From the Lipid Research Center, PHS Mount Sinai Medical Center (J.P.F.,
P.S.S.), Cleveland, Ohio; and Case Western Reserve University School of
Medicine (J.M.S.), Department of Medicine (J.P.F.) and Department of Family
Medicine (S.J.Z.), Cleveland, Ohio.
Correspondence to Joseph P. Frolkis, MD, PhD, FACP, Sections of Preventive Cardiology and Preventive Medicine, The Cleveland Clinic Foundation, Desk A42, 9500 Euclid Ave, Cleveland, OH 44195.
Methods and Results—We conducted a retrospective chart review on
randomly sampled charts of 225 patients admitted to the
coronary care unit between January and June 1996. The main
outcome measures were rates of physician screening for coronary
heart disease risk factors; rates of counseling for cigarette
cessation, diet, and exercise; and extent of use of NCEP algorithms for
obtaining LDL cholesterol values and treating
hypercholesterolemia. Screening rates for
interns (who performed best) were: cigarette use (89%), known
coronary heart disease (74%), hypertension (68%),
hyperlipidemia (59%), family history (56%), diabetes
(37%), postmenopausal hormone therapy (11%), and premature menopause
(1%). Four percent of smokers were counseled to quit, 14% of patients
were referred to dietitians, and 1% were encouraged to exercise. A
full lipid panel was obtained in 50% of patients in whom it was
indicated on the basis of NCEP criteria. Patients were more likely to
receive lipid-lowering treatment if NCEP criteria indicated that they
should, but 36% of hospitalized patients and 46% of patients who
should have been treated on discharge were not.
Conclusions—Physicians are poorly compliant with NCEP guidelines
for risk factor assessment and counseling, even in patients at high
risk for coronary heart disease. Physicians follow NCEP-ATPII
algorithms for obtaining an LDL value, a key step in evaluating the
need for treatment, only 50% of the time. NCEP criteria seem to
influence the decision to initiate lipid-lowering therapy, but
significant numbers of eligible patients remain untreated.
In the case of cholesterol, compelling data provide
evidence that aggressive lipid-lowering therapy prevents recurrent
cardiac events and lowers total mortality in patients with significant
hyperlipidemia and known CHD,1 in
those with elevated cholesterol and no prior heart
attack,2 and in those with coronary
disease but only mildly elevated levels of total
cholesterol and LDL
cholesterol.3 The benefits of lipid
lowering in these studies apply to both men and women, to those older
and younger than 55 years of age, and to diabetic individuals. The data
also demonstrate significant reductions in the frequency of strokes and
in the need for bypass procedures and angioplasties. Total number of
hospital admissions, total days in the hospital, and average length of
stay all decreased as well.
The effectiveness of aggressive risk factor assessment and control in
altering subsequent cardiovascular morbidity and
mortality led the National Cholesterol Education Program's
Adult Treatment Panel (NCEP-ATP) to issue its initial guidelines for
the detection, evaluation, and treatment of
hyperlipidemia in 1988
(NCEP-ATPI).4 In 1993, updated guidelines were
issued (NCEP-ATPII).5 Among other changes,
NCEP-ATPII recognized the significant risks of
cardiovascular morbidity and mortality in
postmenopausal women and in both men and women with documented CHD. By
combining an assessment of the patient's risk factor status with
current lipid levels, the NCEP created logical algorithms to assist
physicians in initiating appropriate treatment.
Despite the comprehensive nature and wide dissemination of NCEP-ATPII,
a number of studies6 7 8 9 published between the
1988 and 1993 reports documented that patients continued to be
underscreened and undertreated for cardiovascular risk
factors, especially hyperlipidemia. One recent study of
postmenopausal women enrolled after the publication of NCEP-ATPII
suggested persistent deficits in adherence to treatment
goals.10 Few other trials, however, have
evaluated the impact of the updated NCEP guidelines on physician
behavior. To ascertain the extent to which physicians were following
NCEP guidelines in assessing CHD risk factors and initiating treatment
for hyperlipidemia, we conducted a retrospective chart
review of 225 patients admitted in 1996 to the coronary care
unit (CCU) of a university-affiliated teaching hospital. We also
evaluated the effect of patient demographic variables on treatment
frequency.
