Elsevier

American Heart Journal

Volume 200, June 2018, Pages 118-124
American Heart Journal

Clinical Investigation
Does clinician-reported lipid guideline adoption translate to guideline-adherent care? An evaluation of the Patient and Provider Assessment of Lipid Management (PALM) registry

https://doi.org/10.1016/j.ahj.2018.03.011Get rights and content

Abstract

Background

The 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol guideline recommends statin treatment based on patients' predicted atherosclerotic cardiovascular disease (ASCVD) risk. Whether clinician-reported guideline adoption translates to implementation into practice is unknown.

Objectives

We aimed to compare clinician lipid management in hypothetical scenarios versus observed practice.

Methods

The PALM Registry asked 774 clinicians how they would treat 4 hypothetical scenarios of primary prevention patients with: (1) diabetes; (2) high 10-year ASCVD risk (≥7.5%) with high low-density lipoprotein cholesterol (LDL-C; ≥130 mg/dL); (3) low 10-year ASCVD risk (<7.5%) with high LDL-C (130–189 mg/dL); or (4) primary and secondary prevention patients with persistently elevated LDL-C (≥130 mg/dL) despite high-intensity statin use. We assessed agreement between clinician survey responses and observed practice.

Results

In primary prevention scenarios, 85% of clinicians reported they would prescribe a statin to a diabetic patient and 93% to a high-risk/high LDL-C patient (both indicated by guidelines), while 40% would prescribe statins to a low-risk/high LDL-C patient. In clinical practice, statin prescription rates were 68% for diabetic patients, 40% for high-risk/high LDL-C patients, and 50% for low-risk/high LDL-C patients. Agreement between hypothetical and observed practice was 64%, 39%, and 52% for patients with diabetes, high-risk/high LDL-C, and low-risk/high LDL-C, respectively. Among patients with persistently high LDL-C despite high-intensity statin treatment, 55% of providers reported they would add a non-statin lipid-lowering medication, while only 22% of patients were so treated.

Conclusions

While the majority of clinicians report adoption of the 2013 ACC/AHA guideline recommendations, observed lipid management decisions in practice are frequently discordant.

Section snippets

Study population

The PALM registry consists of 7938 patients enrolled at 140 outpatient cardiology, endocrinology, and primary care practices across the United States. The design, rationale, inclusion, and exclusion criteria for the PALM registry have been previously published.9 After each site obtained institutional review board approval for participation, all clinicians at participating sites were asked to complete a web-based provider survey. Sites were required to have completed surveys for >80% of

Provider survey results

The PALM Registry collected provider surveys for 774 clinicians treating patients at 51 primary care practices, 82 cardiology practices, and 8 endocrinology practices. Among surveyed clinicians, 574 (74.2%) reported that the 2013 ACC/AHA guidelines primarily guides their lipid management, 137 (17.7%) are primarily guided by the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATPIII), 16 (2.1%) by the American Association of Clinical

Discussion

In this analysis of the PALM registry, we compared clinician responses to hypothetical scenarios with the observed treatment of their patients. We demonstrated that: (1) the majority of cardiologists reported adoption of the 2013 ACC/AHA guidelines and were more likely to adopt than primary care physicians or endocrinologists. (2) Clinician responses to hypothetical scenarios do not always align with observed lipid management decisions. (3) When the risk calculator was utilized, more guideline

Conclusions

Since the release of the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, there has been variable uptake in implementation of these guidelines, with cardiologists reporting the highest guideline adoption. Despite recommendations, statin therapy remains under-utilized in primary prevention patients with diabetes or with high ASCVD risk. Additional clinician treatment uncertainty remains around the management of patients with

Disclosures

The authors report the following disclosures: Dr. Lowenstern received funding through NIH T-32 training grant #5 T32 HL069749-14. Ms. Li reports no relevant disclosures. Dr. Navar reports research support from Amgen, Sanofi, and Regeneron; consulting fees from Amgen and Sanofi. Dr. Virani reports research support from ADA/AHA/ VA; honorarium from ACC as the Associate Editor for Innovations, ACC.org. Dr. Lee reports employment with Sanofi. Dr. Louie reports employment with Regeneron

Author Contributions

All authors have been involved in the study design, analysis, and manuscript revision. All authors read and approved the final manuscript. Dr Lowenstern is the guarantor who accepts full responsibility for the work and the conduct of the study, had access to the data, and controlled the decision to publish.

A Lowenstern: Dr Lowenstern 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. Dr Lowenstern

Acknowledgements

We thank Erin Campbell, MS, for her editorial contributions to this article. Ms. Campbell did not receive compensation for her assistance, apart from her employment at the institution where this study was conducted. This study was funded by Sanofi and Regeneron Pharmaceuticals.

References (18)

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    The lack of medication changes together with evidence that >70% of this cohort’s LDL-C levels were not to target supports the presence of significant clinician inertia.23 Some of the contributing factors may include a lack of knowledge of guidelines and the role of high-intensity statins,17 discordance between guideline knowledge and physician prescribing habits,24 a lack of confidence navigating perceived statin intolerance,25 and contrarian beliefs about the role of statins.26 Given that prior studies have previously documented evidence of widespread practice- and provider-level variation in the use of high-intensity statins,27,28 multifaceted interventions harnessing educational outreach as well as audit and feedback are likely to be needed to overcome patient-, clinician-, and system-level barriers.

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    Further, guideline-recommended treatment with a statin was based on definitions from the 2013 ACC/AHA guideline. While 74.2% of clinicians from the PALM registry reported use of the ACC/AHA guideline as their primary tool for lipid management,19 use of other guideline recommendations may have contributed to some of the treatment results we observed. Additionally, there are minor differences in determining high intensity statin treatment for primary prevention patients with DM between the ACC/AHA 2013 and 2018 guidelines.

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Sources of funding: This study was funded by Sanofi and Regeneron Pharmaceuticals.

Christopher P. Cannon, MD served as guest editor for this article.

1

Dr Lowenstern received funding through NIH T-32 training grant #5 T32 HL069749–14.

2

Ms Li reports no relevant disclosures.

3

Dr Navar reports research support from Amgen, Sanofi, and Regeneron; consulting fees from Amgen and Sanofi.

4

Dr Virani reports research support from ADA/AHA/ VA; honorarium from ACC as the Associate Editor for Innovations, ACC.org.

5

Dr Lee reports employment with Sanofi.

6

Dr Louie reports employment with Regeneron Pharmaceuticals, Inc.; ownership interest in Regeneron Pharmaceuticals, Inc.

7

Dr Peterson reports research support from Eli Lilly, Janssen, Merck, Consulting from AstraZeneca, Bayer, Boehringer Ingelheim, Genentech, Janssen, Merck, and Sanofi Aventis;

8

Dr Wang reports research support from AstraZeneca, Daiichi Sankyo, Eli Lilly, Gilead, Glaxo SmithKline, Regeneron, Sanofi; consultant/advisory/education from Bristol Myers Squibb, Astra Zeneca, Eli Lilly, Premier, Inc.

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