Kaiser Permanente Improvement Team:

Winston Wong, MD, MS, Medical Director of Community Benefit-National Program Office, Kaiser Permanente
Jim Dudl, MD, Physician Consultant, Kaiser Permanente

San Diego Community Health Clinics Network Improvement Team:

Lynne Farrell, RN, Manager of Quality Management, San Diego Council of Community Clinics
Ken Morris, MD, Medical Director, North County Health Services
Jen Tuteur, MD, Associate Medical Director of Quality Management, North County Health Services
Mickey Keil, FNP, Quality Management Administrator, North County Health Services
Lisa Sacco, FNP-C, Family Nurse Practitioner, Comprehensive Health Center
Dorothy Lujan, Assistant Director, Vista Community Clinic
Raquel Aguirre, Project Coordinator, Vista Community Clinic

To achieve 90 percent adherence of bundled therapy of three drugs (aspirin, lisinopril, and lovastatin), referred to as the Kaiser Permanente A.L.L. protocol, among diabetic patients of San Diego community health centers who are at high risk for cardiovascular mortality.

• Patients participating in the A.L.L. protocol across the pilot community clinic sites (see graph 1 below)
• Projected number of cardiovascular events prevented by the A.L.L. bundle therapy versus statin only, ACE/ARB only, and aspirin only (see graph 2 below)

In partnership with Kaiser Permanente, three community health centers in San Diego identified high-risk diabetics (individuals 55 years and older) who would optimally benefit from a daily protocol of three cardiovascular risk-reducing drugs (i.e., aspirin, lisinopril, and lovastatin), which constitute the Kaiser Permanente A.L.L. protocol. Interdisciplinary primary care teams were organized for effective patient support to achieve high adherence with sustainable results to reduce long-term cardiovascular risk.

Four changes were key to the success of the A.L.L. project:

1. Instead of titrating individual medications, we bundled fixed doses of three medications (aspirin, lisinopril, and lovastatin) so that in one visit we could achieve what previously took many visits and titrations.
2. We changed the concept of treating blood pressure and lipids to just preventing cardiovascular disease, a concept that is new to the practitioners.
3. We vastly simplified the instructions ("just take these three pills each day") for the benefit of increasing patient adherence amidst differing health literacy levels in the underserved populations. 
4. We used only generic or inexpensive medications and decreased lab testing to an annual review after the first repeat.

Since implementation of the A.L.L. protocol project at community health centers belonging to the San Diego Community Health Clinics Network in 2006, a total of 646 patients to date have been participating in the A.L.L. protocol, with 74 percent being Hispanic, 17 percent being Caucasian, 6 percent being African American, and 3 percent being Asian Pacific Islander. A projected number of 81 adverse cardiovascular events (e.g., myocardial infarction, stroke, or cardiovascular death) will be prevented if these patients maintain therapy for five years.

Lessons Learned:

• Identifying a dedicated physician champion is essential to build a shared vision amongst providers and gain acceptance of the A.L.L. protocol project.
• Engaging a pharmacy representative, nurse representative, and physician champion in the planning stages of the A.L.L. protocol roll-out for the pilot implementation sites is essential to getting the project off the ground.
• Developing pre-printed prescription forms listing the A.L.L. medications facilitates pharmacy tracking of A.L.L. patients. 
• Medical assistants can effectively make the initial patient contact call to inform them about the A.L.L. program by following a written script.
• Evaluating patient readiness to change saves time spent on those who will not participate.
• Implementing A.L.L. improved clinician and patient satisfaction. 

Winston Wong, MD
Medical Director, Community Benefit Disparities Improvement and Quality Initiatives
Kaiser Permanente, National Program Office
Winston.F.Wong@kp.org

[Posterboard presentation from IHI's December 2007 National Forum]