tw pints f the median fr verall quality f the indicatr. Page 41

44 LOGIC MODEL BOX 2: Prvider Changes Healthcare system plicy and system changes (lgic mdel cmpnent 1) supprt prvider level changes in treatment. The Natinal Chlesterl Educatin Prgram Adult Treatment Panel III (ATP III) guidelines address chlesterl measurement, recmmended chlesterl treatment algrithms, related cardivascular risk factrs, and treatment gals. Prviders are crucial t initiating and maintaining therapeutic lifestyle mdificatins amng their patients and mnitring and mdifying medicatin regimens (Brwn & Cfer, 2000; Fnarw & Gawlinski, 2000; Lester, Grant, Barnett, & Chueh, 2006; Pearsn, Laurra, Chu, & Kafnek, 2000; Stams, Shaltni, Girard, Parrill, & Calvin, 2001). Evidence suggests that imprvements in prvider prescriptin practices lead t significant increases in the prprtin f patients receiving chlesterl-lwering prescriptins, leading t imprved chlesterl cntrl (Brwn & Cfer, 2000; Pearsn et al., 2000; Stams et al., 2001). Furthermre, research demnstrates that patients wh achieve recmmended ATP III gals have imprved health utcmes (Fletcher et al., 2005; NIH, 2002; Stanek et al., 2007). Studies demnstrate that infrmatin-based interventins can lead t significant increases in prvider adherence t ATP III guidelines (Lester et al., 2006; Stams et al., 2001). Additinally, prvider-fcused quality imprvement initiatives t increase adherence t evidence-based guidelines have been shwn t enhance high chlesterl screening, treatment and cntrl (Feder et al., 1999; Ornstein, 2004). The shrt-term utcme indicatrs fr cntrlling high chlesterl fr this cmpnent are: Prprtin f prviders wh rder bld chlesterl tests accrding t current evidence-based guidelines Prprtin f prviders wh classify LDL, HDL, and ttal chlesterl accrding t current evidence-based guidelines Prprtin f prviders wh dcument majr cardivascular risk factrs nted in current evidence-based chlesterl guidelines Prprtin f prviders wh increase mnitring and shifts in medicatin fr patients unable t achieve chlesterl treatment gals Prprtin f prviders wh fllw current evidence-based guideline algrithms fr pharmaclgic therapies t treat high chlesterl Prprtin f patients with high chlesterl wh receive prvider-initiated recmmendatin and fllw-up f therapeutic lifestyle mdificatins Prprtin f prviders wh cunsel patients with high chlesterl n hw t fllw prescribed medicines Prprtin f prviders wh wrk with patients t identify chlesterl selfmanagement gals Page 42

45 References Brwn AS, Cfer LA. Lipid management in a private cardilgy practice (the Midwest Heart experience). American Jurnal f Cardilgy 2000;85:18A 22A. Feder G, Griffiths C, Eldridge S, Spence M. Effect f pstal prmpts t patients and general practitiners n the quality f primary care after a crnary event (POST): Randmised cntrlled trial. BMJ 1999;318(7197): Fletcher B, Berra K, Ades P, Braun LT, Burke LE, Durstine JL, et al. Managing abnrmal bld lipids: A cllabrative apprach. Circulatin 2005;112: Fnarw GC, Gawlinski A. Ratinale and design f the Cardiac Hspitalizatin Athersclersis Management Prgram at the University f Califrnia Ls Angeles. American Jurnal f Cardilgy 2000;85(3A):10A 17A. Lester WT, Grant RW, Barnett GO, Chueh HC. Randmized cntrlled trial f an infrmaticsbased interventin t increase statin prescriptin fr secndary preventin f crnary disease. Jurnal f General Internal Medicine 2006;21(1): NIH. Third Reprt f the Natinal Chlesterl Educatin Prgram (NCEP) Expert Panel n Detectin, Evaluatin, and Treatment f High Bld Chlesterl in Adults (Adult Treatment Panel III) Final Reprt: Natinal Chlesterl Educatin Prgram - Natinal Heart, Lung, and Bld Institute - Natinal Institutes f Health Ornstein S, Jenkins RG, Nietert PJ, Feifer C, Rylance LF, Nemeth L. et al. A multi-methd quality imprvement interventin t imprve preventive cardivascular care: A cluster randmized trial. Annals f Internal Medicine 2004;141: Pearsn TA, Laurra I, Chu H, Kafnek S. The lipid treatment assessment prject (L-TAP): a multicenter survey t evaluate the percentages f dyslipidemic patients receiving lipid-lwering therapy and achieving lw-density lipprtein chlesterl gals. Archives f Internal Medicine 2000;160(4): Stams TD, Shaltni H, Girard SA, Parrill JE, Calvin JE. Effectiveness f chart prmpts t imprve physician cmpliance with the Natinal Chlesterl Educatin Prgram guidelines. American Jurnal f Cardilgy 2001;88(12): , A1428. Page 43