Review of evidence and explanations for suboptimal screening and treatment of dyslipidemia in women. A conceptual model

Gender disparities in patient education provided during patient visits with a diagnosis of coronary heart disease

Background:

Cardiovascular disease is the leading cause of death in females in the United States. Prior studies have reported that females receive less patient education and preventive counseling for cardiovascular disease as compared with males. The American Heart Association and others have embarked on several initiatives over the last 20 years to narrow this disparity of care. The primary objective of this study was to determine whether a gender disparity remains in the provision of patient education among patients diagnosed with coronary heart disease, a form of cardiovascular disease. The secondary objective was to determine whether there is an association between the provision of patient education and sociodemographic variables and risk factors.

Methods:

This was a retrospective, cross-sectional, observational study of adults (⩾18 years) diagnosed with coronary heart disease who participated in National Ambulatory Medical Care Survey between the years 2005 and 2014, inclusive. Chi-square tests of independence were performed to address the primary objective. A multivariable logistic regression model was constructed to assess the association between gender and provision of patient education while adjusting for sociodemographic variables and risk factors of interest.

Results:

A total raw survey sample size of 17,332 patient visits meeting the study inclusion/exclusion criteria was utilized. Patients were predominately white, male, non-Hispanic, and ⩾75 years of age. Females had 0.86 times the odds of receiving patient education compared with males (95% confidence interval = 0.78–0.95, p = 0.0024). After adjusting for covariates of interest, gender remained statistically significant in the multivariable logistic model. In addition, the variables “other payer” (vs private insurance), tobacco use, primary care physician type, obesity, hyperlipidemia, and hypertension were found to be statistically significantly associated with the provision of patient education (p < 0.05) in the multivariable analysis.

Conclusion:

In the data analyzed, gender disparities exist, as evidenced by a greater proportion of males receiving patient education than females, among coronary heart disease patients during visits seeking medical care. The acceptability of these findings in terms of overall patient management and treatment goals requires further evaluation.

Hyperlipidemia and Medical Expenditures by Cardiovascular Disease Status in US Adults

BACKGROUND

Hyperlipidemia is a major risk factor for cardiovascular disease (CVD), affecting 73.5 million American adults. Information about health care expenditures associated with hyperlipidemia by CVD status is needed to evaluate the economic benefit of primary and secondary prevention programs for CVD.

METHODS

The study sample includes 48,050 men and nonpregnant women ≥18 from 2010 to 2012 Medical Expenditure Panel Survey. A 2-part econometric model was used to estimate annual hyperlipidemia-associated medical expenditures by CVD status. The estimation results from the 2-part model were used to calculate per-capita and national medical expenditures associated with hyperlipidemia. We adjusted the medical expenditures into 2012 dollars.

RESULTS

Among those with CVD, per person hyperlipidemia-associated expenditures were $1105 [95% confidence interval (CI), $877-$1661] per year, leading to an annual national expenditure of $15.47 billion (95% CI, $5.23-$27.75 billion). Among people without CVD, per person hyperlipidemia-associated expenditures were $856 (95% CI, $596-$1211) per year, resulting in an annual national expenditure of $23.11 billion (95% CI, $16.09-$32.71 billion). Hyperlipidemia-associated expenditures were attributable mostly to the costs of prescription medication (59%-90%). Among people without CVD, medication expenditures associated with hyperlipidemia were $13.72 billion (95% CI, $10.55-$15.74 billion), higher in men than in women.

CONCLUSIONS

Hyperlipidemia significantly increased medical expenditures and the increase was higher in people with CVD than without. The information on estimated expenditures could be used to evaluate and develop effective programs for CVD prevention.

Patient, Physician, and Practice Characteristics Associated with Cardiovascular Disease Preventive Care for Women

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death for American women. Although CVD preventive care has the potential to reduce a significant number of these deaths, the degree to which healthcare providers deliver such care is unknown. The purpose of this study was to identify patient, physician, and practice characteristics that significantly influence the provision of CVD preventive care during ambulatory care visits for female patients.

METHODS

The National Ambulatory Medical Care Survey datasets from 2005 to 2010 were utilized. The study sample included female patients ≥20 years of age whose healthcare provider performed CVD preventive care and who had visits for a new health problem, a routine chronic problem, management of a chronic condition, and preventive care. Binary logistic regression models estimated the association of patient, physician, and practice characteristics and CVD preventive care; cholesterol testing, body mass index (BMI) screening, and tobacco education.

RESULTS

Of the 32,009 visits, 15.9% involved cholesterol testing, 50.3% involved BMI screening, and 3.20% involved tobacco education. Obstetricians/gynecologists were less likely to perform cholesterol testing (aOR: 0.39; 95% CI: 0.25-0.61) and tobacco education (aOR: 0.56; 95% CI: 0.32-0.98) than general/family physicians.

CONCLUSION

The delivery of CVD preventive care varied by healthcare provider type, with obstetricians/gynecologists having lower odds of providing two of the three services. The amount of time a physician spent with a patient was a significant predictor for the provision of all three services. These findings demonstrate the need to implement multifaceted approaches to address predicting characteristics of CVD preventive care.