Data Collection
Descriptive and analytical statistics were used in the analysis
of these data. For categorical variables, basic descriptive
statistics are reported as numbers and percentages. For continuous
data, the descriptive statistics reported included means and standard
deviations. In the first phase of analysis, descriptive
statistics were used to describe the demographics of the sample, as
well as the distribution of coronary heart disease risk
factors.
In Table 2
To evaluate how well practitioners followed up on the risk
factors discovered during screening, 3 variables were selected, and
charts were reviewed to determine whether any practitioner
had offered patients counseling or referral. Of the 71 patients who
smoked cigarettes, only 3 (4%) were counseled to quit. Only 1 patient
(<1%) was encouraged to exercise, and only 32 patients (14%) were
referred to a dietitian.
We examined the influence of NCEP-ATPII not only on how aggressively
physicians screened for CHD risk factors but also on how they made
clinical decisions to evaluate further a patient's lipid status and to
initiate appropriate lipid-lowering therapies. To begin, we evaluated
the relationship between the nonclinical patient demographic
variables of insurance type, sex, race, and median household income
and whether not patients were offered lipid-lowering therapy while in
the hospital or at CCU discharge. In this sample, the selected
demographic variables bore no statistical relationship to the
decision to initiate lipid-lowering therapy either during
hospitalization in the CCU or at discharge.
We next turned our attention to clinical factors that might influence
physician behavior. First, we examined the relationship between serum
lipid values and whether cholesterol-lowering therapy was
offered either during hospitalization or at discharge. Lipid values
included total cholesterol (TC) obtained as part of a
chemistry panel, as well as values from a specifically requested
fasting lipid panel (FLP). TC levels from a chemistry panel
(P
NCEP treatment algorithms are not based purely on lipid values,
however. Instead, the combination of TC level, HDL
cholesterol level, and risk factor count are used to
trigger the request for an FLP, which provides an LDL level that can
then be used to make therapeutic decisions. Specifically, NCEP criteria
for obtaining an FLP include the presence of documented CHD, a TC level
>240 mg/dL, or a TC level of 200 to 239 mg/dL and either
Based on NCEP guidelines, the decision to initiate lipid-lowering
therapy is linked to the level of LDL cholesterol, the risk
factor count, and the presence or absence of documented CHD or other
atherosclerotic disease. Accordingly, a Statistical Package for Social
Science algorithm was created that used NCEP criteria for LDL values
and risk factor count. The analysis was performed only on those
patients for whom an FLP had been obtained. For patients who met NCEP
criteria for lipid-lowering medication, Table 3
To determine whether patients with CHD were treated differently in the
CCU, we examined the data presented in Table 3
Finally, although this study was not designed to document postdischarge
follow-up, we were curious as to the frequency with which follow-up was
offered. For the study population as a whole, 91% (204/223) of
patients were discharged with a follow-up appointment.
CHD is the leading cause of death in American women >50 years of age,
with CHD incidence for women reaching and then surpassing that for men
as women move into the postmenopausal years. These data led the NCEP
panel to include being a woman aged
Risk factor status, including the presence of documented CHD, and lipid
values constitute the criteria for clinical decision making according
to the NCEP guidelines. We sought to examine whether and to what extent
physicians were adhering to NCEP-guided algorithms in the care of their
patients. If physicians were not using NCEP criteria, we hoped to
discover what factors did influence their behavior. Numerous studies,
for example, have shown the relationship of demographic variables
to health outcomes, from the underutilization of coronary
revascularization procedures based on
race11 to the impact on total mortality of
socioeconomic status.12 In the present study,
race, sex, median household income, and type of medical insurance had
no impact on whether patients received lipid-lowering therapy while in
the hospital or at discharge. For a population as demographically
heterogeneous as ours (see Table 1
Lipid values per se clearly influenced the decision to begin
lipid-lowering therapy. It is difficult to assess the intentionality of
the TC value reported automatically with a chemistry panel. Of the
sample, 198 (90%) had an admission chemistry panel ordered (for which
individual tests do not have to be specified). For both in-hospital and
discharge lipid-lowering therapy, chemistry panel TC levels were
correlated. AN FLP was ordered for 96 (44%) of patients. The values
for TC and LDL cholesterol, but not
triglycerides or HDL, were correlated with the receipt of
lipid-lowering therapy both in the hospital and at discharge.
