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interprofessionalIn 1999, the IOM’s landmark report To Err is Human: Building a Safer Health System, explored the impact of medical errors on clinical outcomes in terms of human lives.1 Importantly, recommendations from that report included establishing interdisciplinary team training and implementing an interdisciplinary, collaborative approach to re-designing complex systems of healthcare delivery. Innovative and inclusive education and training were seen as critical for success because most care is indeed delivered by multidisciplinary, interprofessional teams of people, yet health care training is focused too often on individual responsibilities. In this series, we look at the importance of interprofessional care—and therefore, the continuing education needed to provide that care—in the management of specific disease states.

The Importance of Interprofessional Care in Managing Dys- (Hyper-)lipidemia

Landmark trials in newer classes of blood sugar- and lipid-lowering agents may soon change the treatment paradigm for primary and secondary cardiovascular disease prevention. Patients with dyslipidemia remain at risk for atherosclerotic disease, however, and better therapies are still needed. RNA-based therapeutics are slowly emerging as a viable alternative to traditional statin treatment.

Interprofessional and multidisciplinary teamwork is essential in the provision of healthcare.2 Today’s patients have complex health needs and typically require more than one discipline to address issues regarding their health status.3 The division of labor among medical, nursing and allied health practitioners means that no single professional can deliver a complete episode of healthcare.2

Team-based care involving nurses and pharmacists is one of the most effective interventions available for improving hypertension, diabetes, and dyslipidemia treatment.4 Interprofessional work is increasingly important in various settings including primary care, in which the role of pharmacists is particularly important. Many studies have shown that in cases of hypertension, diabetes, dyslipidemia, and metabolic syndrome; physician-pharmacist collaboration can improve medication adherence and help to identify drug-related problems.5 Collaborative practices allow physicians and pharmacists to co-manage pharmacotherapy to maximize the benefits of medication regimens.6 The potential benefits of a clinical pharmacist-managed lipid clinic would be to improve rates of success in achieving these goals, improve drug adherence and compliance with therapy, and reduce cardiovascular events.7 Previous studies have shown that collaborative care involving pharmacists may help the management of dyslipidemia and cardiovascular disease.7–9

To determine the clinical and economic impact of a pharmacy-based cholesterol management program, 300 patients with a documented history of CVD were enrolled in a pharmacy-based cholesterol program for six months. A similar group of 150 randomly selected patients receiving usual care during the same period served as the comparator group. The following were collected for both groups: patient demographics, comorbidities, fasting lipid profiles, cholesterol medication, cost of medication, and cardiovascular events. Results showed that regular patient interaction and close patient monitoring allowed the pharmacy-based lipid management program to improve cholesterol management in patients with cardiovascular disease. Despite increased medication use among program patients, their cost per patient per month was lower at 1-year follow-up vs. baseline.10

The Trial to Evaluate an Ambulatory primary care Management program for patients with dyslipidemia (TEAM) study compared the efficacy of a physician-pharmacist collaborative primary care (PPCC) intervention, where pharmacists requested laboratory tests and adjusted medication dosage, to the usual care for patients under treatment with lipid-lowering medication. The qualitative results, were attained through physician, pharmacist, and patient interviews. Many patients felt they received better follow-up and reported being reassured and well informed, making them more inclined to care for themselves better. These feelings were attributed largely to the pharmacists’ accessibility and ability to communicate with them easily. The PPCC model was highly appreciated by patients, and clinicians saw it as beneficial to patients. However, several obstacles still have to be overcome before the model can be implemented in the current healthcare context.6

A systematic review was conducted to determine the impact of pharmacist care on the management of CVD risk factors among outpatients. The MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials that involved pharmacist care interventions among outpatients with CVD risk factors. Mean changes in blood pressure, total cholesterol, low-density lipoprotein cholesterol (LDL-C), and proportion of smokers were estimated using random effects models. Thirty randomized controlled trials (11,765 patients) were identified. Pharmacist interventions exclusively conducted by a pharmacist or implemented in collaboration with physicians or nurses included patient educational interventions, patient-reminder systems, measurement of CVD risk factors, medication management and feedback to physician, or educational intervention to healthcare professionals. Pharmacist care was associated with significant reductions in systolic/diastolic blood pressure, total cholesterol, LDL-C, and a reduction in the risk of smoking.11 A 50+ year literature review sought to evaluate how nurse-based case management (NCM) according to recommended guidelines improves patient outcomes and enhances cardiovascular risk reduction. The studies summarized demonstrate that individualized, systematic, and guideline-based NCM can translate into clinically meaningful reductions in cardiovascular-related morbidity and mortality.12

Delivery of interprofessional, collaborative, patient-centered care is key to contemporary healthcare policy. Healthcare settings worldwide are therefore attempting to move away from a traditional organization of care, built around siloes of discipline-based specialization, towards an approach of delivering care through interprofessional teamwork.13,14 The high-performing team is now widely recognized as an essential tool for constructing a more patient-centered, coordinated, and effective healthcare delivery system.15 When members of the healthcare team understand each other’s professional roles and buy into the need of those roles complementing and depending on each other, the collaboration becomes more effective, thus improving safety and patient outcomes.16