Gender Disparities in Lipid-Lowering Therapy in Cardiovascular Disease: Insights from a Managed Care Population

BACKGROUND

Numerous studies have documented the strong inverse relationship between low-density lipoprotein cholesterol (LDL-C) levels and atherosclerotic cardiovascular disease (ASCVD). However, women are less likely to be screened for hypercholesterolemia, receive lipid-lowering therapy (LLT), and achieve optimal LDL-C levels.

MATERIALS AND METHODS

Data were extracted from a U.S. administrative claims database between January 2008 and December 2012 for patients with established ASCVD. The earliest date of valid LDL-C value was defined as the index date. Patients were followed for ±12 months from the index date and were stratified by gender, by baseline LDL-C level, and whether they were initially treated with a LLT then propensity score matched by gender using demographic and clinical characteristics. Both descriptive statistics and logistic regression models were used to explore the association of gender with the frequency of LDL-C monitoring, LLT treatment initiation in initially untreated patients, and prescribing patterns in initially treated patients.

RESULTS

A total of 76,414 subjects with established ASCVD were identified; 42% of the sample was women. In the unmatched cohort, 50.3% of men and 32.0% of women were prescribed a preindex statin (p < 0.0001). Among matched patients (n = 51,764), women initially treated with LLT were significantly less likely to receive a prescription for a higher potency LLT. Even among those with LDL-C levels above 160 mg/dL, women were more likely to discontinue LLT, odds ratio (95% confidence interval) 1.8 (1.2-2.3). Female gender and older age were significant predictors of discontinuation, and the potency of the index medication was the strongest predictor of dose titration. Initially untreated women were less likely to initiate LLT treatment than men, irrespective of index LDL-C levels (p < 0.0001).

CONCLUSIONS

The observed disparities further reinforce the need for targeted efforts to reduce the gender gap for secondary prevention in women at high risk of cardiovascular disease.

Sex differences in patient and provider response to elevated low-density lipoprotein cholesterol

BACKGROUND

Despite American Heart Association recommendations of diet/lifestyle modification and statin therapy to achieve low-density lipoprotein cholesterol (LDL) control, women are less likely than men to be screened and achieve treatment goals. This study determined whether the provider and patient response to electronic medical record (EMR) notification of an elevated LDL varied by patient sex in veterans.

METHODS

Provider responses to EMR clinical reminders for an elevated LDL (≥100 mg/dL) were assessed in men (n = 40,738) and women (n = 1,025) veterans with ischemic heart disease or diabetes between October 2008 and September 2009. Responses were classified into four types: 1) Whether the patient refused medication, 2) the provider ordered or adjusted medication, 3) treatment was deferred/medications were not changed, or 4) medications were contraindicated. Logistic regression with generalized estimating equations was used to compare clinical reminder responses between men and women patients.

FINDINGS

Providers were less likely to order or adjust medications for women (adjusted odds ratio [OR], 0.75; 95% CI, 0.63, 0.88) and women were more likely than men to refuse medication (adjusted OR, 1.71; 95% CI, 1.34, 2.17). These associations were not modified by degree of LDL elevation or use of lipid-lowering medications.

CONCLUSION

These results indicate that poorer cholesterol control in at risk women is likely a consequence of both provider and patient factors.

Goal attainments and their discrepancies for low density lipoprotein cholesterol (LDL-C) and apolipoprotein B (apo B) in over 2,000 Chinese patients with known coronary artery disease or type 2 diabetes

PURPOSE

Low density lipoprotein cholesterol (LDL-C) is primary treatment target for patients with dislipidemia. The apolipoprotein B (apo B), an emerging biomarker for cardiovascular risk prediction, appears to be superior to the LDL-C. However, little is known about goal attainments and their discrepancies for LDL-C and apo B in Chinese patients with known CAD or DM.

METHODS

A total of 2,172 hospitalized patients with known coronary artery disease (CAD) or DM, aged >27 years of old, were enrolled. The success rates for apo B and LDL-C goal attainments were evaluated and compared by categorization and by sex.

RESULTS

When the success rates for apo B were compared with the ones for LDL-C, the former was higher than the latter across all categorizations, with the statistically significant differences seen in all patients, CAD alone and DM alone (P<0.0001), but not in coexistence of CAD and DM (P=0.190). The trend toward to higher success rates for LDL-C and apo B goal attainments in men than in women were noteworthy across all categorizations although only in all patients and in DM alone patients were the statistically significant differences found (P<0.01).

CONCLUSIONS

The LDL-C lags behind the apo B in goal attainments in Chinese patients. Whether these discrepancies are associated with the occurrence differences for CAD and for stroke between the East Asia and the Western countries warrants further study.

Association between facility characteristics and the process of care delivered to patients with hepatitis C virus infection

BACKGROUND

Available data suggest problems in the process of care provided to patients with chronic hepatitis C (HCV). However, the solutions to these problems are less obvious. Healthcare facility factors are potentially modifiable and may enhance process quality in HCV treatment.

