Dyslipidemia

Pandemic Flips Script on Patient-Partnered Dyslipidemia Care

Laurence Sperling, MD; Martha Gulati, MD, MS; Joseph J. Saseen, PharmD

Disclosures

October 21, 2021

This transcript has been edited for clarity.

Laurence Sperling, MD: Welcome to Medscape's InDiscussion series on dyslipidemia. This is episode 2. Today, we'll be focusing on patient-partnered care, optimizing the care team, and the promise of telehealth. This topic is highly relevant. We've been living during challenging times, and during these challenging times, I hope we've learned some lessons and identified opportunities about the future as we consider new ways of approaching heart disease prevention and the management of dyslipidemia.

I'll start with a reality check in the form of a case presentation. Mrs P is a longtime patient. She's 61 years old and has a history of stable coronary artery disease. She had a stent placed in her left anterior descending artery about 3 years ago. She has a history of dyslipidemia and hypertension. She's scheduled for a telemedicine follow-up visit. She was last seen in the clinic in February 2020, before COVID restrictions. Evidently, she's been out of her statin and blood pressure medications for several months and is past due for a lipid profile.

After signing in for the telemedicine video visit, we waited. We looked over the chart and after 10 minutes, she still hadn't joined. We can see that many other patients are waiting; it's a busy day in our clinic. What would you do in this situation? We'll come back to this later.

We have two all-star guests with us today. I call this the "presidential guest episode." First is Dr Martha Gulati. Martha is the president-elect of the American Society for Preventive Cardiology. Welcome, Martha.

Martha Gulati, MD, MS: Thanks for having me.

Sperling: Before we dive into dyslipidemia and patient-partnered care, optimizing the care team, and the promise of telehealth, Martha, tell us a fun fact about you that most people don't know.

Gulati: That's the hardest question of the day. I guess, since COVID started, I can say I'm probably the only person who still hasn't had a haircut or a hair color.

Sperling: Well, thank you for being honest. I'm sure you're managing quite well despite not getting those regular hair "checkups."

Our second presidential guest is Dr Joseph Saseen. Dr Saseen is professor and associate dean for clinical affairs at the Skaggs School of Pharmacy, University of Colorado Anschutz, in Aurora, Colorado. He is the current president of the National Lipid Association. Thanks for joining us today, Joe.

Joseph J. Saseen, PharmD: Thank you, Larry. I appreciate this opportunity.

Sperling: Joe, I'm going to ask you the same question I asked Martha. Tell us a fun fact about you that many people wouldn't be aware of.

Saseen: I can't say that I haven't had a haircut because I cut my own hair. I shave my head because there's not much to cut. However, an interesting fact might be that even though I've lived in Denver, Colorado, for my entire professional career, I still remain a loyal member of the Bills Mafia. So if you're a football fan, that means that I root for my Buffalo Bills and I'm waiting for a Super Bowl.

Sperling: Let's move on from the football preseason predictions here and talk about our current state of affairs. We're in a dynamic situation. We're learning every day about new challenges. In the midst of a global pandemic, we are trying our best to focus on our regular duties of preventing cardiovascular events and treating dyslipidemia. Joe, what are some of the lessons we're learning right now about the opportunities to utilize the full care team? And how can we move away from our usual mode of operation?

Saseen: That's a great question, because when you think of the optimal care team, you really should have a patient focus and think of those team members that can provide value to your patient. And we sometimes get stuck in thinking that a team member might just be the physician and the medical assistant, or the physician and maybe one nurse. But if we want to have the patient in the center of our focus for improving care, we really need to exploit some of the talents of other team members.

Now, some teams can be more robust than others. We're very fortunate in our academic health center that we have clinical pharmacists, along with physician assistants; nurse practitioners; dietitians, and, of course, physicians and nurses that can help with our patients. But I think we need to be confident and be willing to allow our team members to practice at the top of their license. We sometimes underutilize the talents of our team members. For example, your clinical pharmacist and what we do at the University of Colorado is we work (we hope) at the top of our license by engaging in collaborative practice agreements or collaborative drug therapy management protocols, which allow us to work with our physician and nursing partners to optimize medication use at the patient level. So we are willing to engage in that process to provide better care to our patients.

