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Ibrahim S, de Goeij JN, Nurmohamed NS, Pang J, van den Bosch SE, Martens FMAC, Roeters van Lennep JE, Corpeleijn W, Tumkaya T, Hovingh GK, Watts GF, Stroes ESG, Reeskamp LF. Unexpected gaps in knowledge of familial hypercholesterolaemia among Dutch general practitioners. Neth Heart J 2024; 32:213-220. [PMID: 38573436 DOI: 10.1007/s12471-024-01862-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Familial hypercholesterolaemia (FH) warrants early diagnosis to prevent premature atherosclerotic cardiovascular disease (CVD). However, underdiagnosis and undertreatment of FH persist. This study aimed to assess the knowledge and practice of FH care among general practitioners (GPs) in the Netherlands. METHODS An internationally standardised, online questionnaire was sent to Dutch GPs between February 2021 and July 2022. The survey assessed knowledge and awareness of FH, encompassing general familiarity, awareness of management guidelines, inheritance, prevalence, CVD risk, and clinical practice related to FH. Comparative analysis was performed using data on primary care physicians from Western Australia, the Asia-Pacific region and the United Kingdom. RESULTS Of the 221 participating GPs, 62.4% rated their familiarity with FH as above average (score > 4 on a 1-7 scale), with 91.4% considering themselves familiar with FH treatment and referral guidelines. Correct identification of the FH definition, typical lipid profile, inheritance pattern, prevalence and CVD risk was reported by 83.7%, 87.8%, 55.7%, 19.5%, and 13.6% of the respondents, respectively. Of the participants, 58.4% answered fewer than half of the 8 knowledge questions correctly. Dutch GPs reported greater FH familiarity and guideline awareness compared with their international counterparts but exhibited similar low performance on FH knowledge questions. CONCLUSION Despite the Netherlands' relatively high FH detection rate, substantial knowledge gaps regarding FH persist among Dutch GPs, mirroring global trends. Enhanced FH education and awareness in primary care are imperative to improve FH detection and ensure adequate treatment. Targeting the global suboptimal understanding of FH might require international efforts.
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Affiliation(s)
- Shirin Ibrahim
- Department of Vascular Medicine, Amsterdam University Medical Centres, location Amsterdam University Medical Centre-University of Amsterdam, Amsterdam, The Netherlands
| | - Jim N de Goeij
- Department of Vascular Medicine, Amsterdam University Medical Centres, location Amsterdam University Medical Centre-University of Amsterdam, Amsterdam, The Netherlands
| | - Nick S Nurmohamed
- Department of Vascular Medicine, Amsterdam University Medical Centres, location Amsterdam University Medical Centre-University of Amsterdam, Amsterdam, The Netherlands
- Department of Cardiology, Amsterdam University Medical Centres, location Vrije Universiteit medical centre, Amsterdam, The Netherlands
| | - Jing Pang
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Sibbeliene E van den Bosch
- Department of Paediatrics, Division of Metabolic Disorders, Emma Children's Hospital, Amsterdam University Medical Centres and Gastroenterology, Endocrinology & Metabolism (AGEM), location Academic Medical Centre-University of Amsterdam, Amsterdam, The Netherlands
| | - Fabrice M A C Martens
- Department of Cardiology, Amsterdam University Medical Centres, location Vrije Universiteit medical centre, Amsterdam, The Netherlands
| | | | - Willemijn Corpeleijn
- Department of Paediatrics, Division of Metabolic Disorders, Emma Children's Hospital, Amsterdam University Medical Centres and Gastroenterology, Endocrinology & Metabolism (AGEM), location Academic Medical Centre-University of Amsterdam, Amsterdam, The Netherlands
| | - Talip Tumkaya
- Department of General Practice, Huisartsenpraktijk Parkhof, Maassluis, The Netherlands
| | - G Kees Hovingh
- Department of Vascular Medicine, Amsterdam University Medical Centres, location Amsterdam University Medical Centre-University of Amsterdam, Amsterdam, The Netherlands
| | - Gerald F Watts
- Medical School, University of Western Australia, Perth, WA, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, WA, Australia
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam University Medical Centres, location Amsterdam University Medical Centre-University of Amsterdam, Amsterdam, The Netherlands
| | - Laurens F Reeskamp
- Department of Vascular Medicine, Amsterdam University Medical Centres, location Amsterdam University Medical Centre-University of Amsterdam, Amsterdam, The Netherlands.