METHODS

We evaluated the relationship between the process of HCV care and facility factors including number of weekly half-day HCV clinics per 1,000 HCV patients, HCV-specific quality-improvement initiatives, and administrative service of the HCV clinic (gastroenterology, infectious disease, primary care) for a cohort of 34,258 patients who sought care in 126 Veterans Affairs facilities during 2003-2006. We measured HCV care on the basis of 23 HCV-specific process measures capturing pretreatment (seven measures), preventive and/or comorbid (seven measures), and treatment and treatment monitoring care (nine measures).

RESULTS

Patients seen at a facility with >8 half-day clinics were 52 % more likely to receive overall indicated care (OR 1.52, 95 % CI 1.13-2.05). Patients seen at a facility with >3 HCV quality improvement initiatives were more likely to receive better preventive and/or comorbid care (OR 1.32, 95 % CI 1.00-1.74). Compared with patients in facilities with no dedicated HCV clinic, patients at facilities with gastroenterology-based clinics received better pretreatment care (OR 1.36, 95 % CI 1.01-1.85) and more antiviral treatment (OR 1.45, 95 % CI 1.06-1.97) whereas those at facilities with infectious disease-based or primary care-based clinics received better preventive and/or comorbid care (OR 1.59, 95 % CI 1.06-2.39 and 1.84, 95 % CI 1.21-2.79 respectively).

CONCLUSION

Several facility factors affected the process of HCV care. These factors may serve as targets for quality-improvement efforts.

Impact of performance improvement continuing medical education on cardiometabolic risk factor control: the COSEHC initiative

INTRODUCTION

The Consortium for Southeastern Hypertension Control (COSEHC) implemented a study to assess benefits of a performance improvement continuing medical education (PI CME) activity focused on cardiometabolic risk factor management in primary care patients.

METHODS

Using the plan-do-study-act (PDSA) model as the foundation, this PI CME activity aimed at improving practice gaps by integrating evidence-based clinical interventions, physician-patient education, processes of care, performance metrics, and patient outcomes. The PI CME intervention was implemented in a group of South Carolina physician practices, while a comparable physician practice group served as a control. Performance outcomes at 6 months included changes in patients' cardiometabolic risk factor values and control rates from baseline. We also compared changes in diabetic, African American, the elderly (> 65 years), and female patient subpopulations and in patients with uncontrolled risk factors at baseline.

RESULTS

Only women receiving health care by intervention physicians showed a statistical improvement in their cardiometabolic risk factors as evidenced by a -3.0 mg/dL and a -3.5 mg/dL decrease in mean LDL cholesterol and non-HDL cholesterol, respectively, and a -7.0 mg/dL decrease in LDL cholesterol among females with uncontrolled baseline LDL cholesterol values. No other statistical differences were found.

DISCUSSION

These data demonstrate that our PI CME activity is a useful strategy in assisting physicians to improve their management of cardiometabolic control rates in female patients with abnormal cholesterol control. Other studies that extend across longer PI CME PDSA periods may be needed to demonstrate statistical improvements in overall cardiometabolic treatment goals in men, women, and various subpopulations.

Translating cholesterol guidelines into primary care practice: a multimodal cluster randomized trial

PURPOSE We wanted to determine whether an intervention based on patient activation and a physician decision support tool was more effective than usual care for improving adherence to National Cholesterol Education Program guidelines. METHODS A 1-year cluster randomized controlled trial was performed using 30 primary care practices (4,105 patients) in southeastern New England. The main outcome was the percentage of patients screened for hyperlipidemia and treated to their low-density lipoprotein (LDL) and non-high-density lipoprotein (HDL) cholesterol goals. RESULTS After 1 year of intervention, both randomized practice groups improved screening (89% screened), and 74% of patients in both groups were at their LDL and non-HDL cholesterol goals (P <.001). Using intent-to-treat analysis, we found no statistically significant differences between practice groups in screening or percentage of patients who achieved LDL and non-HDL cholesterol goals. Post hoc analysis showed practices who made high use of the patient activation kiosk were more likely to have patients screened (odds ratio [OR] = 2.54; 95% confidence interval [CI], 1.97-3.27) compared with those who made infrequent or no use. Additionally, physicians who made high use of decision support tools were more likely to have their patients at their LDL cholesterol goals (OR = 1.27; 95% CI, 1.07-1.50) and non-HDL goals (OR = 1.23; 95% CI, 1.04-1.46) than low-use or no-use physicians. CONCLUSION This study showed null results with the intent-to-treat analysis regarding the benefits of a patient activation and a decision support tool in improving cholesterol management in primary care practices. Post hoc analysis showed a potential benefit in practices that used the e-health tools more frequently in screening and management of dyslipidemia. Further research on how to incorporate and increase adoption of user-friendly, patient-centered e-health tools to improve screening and management of chronic diseases and their risk factors is warranted.