Physicians obviously incorporated lipid values into their decision
making. Lipid values, however, must be used in combination with risk
factor status to follow NCEP algorithms. Lipid values alone may not be
a valid surrogate for the criteria used in the first 2 steps of the
NCEP pathway (TC, HDL, and risk factors to determine need for an FLP;
LDL value and risk factors to initiate therapy). In fact, when we
compared the NCEP-driven indications for either obtaining an FLP or
beginning therapy with TC and LDL cholesterol levels, we
found no statistical correlation (data not shown). Although physicians
seem to use TC and LDL cholesterol levels to make decisions
about treatment, these levels are not valid markers for NCEP-guided
criteria for such decisions. Additionally, our data call into question
whether physicians are following the logical, orderly progression of
clinical decision making inherent in the NCEP guidelines. AN FLP is
obtained only 50% of the time when the combination of TC level and
risk factor status suggests that it should be. Because this is the key
initial step that ultimately leads to any decision to begin treatment
(diet or drug), the fact that only half of eligible patients have an
FLP points to significant underscreening in this high-risk group.
Our separate analyses of patients with documented CHD
demonstrate that despite recent
exhortations,13 14 physicians in this study are
no more likely to treat such patients than the study population as a
whole. This is particularly discouraging because there is widespread
agreement on the value of aggressive lipid lowering in secondary
prevention, with some even arguing14 that
cholesterol screening itself is unnecessary in CHD patients
because the presence of their disease is de facto proof that the level
is too high.
The present study has several limitations. We considered that our
conclusions are based on documented risk factor screening and health
counseling and that physicians might actually have been more thorough
than is noted in the hospital chart. However, for both managed care
quality assurance and malpractice functions, what is documented is
increasingly considered a valid substitute for what is actually asked
or done. Physicians at all levels are encouraged to keep careful and
updated chart notes. Additionally, in at least 1
study,15 this question was addressed by
performing a subanalysis in which the recorded risk
assessment was compared with direct verbal questioning of patients
about their risk assessment. Except for a slight underreporting of
smoking and sedentariness, the medical record was an accurate
reflection of actual risk assessment. Finally, for health counseling
about cigarettes, weight, and exercise, our criteria were quite
generous in that we considered any reference in any note by any
practitioner to constitute counseling.
Because we only reviewed records of patients' stays in the CCU, we
may have underestimated the frequency with which lipid-lowering therapy
was begun after hospital discharge. Although we cannot estimate the
eventual postdischarge rate of therapy, 2 points may be made. First,
CCU admission of a high-risk patient is considered an ideal time to
initiate therapy, which can then be titrated or "fine-tuned" in
follow-up. Clearly, some patients were begun on therapy, so aversion to
in-hospital treatment seems not to be the issue. Second, considerable
data suggest that fewer than one third of eligible patients receive any
lipid-lowering therapy (including diet).7
Therefore, it is dangerous to assume that therapy will be initiated
after discharge. In response, a number of programs are advocating
aggressive, comprehensive risk factor assessment and treatment before
discharge.
Some concern may exist that treatment rates were depressed because
cholesterol values were transiently lowered by the
acute-phase response known to affect all lipid subfractions within
several hours of a number of stressors (eg, burns, trauma, surgery, and
myocardial infarction). In our study population, not all patients were
confirmed to have had myocardial infarctions; if they underwent bypass
surgery or balloon angioplasty, lipid values were obtained beforehand.
More important, our most striking findings concerning therapeutic
decision making were based on these potentially lowered lipid values
applied to strict NCEP criteria. Even based on possibly artificially
lowered lipid values, only 50% of eligible patients had an FLP and one
third to one half of eligible patients were untreated.
