VA-IHD ELEVATED LDL (73)    REMINDER DEFINITION (811.9)

• EDIT DATE:   2005-03-11 12:23:10
  EDIT BY:   USER,ONE
  EDIT COMMENTS:   

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The VHA/DOD Clinical Practice Guideline for Management of Dyslipidemia 
If a more recent record of an UNCONFIRMED IHD DIAGNOSIS is found, the 
reminder will not be applicable to the patient.
 
Documenting an outside LDL <120 mg/dl satisfies the reminder for 12 
months from the lab test date.
 
Ordering initial lipid lowering medications or adjusting current lipid 
lowering medications satisfies the reminder for 2 months. (This is 
tracked by Health Factors, not the order.)
 
recommends an LDL goal of <120 mg/dl for patients with Ischemic Heart 
A patient's refusal of lipid lowering therapy satisfies the reminder
for 6 months.
 
Documenting that no treatment change is needed based on patient's current
clinical status, that lipid management is provided by another VA or non-VA
facility, or deferring lipid treatment for other reasons satisfies the
reminder for 6 months.
 
Documenting that lipid lowering medications are contraindicated satisfies 
the reminder for 12 months.
Disease; and the NCEP Adult Treatment Panel II recommends a more stringent
goal of <100 mg/dl.
 
This national reminder identifies patients with known IHD (i.e., a 
documented ICD-9 code for IHD on or after 10/01/99) who have had a
serum lipid panel within the last year, where the most recent LDL lab
test (or documented outside LDL) is greater than or equal to 120 mg/dl.

• FINDING ITEM:   VA-IHD DIAGNOSIS
  USE INACTIVE PROBLEMS:   N
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  NOT FOUND TEXT:   

  Patient has no IHD Diagnosis on file.
  

  USE IN PATIENT COHORT LOGIC:   AND
  BEGINNING DATE/TIME:   OCT 01, 1999
• FINDING ITEM:   VA-LIPID LOWERING THERAPY MGMT - 6M
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  FOUND TEXT:   

  Lipid lowering management underway.  Reminder satisfied for 6 months.
  

  USE IN RESOLUTION LOGIC:   OR
  BEGINNING DATE/TIME:   T-6M
• FINDING ITEM:   VA-REFUSED ELEVATED LDL THERAPY
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  FOUND TEXT:   

  Patient refused therapy for elevated LDL. Reminder satisfied for 6 months.
  

  USE IN RESOLUTION LOGIC:   OR
  BEGINNING DATE/TIME:   T-6M
• FINDING ITEM:   VA-LIPID MEDS CONTRAINDICATED
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  NO. NOT FOUND TEXT LINES:   0
  FOUND TEXT:   

  Lipid lowering medications are contraindicated. Reminder satisfied for 1 
  year.
  

  USE IN RESOLUTION LOGIC:   OR
  BEGINNING DATE/TIME:   T-1Y
• FINDING ITEM:   VA-UNCONFIRMED IHD DIAGNOSIS
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  USE IN PATIENT COHORT LOGIC:   AND NOT
• FINDING ITEM:   VA-LIPID LOWERING MEDS
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  NO. NOT FOUND TEXT LINES:   0
  BEGINNING DATE/TIME:   T-90D
• FINDING ITEM:   VA-TRANSFERASE (AST) (SGOT)
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  NO. NOT FOUND TEXT LINES:   0
• FINDING ITEM:   VA-ALANINE AMINO (ALT) (SGPT)
  NO. OF FOUND TEXT LINES:   0
  NO. NOT FOUND TEXT LINES:   0
• FINDING ITEM:   VA-OUTSIDE LDL <100
  NO. OF FOUND TEXT LINES:   0
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  USE IN PATIENT COHORT LOGIC:   AND NOT
  BEGINNING DATE/TIME:   T-1Y
• FINDING ITEM:   VA-OUTSIDE LDL 100-119
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  USE IN PATIENT COHORT LOGIC:   AND NOT
  BEGINNING DATE/TIME:   T-1Y
• FINDING ITEM:   VA-OUTSIDE LDL 120-129
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  USE IN PATIENT COHORT LOGIC:   OR
  BEGINNING DATE/TIME:   T-1Y
• FINDING ITEM:   VA-OUTSIDE LDL >129
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  USE IN PATIENT COHORT LOGIC:   OR
  BEGINNING DATE/TIME:   T-1Y
• FINDING ITEM:   VA-LDL >119
  CONDITION:   I V>119
  INTERNAL CONDITION:   I V>119
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  FOUND TEXT:   

  The most recent lab results document LDL greater than or equal to 120
  mg/dl.
  