National gender-specific trends in myocardial infarction hospitalization rates among patients aged 35 to 64 years

In recent years, the prevalence of myocardial infarction (MI) has increased among women and decreased among men aged 35 to 54 years. To determine the extent to which changes in incidence account for recent variations in prevalence, we assessed the temporal trends in gender-specific hospitalization rates for MI. Using the Nationwide Inpatient Sample, we identified patients aged 35 to 64 years admitted to United States hospitals with a primary discharge diagnosis of MI from 1997 to 2006 (n = 2,824,615). The age-standardized MI hospitalization rates per 100,000 subjects were assessed for men and women aged 35 to 44, 45 to 54, and 55 to 64 years. The MI hospitalization rates per 100,000 subjects decreased by 26% from 168 to 126 for men and by 18% from 56 to 46 for women (both p <0.001). The reductions in the MI hospitalization rates were greatest among men aged 45 to 54, men aged 55 to 64, and women aged 55 to 64 years (standardized rates of change -3%, -4%, and -3% annually, p <0.001). The MI hospitalization rates decreased slightly for women aged 45 to 54 years and men aged 35 to 44 years (standardized rate of change -2% annually, p <0.001) and increased for women aged 35 to 44 years (standardized rate of change 2% annually, p = 0.008). In conclusion, from 1997 to 2006, men and women aged 35 to 64 years experienced an overall decrease in MI hospitalization rates; the reductions were more pronounced in men than in women. The slight increase in MI hospitalizations among women aged 35 to 44 years might have played a small role in the previously noted increases in MI prevalence among middle-age women.

Response by sex to statin plus ezetimibe or statin monotherapy: a pooled analysis of 22,231 hyperlipidemic patients

Background

Despite documented benefits of lipid-lowering treatment in women, a considerable number are undertreated, and fewer achieve treatment targets vs. men.

Methods

Data were combined from 27 double-blind, active or placebo-controlled studies that randomized adult hypercholesterolemic patients to statin or statin+ezetimibe. Consistency of treatment effect among men (n = 11,295) and women (n = 10,499) was assessed and percent of men and women was calculated to evaluate the between-treatment ability to achieve specified treatment levels between sexes.

Results

Baseline lipids and hs-CRP were generally higher in women vs. men. Between-treatment differences were significant for both sexes (all p < 0.001 except apolipoprotein A-I in men = 0.0389). Men treated with ezetimibe+statin experienced significantly greater changes in LDL-C (p = 0.0066), non-HDL-C, total cholesterol, triglycerides, HDL-C, apolipoprotein A-I (all p < 0.0001) and apolipoprotein B (p = 0.0055) compared with women treated with ezetimibe+statin. The odds of achieving LDL-C < 100 mg/dL, apolipoprotein B < 90 mg/dL and the dual target [LDL-C < 100 mg/dL & apoliprotein B < 90 mg/dL] was significantly greater for women vs. men and the odds of achieving hs-CRP < 1 and < 2 mg/L and dual specified levels of [LDL-C < 100 mg/dL and hs-CRP < 2 mg/L] were significantly greater for men vs. women. Women reported significantly more gall-bladder-related, gastrointestinal-related, and allergic reaction or rash-related adverse events (AEs) vs. men (no differences between treatments). Men reported significantly more CK elevations (no differences between treatments) and hepatitis-related AEs vs. women (significantly more with ezetimibe+simvastatin vs. statin).

Conclusions

These results suggest that small sex-related differences may exist in response to lipid-lowering treatment and achievement of specified lipid and hs-CRP levels, which may have implications when managing hypercholesterolemia in women.

A taxonomy of reasons for not prescribing guideline-recommended medications for patients with heart failure

BACKGROUND

Performance-measurement systems may work best when they account for the reasons why physicians do not provide guideline-recommended interventions.

OBJECTIVE

This article develops a conceptual framework for understanding the proximate, patient-centered reasons why physicians do not prescribe angiotensin-converting enzyme (ACE) inhibitors or β-blockers to patients with heart failure and reduced systolic function.

METHODS

This was a focus group study using a 2-stage design. Academically affiliated clinicians of different specialties and levels of training were recruited by e-mailed invitations sent to clinicians within each target group. To be included, candidates needed to be currently practicing in an ambulatory care setting in which they encountered patients with heart failure. In the first part of each group, participants were asked to describe reasons for not prescribing ACE inhibitors or â-blockers for patients with heart failure. Next, participants were asked to develop concept maps that organized these reasons into categories and described the relationships between these categories. The concept maps from each group were synthesized to develop a consensus scheme for categorizing reasons for nonprescribing.

RESULTS

There were 31 participants in 7 focus groups; median age was 31 years and 55% (17/31) were women. Two broad themes emerged. First, clinicians hinted at their own attitude-related barriers to prescribing. However, they framed their comments largely in terms of patient-centered reasons for nonprescribing that arose in individual patient encounters. Second, decision making about heart failure drug therapy often involved a complex and overlapping series of considerations. Five categories of reasons for not prescribing ACE inhibitors or â-blockers emerged: (1) adverse effects of drug therapy; (2) nonadherence to therapeutic and monitoring plan; (3) patients' preferences and beliefs; (4) comanagement and transitions of care; and (5) prioritization and patient benefit.

CONCLUSIONS

Physicians' reasons for not prescribing guideline-recommended drugs for heart failure are complex but can be organized into a useful taxonomy. This taxonomy may be helpful for performance-measurement and quality-improvement programs that seek to understand reasons for physicians' nonadherence to guidelines.

