#	mnemonic	QUESTION TEXT	RESPONSE	DEFINITIONS/DECISION RULES

32	lipid2	Within the past two years, was a lipid profile, to include total cholesterol, triglycerides, and HDL-C or LDL-C obtained for this patient?	1,2* *If 2, go to fundscop, else go to lipidt	A cholesterol level alone is not a lipid profile. At a minimum, total cholesterol, triglycerides, and HDL-C or LDL-C have to be reported to respond “1” to this question.
33	lipidt	Enter the date of the most recent lipid profile obtained within this period.	mm/dd/yyyy	Day may be entered as 01, if exact date is unknown. At a minimum, the month and year must be entered accurately.
34	ldlmeas	Was the LDL-C measured as part of the lipid profile? 1 = yes 2 = no 3 = triglycerides too high to obtain valid LDL-C	1,2,3 *If 2 or 3, go to totalc, else go to ldlclvl2	Either a direct or calculated LDL-C value is acceptable. If fasting triglycerides are over 400 mg/dL, and LDL-C value is noted to be invalid, answer “3.”
35	ldlclvl2	Enter the value of the LDL-C measured on this date.	______	Normal range is usually 60 – 130 mg/dl or less than 3.36 mmol/L (although this varies depending on the way the LDL is calculated, if it is not a direct measurement.)
36	ldl2unit	Enter the LDL-C unit of measurement: 1= mg/dL 2 = mmol/L	1,2	This data must be taken from the lab report in order to ensure the correct unit of measurement is linked to the LDL-C value
37	totalc	Enter the total cholesterol value obtained as part of the lipid profile.	______	Value is generally reported as mg/dl or mmol/L and the normal range is usually less than 200mg/dl or 5.18 mmol/L. This value cannot be zero-filled.
38	totalunt	Enter the total cholesterol unit of measure 1 = mg/dL 2 = mmol/L	1,2	This data must be taken from the lab report in order to ensure the correct unit of measurement is linked to the total cholesterol value
39	hdlval	Enter the HDL cholesterol value obtained as part of the lipid profile.	_____	Value is generally reported as mg/dl or mmol/L and the normal findings are usually greater than 45 mg/dl (1.17 mmol/L) in males or 55 mg/dl (1.42 mmol/L) in females. May zero-fill if this value was not included in the lipid profile.
40	hdlunit	Enter the HDL cholesterol unit of measure 1 = mg/dL 2 = mmol/L	1,2	This data must be taken from the lab report in order to ensure the correct unit of measurement is linked to the HDL-C value

#	mnemonic	QUESTION TEXT	RESPONSE	DEFINITIONS/DECISION RULES

41	trivalue	Enter the triglycerides value obtained as part of the lipid profile.	_____	Normal findings are usually <180 mg/dL (2.01 mmol/L) in females and <190 mg/dL (2.12 mmol/L) in males. This value cannot be zero-filled
42	triunit	Enter the triglycerides unit of measure 1 = mg/dL 2 = mmol/L	1,2	This data must be taken from the lab report in order to ensure the correct unit of measurement is linked to the triglyceride value

If ldlclvl2 > = 130mg/dL or 3.36 mmol/L, or hdlval < 35 mg/dL or 0.91 mmol/L, go to lipdlowr, else go to fundscop.

lipdlowr

Within the past two years, was the patient taking or prescribed lipid-lowering medication?

1,2*

*If 2, go to cardvise, else go to medname

“Taking or prescribed” = lipid-lowing medication was listed among the patient’s medications within the past two years or was prescribed at a clinic visit or inpatient admission

Question does not reference a new prescription. The patient can have been on lipid-lowering medication for many years.

Classifications of lipid-lowering medication=HMG Co-A reductase inhibitors (statins), niacin, bile acid resins, and fibrates.

mnemonic

QUESTION TEXT

RESPONSE

DEFINITIONS/DECISION RULES

medname

Designate all lipid-lowering medications the patient was taking at the most recent clinic visit:

Statins:

1. fluvastatin sodium (Lescol)

2. atorvastatin calcium (Lipitor)

3. lovastatin (Mevacor)

4. pravastatin sodium (Pravachol)

5. simvastatin (Zocor)

Niacin:

6. niacin extended release tablets (Niaspan)

Bile Acid Resin:

7. colestipol hydrochloride (Colestid)

8. colesevelam hydrochloride (Welchol)

Fibrates:

9. clofibrate (Atromid-S)

10. gemfibrozil (Lopid)

11. fenofibrate (Tricor)

12. pt not taking any of these meds at most recent visit

13. Chloride salt of basic anion exchange resin
cholestryamine (Prevalite)

1,2,3,4,5,6,7,8,
9,10,11,12,13

This question references the most recent visit prior to the pull list date.

More than one lipid-lowering drug may be designated by the abstractor if the patient is on multiple medications for dyslipidemia.

#	mnemonic	QUESTION TEXT	RESPONSE	DEFINITIONS/DECISION RULES

45	cardvise	Within the past two years, was the patient advised of any of the following lifestyle changes to manage cholesterol/reduce cardiac risk factors? Indicate all that apply: 1. dietary/nutritional management of fat and/or cholesterol intake 2. increase in physical activity 3. weight control 4. no recommendations provided to patient	1,2,3,5	Answer ‘1’ if patient was prescribed (or advised to follow) a low fat or low cholesterol diet. The information used to answer “yes” to weight counseling in the Core Module cannot be used for cholesterol management unless there is specific reference to low fat or low cholesterol diet. Information used to answer the weight control question in the Core Module may be used for option #3. Answer ‘2’ if patient is counseled regarding an increase in physical activity. Specificity to lowering cholesterol is not necessary.
46	fundscop	Within the past year, does the record document a funduscopic examination of the retina? 1 = exam performed at this or another VAMC 3 = exam performed by a private sector provider 4 = no documentation funduscopic exam was performed	1,3,4* *If 4, go to prevexam, else go to fundt	Blind patients are not excluded from this question. Documentation indicating funduscopic exam of the retina was performed: reference to optic disc, arterioles, no hemorrhage or exudates, microaneuryms, no papilledema, any reference to terms indicating retinopathy Acceptable: 1. Presence of a note, report, or letter summarizing exam results 2. Note by the PCP/staff that the exam was completed by a private eye care specialist or documentation of a dilated retinal exam done outside VHA. The month and year should be known. 3. Retinal photo taken in the ambulatory care setting and sent to an eye care specialist for review, if the results are in the record. 4. Screening for retinopathy by digital imaging, although it is not a substitute for a comprehensive exam. Unacceptable: Pt referred to ophthalmology/optometry but no exam results available.