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Birkenhead K, Sullivan D, Trumble C, Spinks C, Srinivasan S, Partington A, Elias L, Hespe CM, Fleming G, Li S, Calder M, Robertson E, Trent R, Sarkies MN. Implementation of a primary-tertiary shared care model to improve the detection of familial hypercholesterolaemia (FH): a mixed methods pre-post implementation study protocol. BMJ Open 2024; 14:e082699. [PMID: 38692720 PMCID: PMC11086381 DOI: 10.1136/bmjopen-2023-082699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/12/2024] [Indexed: 05/03/2024] Open
Abstract
INTRODUCTION Familial hypercholesterolaemia (FH) is an autosomal dominant inherited disorder of lipid metabolism and a preventable cause of premature cardiovascular disease. Current detection rates for this highly treatable condition are low. Early detection and management of FH can significantly reduce cardiac morbidity and mortality. This study aims to implement a primary-tertiary shared care model to improve detection rates for FH. The primary objective is to evaluate the implementation of a shared care model and support package for genetic testing of FH. This protocol describes the design and methods used to evaluate the implementation of the shared care model and support package to improve the detection of FH. METHODS AND ANALYSIS This mixed methods pre-post implementation study design will be used to evaluate increased detection rates for FH in the tertiary and primary care setting. The primary-tertiary shared care model will be implemented at NSW Health Pathology and Sydney Local Health District in NSW, Australia, over a 12-month period. Implementation of the shared care model will be evaluated using a modification of the implementation outcome taxonomy and will focus on the acceptability, evidence of delivery, appropriateness, feasibility, fidelity, implementation cost and timely initiation of the intervention. Quantitative pre-post and qualitative semistructured interview data will be collected. It is anticipated that data relating to at least 62 index patients will be collected over this period and a similar number obtained for the historical group for the quantitative data. We anticipate conducting approximately 20 interviews for the qualitative data. ETHICS AND DISSEMINATION Ethical approval has been granted by the ethics review committee (Royal Prince Alfred Hospital Zone) of the Sydney Local Health District (Protocol ID: X23-0239). Findings will be disseminated through peer-reviewed publications, conference presentations and an end-of-study research report to stakeholders.
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Affiliation(s)
- Karen Birkenhead
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Sydney Health Partners, Implementation Science Academy, Sydney, New South Wales, Australia
| | - David Sullivan
- Department of Chemical Pathology, NSW Health Pathology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Claire Trumble
- Institute of Precision Medicine and Bioinformatics, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Catherine Spinks
- Institute of Precision Medicine and Bioinformatics, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Shubha Srinivasan
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
- Discipline of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew Partington
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Luke Elias
- FH Australasia Support Group, Sydney, New South Wales, Australia
| | - Charlotte Mary Hespe
- School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Gabrielle Fleming
- Institute of Precision Medicine and Bioinformatics, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Stephen Li
- Core Pathology and Clinical Chemistry, NSW Health Pathology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Madeline Calder
- Institute of Precision Medicine and Bioinformatics, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Elizabeth Robertson
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Ronald Trent
- Institute of Precision Medicine and Bioinformatics, Sydney Local Health District, Sydney, New South Wales, Australia
- Department of Medical Genomics, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Mitchell N Sarkies
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Sydney Health Partners, Implementation Science Academy, Sydney, New South Wales, Australia