Importance of patient, provider, and facility predictors of hepatitis C virus treatment in veterans: a national study

OBJECTIVES

Several patient characteristics are known to impact hepatitis C virus (HCV) antiviral treatment rates. However, it is unclear whether, and to what extent, health-care providers or facility characteristics impact HCV treatment rates.

METHODS

Using national data obtained from the Department of Veterans Affairs (VA) HCV Clinical Case Registry, we conducted a retrospective cohort study of patients with active HCV viremia, who were diagnosed between 2003 and 2004. We evaluated patient-, provider-, and facility-level predictors of receipt of HCV treatment with hierarchical logistic regression.

RESULTS

The overall HCV treatment rate in 29,695 patients was 14.2%. The strongest independent predictor for receipt of treatment was consultation with an HCV specialist (odds ratio=9.34; 8.03-10.87). Patients were less likely to receive HCV treatment if they were Black, older, male, current users of alcohol or drugs, had HCV genotype 1 or 4, had higher creatinine levels, or had severe anxiety/post-traumatic stress disorder or depression. Patients with high hemoglobin levels, cirrhosis, and persistently high liver enzyme levels were more likely to receive treatment. Patient, provider, and facility factors explained 15, 4, and 4%, respectively, of the variation in treatment rates.

CONCLUSIONS

Treatment rates for HCV are low in the VA. In addition to several important patient-level characteristics, a specialist consultant has a vital role in determining whether a patient should receive HCV treatment. These findings support the development of patient-level interventions targeted at identifying and managing comorbidities and contraindications and fostering greater involvement of specialists in the care of HCV.

National sex-specific trends in hospital-based stroke rates

Mounting regional and national evidence suggests a decline in primary in-hospital stroke diagnoses. However, these data do not include secondary diagnoses of stroke, and little is known about whether this decline varies significantly by sex. Compared with men, women are less likely to have optimal control of stroke risk factors, which may be leading to less impressive declines in stroke incidence in women. This study evaluated sex trends in hospital-based stroke diagnoses in the United States. The study was a time-trend analysis by sex of national age-adjusted rates of primary or secondary hospital-based stroke diagnosis per 100,000 persons (identified by ICD-9 procedure codes) among patients for 1997-2006 using data from all US states contributing to the Nationwide Inpatient Sample. Adjustments were made to correct for some inaccuracies in diagnostic codes. Between 1997 and 2006, total hospital-based stroke diagnoses decreased from 680,607 to 609,359. The age-adjusted hospital-based stroke diagnosis rate per 100,000 persons decreased in a roughly linear pattern from 282.7 to 210.4 in men (26%; P < .001) and from 240.5 to 184.7 in women (23%; P < .05). The average rate of decrease (slope) in hospital-based stroke diagnosis rates was greater in men than in women (-8.7 vs -7.5 per 100,000 persons; P = .003). Age-adjusted rates of hospital-based stroke diagnoses have decreased substantially in the United States during the last decade, but slightly less so in women. These results are generally encouraging, but nonetheless indicate that more intensive preventive efforts are warranted to completely eliminate sex disparities in stroke occurrence.

Differences in cardiovascular disease risk factor management in primary care by sex of physician and patient

PURPOSE

The purpose of this study was to evaluate differences in the management of cardiovascular disease (CVD) risk factors based upon the sex of the patient and physician and their interaction in primary care practice.

METHODS

We evaluated CVD risk factor management in 4,195 patients cared for by 39 male and 16 female primary care physicians in 30 practices in southeastern New England.

RESULTS

Many of the sex-based differences in CVD risk factor management on crude analysis are lost once adjusted for confounding factors found at the level of the patient, physician, and practice. In multilevel adjusted analyses, styles of CVD risk factor management differed by the sex of the physician, with more female physicians documenting diet and weight loss counseling for hypertension (odds ratio [OR] = 2.22; 95% confidence interval [CI], 1.12-4.40) and obesity (OR = 2.14; 95% CI, 1.30-3.51) and more physical activity counseling for obesity (OR = 2.03; 95% CI, 1.30-3.18) and diabetes (OR = 6.55; 95% CI, 2.01-21.33). Diabetes management differed by the sex of the patient, with fewer women receiving glucose-lowering medications (OR = 0.49; 95% CI, 0.25-0.94), angiotensin-converting enzyme inhibitor therapy (OR = 0.39; 95% CI, 0.22-0.72), and aspirin prophylaxis (OR = 0.30; 95% CI, 0.15-0.58).

CONCLUSION

Quality of care as measured by patients meeting CVD risk factors treatment goals was similar regardless of the sex of the patient or physician. Selected differences were found in the style of CVD risk factor management by sex of physician and patient.

Gender differences in the lipid profile of dyslipidemic subjects

OBJECTIVE

We evaluated the gender-associated differences in lipid profile of subjects intended to receive lipid-lowering therapy with emphasis on the associations between triglycerides (TG) and other plasma lipid variables.