Sperling: Thanks. And it clearly takes a team, and I think we're learning more than ever right now. We need all of our team members on board during this pandemic. I was going to ask Martha: You've worked in many leadership roles as well. How do we think about building the right team and recognizing, as Joe said, that the team is not just the physician and the medical assistant? And how do we utilize new ways of doing things that we hadn't done in the past?

Gulati: That's such a great question, because especially during the pandemic, we've learned how we could utilize even our front staff. That used to be the people who would greet the patient and get the medical information, and then suddenly they became part of the whole visit, even remotely. They started gathering the information, but they were also checking in advance: Do you know how to connect to the computer, to talk with the team? And they would come back with so much information about the patient after chatting with them up front, usually the day before setting it up for us. So I think everybody has a role.

I think obviously we have to be realistic in some settings. Of course, in universities, we tend to have a lot more resources and having an entire team might be the norm. But I also think in other practices, it may just be the physician or the nurse or nurse practitioner who has to run the whole thing.

Sperling: Martha, specific to dyslipidemia, we are recognizing that many of our patients have not seen a clinician in the past 2 years, and many of them are not getting their regular medications. They are having personal stress and lifestyle and behavioral challenges, COVID weight gain, and straying from their usual diet. As we think about the gaps in care right now, what are some of the things that you're seeing that we should red-flag as lessons learned? And what are some of the opportunities we need to think about going forward, specifically related to treating dyslipidemia?

Gulati: With our whole messaging around COVID and trying to keep people at home, somehow that message got translated to the patient also to not go to the hospital. And early on, it is true that we shut down things that weren't emergent for fear that our hospitals would fill up. One thing I think we did wrong was closing routine visits to patients, because it gave the message that somehow they weren't important or there was something else we must be doing in that moment, whether it's taking care of patients or not. That got a message out saying that your visit is definitely not urgent. And I think what happened over time is patients either put off or were told not to come for their visits.

Then on top of that, the risk factors for many of our cardiac patients and in our cardiac prevention clinics got worse for many patients. They were less active. They were gaining weight. We know that 1 in 2 people have gained weight over the pandemic and on average, it's like 1-2 lb a month since the initiation of COVID in our country. People ate differently, people did things differently, and they didn't go to the doctor on top of it. Many were just refilling medications without a visit.

We've been trying to get the message out that despite COVID, your routine care matters, you matter, your health matters. I hope that now that message is getting through. Across the country, we're seeing surges with our hospitals being full again, but our outpatient clinic is not full. We should keep these visits. We have easy ways, as I think everyone knows now, to see our patients. We need to get the routine visits and routine lab work done before we can really know what's going on with our patients. We're seeing people wait at home and having a higher incidence of at-home heart attacks — people putting off care despite having symptoms — and delaying routine prevention visits. If we can't see your blood pressure or your cholesterol then we don't know how to intervene. And yet we have such good interventions for prevention.

Sperling: Those are really important comments. Joe. As a national leader and a clinical pharmacist, how can we think about utilizing new care modalities to not only toe the line but continue to improve care?

Saseen: It really comes to what our actions are going to be. We need to think outside the box. Perhaps if there's one good thing about COVID, if there is a silver lining, it's that providers and healthcare teams are immersed in other technologies that are used to engage patients. We know about telephone visits; we used those before the pandemic. We know about virtual visits, which have expanded during the pandemic. But there are other ways to reach our patients. We need to fully embrace prospectively looking for patients who need our help, in the vein of population health. It should be simple to use all the tools at our disposal, which include using all the team members in addition to the technology.

What Martha said that really was meaningful is what we look at as clinicians. We already have a challenge with such diseases as dyslipidemia and hypertension being asymptomatic, but we need to have our patients fully understand that we need their partnership. Also, the patient is part of the team to get them to more routinely look at their data, whether it be their blood pressure or knowing that it's important to look at their low-density lipoprotein (LDL) cholesterol to ascertain whether it's controlled or not.

I think we need to implement our workflows, which sort of enculture patients to have their asymptomatic disease evaluated, whether it be on a semiweekly basis with blood pressure or a quarterly basis with dyslipidemia, or even a daily basis with regard to lifestyle modifications. We need to use workflows to pull those data routinely into the hands of the care team, whether that be a first pass with the clinical pharmacist at the time of a refill or through a nurse, or perhaps through the physician or the physician assistants or nurse practitioners to evaluate those data. We have some wonderful tools, such as blood pressure monitors that, through Bluetooth technologies, automatically populate certain electronic health records data and send alerts to our providers on our care team. Now, there's a balance between data overload and useful data, so we have to make sure that we manage that appropriately.

