STRAIGHT TALK
Patients Face Range of Challenges when Seeking Treatment for High LDL
From confusion about medications to high costs and preauthorization difficulties , patients can encounter many challenges when seeking effective , appropriate care for high LDL cholesterol . CardioSource WorldNews interviewed patient advocates and clinicians working in this area to find out how these obstacles might be negotiated for more effective cholesterol lowering .
With clinicians often pressed for time , many patients leave a consultation unclear about their condition , its implications , and what they can do to help manage their care . Katherine Wilemon , founder and CEO of the FH Foundation , explains that misunderstandings are particularly likely among patients with familial hypercholesterolemia , whose “ condition is not in the public conversation .” To aid in understanding , patient advocate Debbe McCall encourages patients to “ learn all you can before your appointment about your disease process . Practice your top 2 or 3 questions so you can ask them without too much detail .” McCall adds that asking patients how they would explain the clinician ’ s advice to their children offers clinicians a non-patronizing way of gauging understanding and providing clarification . Requesting that a non-English-speaking patient bring an English-speaking relative ( or friend ) to an appointment can facilitate communication in the clinic and reinforce adherence at home .
To ensure patient buy-in and understanding within time constraints , Seth Martin , MD , MHS , associate director of the lipid clinic at the Johns
Seth Martin , MD , MHS
Lynne Braun , PhD , CNP
Hopkins Hospital , often “ has a discussion with a patient , then gives them additional information or refers them to the reliable web sites like the FH Foundation or from the ACC to read up more . Then we can come back and further discuss it and make a much better decision together .” Lynne Braun , PhD , CNP , professor at Rush
College of Nursing and Medicine , also stresses a team approach : “ Some of my physician partners will refer patients to me because I have time to be patient with getting the patient on a regimen they can tolerate .”
Patients who lack a clear understanding of their condition may also be less likely to adhere to treatment . McCall stresses that clinicians must convey “ that this treatment is preventing a life-changing event , not just lowering a number .” Additionally , booking patients in for follow-up bloodwork 30 days post-treatment initiation may provide evidence of a drug ’ s benefits and an opportunity for patient encouragement . Patients should be reassured that adverse side effects are rare and the clinician is available to address any concerns arising before the next consultation . To prevent inadvertent nonadherence or adverse drug interactions resulting from misunderstandings , clinicians should always ensure they have a clear picture of the drugs a patient is taking before providing a new prescription or advising drug cessation .
Even patients who understand their condition may experience pill fatigue , particularly if they take multiple medications , as is often the case with FH . Wilemon reports that “ maintaining a treatment regimen and advocating for themselves become a part-time job for some of those who are most affected .” Patients may find a transparent pill box provides an easy indication of whether drugs have been taken . Braun advocates simplifying the daily regimen when patients report pill fatigue , perhaps allowing patients to take their statin medications with other drugs in the morning if the statin will otherwise be the only medication taken at night .
Cost can also be an obstacle to obtaining appropriate care , particularly for patients requiring multiple drugs to lower cholesterol , as is commonly the case for patients with FH . Dr . Martin advises discussing cost explicitly , asking patients to contact their insurer about costs , and , when possible , offering more than 1 pharmacotherapy option . If no options are affordable , referral to a patient assistance program is advisable .
Lengthy preauthorization processes are another potential barrier to effective care , with patients requiring newer drug therapies ( e . g ., PCSK9 inhibitors ) most likely to be affected . To maximize the chances of successful preauthorization , Dr . Martin stresses appropriate patient selection based on FDA indications and the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk . Meticulous documentation and continued monitoring of the process are also essential . Where available , a specialty pharmacist can guide both patients and clinicians . Lynne Braun advocates mapping out the process , “ letting patients know that this approval is not going to happen overnight and that the next phone call they receive will be from our specialty pharmacist .”
Finally , effective treatment also requires efficient care coordination to ensure patients do not go unmonitored or — as is too often the case with FH — undiagnosed . The clinician should ensure that the patient has a primary care provider to coordinate care . If the patient does not have a relationship with such a provider , helping to establish such a relationship can assist greatly with ensuring adherence , minimizing adverse drug interactions , and identifying problems early .
Visit ACC . org / LDL for more information on ACC ’ s LDL : Address the Risk quality initiative . ■
44 CardioSource WorldNews November 2016