A Treatment Guideline for the Management of Dyslipidemia at the Hope Clinic

Dyslipidemia is a major independent risk factor for the development of coronary heart disease, the current leading cause of death in the United States. Despite wide dissemination of the National Cholesterol Education Program Adult Treatment Panel III guidelines and strong evidence supporting the clinical benefits of medical treatment, there continues to be significant variation in provider approaches to screening and treating dyslipidemia in clinical practice with providers failing to screen, initiate, or intensify treatment when warranted. This recognition of a problem but failure to act, termed clinical inertia, is a major factor in the sub-optimal rate of dyslipidemia treatment. An effective approach for overcoming clinical inertia in implementing best practice guidelines in the practice setting is to combine flow sheets with reminders and feedback on clinicians' performance. This scholarly project combined the current Adult Treatment Panel III guidelines with current research to create a simplified guideline in the form of a flip chart for use by providers at the Hope Clinic in Midvale, Utah. The Hope Clinic is a primary care medical facility that provides free medical care to the underserved and uninsured in the Salt Lake Valley region. Providers at the clinic noted that there was wide variation in prescribing practices relating to dyslipidemia treatment, in part spurring this project. There is a range of educational backgrounds among providers, who include physicians, nurse practitioners, physician assistants, medical residents, and students of various disciplines. In order to meet the needs of the Hope Clinic, the guideline created for this project was focused on being a quick and effective resource that could be utilized by providers with different educational backgrounds. The ultimate objective of this project was to improve patient outcomes. This outcome was indirectly measured through meeting the objectives of this project which were to: (a) create a treatment guideline in the form of a flip chart for use at the Hope clinic, (b) improve provider adherence to current evidence-based recommendations for the management of dyslipidemia, (c) increase consistency in provider treatment of dyslipidemia, and (d) increase the frequency with which providers initiate treatment of dyslipidemia in patients with non-alcoholic fatty liver disease. Chart audits were conducted comparing treatment of dyslipidemia before and after implementation of the guideline in order to assess if these objectives were met. With use of the guideline, adherence to the ATP III guidelines improved from 40% to 78%. There was a significant decrease in the use of fish oil from 46% to 11% as providers focused on targeting LDL cholesterol over triglycerides. There was an increase in the prescription of statin medications from 35% to 46%. Reviews of provider notes revealed an increase in individualizing care based on risk category, starting at therapeutic statin dosages, and titrating up statin dosages when appropriate. Use of the guideline also improved consistency in treatment of dyslipidemia and increased the rate of dyslipidemia treatment in patients with on-alcoholic fatty liver disease. Given that these parameters are measurable markers of improved dyslipidemia management, continued use of this guideline should improve long-term patient outcomes