Who Is at Increased Risk of CAD/PAD?

Panelists discuss how providers are identifying patients who are more likely to develop CAD/PAD.

Paul Dobesh, PharmD: As we talk about these patients, as you mentioned, there are a lot of them, and there are therapies that we want to make sure we do to optimize patient care. At your institution and in other places you’ve been and people you’ve talked with, how are providers identifying these patients? How do we capture them to make sure that we can provide optimal care?

James Groce III, PharmD: Well, I think certainly it’s a component of how we get reimbursed for seeing patients. But, of course, the obvious is a careful review of the patient’s problem list. Indeed, we know, really, it has to be more than just a click. It has to be an important review and consideration of what that really means for our patients. I think in doing so—putting that information that’s on the problem list and thinking about it in context—that should help us certainly begin to build what we, within our own institution, do for certain subsets of patients. We create order sets within the electronic health record, for which we know that then, when the patient we’ve been talking about—as we both described in terms of their risk factors and their diagnosed disease states of CAD [coronary artery disease] and PAD [peripheral artery disease]—when those patients come to hospital, even in the setting of stable disease, we’re going to find them getting the best evidence-based approach to managing the care of that patient. In those order sets, certainly within our own institution, often it’s given as a question mark, if you will, to the provider: “Have you thought about or given consideration for the role of this drug or another drug?” So it’s sort of a course of reminding, if you will.

One of the other things that sometimes happens, which I think most of us would recognize, is that perhaps we’re in a health care system that maybe doesn’t use order sets that have been prebuilt and predefined, to the extent that could be possible within the electronic health record, where providers are giving what I think in our pharmacy vernacular we refer to as one-off orders, and they’re just simply ordering a drug. I know we’ll have some more discussion about this issue with some subsequent questions that are going to come up. But when we see those one-off orders being written, we certainly need to make certain that it’s for the right drug, for the right patient, for the right indication, for the right dose, for the right dosing interval. Again, I think it’s part of our vigilance as pharmacists in whatever our practice setting may be, whether we’re in the acute care hospital setting or the ambulatory setting of a large health care system or even for our colleagues in community pharmacy. We really need to be looking at those problem lists and making certain that patients are on the right agents relative to the problem list. Certainly when both of us, you know, we teach pharmacy students, and when we’re talking with our pharmacy students, we liken it to not just medication reconciliation but also medication reconciliation tied to an appropriate indication on the problem list, and when we see the absence, based upon a problem list, of a certain drug therapy that we know should be present, then it really is incumbent upon us as pharmacists to make an intervention by calling the provider and really giving what would be recommended drug therapy for that patient that we’re discussing.

Paul Dobesh, PharmD: I agree totally. I think another thing is to make sure we’re optimizing therapy. When we talk about these patients who have symptoms and they’ve got chest pain episodes or they’ve got leg pain episodes—I always tell my students this, as well—asking the patient “Do you have pain?” is not enough, because they may say no. But the reason they’re not having pain is because they’re not doing anything.

James Groce III, PharmD: Right.

Paul Dobesh, PharmD: Right? They’ve stopped the evening walks with their spouse that they used to love to go on, they gave up on the garden that they wanted to have in retirement, they don’t get on the floor and roll around with the grandkids because they’re scared. So: “Are you having pain, and are you doing the things you want to be able to do?” Are we optimizing a patient’s medical therapy to let them live a full life? I think those are things that we should make sure that, as clinicians, we focus on.

James Groce III, PharmD: I agree. That’s great information. I think it, again, takes out the context of standardized order sets and puts it on a real day-to-day basis for which we really could be asking patients those questions that you just identified that are so important.