Geisinger is an integrated healthcare system consisting of multiple hospitals, outpatient facilities, and a health plan located in 45 counties in central and northeast Pennsylvania. The system provides care for approximately 1.5 million patients annually. Clinical decisions and guidance for procedures and treatments are made by designated clinical teams and full implementation is expected by every healthcare provider in the system. This method not only ensures consistency and high-quality care, but also promotes evidence-based care by reducing unexplained clinical variation. Additionally, coverage by the health plan is synchronized with clinical decisions made within the healthcare system to ensure high-quality care is affordable and accessible to all health plan members (about a third of Geisinger patients). Geisinger serves a rural, medically underserved, and low-income population. In Geisinger’s coverage area 32 of the 45 counties are designated as rural and the average household income is 15.3% lower than the US average. Geisinger’s mission and vision is to be a model for other developing healthcare systems through continued learning via clinical research (12).
In January 2019, Geisinger implemented an MDLC to facilitate the translation of evidence-based guidelines(13) to the management of high-risk lipid conditions. Patients referred are currently unable to meet cholesterol and triglyceride treatment goals in primary care or cardiology clinics. The Geisinger MDLC is staffed with a cardiologist boarded in lipidology. The genetic counselor and pharmacist both have specialized training in lipid conditions. This clinic meets bi-monthly at one clinic location within the healthcare system. Patients could have traveled from any of Geisinger’s 45 counties within their service area to attend the MDLC.
Any individual within the Geisinger system diagnosed with or suspected to have a lipid condition can be referred to and seen by the MDLC. A variety of lipid conditions are evaluated and treated in this clinic, including, but not limited to, familial hypercholesterolemia (FH), hypertriglyceridemia, various rare familial dyslipidemias, and other unnamed or undiagnosed dyslipidemias (Table 1) (13).
The purpose of the Geisinger MDLC is to increase uptake of guideline-recommended treatment for all lipid conditions (13). Prior to implementation of this clinic, individuals with these conditions had to receive specialty multidisciplinary lipid care outside the Geisinger system at locations that required significant travel to urban sites in Pennsylvania for specialized management. Preventive cardiology leadership within the Heart Institute initiated the MDLC and sent out an email to the entire Heart Institute, and Community and Family Medicine providers inviting them to refer patients. The invitation introduced the MDLC, purpose, details on which providers were part of this clinic and how to refer. Table 2 details the MDLC implementation strategy using Proctor’s guidelines for defining and specifying implementation strategies (14) and the template for intervention description and publication checklist.
Data Collection and Outcomes Measured
This study evaluates the first year of MDLC implementation using the RE-AIM framework. Using a pre/post study design, clinical outcomes were assessed for all patients one year after implementation of the MDLC. Outcomes were collected from administrative data and clinical information was collected from the electronic health record (EHR). Two study staff were trained to search the EHR for laboratory measures, medication profiles, and appointment visits and performed chart review after each patient appointment.
Reach is measured at the individual-level with the numerator defined as the number of patients seen by the MDLC who had both a documented lipid condition on their problem list and had been active patients within the healthcare system (i.e., had a primary care or cardiology visit in 2019). The denominator included those with a problem list diagnosis for a lipid condition. Patients could be referred to the MDLC by any provider using an existing general cardiology outpatient referral for lipid management and were requested to note the MDLC in a comment section. At the time of MDLC implementation the decision for the system was to use the existing referral rather than to create a new referral specific to MDLC. If the MDLC was not specified in the note, patients could potentially have been seen by any provider with an interest in managing lipid patients.
Effectiveness is stratified to create three clinical patient lipid subgroups: FH, hypertriglyceridemia, and dyslipidemia because treatment approaches differ by condition. The final diagnosis was extracted from cardiologist documentation after all relevant information was obtained. The effectiveness measure chosen for this study was the change in lipid levels assessed using a baseline lipid value either from the initial MDLC visit, or the most recent lipid panel result prior to the initial MDLC follow up visit compared with the value from the most recent MDLC visit. Patients without a lipid panel in their health record were documented as having no prior lipid measurements. The most recent lipid panel was recorded as post-MDLC measurement, unless that measurement was the pre-MDLC value. All post-MDLC measurements were at least 1 month after their initial visit date.
Adoption has two metricsAny PCP or cardiologist who saw a patient with a lipid condition documented on their problem list diagnoses in 2019 was included in the analyses. The percent of eligible providers referring to the MDLC was calculated as the number of providers making a referral divided by the total number of eligible providers multiplied by a 100. The percent of eligible patients referred per provider-–as measured by having a lipid condition in the problem list– was calculated as the number referred over the total number of lipid patients managed by that provider.
Implementation is measured at the patient-level. The numerator is the number of patients with multiple visits and the denominator is the number of patients seen in 2019. The percentage of patients who underwent genetic testing and medication use details were reported using descriptive statistics.
Maintenance, for this study, is reported as the current and potential for sustaining the MDLC in the future.
Descriptive statistics were used for the demographics of both the study cohort and three subgroups. Continuous variables were analyzed using the Kruskal-Wallis test, and categorical variables were analyzed using a Fisher exact test. We reported Mean ± SD and Median (range) of lipid levels for all subgroups and used the Wilcoxon signed rank test to detect any differences in lipid levels before and after for each subgroup.