In summary, our data suggest that despite the NCEP-ATPII guidelines,
risk factor assessment and counseling remain inadequate, even for
patients at high risk of CHD. Physicians in our sample did not seem to
be influenced by demographic characteristics in making clinical
decisions about lipid-lowering therapy, which was a positive finding.
They did seem to be influenced by isolated TC and LDL
cholesterol levels, which are questionable surrogates for
NCEP-directed care. Physicians seem to follow NCEP guidelines for
initiating therapy, but significant numbers of eligible patients remain
untreated. Finally, NCEP guidelines do not seem to influence whether
physicians ascertain a patient's LDL level, the key NCEP datum in
evaluating the need for treatment.
Received January 27, 1998;
revision received April 21, 1998;
accepted April 27, 1998.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Physician Noncompliance With the 1993 National Cholesterol Education Program (NCEP-ATPII) Guidelines
Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
References
Background—We sought to determine the frequency with which
physicians follow National Cholesterol Education Program
(NCEP-ATPII) guidelines in screening for cardiovascular
risk factors and treating hyperlipidemia.
Key Words: lipoproteins • risk factors • practice guidelines • compliance
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References
Coronary heart
disease (CHD) continues to be the leading cause of mortality in the
United States, causing 500 000 deaths annually and costing the country
>$100 billion yearly. Unfortunately, 
50% of myocardial infarctions
occur in patients without prior manifestations of disease, and about
one third are fatal. Aggressive management of risk factors has a
significant positive impact on the natural history of atherosclerotic
cardiovascular disease. Whereas age, sex, and family
history are fixed, the modifiable risk factors of hypertension,
cigarette smoking, diabetes, depressed HDL cholesterol
levels, and elevated LDL cholesterol levels are responsible
for a significant proportion of CHD cases and are amenable to medical
intervention.
Methods
Top
Abstract
Introduction
Methods
Results
Discussion
References
Sample Selection
Using a sampling fraction based on an initial random number, we
selected 225 charts for review. This sample represented
approximately one third of all patients admitted to the CCU of a
university-affiliated teaching hospital between January and June 1996.
By sampling over an extended period of time, we hoped to offset the
influence of any particular house officer,
cardiology fellow, cardiology attending
physician, or primary care physician.
An instrument was created, then refined after pilot testing, to
allow consistent and uniform review of each patient record.
Patient demographic and clinical variables and healthcare provider
markers were collected for each admission. Patient demographic
variables included age, sex, race, median household income, and
type of insurance. Patient clinical variables included discharge
diagnoses, lipid values (and whether or not these values were obtained
as part of an admission chemistry profile or through a fasting lipid
profile), and the presence or absence of the accepted NCEP risk factors
(personal history of coronary or other atherosclerotic vascular
disease, hypertension, diabetes, cigarette use, family history of
premature CHD, and menopausal status and presence or absence of hormone
replacement therapy for women). To establish a true incidence of each
risk factor, discharge International Codes of Diagnosis-9 (ICD-9) were
used alone for the presence of CHD, hypertension, and diabetes. For the
risk factors of premature menopause without hormone replacement therapy
and family history of premature CHD, each risk factor was considered
present if it was documented in any note by any
practitioner (including nurses). For current cigarette
smoking, a combination of discharge ICD-9 codes and chart documentation
by any practitioner was used. For each level of training
(intern, resident, cardiologist, primary care physician, and nurse),
healthcare provider variables included whether each risk factor had
been screened for, the mean and median number of risk factors screened
for, and whether counseling had been offered concerning cigarette
cessation, dietary referral, and exercise. In the CCU, separate
work-ups, examinations, and notes are mandatory on each admission for
interns, residents, and primary nurses. Additionally, because a
cardiologist consults on every patient, there is a formal
cardiology note on each chart. Finally, the primary
care physician is expected to write a note for each patient within 24
hours of admission. 
2 statistics were then used to test
for associations between the patient's demographic profile and the
presence and type of lipid-lowering therapy provided in the hospital or
at discharge. Differences in lipid profiles by the presence and type of
lipid-lowering therapy were tested by 1-way ANOVA. Finally,
2 analyses relating type of therapy
and therapeutic indication were performed on the subset of patients
(n=96) who had lipid panels drawn.