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Johnson C, Chen J, McGowan MP, Tricou E, Card M, Pettit AR, Klaiman T, Rader DJ, Volpp KG, Beidas RS. Family cascade screening for equitable identification of familial hypercholesterolemia: study protocol for a hybrid effectiveness-implementation type III randomized controlled trial. Implement Sci 2024; 19:30. [PMID: 38594685 PMCID: PMC11003060 DOI: 10.1186/s13012-024-01355-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 02/25/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Familial hypercholesterolemia (FH) is a heritable disorder affecting 1.3 million individuals in the USA. Eighty percent of people with FH are undiagnosed, particularly minoritized populations including Black or African American people, Asian or Asian American people, and women across racial groups. Family cascade screening is an evidence-based practice that can increase diagnosis and improve health outcomes but is rarely implemented in routine practice, representing an important care gap. In pilot work, we leveraged best practices from behavioral economics and implementation science-including mixed-methods contextual inquiry with clinicians, patients, and health system constituents-to co-design two patient-facing implementation strategies to address this care gap: (a) an automated health system-mediated strategy and (b) a nonprofit foundation-mediated strategy with contact from a foundation-employed care navigator. This trial will test the comparative effectiveness of these strategies on completion of cascade screening for relatives of individuals with FH, centering equitable reach. METHODS We will conduct a hybrid effectiveness-implementation type III randomized controlled trial testing the comparative effectiveness of two strategies for implementing cascade screening with 220 individuals with FH (i.e., probands) per arm identified from a large northeastern health system. The primary implementation outcome is reach, or the proportion of probands with at least one first-degree biological relative (parent, sibling, child) in the USA who is screened for FH through the study. Our secondary implementation outcomes include the number of relatives screened and the number of relatives meeting the American Heart Association criteria for FH. Our secondary clinical effectiveness outcome is post-trial proband cholesterol level. We will also use mixed methods to identify implementation strategy mechanisms for implementation strategy effectiveness while centering equity. DISCUSSION We will test two patient-facing implementation strategies harnessing insights from behavioral economics that were developed collaboratively with constituents. This trial will improve our understanding of how to implement evidence-based cascade screening for FH, which implementation strategies work, for whom, and why. Learnings from this trial can be used to equitably scale cascade screening programs for FH nationally and inform cascade screening implementation efforts for other genetic disorders. TRIAL REGISTRATION ClinicalTrials.gov, NCT05750667. Registered 15 February 2023-retrospectively registered, https://clinicaltrials.gov/study/NCT05750667 .
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Affiliation(s)
- Christina Johnson
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jinbo Chen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary P McGowan
- Family Heart Foundation, Fernandina Beach, FL, USA
- Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Eric Tricou
- Family Heart Foundation, Fernandina Beach, FL, USA
| | - Mary Card
- Family Heart Foundation, Fernandina Beach, FL, USA
| | | | - Tamar Klaiman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel J Rader
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin G Volpp
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
- The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Rinad S Beidas
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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Schubert TJ, Gidding SS, Jones LK. Overcoming the real and imagined barriers to cholesterol screening in pediatrics. J Clin Lipidol 2024:S1933-2874(24)00031-X. [PMID: 38485620 DOI: 10.1016/j.jacl.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/19/2024] [Accepted: 02/21/2024] [Indexed: 03/20/2024]
Abstract
Recent guidance by the United States Preventive Services Task Force has renewed the debate surrounding the benefits of pediatric lipid screening. This commentary reviews the evolution of the pediatric lipid screening recommendations in the United States, followed by an exploration of real and imagined challenges that prevent optimal cholesterol screening rates in children. Real challenges substantively prevent the uptake of these guidelines into practice; imagined challenges, such as identifying the best age to screen, are often context-dependent and can also be surmounted. Experiences from other countries identify potential facilitators to improving screening and additional barriers. Implementation science provides guidance on overcoming the real barriers, translating evidence-based recommendations into clinical practice, and informing the next wave of solutions to overcome these challenges.
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Affiliation(s)
- Tyler J Schubert
- Department of Genomic Health, Geisinger, Danville, PA, USA; Geisinger Commonwealth School of Medicine, Scranton, PA, USA.
| | | | - Laney K Jones
- Department of Genomic Health, Geisinger, Danville, PA, USA; Heart and Vascular Institute, Geisinger, Danville, PA, USA.
