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Clinical Decisionmaking

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Physicians vary in their adherence to guidelines for managing high cholesterol among patients with atherosclerosis

Reducing levels of low-density lipoprotein cholesterol (LDL-C), so-called "bad cholesterol," lowers the risk of recurrent cardiac problems among people who already have cholesterol-clogged arteries (atherosclerosis). Indeed, use of statin drugs to lower LDL-C levels by 20 to 30 percent can reduce mortality and heart problems by 25 to 40 percent.

Unfortunately, many primary care doctors do not follow secondary prevention guidelines for managing high cholesterol among patients with atherosclerosis. They are least likely to follow these guidelines for women, blacks, patients without a cardiologist, and those with cerebrovascular and peripheral vascular disease, according to the results of a study supported by the Agency for Healthcare Research and Quality (HS07107).

Researchers from Brigham and Women's Hospital and Partners Healthcare System in Boston used electronic medical records from 19 primary care clinics to measure rates of compliance with the National Cholesterol Education Program (NCEP) cholesterol guidelines for secondary prevention. Less than one-third (31 percent) of the 2,019 patients who qualified for secondary prevention were being managed in compliance with NCEP recommendations. More than one-third (38 percent) had not had their LDL-C level measured within the last 3 years, and another 40 percent had a recent LDL-C that was above the recommended target of 100 mg/dL. In this latter group, 46 percent were not on a statin, including 188 patients with an LDL-C greater than 130 mg/dL, the point when statin therapy is recommended.

Overall, 40 to 60 percent of physician noncompliance could be attributed to failure to diagnose or monitor cholesterol levels, 25 to 40 percent was related to failure to optimize therapy, and 5 to 15 percent involved failure to initiate statin therapy. Furthermore, females, blacks, patients younger than 50 or older than 79 years, patients without coronary artery disease, and those without a cardiologist were about 30 percent less likely than the average patient to be in compliance with NCEP guidelines.

More details are in "Using an electronic medical record to identify opportunities to improve compliance with cholesterol guidelines," by Saverio M. Maviglia, M.D., M.Sc., Jonathan M. Teich, M.D., Ph.D., Julie Fiskio, M.S., and David W. Bates, M.D., M.Sc., in the August 2001 Journal of General Internal Medicine 16, pp. 531-537.

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