Multidisciplinary/Team Based Approach for Lipid Management

Erin D. Michos, MD, MHS, FACC, FASPC: In our next segment, I wanted to get into how we can address these unmet needs. One thing that’s important is we need all hands-on deck: we need a team-based approach. I’m happy that we’re here with our endocrinology colleague. I was wondering, Bob, if you could tell us a little bit about the team-based approach to care; how you, as an endocrinologist, interact with cardiologists in co-management of your pts.

Robert Busch, MD: The question is, who’s going to do it? Well, it’s each of our responsibilities. Whether you’re the primary care clinician, the endocrinologist, or the cardiologist, someone has to do it. Don’t just say, “Oh, I’ll defer to my cardiologist to get you down.” Define with the patient the whole goal is lowering heart disease, and the different manifestations of ASCVD [atherosclerotic cardiovascular disease] that Pam outlined. We’re very spoiled where we are. We have nutritionists and dieticians to cover what Alison covered. We have Pharm.D.s to have the in-depth discussions as your other drug interacts with- if you’re on amiodarone as a P50 inhibitor- switch statins. We have the clinician there. My job as an endo[crinologist] is I must do the ABCs. Get your A1C down, blood pressure down, which takes combination therapy. To give a combination for cholesterol, we’ve been there, done that. We know what our target is and discuss it with the patient. The whole goal is I’m trying to avoid a heart attack, stroke, death, peripheral vascular disease. We know about eye, kidney nerve disease, we’ve accomplished that by lowering your A1. But the macrovascular disease is what kills you. Those are the big morbidities we want to avoid, and that’s why we’re doing that. We have a team. Whoever the clinician is that they’re seeing should at least initiate the conversation and try to put their toe in the water, not just pass the buck.

Erin D. Michos, MD, MHS, FACC, FASPC: I agree completely in involving all team members, including pharmacists, and nurses, and nurse practitioners, and exercise physiologists, and nutritionists. I know, in our prevention practice, I’m very delighted to work with an excellent cardiology nurse who helps with a lot of this management. This includes teaching about injections and helping with some of these burdens, helping with some of the preauthorization paperwork. I know this recent conference we were at. Pam, I got to meet your wonderful nurse that helps you in the lipid clinic. Why don’t you tell us a little bit about your lipid clinic, and how you utilize other team members in co-management of your patients, such as your nurse that I met?

Pam Taub, MD, FACC, FASPC: As Bob mentioned, the multi-disciplinary approach is critical. It takes a village. We sometimes only spend a very small portion of time with the patient. The patient gets to spend a lot more time with the dietician. If they’re in cardiac rehab, our staff gets to spend 36-72 sessions with the patient. We have to utilize these other points of contact in the patient’s journey. In our clinic, we utilize advanced practitioners to see the patients, especially after discharge, because they can see the patient quickly. We also use dieticians, and pharmacists, to educate the patient about the drugs. You had mentioned my nurse. Our nursing staff is critical in the prior authorization part of the equation. A lot of these drugs are not going to get to the patient unless somebody takes time to do the prior authorizations, and the proper documentation is there. We have to be really working with our medical assistants and our nurses to get this prior authorization done. It can be done if we just put in the right documentation. We have an up-to-date LDL [low-density lipoprotein]. We can get these medications. One thing I wanted to mention about inclisiran; Alison had mentioned this before. For Medicare patients who have a supplement, the way inclisiran is structured, their copay is $0. It’s very accessible to our Medicare patients, which some of the other drugs historically have not been as accessible. We need to work in a multi-disciplinary team, and also, we need to work on access.

Transcript edited for clarity