  USE IN PATIENT COHORT LOGIC:   OR
  BEGINNING DATE/TIME:   T-1Y
• FINDING ITEM:   VA-LDL <120
  CONDITION:   I (V<120)&(+V>0)
  INTERNAL CONDITION:   I (V<120)&(+V>0)
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  The most recent lab results document LDL less than 120 mg/dl.
  

  USE IN PATIENT COHORT LOGIC:   AND NOT
  BEGINNING DATE/TIME:   T-1Y
• FINDING ITEM:   VA-LIPID LOWERING THERAPY MGMT - 2M
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  FOUND TEXT:   

  Lipid lowering management underway. Reminder satisfied for 2 months.
  

  USE IN RESOLUTION LOGIC:   OR
  BEGINNING DATE/TIME:   T-2M

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  FUNCTION STRING:   MRD(1)>MRD(13)
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    FUNCTION:   MRD

    FUNCTION PARAMETER LIST:

  • FUNCTION NUMBER:   2
    FUNCTION:   MRD

    FUNCTION PARAMETER LIST:

• LOGIC:   FN(1)>FN(2)
  FUNCTION STRING:   MRD(5,6,7)>MRD(8,3,4)
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  FUNCTION LIST:

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    FUNCTION:   MRD

    FUNCTION PARAMETER LIST:

  • FUNCTION NUMBER:   2
    FUNCTION:   MRD

    FUNCTION PARAMETER LIST:

This reminder is recommended for use by clinicians at Primary Care Clinics
       IHD DIAGNOSIS 
     
    2. Use the Reminder Dialog edit option to define the national 
       reminder dialog finding items which should be updated during CPRS
       GUI reminder processing.
    
       Review dialog elements in the national reminder dialog and change 
       any national health factors to local health factors, if
       necessary.  It is not unusual for local findings to be used in 
       your national dialogs. 
 
               No mapping necessary. Use the VA-ISCHEMIC HEART DISEASE
       Any local findings used in the national dialogs should be mapped
       to the appropriate national reminder term.
 
       Add local Order Dialog items to the Dialog elements used for 
       ordering a calculated LDL and/or direct LDL, and AST/ALT.
     
       Add local Order Dialog items to the Dialog Elements for clinicians
       to order initial lipid lowering medications or lab work. The
       dialog group contains a sampling of orders related to starting the
       patient on lipid lowering medication, which includes future lab
               reminder taxonomy distributed with this term.
       orders to monitor liver function and lipid levels. The distributed
       group contains:
     
          Order Simvastatin --  Note:  Sites using a different first line
               lipid lowering agent should replace Simvastatin with that
               medication (e.g., Pravastatin), which will require 
               copying the national dialog reminder, and editing the
               local copy with local dialog elements.
 
          Order baseline LFTs today (if not available w/in past year).  
 
          Order LFTs in 60 days after starting therapy.  
          Order fasting Lipid Profile in 60 days.  
                 
       The Adjust lipid lowering medication dialog group contains a
       dialog element that recommends using the meds and order tab to
       cancel old and order new medications.  It also includes dialog
       elements for future lab orders to monitor liver function and
       lipid levels.
 
          Order LFTs today (if not available w/in past year).  
       UNCONFIRMED IHD DIAGNOSIS 
          Order LFTs in 60 days after starting therapy.  
          Order fasting Lipid Profile in 60 days.  
 
 3. Alternatively, use the Reminder Dialog options to copy the national
    dialog, dialog elements, and dialog groups to make local changes.
 
    If your site has a Lipid Panel and AST/ALT TIU Object, add this
    TIU Object to the dialog element header text.  The TIU Object
    should include Chol, Trigly, HDL, LDL-C, direct LDL, AST, and ALT
    values and dates.
               Use the UNCONFIRMED IHD DIAGNOSIS health factor 
 
    Some sites have clinicians order a consult to a service that 
    corrects unconfirmed diagnoses the clinician finds in a patient's
    record.  If your site has this method in place, copy the reminder
    dialog to a local reminder dialog and then add a local dialog element
    for the consult order to the reminder dialog so this practice can
    continue.
               distributed with this term or add any local health 
               factor representing an unconfirmed or incorrect IHD
               diagnosis.  
 