DESIGN

Lipid profiles of 1385 patients [aged 55+/-11 years, 549 women (40%)] were evaluated. Eligible subjects fulfilled one or more of the following criteria: total cholesterol (TC)>or=6.2 mmol/l, TG>or=1.7 mmol/l, and high-density lipoprotein cholesterol (HDL-C)<1.0 mmol/l. Patients were divided into subgroups according to TG and HDL-C levels.

RESULTS

Women aged on average 3.5 years older, had higher TC and HDL-C, lower TG and a correspondingly lower TC/HDL-C ratio than men. High TG and low HDL-C in tandem appeared twice more frequently in men. Inverse correlations between HDL-C and TG levels were found to exist in the entire cohort (r=-0.354, p<0.001) and in all various subgroups. In the subgroup with TG<1.7 mmol/l, women had higher TC and HDL-C, lower TG levels and lower TC/HDL-C ratio compared with men. In the subgroup with TG>or=1.7 mmol/l, women had higher TC and HDL-C levels and lower TC/HDL ratio compared with men. In the subgroup with HDL-C>or=1.0 mmol/l women had higher HDL-C, lower TG levels and lower TC/HDL-C ratio compared with men.

CONCLUSIONS

Elevated TG levels and low HDL-C in tandem are common lipid abnormalities in the clinical setting of primary and secondary preventions. Gender-associated differences in the lipid profile are evident in subjects presenting with dyslipidemia and might be of potential relevance for diagnostics and therapy for the prevention of atherosclerosis.

Clinical inertia in the management of low-density lipoprotein abnormalities in an HIV clinic

A retrospective cohort study evaluating the frequency of and factors related to clinical inertia in low-density lipoprotein (LDL) management was performed. Subjects were 90 patients that were not meeting National Cholesterol Education Program Adult Treatment Panel III LDL goals at the University of Alabama at Birmingham 1917 HIV/AIDS Clinic between 1 August 2004 and 1 August 2005. Clinical inertia was observed in 44% of cases. Patients with higher baseline LDL levels were less likely to experience inertia, whereas women and those in the highest coronary heart disease risk category were more likely to be affected.

Predictors of treatment in patients with chronic hepatitis C infection - role of patient versus nonpatient factors

Treatment with interferon and ribavirin is effective in patients with chronic infection with hepatitis C virus (HCV). Previous data indicate that treatment rates are suboptimal. We sought to identify patient and provider-level predictors of treatment receipt in HCV by conducting a retrospective cohort study of 5701 HCV patients in a large regional Veteran's Administration (VA) healthcare network. We also determined the degree of variation in treatment rates attributable to patient, provider, and facility factors. Three thousand seven hundred forty-three patients (65%) were seen by a specialist and 894 (15.7%) received treatment. Treatment rates varied from 6% to 29% across the 5 facilities included in the analysis. Patients were less likely to receive treatment if they were older [RR, 0.55; 95% CI, 0.45, 0.67), single (RR, 0.77; 95%CI, 0.67, 0.88), had hepatic dysfunction (RR, 0.73; 95%CI, 0.66, 0.89), had normal alanine aminotransferase (ALT) (RR, 0.73; 95%CI, 0.59, 0.89), had HCV genotype 1 (RR, 0.78; 95%CI, 0.71, 0.86), were African American with genotype 1 (RR, 0.78; 95% CI, 0.71, 0.86), or were anemic (RR, 0.70; CI, 0.60, 0.89). In addition, patients evaluated by less experienced providers were 77% less likely to receive treatment than those evaluated by more experienced providers. The patient, provider, and facility factors explained 23%, 25%, and 7% of variation in treatment rates, respectively.

CONCLUSION

These data suggest that although patient characteristics are important predictors of treatment in HCV, a significant proportion of variation in treatment rates is explained by provider factors. These potentially modifiable provider-level factors may serve as high-yield targets for future quality improvement initiatives in HCV.

Hyperlipidemia guideline adherence and association with patient gender

BACKGROUND

Gender disparities in cardiovascular disease (CVD) management have become increasingly apparent in recent years. Previous research has focused on inpatient disparities, but little is known about how patient gender affects assessment, treatment, and management of patients for hyperlipidemia and cardiovascular risk in primary care settings. Patients with coronary artery disease (CAD) and hyperlipidemia are at high risk for cardiovascular and cerebrovascular morbidity. We sought to examine the effect of patient gender on assessment, treatment, and target maintenance of hyperlipidemia among patients with CAD in a primary care setting.

METHODS

Chart abstraction was done for 715 patients with CAD in 55 family practices in New Jersey and eastern Pennsylvania as part of the Using Learning Teams for Reflective Adaptation (ULTRA) project. Hyperlipidemia assessment, treatment, and target adherence scores were determined for those at-risk patients based on National Heart, Lung, and Blood Institute (NHLBI) recommended National Cholesterol Education Program (NCEP) ATP III guidelines. Generalized linear models were used to determine the association of hyperlipidemia guideline adherence with patient gender, using comorbidities and age as confounders.

RESULTS

After controlling for comorbidities and age, women were less likely to be assessed for lipids (p = 0.0462). There was no difference in treatment (p = 0.1074) or target laboratory values (p = 0.3949).