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5
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Mensah GA, Fuster V, Roth GA. A Heart-Healthy and Stroke-Free World: Using Data to Inform Global Action. J Am Coll Cardiol 2023; 82:2343-2349. [PMID: 38092508 DOI: 10.1016/j.jacc.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- George A Mensah
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
| | - Valentin Fuster
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Gregory A Roth
- Department of Health Metrics Sciences, Institute for Health Metrics and Evaluation, School of Medicine, University of Washington, Seattle, Washington, USA; Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
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Longoni M, Bhasin K, Ward A, Lee D, Nisson M, Bhatt S, Rodriguez F, Dash R. Real-world utilization of guideline-directed genetic testing in inherited cardiovascular diseases. Front Cardiovasc Med 2023; 10:1272433. [PMID: 37915745 PMCID: PMC10616303 DOI: 10.3389/fcvm.2023.1272433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/29/2023] [Indexed: 11/03/2023] Open
Abstract
Background Cardiovascular disease continues to be the leading cause of death globally. Clinical practice guidelines aimed at improving disease management and positively impacting major cardiac adverse events recommend genetic testing for inherited cardiovascular conditions such as dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), long QT syndrome (LQTS), hereditary amyloidosis, and familial hypercholesterolemia (FH); however, little is known about how consistently practitioners order genetic testing for these conditions in routine clinical practice. This study aimed to assess the adoption of guideline-directed genetic testing for patients diagnosed with DCM, HCM, LQTS, hereditary amyloidosis, or FH. Methods This retrospective cohort study captured real-world evidence of genetic testing from ICD-9-CM and ICD-10-CM codes, procedure codes, and structured text fields of de-identified patient records in the Veradigm Health Insights Ambulatory EHR Research Database linked with insurance claims data. Data analysis was conducted using an automated electronic health record analysis engine. Patient records in the Veradigm database were sourced from more than 250,000 clinicians serving over 170 million patients in outpatient primary care and specialty practice settings in the United States and linked insurance claims data from public and private insurance providers. The primary outcome measure was evidence of genetic testing within six months of condition diagnosis. Results Between January 1, 2017, and December 31, 2021, 224,641 patients were newly diagnosed with DCM, HCM, LQTS, hereditary amyloidosis, or FH and included in this study. Substantial genetic testing care gaps were identified. Only a small percentage of patients newly diagnosed with DCM (827/101,919; 0.8%), HCM (253/15,507; 1.6%), LQTS (650/56,539; 1.2%), hereditary amyloidosis (62/1,026; 6.0%), or FH (718/49,650; 1.5%) received genetic testing. Conclusions Genetic testing is underutilized across multiple inherited cardiovascular conditions. This real-world data analysis provides insights into the delivery of genomic healthcare in the United States and suggests genetic testing guidelines are rarely followed in practice.
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Affiliation(s)
- Mauro Longoni
- Global Medical Affairs Organization, Illumina, Inc., San Diego, CA, United States
| | | | | | | | | | - Sucheta Bhatt
- Global Medical Affairs Organization, Illumina, Inc., San Diego, CA, United States
| | - Fatima Rodriguez
- HealthPals Inc., Redwood, CA, United States
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
| | - Rajesh Dash
- HealthPals Inc., Redwood, CA, United States
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
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7
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Lan NSR, Bajaj A, Watts GF, Cuchel M. Recent advances in the management and implementation of care for familial hypercholesterolaemia. Pharmacol Res 2023; 194:106857. [PMID: 37460004 DOI: 10.1016/j.phrs.2023.106857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/07/2023] [Accepted: 07/14/2023] [Indexed: 07/22/2023]
Abstract
Familial hypercholesterolaemia (FH) is a common autosomal semi-dominant and highly penetrant disorder of the low-density lipoprotein (LDL) receptor pathway, characterised by lifelong elevated levels of low-density lipoprotein cholesterol (LDL-C) and increased risk of atherosclerotic cardiovascular disease (ASCVD). However, many patients with FH are not diagnosed and do not attain recommended LDL-C goals despite maximally tolerated doses of potent statin and ezetimibe. Over the past decade, several cholesterol-lowering therapies such as those targeting proprotein convertase subtilisin/kexin type 9 (PCSK9) or angiopoietin-like 3 (ANGPTL3) with monoclonal antibody or ribonucleic acid (RNA) approaches have been developed that promise to close the treatment gap. The availability of new therapies with complementary modes of action of lipid metabolism has enabled many patients with FH to attain guideline-recommended LDL-C goals. Emerging therapies for FH include liver-directed gene transfer of the LDLR, vaccines targeting key proteins involved in cholesterol metabolism, and CRISPR-based gene editing of PCSK9 and ANGPTL3, but further clinical trials are required. In this review, current and emerging treatment strategies for lowering LDL-C, and ASCVD risk-stratification, as well as implementation strategies for the care of patients with FH are reviewed.
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Affiliation(s)
- Nick S R Lan
- Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia; School of Medicine, The University of Western Australia, Perth, Australia.
| | - Archna Bajaj
- Division of Translational Medicine & Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gerald F Watts
- Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia; School of Medicine, The University of Western Australia, Perth, Australia
| | - Marina Cuchel
- Division of Translational Medicine & Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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