Clinical research study
Cholesterol Treatment and Changes in Guidelines in an Academic Medical Practice

https://doi.org/10.1016/j.amjmed.2014.10.039Get rights and content

Abstract

Background

National guidelines are intended to influence physician cholesterol treatment practices, yet few studies have documented the effect of new guidelines on actual prescribing behaviors and impacts on patient eligibility for treatment. We describe current cholesterol treatment in an academic practice of Family and Internal Medicine physicians as well the effect of a change in cholesterol treatment guidelines from 2001 Adult Treatment Panel III (ATPIII) to 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines.

Methods

Medical records were extracted from primary care patients aged 40-75 years with at least one outpatient visit from January 1, 2012 to July 31, 2013; patients were included if they had records of cholesterol testing, blood pressure measurement, sex, race, and smoking status. Patients were classified into ATPIII and ACC/AHA categories based on clinical variables (eg, diabetes, hypertension, atherosclerotic cardiovascular disease), Framingham Risk Score, and 10-year atherosclerotic cardiovascular disease risk.

Results

There were 4536 patients included in the analysis. Of these, 71% met ATPIII goals and 56% met ACC/AHA guidelines, a 15% decrease. Forty-three percent of high-risk patients met their low-density lipoprotein goals and 46% were on statins. Overall, 32% of patients would need to be started on a statin, 12% require an increased dose, and 6% could stop statins. Of patients considered low risk by ATPIII guidelines, 271 would be eligible for treatment by ACC/AHA guidelines, whereas 129 patients were shifted from intermediate risk to low risk with the change in guidelines.

Conclusions

The ACC/AHA guidelines expand the number of patients recommended to receive statins, particularly among patients who were previously thought to be at moderate risk, and would increase the intensity of treatment for many patients at high risk. Significant numbers of patients at risk for cardiovascular events were not receiving guideline-based treatment. New cholesterol guidelines may make treatment decisions easier.

Section snippets

Methods

SLUCare is the academic clinical practice of the School of Medicine at Saint Louis University, based in Saint Louis, Missouri. The Division of General Internal Medicine and Department of Family Medicine include approximately 115 physicians, resident trainees, and associated staff at 3 ambulatory care clinics that see an average of approximately 13,000 unique patients per year. A Primary Care Patient Data registry was created by extracting records from 27,225 patients (Family Medicine = 10,994,

Results

The number of eligible patients was 4536 (Figure 1), with an average age of 56.7 years (SD 9.1). Table 1 describes the demographic characteristics of the study population. There were more female patients (60%) than male. The racial distribution of eligible patients was appropriate for the area of St. Louis that SLUCare serves, with 53% white (Caucasian), 44% Black (African-American), and 3% other race. Approximately 10% of the cohort had atherosclerotic vascular disease, and 12% were actively

Discussion

In our evaluation of real-world cholesterol management in a large, academic group practice, we found that treatment would be affected considerably by the ACC/AHA guidelines on cholesterol reduction management. The 2013 ACC/AHA guidelines shifted away from an emphasis on LDL treatment targets as recommended by ATPIII guidelines to treatment based on calculated cardiovascular risk. Across all risk categories, the ACC/AHA treatment regimens will result in an increased prescribing of statins.

Over

Acknowledgment

We appreciate the support of the Departments of General Internal Medicine and Family Medicine at Saint Louis University.

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    Funding: Supported with funds from the Department of Family Medicine and Division of General Internal Medicine, Saint Louis University School of Medicine.

    Conflict of Interest: None.

    Authorship: All authors had access to the data and a role in writing the manuscript. Study concept and design was performed by MWS and FB Data collection and processing was performed by JS and JFS, data analysis was performed by MWS. The manuscript was drafted by MWS, with editing by FB, JS, and JFS, MS had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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