Knowledge of recent clinical trial findings will enhance the delivery of evidence-based care and improve levels of confidence among healthcare providers who treat patients with dyslipidemia. The collaboration of professionals as an integrated team has shown both disease and quality of life improvement. Data has emerged from European-based clinics and US team-based initiatives that demonstrate better outcomes for patients when treated by an interprofessional team. As the efforts to progress the science of dys56 continue, so should the transfer of knowledge and evidence-based clinical practice progress from bench to bedside.

Dr. Pollack is privileged to serve as the Medical Director for AcademicCME, https://academiccme.com/, a joint accredited education provider, where he is able to help develop innovative and engaging multidisciplinary, interprofessional programs aimed at improving patient care. This review of the importance of interprofessional education was initially developed by Michelle Yechout, lead medical writer at AcademicCME.

References

1. Institute of Medicine (US) Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. (Kohn LT, Corrigan JM, Donaldson MS, eds.). Washington (DC): National Academies Press (US); 2000. http://www.ncbi.nlm.nih.gov/books/NBK225182/. Accessed February 23, 2020.
2. Leggat SG. Effective healthcare teams require effective team members: defining teamwork competencies. BMC Health Serv Res. 2007;7:17. doi:10.1186/1472-6963-7-17
3. Bridges DR, Davidson RA, Odegard PS, Maki IV, Tomkowiak J. Interprofessional collaboration: three best practice models of interprofessional education. Med Educ Online. 2011;16. doi:10.3402/meo.v16i0.6035
4. Lalonde L, Goudreau J, Hudon É, et al. Development of an interprofessional program for cardiovascular prevention in primary care: A participatory research approach. SAGE Open Med. 2014;2. doi:10.1177/2050312114522788
5. Son D, Kawamura K, Nakashima M, Utsumi M. [The pharmacist-physician collaboration for IPW: from physician’s perspective]. Yakugaku Zasshi. 2015;135(1):109-115. doi:10.1248/yakushi.14-00222-1
6. Lalonde L, Hudon E, Goudreau J, et al. Physician-pharmacist collaborative care in dyslipidemia management: the perception of clinicians and patients. Res Social Adm Pharm. 2011;7(3):233-245. doi:10.1016/j.sapharm.2010.05.003
7. Bozovich M, Rubino CM, Edmunds J. Effect of a clinical pharmacist-managed lipid clinic on achieving National Cholesterol Education Program low-density lipoprotein goals. Pharmacotherapy. 2000;20(11):1375-1383.
8. Taveira TH, Wu W-C, Martin OJ, Schleinitz MD, Friedmann P, Sharma SC. Pharmacist-led cardiac risk reduction model. Prev Cardiol. 2006;9(4):202-208.
9. Tsuyuki RT, Johnson JA, Teo KK, et al. A randomized trial of the effect of community pharmacist intervention on cholesterol risk management: the Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP). Arch Intern Med. 2002;162(10):1149-1155.
10. Ditusa L, Luzier AB, Brady PG, Reinhardt RM, Snyder BD. A pharmacy-based approach to cholesterol management. Am J Manag Care. 2001;7(10):973-979.
11. Santschi V, Chiolero A, Burnand B, Colosimo AL, Paradis G. Impact of pharmacist care in the management of cardiovascular disease risk factors: a systematic review and meta-analysis of randomized trials. Arch Intern Med. 2011;171(16):1441-1453. doi:10.1001/archinternmed.2011.399
12. Berra K. Does nurse case management improve implementation of guidelines for cardiovascular disease risk reduction? J Cardiovasc Nurs. 2011;26(2):145-167. doi:10.1097/JCN.0b013e3181ec1337
13. Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice: 2016 Update.; 2016. https://hsc.unm.edu/ipe/resources/ipec-2016-core-competencies.pdf. Accessed February 26, 2020.
14. Liberati EG, Gorli M, Scaratti G. Invisible walls within multidisciplinary teams: Disciplinary boundaries and their effects on integrated care. Soc Sci Med. 2016;150:31-39. doi:10.1016/j.socscimed.2015.12.002
15. Mitchell P, Wynia M, Golden R, McNellis B, et al. Core Principles & Values of Effective Team-Based Health Care. National Academy of Medicine. October 2012. https://nam.edu/wp-content/uploads/2015/06/VSRT-Team-Based-Care-Principles-Values.pdf. Accessed December 11, 2019.
16. World Health Organization. Framework for Action on Interprofessional Education & Collaborative Practice.; 2010. http://apps.who.int/iris/bitstream/10665/70185/1/WHO_HRH_HPN_10.3_eng.pdf. Accessed February 28, 2020.

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