Results
Top
Abstract
Introduction
Methods
Results
Discussion
References
Salient demographic characteristics and the frequency of the
clinical conditions constituting the NCEP risk factors in the study
population are presented in Table 1
. The racial and insurance
characteristics of the sample reflect the location of the hospital in
an urban area with a high concentration of indigent and black citizens.
The prevalence of CHD risk factors, including the existence of
documented CHD in nearly two thirds of the population, establishes the
high-risk nature of these patients admitted to the CCU, a group in whom
aggressive risk factor assessment and intervention should produce the
greatest clinical benefit.
View this table:
[in a new window]
Table 1. Demographic and Risk Factor Characteristics of 225
Patients Admitted to the CCU From January to June 1996 , the frequency with which each
practitioner group inquired about each of the NCEP risk
factors is presented. Age and sex are not indicated as risk
factors because they represent data readily available to all
practitioners and do not require independent inquiry.
Interns performed best, as might be anticipated because they are
expected to take the most thorough admission history from patients, but
even interns inquired about only 2 risk factors (known CHD and
cigarette smoking) >70% of the time. Rates of risk factor assessment
decrease sharply when house officers (interns and residents)
are compared with primary physicians, cardiologists, and nurses. Rates
of inquiry about diabetes, premature menopause, and current hormone
replacement therapy were particularly low. The mean number of risk
factors screened for by each practitioner is also
calculated. Of the 8 possible risk factors, interns screened for 3.3,
residents for 3.0, primary physicians for 1.9, cardiologists for 1.8,
and nurses for 2.3.
View this table:
[in a new window]
Table 2. Practitioner Risk Factor Screen
Performance 
0.001), TC levels from an FLP (P=0.004), and
LDL cholesterol levels (P=0.002) were strongly
associated with the administration of lipid-lowering medication while
the patient was in the CCU. Similarly, TC levels from a chemistry panel
(P0.001), TC levels from an FLP (P=0.006), and
LDL levels (P=0.002) predicted the prescription of
lipid-lowering therapies on discharge from the CCU. HDL
cholesterol and triglyceride levels were
unrelated to therapeutic intervention either during hospitalization or
at discharge. 
2
risk factors or an HDL level <35 mg/dL. In the setting of the
present study, however, an HDL value was only obtained as part of
an FLP. Thus, when an HDL value was obtained, an LDL value was
automatically provided as well, invalidating the use of the HDL level
alone, as intended in the NCEP algorithm. We therefore constructed a
Statistical Package for Social Science algorithm that omitted HDL
values but included the other NCEP criteria, as previously outlined.
The results showed that when an FLP was not indicated by NCEP
guidelines, it was not obtained 76% of the time. In contrast, when
NCEP guidelines indicated that an FLP should be obtained, there was
only a 50% chance that it would be. These contrasts are statistically
significant. shows the percentage of those who did
and did not receive therapy on admission, during hospitalization, or at
discharge. NCEP guidelines did not predict whether patients were
receiving lipid-lowering therapy at the time of their admission. On the
other hand, patients were more likely to receive hospital therapy and
discharge therapy if NCEP guidelines suggested that it was appropriate.
However, a significant number of patients for whom hospital therapy or
discharge therapy was indicated by NCEP criteria remained
untreated.
View this table:
[in a new window]
Table 3. Actual Therapy Vs NCEP-Indicated Therapy for
Patients 
separately for
those patients who had documented CHD, had an FLP obtained, and were
drug-eligible by NCEP-ATPII criteria. Of this group, 14% (3/21)
received lipid-lowering medication on admission, 62% (13/21) had it
prescribed during hospitalization, and 52% (11/21) were offered such
treatment on discharge. We next asked 3 related questions that were
slightly broader in scope: (1) Independent of NCEP status, what
percentage of patients who received lipid-lowering medication had CHD?