But I think we have these touch points, and since you mentioned refills, that's a daily reminder. Even before the pandemic, adherence was perhaps barrier number one to actually realizing the healthcare benefits. We need to be open-minded to different workflows that fully use the appropriate people to interact with our patients to get the biggest return on our investment. Perhaps these are workflows related to medication refills, or prospectively reaching out to patients to assess their adherence, or using other tools, such as patient-entered data. We should think about all those things to improve care not only when we need to use telemedicine, but also during routine normal times.

Sperling: You bring up several key points. I think one of the things that we need to think about is the opportunities for population health, as you mentioned, and population health strategies enable us to be better prepared as well. So if we take a population health approach, we can risk-stratify our patient population in the setting of a pandemic, or hopefully on the back end of the pandemic. We can try to understand who is at highest risk and who we really want to focus our immediate attention on, but also recognize that we want to focus on the health and well-being of the entire population. Joe, you mentioned patient-centered care. I'm going to ask you to share some pearls, as a clinician and a national leader. What are some of the steps you take to not only engage but partner with your patients? Of course, that is the secret sauce.

Saseen: Absolutely. You know, even in our 2018 guidelines from the American Heart Association and the American College of Cardiology, we talk about having a patient-clinician discussion to talk about risks and benefits of therapy. But one very important part of that patient-clinician discussion is allowing your patients to have a voice in their care. That can be interpreted many different ways but can perhaps something as simple as having your patient have some level of choice. Maybe it's between one statin regimen and another when we're thinking of dyslipidemia and having them fully understand and maybe verbalize their preference. We teach pharmacy students the teach-back method when we're counseling patients on medications. But we don't always do it in real practice. Not that we have to go through every step as stated, but I think it may start with including your patients voicing their opinions, and if they have concerns, to get those out so they can deal with the barriers.

It is also important to have some level of decision-making within that process, realizing that within it, within a healthcare team, if your patient is part of it, they should be contributing to the extent that is important for their care. But also, maybe the most understated idea is that a lot of people don't always understand why they're taking a drug regimen or why they're engaging in lifestyle modifications. They may have a misperception that it's all about making their LDL value go down, when it really is that plus reducing their risk for a cardiovascular event. I find it interesting that some people feel that they need to take their medicine so that when they come for their office visit or their telephone visit or their video visit, the numbers look good to the clinician. The numbers should be good for the patient's benefit, but sometimes there is a disconnect. So my biggest pearl is to have your patient be fully engaged as a team member with some level of choice and voice.

Sperling: Wonderful. Martha, you're known as a master communicator, teaching others how to communicate, and I think you're also a wonderful listener. Share some pearls. How do we partner better with our patients?

Gulati: Joe expressed it nicely: The patient's voice always matters. And I think the idea is that we're just part of the partnership; the patient comes first, listening to them, allowing them the time to express why they have concerns about specific medications, and what they understand about the issue you're trying to address. This is where telehealth in particular has helped us, because we may be talking with the patient but another family member may be sitting with the patient and potentially talking as well, telling us about the barriers. Sometimes seeing, in the background, someone's house makes you realize that whatever you're recommending is next to impossible for that particular person — for example, if there's like 10 grandchildren in the background and you're realize that's her day-to-day life. It can help, I think, if we listen to our patients and give them the time.

And remember that shared decision-making is part of everything that we do. If a patient doesn't understand their medical issue, if they don't understand their labs, if they don't understand why they're taking a medication, they won't be compliant with it long-term. As Joe said, they think they're doing it for us. It's just like when, for the week before your doctor's appointment, you work really hard to get your weight down because you know you're going to have to step on the scale. Our patients are doing the same thing. They're like, oh, it's so the doctor is pleased, but I don't know how it applies to me. We have to empower them more with making them understand these values and giving them some amount of health literacy, because that's the way that they're going to be a better partner and help us take care of them.

Sperling: That is a perfect transition to my next line of questions. We know that almost 10% of Americans do not have broadband access. Many Americans as well are technically challenged. Frequently, I tell our students, interns, residents, and house staff that when in doubt, listen to the patient. Martha, how can we be attuned to this digital divide? I'm not sure we have all the answers yet, but how can we at least recognize and identify this?