(Primary Care/Medicine, GIMC, Geriatric, Women's), Cardiology, Cholesterol
       LDL >119
               Enter the Laboratory Test names from the Lab Package 
               for calculated LDL and direct LDL with a CONDITION to 
               identify LDL values > 119. Although the condition is 
               defined in the reminder, also define the condition in
               the term so the term can be used for uses that don't
               involve the reminder definition. If your site uses 
               comments frequently you may want to change the condition
               to check for specific text.
 
Screening and any other specialty clinics where primary care is given.
       LDL <120    
               Enter the Laboratory Test names from the Lab Package 
               for calculated LDL and direct LDL with a CONDITION to 
               identify LDL values < 120. Although the condition is 
               defined in the reminder, also define the condition in
               the term so the term can be used for uses that don't
               involve the reminder definition. If your site uses 
               comments frequently you may want to change the condition
               to check for specific text.     
 
 
       For the following OUTSIDE LDL Reminder Terms, use the 
       health factors distributed with these terms or add any local
       health factors or other findings to the appropriate reminder
       terms. The findings should represent LDL values from a source 
       outside the local facility.
 
         OUTSIDE LDL <100
            Distributed with health factor: OUTSIDE LDL <100 
         OUTSIDE LDL 100-119
            Distributed with health factor: OUTSIDE LDL 100-119
Setup issues before using this reminder:
         OUTSIDE LDL 120-129
            Distributed with health factor: OUTSIDE LDL 120-129           
         OUTSIDE LDL >129
            Distributed with health factor: OUTSIDE LDL >129
     
       LIPID LOWERING THERAPY MGMT - 2M
               Use the health factors distributed with this reminder term
               or enter any local health factors or other findings that
               should defer the reminder for 2 months. Health Factors
               distributed with this reminder term are:
     
                   LIPID LOWERING MEDS INITIAL ORDER
                   LIPID LOWERING MEDS ADJUSTED
 
       LIPID LOWERING THERAPY MGMT - 6M
               Use the health factors distributed with this reminder term
               or enter any local health factors or other findings that
               should defer the reminder for 6 months.  Health Factors
               distributed with this reminder term are: 
                   NO CHANGE IN IHD LIPID TREATMENT
                   OTHER DEFER ELEVATED LDL THERAPY
     1. Use the Reminder Term options to map local representations of 
                   LIPID MGMT PROVIDED OUTSIDE 
     
       REFUSED ELEVATED LDL THERAPY 
               Use the REFUSED ELEVATED LDL THERAPY health factor 
               distributed with this term or add any local health
               factor representing the patient's refusal to have 
               elevated LDL therapy provided.  
 
       LIPID MEDS CONTRAINDICATED 
               Use the LIPID MEDS CONTRAINDICATED health factor
        findings:
               distributed with this term or add any local health
               factors representing contraindication to lipid lowering
               medications.  
     
       LIPID LOWERING MEDS 
               Enter the formulary drug names for investigation drugs.
               Mapping non-investigative formulary drugs to the
               VA-GENERIC drugs in the Pharmacy Package will ensure
               the lipid lowering agents are found. The medications
               are informational findings for this reminder.
 
 
       TRANFERASE (AST) (SGOT) 
               This reminder term should already be mapped at your site
               from the Hepatitis C EPI patch setup. The AST lab test
               is an informational finding in this reminder.  
     
       ALANINE AMINO (ALT) (SGPT) 
               This reminder term should already be mapped at your site
               from the Hepatitis C EPI patch setup. The ALT lab test
               is an informational finding in this reminder.  

• URL:   http://www.oqp.domain.ext/cpg/DL/dl_cpg/algo4frameset.htm
  WEB SITE TITLE:   VHA/DoD CPG for Dyslipidemia
  WEB SITE DESCRIPTION:   

  The VHA/DoD CPG for Management of Dyslipidemia is a comprehensive 
  guideline incorporating current information and practices for 
  practitioners throughout the DoD and Veterans Health Administration 
  system. See Section S, Table 3b for reference to LDL<120 in the
  Guideline.
  

• REMINDER FREQUENCY:   1Y
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