(2) What percentage of CHD patients received medication? and (3) What
percentage of CHD patients received lifestyle advice concerning diet
and exercise? During hospitalization, 85% (58/68) of patients who
received lipid-lowering medication had CHD. Of patients who received
lipid-lowering medications on discharge, 85% (56/66) had CHD. Of CHD
patients, 41% (58/143) received medication during hospitalization and
39% (56/143) received medication on discharge. Of CHD patients, 30%
(43/143) were given lifestyle advice.
Discussion
Top
Abstract
Introduction
Methods
Results
Discussion
References
Our results indicate that despite the widespread availability of
the NCEP-ATPII recommendations for the detection, evaluation, and
treatment of hyperlipidemia and the highly publicized
results of recent major clinical trials of both primary and secondary
prevention of CHD,1 2 3 physician implementation
of risk factor assessment, lifestyle counseling, and appropriate use of
therapeutic algorithms remains inadequate. Using only the
performance of medical interns, we compared our data with those
of Miller et al8 for 258 cases admitted for
coronary artery bypass surgery (Table 4). No significant impact of NCEP-ATPII
was seen on physician performance. This is particularly
striking because our sample represented patients at high
risk of initial or recurrent CHD events, the population identified as
most likely to benefit from comprehensive risk factor management.
View this table:
[in a new window]
Table 4. Risk Factor Identification by Medical Interns 55 years or having had premature
menopause and not being on hormone replacement therapy as an official
risk factor for CHD. It was therefore particularly disheartening that
when questioning female patients, physicians inquired about premature
menopause only 1 to 3% of the time and about hormone replacement
therapy only 7 to 11% of the time. ), this negative finding
was reassuring.
Acknowledgments
This study was supported in part by an unrestricted research
grant from Merck & Co. We thank Shelly Galvin for her editorial
assistance.
References
Top
Abstract
Introduction
Methods
Results
Discussion
References
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|
|
S. John, C. Delles, J. Jacobi, M. P. Schlaich, M. Schneider, G. Schmitz, and R. E. Schmieder Rapid improvement of nitric oxide bioavailability after lipid-lowering therapy with cerivastatin within two weeks J. Am. Coll. Cardiol., April 1, 2001; 37(5): 1351 - 1358. [Abstract] [Full Text] [PDF]
|
|
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|
|
|
G. C. Fonarow, W. J. French, L. S. Parsons, H. Sun, and J. A. Malmgren Use of Lipid-Lowering Medications at Discharge in Patients With Acute Myocardial Infarction : Data From the National Registry of Myocardial Infarction 3 Circulation, January 2, 2001; 103(1): 38 - 44. [Abstract] [Full Text] [PDF]
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R. Cooper, J. Cutler, P. Desvigne-Nickens, S. P. Fortmann, L. Friedman, R. Havlik, G. Hogelin, J. Marler, P. McGovern, G. Morosco, et al. Trends and Disparities in Coronary Heart Disease, Stroke, and Other Cardiovascular Diseases in the United States : Findings of the National Conference on Cardiovascular Disease Prevention Circulation, December 19, 2000; 102(25): 3137 - 3147. [Abstract] [Full Text] [PDF]
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D. Grant, J. P. Frolkis, P. Suhan, J. Schwartz, and S. J. Zyzanski Documentation for the Sake of Documentation? • Response Circulation, September 28, 1999; 100(13): 1461 - 1461. [Full Text] [PDF]
|
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|
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|
J. Dupuis, J.-C. Tardif, P. Cernacek, and P. Theroux Cholesterol Reduction Rapidly Improves Endothelial Function After Acute Coronary Syndromes : The RECIFE (Reduction of Cholesterol in Ischemia and Function of the Endothelium) Trial Circulation, June 29, 1999; 99(25): 3227 - 3233. [Abstract] [Full Text] [PDF]
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P. G. Danias, D. I. Silverman, J. P. Frolkis, P. Suhan, J. Schwartz, and S. J. Zyzanski Physician Noncompliance With the 1993 National Cholesterol Education Program (NCEP-ATPII) Guidelines • Response Circulation, June 29, 1999; 99 (25): 3323 - 3326. [Full Text] [PDF]
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 Compliance with Cholesterol Guidelines Remains Poor Journal Watch Cardiology, October 9, 1998; 1998(1009): 2 - 2. [Full Text]
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