Gulati: There's many great things about telehealth. And we saw during the pandemic how it changed things for us to be able to access our patients and for our patients to be able to access us. But the people who are already at a health disadvantage are the ones we probably also ignored. It wasn't as easy for them. So we need to keep that in mind.

We really do need everyone to have broadband access. Of course, that's a governmental issue and it's beyond us to determine how that happens, but we need to push for it. But the literacy even to use the internet can be challenging. We need to make it easy, even from a hospital or university system or a clinical practice.

We learned that our system was cumbersome; there were about three to four steps that every patient had to take to get in, so usually every visit turned into a telephone visit rather than a video visit because it was too hard for most of our patients. If we can make it easy for them to see us, we can make it better for them.

Sperling: I'm all for that and certainly for rising to the challenges. Recognizing that we can have a better future is the right way to approach this. Well, Joe, we have amazing therapies today, including biologic therapies. We can address dyslipidemia often with powerful combination therapies, but what's your prediction for the future as it relates to telehealth and preventive cardiology?

Saseen: I do not think it's going away. I think some patients actually have embraced within this pandemic the use of flexible alternatives, such as video and telephone visits.

And maybe if we take a step back with the care of dyslipidemia, once a patient has been identified as being eligible for therapy, we sometimes had our visits backward anyway in the past, where we would see a patient and then wait for their results. So perhaps this is an opportunity to flip that script right, to get their data before you engage with the patient. And if that has to be in a telephone visit, a video visit, or perhaps a face-to-face visit, maybe that's a good thing.

So maybe getting into the norm, we're going to be using more of these types of visits because that's what works for the majority of our patients, whether it's somebody who's fully employed in the middle of their livelihood and their career, or where going away for 2 hours in the middle of a busy day is really off-putting to that older or elderly person who may be caring for grandchildren, or other people who really have a hard time leaving their home.

I believe that virtual and telephone visits will become the norm for patients with chronic diseases. I think the future is also that we're going to do it smarter. I think there'll be industries that pop up — perhaps the concept where people go to a place something like a studio, where that internet access or video capability is provided to them in a more convenient manner. I think that might be something that we see over the next 5-10 years, as a norm for chronic diseases.

Sperling: Great points. If we continue to do the same thing, we get the same results. Let's face it, there are many, many gaps in cardiovascular care and cardiovascular disease prevention. And there remain many gaps in the management of dyslipidemia. Martha, are telemedicine and telehealth here to stay? Do you think that will be a dominant way of approaching care and dyslipidemia management?

Gulati: We've been practicing medicine as Osler did even in our modern day, and almost overnight COVID made us change. That's a good thing, because medicine didn't need to stay stuck in the routine we were in. Did you need a physical exam for every single visit? Let's be honest, it wasn't always necessary. It's not that it isn't necessary in certain patients. But especially in dyslipidemia management and in our prevention visits, after we get to know our patient, we're managing and improving things. With our teams, we may only need the lab work, as Joe said. We can use visits to ask, how did you respond to those medications? Let's have a visit focusing on how your lipids improved or didn't improve. What's the next step? We're ready for a change in medicine, a change in our delivery model, and a change and an improvement for our patients.

Sperling: Thanks very much. So, let's come back to our case. We started out talking about Mrs P. What ended up happening with that patient was that we quickly adapted from a telemedicine to a phone visit, which we often do. We listened intently. She'd had trouble getting her computer to work, which often occurs. It turned out that her daughter and granddaughter have special needs and had moved in with her during the pandemic, so her focus had shifted from taking care of herself to taking care of her family. She gained weight; she gained those pandemic pounds Martha mentioned, to the point where her clothes were getting tight, and she thought her cholesterol probably was high because she hadn't been taking her medicines regularly and had been eating more junk food. After she explained her situation, we came up with a partner plan for her to get her labs drawn and to get a home blood pressure device so she could monitor her own blood pressure, and we refilled her prescriptions. Finally, we set up a follow-up visit for her to return to our care.

I want to thank our phenomenal guests today, Dr Martha Gulati, president-elect of the American Society for Preventive Cardiology, and Dr Joe Saseen, current president of the National Lipid Association. True national experts. They shared some practical pearls and words of wisdom that we should take back to our patients.

Our next episode will be on the impact of social determinants of health and lipid management, focusing on health equity with Dr Carol Watson from UCLA. This is Dr Laurence Sperling, for Medscape InDiscussion.

Resources

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