CONCLUSIONS

Women with CAD are less often assessed for lipids than men in primary care practices. More intensive efforts may be necessary to educate physicians and patients about cardiovascular risk for women.

Lipid Abnormalities in Women

In multiple randomized, controlled clinical trials, statin treatment of elevated low-density lipoprotein cholesterol in women at increased risk of or with coronary heart disease decreased the risk of coronary events: coronary death, nonfatal myocardial infarction, and myocardial revascularization procedures. Total mortality was unchanged, potentially reflecting the underrepresentation of women in these trials and consequent small number of fatal events. Statin therapy provided comparable benefit for women and men with acute coronary syndromes. Application of lipid-lowering therapy with statin drugs is currently underutilized in women, and represents an opportunity to improve clinical cardiovascular outcomes for women.

Missed targets: gender differences in the identification and management of dyslipidemia

Gender differences in the treatment of heart disease have a significant impact on the outcomes and mortality for women. From screening and detection, through treatment and intervention, women are less likely than men to receive guideline-based care. Risk factor modification, including lipid management, is critical to all levels of prevention. This article discusses gender differences in the detection and management of dyslipidemia. By identifying the suboptimal recognition and treatment of lipid abnormalities in women, healthcare professionals can revise their practice patterns in an effort to improve the outcomes for women with cardiovascular disease.

Dyslipidemia in Menopause: Mechanisms and Management

Data concerning cardiovascular disease in women is rapidly expanding. It is now known that women are more likely to die from cardiovascular disease each year than men and that the incidence of cardiovascular disease in women increases dramatically in the postmenopausal years. Physicians who care for menopausal women should be able to counsel, diagnose, and treat or refer women who have modifiable risk factors for coronary artery disease. Dyslipidemia is one risk factor that can be diagnosed easily. Data from the National Cholesterol Education Program, Adult Treatment Panel III give clear guidelines for interpreting lipid abnormalities and following these women. This article provides an overview of dyslipidemia, screening recommendations, interpretation of results, and management or referral of these patients.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to state that women are more likely to die from cardiovascular disease each year than men, recall that the incidence increases in the postmenopausal years, and explain that dyslipidemia screening and treatment is a method of prevention of adverse outcomes.

Gender differences in the management of risk factors for cardiovascular disease: the importance of insurance status

Despite cardiovascular disease (CVD) being the leading killer of both sexes in the US, there are indications that men and women have different experiences in the health system with prevention and treatment practices. Beyond largely descriptive findings, little research exists that addresses how men and women may differ in their response to certain key influences on CVD health services utilization. This paper examines gender differentials in the effect of insurance coverage on CVD preventive health services in the US. An economics framework is used to model individual demand for preventive services as a function of insurance status, while controlling for a comprehensive set of explanatory variables. The services analyzed include cholesterol and blood pressure screening, pharmaceutical use for hypertension and lipid disorders, and CVD-related physician visits. Both general and high-risk samples are evaluated. The results show that while a lack of insurance is associated with lower rates of utilization in both men and women, there are no observed gender differences in insurance-effects for recommended intervals of risk factor screening in the general population. However, for individuals with previously diagnosed heart disease or stroke, a lack of coverage is more strongly associated with lower rates of screening, pharmaceutical management, and physician contact in women than men. Potential reasons for these findings are discussed and policy implications are noted.

Quality of cardiovascular disease preventive care and physician/practice characteristics

BACKGROUND

Quality of cardiovascular disease (CVD) preventive care is suboptimal. Recent data correlated increasing years in practice for physicians with lower-quality health care.

OBJECTIVE

The purpose of this study was to assess physician awareness/adherence to national blood pressure, cholesterol, and CVD prevention guidelines for women according to physician/practice characteristics.

DESIGN

Standardized online survey and experimental case studies were administered to 500 randomly selected U.S. physicians. Multivariable regression models tested physician age, gender, specialty, and practice type as independent predictors of guideline awareness/adherence.

RESULTS

Compared with older physicians (50+ years), younger physicians (<50 years) reported a lower level of awareness of cholesterol guidelines (P=.04) and lower incorporation of women's guidelines (P=.02). Yet, older physicians were less likely to recommend weight management for high-risk cases (P=.03) and less confident in helping patients manage weight (P=.045) than younger physicians. Older physicians were also less likely to identify a low-density lipoprotein<100 mg/dL as optimal versus younger physicians (P=.01), as were solo versus nonsolo practitioners (P=.02). Solo practitioners were less aware of cholesterol guidelines (P=.04) and were more likely to prescribe aspirin for low-risk female patients than nonsolo practitioners (P<.01). Solo practitioners rated their clinical judgment as more effective than guidelines in improving patient health outcomes (P<.01) and more frequently rated the patient as the greatest barrier to CVD prevention versus nonsolo practitioners (P<.01).

CONCLUSIONS

Though guideline awareness is high, efforts to promote their utilization are needed and may improve quality outcomes. Targeted education and support for CVD prevention may be helpful to older and solo physicians.

