Table 2—

Population management: problems identified and actions taken (542 reviews of 446 patients)

Problems identifiedRisk-factor management
Missing test results107134240481
Elevated levels302291206799
Inadequate treatment603254146
Indicated chemoprophylaxis
    Missing aspirin81
    Missing ACE inhibitor/ARB27
    Patient loss to follow-up12
Actions taken
    PCP e-mail with recommendations297
    Letter to patients108
  • Test results and elevated levels include HbA1c (for hyperglycemia), blood pressure (for hypertension), and LDL cholesterol for hyperlipidemia. Chemoprophylaxis section indicates chemoprophylaxis with aspirin for patients with diagnosed coronary artery disease and with angiotensin-blocking agents if microalbuminuria was present. Loss to follow-up indicates no clinical encounter in the preceding 1 year. ARB, angiotensin receptor blocker.