Reach. Of the 452,748 unique patients who had a visit at the healthcare system in 2019, 32% (143,154/452,748) had a diagnosis of a lipid condition on their problem list. There were 420 referrals received for the MDLC in 2019. Of those 420 referrals, 3 referenced the ‘MDLC’ specifically and 92 referenced the ‘lipid clinic.’ There were 83 patients scheduled and seen by the MDLC in 2019. Of those 83 patients, 1 patient was self-referred, and 4 patients did not have a primary care or cardiology visit in 2019 or lipid condition diagnosis code.
Effectiveness. Of the 83 patients seen in the MDLC in 2019, 82 were alive at the time of analysis and are presented in the results. Of those 82 patients, 29% (24/82) had a clinical or genetic diagnosis of (FH), 20% (16/82) had hypertriglyceridemia, and 51% (42/82) had uncharacterized dyslipidemia. Demographics of these populations are described in Table 3.
Familial hypercholesterolemia. Six of the 24 individuals with FH had prior positive genetic testing for the condition. Those who did not have a prior genetic testing result had testing ordered at the clinic. Genetic testing ordered through the MDLC (n=18) yielded: 5 positive results, 2 variants of unknown significance, and 5 negative results. Six genetic tests are still pending (e.g., order not signed, order expired, active order but sample has not yet been drawn). Of the 24 patients in the FH subgroup, 23 (96%) had intensification of their medication regimens including starting a medication or addition of a new medication. The one untreated patient was pregnant which impacts use of lipid-lowering therapy. At the initial MDLC visit, 17 (71%) patients were prescribed at least one medication. After a visit at the MDLC, 16 patients had medications added to their regimen (11 added ezetimibe, 7 added a statin, and 12 added a PCSK9 inhibitor) and the six (86%) of the 7 patients who were not taking any lipid-lowering medication at the time of their initial MDLC visit were prescribed medication by the MDLC. Fourteen of the 24 individuals with FH were prescribed medications for which their insurance required a prior authorization. A total of 16 prior authorizations were submitted (3 individuals had prior authorizations submitted for both PCSK9 inhibitors and icosapent ethyl, or for two PCSK9 inhibitors). Of the 16 medication prior authorizations, 88% (14/16) were approved (12 were for PCSK9 inhibitors and 2 for icosapent ethyl) and 13% (2/16) were denied for PCSK9 inhibitors. Lipid levels were available for comparison before and after MDLC visits in a subset of patients (n=12) showed a 79 mg/dL reduction in average LDL-C (p<0.001) and reduction in other lipid values (Table 4). Of the 12 patients with pre and post values, only 17% (2/12) had an LDL-C less than 100 mg/dL prior to a visit with the MDLC, however, 75% (9/12) met this goal after seeing the MDLC.
Hypertriglyceridemia. None of the 16 individuals attending MDLC diagnosed with hypertriglyceridemia had prior genetic testing. Genetic testing was ordered on 14 of the 16 individuals (81%) and identified 1 positive result for a variant associated with familial lipoprotein lipase deficiency, 2 variants of unknown significance, and 6 negative results; 3 tests are pending and 2 were not completed. Of the 16 patients in the hypertriglyceridemia subgroup, 13 (81%) patients’ medication regimens were intensified. At the initial MDLC visit, 14 (88%) patients were prescribed at least one of medication to treat their hypertriglyceridemia. While being seen at the MDLC, 13 patients had medication changes (2 dose changes, 1 switched medications within the same medication class, 8 added medications (6 patients started icosapent ethyl, 2 started atorvastatin, and 1 started a fibrate)), and 1 patient who was not taking any triglyceride-lowering medications was prescribed a medication. One drug-drug interaction was reconciled by the clinic to prevent harm to the patient. At the time of analysis, 16 (100%) of the 16 patients in the hypertriglyceridemia subgroup after being seen by the MDLC were prescribed a medication for the treatment of hypertriglyceridemia. Three of the 15 individuals with hypertriglyceridemia were prescribed medications for which their insurance required a prior authorization, resulting in a total of 3 prior authorizations submitted. All were approved (2 were for PCSK9 inhibitors and 1 for icosapent ethyl). Lipid levels were available for comparison before and after MDLC visits for all but one patient (n=4) and showed a 467 mg/dL reduction in average triglycerides (Table 4). Of the 4 patients with pre and post values, only a quarter (1/4) had a triglyceride level less than 150 mg/dL prior to a visit with the MDLC, however, 75% (3/4) met this goal after seeing the MDLC.
Uncharacterized dyslipidemia. None of the 42 individuals with dyslipidemia had prior genetic testing for the condition. Genetic testing found no positive result, 24 negative results, 6 tests are pending and 1 was cancelled by patient due to cost. Genetic testing was not performed for 11 individuals (genetic testing on 33/42; 71%). At the initial MDLC visit, 32 (76%) patients were prescribed at least one medication to treat their dyslipidemia. Of the 42 patients in the dyslipidemia subgroup, 35 (83%) had intensifications to their medication regimens. While being seen at the MDLC, 25 patients added a medication to their current regimen (5 ezetimibe, 6 statin, 17 PCSK9 inhibitor, 2 niacin, 7 icosapent ethyl, and 1 omega-3) and 5 of the 10 patients who were not taking any medication for their dyslipidemia was prescribed a medication by the MDLC. At the time of analysis, 36 (86%) of the 42 patients in the dyslipidemia subgroup were prescribed a medication to treat their dyslipidemia. Eighteen of the 42 individuals with dyslipidemia were prescribed medications for which their insurance required prior authorization. A total of 18 prior authorizations were submitted. Of the 18 medication prior authorizations, 16 were approved (16 were for PCSK9 inhibitors), 1 was denied for icosapent ethyl, and 1 had an unknown status for a PCSK9 inhibitor. Lipid levels were available for comparison before and after MDLC visits in a subset of patients (n=21) showed a 48 mg/dL reduction in average LDL-C (<0.001) and reduction in other lipid values (Table 4). Of the 21 patients, 38% (8/21) had an LDL-C less than 100 mg/dL prior to a visit with the MDLC, however, 71% (15/21) met this goal after seeing the MDLC.
Adoption. Of the 796 active PCP or cardiologists in 2019, only 19% (148/796) referred patients to the MDLC. The average percent of eligible patient referrals from eligible providers was 0.25% (SD 3.75%). Referrals to MDLC were also received from another 48 providers outside of the targeted cardiologists and PCPs (genetic counselors, pharmacists, critical care providers) or from providers whose patient did not have a diagnosed lipid condition on their problem list.
Implementation. At the patient-level, 50% (41/82) of patients who attended the MDLC had at least one follow-up visit with the MDLC, with 12% (10/82) having two or more follow-up visits in 2019. The 50% (41/82) of patients who only had one visit were more likely to have been seen later in 2019 (October through December). At the provider-level, there was an average of 35 patient referrals per month (SD 12) to the MDLC.
Maintenance. In monthly meetings with the MDLC clinic providers and Heart Institute leadership and administration, we discussed the transition from traditional in-person follow-up visits to telehealth appointments. The rationale for this transition was to improve capacity due to limited number of available appointments per clinic day and would increase access as individuals would have the opportunity to be seen virtually, either at home or a clinic site near their home. Additionally, we discussed the platform needed for telehealth visits, training of schedulers to know where and when to book these appointments, where and how the MDLC providers would join the telehealth visit and obtain access for all providers and discuss methods for documenting on these types of visits. Additionally, a recent pandemic, COVID-19, necessitated the use of telemedicine throughout Geisinger, but this merely accelerated the transition that was already planned for the MDLC.