O N L I N E
L E T T E R S
OBSERVATIONS Can Guideline Adherence Be Improved by Letter Outreach?
T
he Heart Protection Study established that statins are beneficial for most patients with diabetes regardless of baseline LDL cholesterol (1–2). Kaiser Permanente Colorado, a groupmodel, nonprofit health-maintenance organization in the Denver/Boulder metropolitan area, developed a letterbased population management strategy to improve statin utilization in patients with diabetes. Kaiser Permanente Colorado maintains a disease state registry of patientspecific data for members with validated diagnoses, which serves as an ideal tool for patient tracking, quality improvement, and population management. Although letters have previously been employed for population education purposes (3–5), no published literature describes their effectiveness at initiating chronic medication(s). We designed a prospective, quasi-experimental study to demonstrate the effectiveness and safety of a letter-based strategy in increasing statin use in eligible patients with diabetes. Patients considered statin eligible were aged 40 – 80 years with a confirmed diabetes diagnosis and total cholesterol ⱖ135 mg/dl. Statin-eligible and statinnaı¨ve subjects were included. Subjects were excluded for using gemfibrozil, fenofibrate, or cyclosporine; for having an alanine aminotransferase ⬎60 IU/l or serum creatinine ⬎2.0 mg/dl; or for not having a primary care provider. We provided region-wide education describing
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the benefits of statin therapy to the diabetic population. Eighteen primary care clinics were stratified by size into two groups, and the letter-based strategy was implemented in two phases 3 months apart. The primary care providers reviewed subjects and authorized statin initiation via letter notification. A letter was sent to those subjects with an explanation of statin benefits and instructions to pick up a prescription and have baseline and follow-up laboratory tests drawn. Medication and laboratory orders were entered into the electronic medical record centrally. Primary care clinical pharmacy specialists at each clinic reviewed and triaged laboratory results with the aid of monthly reports identifying subjects overdue for tests. We identified 17,464 statin-eligible subjects, of whom 3,352 (19.2%) met inclusion criteria. Of these, 1,570 (46.8%) were assigned to phase one (intervention group) and 1,782 (53.2%) to phase two (control group). The groups were similar with respect to age; sex; and total cholesterol, LDL cholesterol, and alanine aminotransferase values. After 3 months, statin initiation was significantly higher in the intervention group (365 [23.2%] vs. the control group 161 [9.0%], P ⬍ 0.001). Overall, current or recent statin use in eligible subjects increased from 75.6 to 82.3%. More statin starters in the intervention group had completed laboratory follow-up at 3 months (61.1 vs. 46.0%, P ⫽ 0.002). Among statin starters, statin persistence at 1 year did not differ between groups (64.7 vs. 61.1% for the control and intervention groups, respectively, P ⫽ 0.511). No serious adverse events related to statin initiation occurred. Findings from this investigation support the concept that a letter-based strategy is safe and more effective than
educational efforts alone at initiating statin therapy in patients likely to substantially benefit. Principles applied in this population management approach, including the patient identification process, the informational and interventional letter, and the central monitoring system, can feasibly be incorporated into other models of health care. MONGTHUONG T. TRAN, PHARMD1,2 SARAH J. BILLUPS, PHARMD1,2 From 1Kaiser Permanente Colorado, Denver, Colorado; and the 2School of Pharmacy, University of Colorado at Denver and Health Sciences Center, Denver, Colorado. Address correspondence to Mongthuong T. Tran, 1375 East 20th Ave., Denver, CO 80205. Email:
[email protected]. DOI: 10.2337/dc07-1661 © 2008 by the American Diabetes Association. ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
References 1. Heart Protection Study Collaborative Group: MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet 361: 2005–2016, 2003 2. American Diabetes Association: Dyslipidemia management in adults with diabetes (Position Statement). Diabetes Care 27 (Suppl. 1):S68 –S71, 2004 3. Somkin CP, Hiatt RA, Hurley LB, Gruskin E, Ackerson L, Larson P: The effect of patient and provider reminders on mammography and papanicolaou smear screening in a large health maintenance organization. Arch Intern Med 157:1658 – 1664, 1997 4. Delate T, Henderson R: Effect of patient notification of formulary change on formulary adherence. J Manag Care Pharm 11:493– 498, 2005 5. Hunt JS, Siemienczuk J, Gouchette D, Payne N: Impact of educational mailing on the blood pressure of primary care patients with mild hypertension. J Gen Intern Med 19:925–930, 2004
DIABETES CARE, VOLUME 31, NUMBER 4, APRIL 2008