Lipid Testing and Lipid-Lowering Therapy in Hospitalized Ischemic Stroke and Transient Ischemic Attack Patients

Background and Purpose— Recent recommendations call for in-hospital initiation of lipid-lowering therapy (LLT) for most ischemic stroke (IS) and transient ischemic attack (TIA) survivors; however, little is known about actual use. This study describes use of and predictors for in-hospital lipid testing and LLT using data from a statewide stroke registry.

Methods— In 2002, the registry ascertained cases from a stratified sample of 16 hospitals. This study includes only IS and TIA cases discharged alive.

Results— In 1907 study subjects, 30.2% (27.2% to 33.5%) were on LLT at admission. In 1399 subjects not on LLT at admission, 37.2% (30.2% to 44.9%) underwent lipid testing, and 12.9% (7.2% to 22.1%) received LLT at discharge. Use of testing and LLT varied widely between hospitals ( P <0.001). In-hospital lipid testing was positively associated with large teaching hospitals ( P =0.029), and neurologist or neurosurgeon ( P =0.004); and negatively associated with increasing age ( P =0.002), being female ( P =0.020), a previous medical history of atrial fibrillation ( P =0.002), nonambulatory status ( P =0.005), and poor prognosis ( P <0.001). LLT at discharge was positively associated with a previous medical history of dyslipidemia ( P <0.001), lipid testing ( P =0.004), and elevated low-density lipoprotein levels ( P <0.001). Among subjects who were not on LLT at admission but who had Adult Treatment Panel III–based indications for use of LLT, only 31.2% (20.5% to 44.5%) received LLT at discharge.

Conclusions— Many hospitalized acute IS and TIA patients with indications for LLT are untreated at discharge. Efforts to close treatment gaps in lipid evaluation and treatment require sustained quality improvement efforts and should pay particular attention to high-risk patients.

Twenty-Year Trends in Serum Cholesterol, Hypercholesterolemia, and Cholesterol Medication Use

Background— Although US cholesterol concentrations have dropped, &50% of adults have total cholesterol concentrations ≥5.18 mmol/L, putting them at “borderline-high risk” for heart disease. Whether the decline has continued into the 21st century is unknown. We assessed 20-year trends in cholesterol, hypercholesterolemia, lipid-lowering drug use, and cholesterol awareness, treatment, and control from Minnesota Heart Survey (MHS) data.

Methods and Results— Five independent, cross-sectional, population-based surveys of 2500 to 5000 adults were conducted in the Minneapolis–St. Paul, Minn, area from 1980 to 2002. Mean (nonfasting) total cholesterol concentrations have continued a 20-year decline, punctuated by an intervening lull. Age-adjusted mean total cholesterol concentrations in 2000 to 2002 were 5.16 and 5.09 mmol/L for men and women, respectively (in 1980 to 1982, 5.49 and 5.38 mmol/L for men and women, respectively) However, the decline has not been uniform across all age groups. Middle-aged to older people have shown substantial decreases, but younger people have shown little overall change and recently had increased total cholesterol values. The mean prevalence of hypercholesterolemia in 2000 to 2002 was 54.9% for men and 46.5% for women and has decreased significantly for both during the study. Age-adjusted mean high-density lipoprotein cholesterol concentrations in 2000 to 2002 were 1.09 and 1.40 mmol/L for men and women, respectively, and were not different from the prior survey. Lipid-lowering drug use rose significantly for both sexes aged 35 to 74 years. Awareness, treatment, and control of hypercholesterolemia have increased; however, more than half of those at borderline-high risk remain unaware of their condition.

Conclusions— Although hypercholesterolemia prevalence continued to fall, significant population segments still have cholesterol concentrations near or at the level of increased risk.

National study of physician awareness and adherence to cardiovascular disease prevention guidelines

BACKGROUND

Few data have evaluated physician adherence to cardiovascular disease (CVD) prevention guidelines according to physician specialty or patient characteristics, particularly gender.

METHODS AND RESULTS

An online study of 500 randomly selected physicians (300 primary care physicians, 100 obstetricians/gynecologists, and 100 cardiologists) used a standardized questionnaire to assess awareness of, adoption of, and barriers to national CVD prevention guidelines by specialty. An experimental case study design tested physician accuracy and determinants of CVD risk level assignment and application of guidelines among high-, intermediate-, or low-risk patients. Intermediate-risk women, as assessed by the Framingham risk score, were significantly more likely to be assigned to a lower-risk category by primary care physicians than men with identical risk profiles (P<0.0001), and trends were similar for obstetricians/gynecologists and cardiologists. Assignment of risk level significantly predicted recommendations for lifestyle and preventive pharmacotherapy. After adjustment for risk assignment, the impact of patient gender on preventive care was not significant except for less aspirin (P<0.01) and more weight management recommended (P<0.04) for intermediate-risk women. Physicians did not rate themselves as very effective in their ability to help patients prevent CVD. Fewer than 1 in 5 physicians knew that more women than men die each year from CVD.

CONCLUSIONS

Perception of risk was the primary factor associated with CVD preventive recommendations. Gender disparities in recommendations for preventive therapy were explained largely by the lower perceived risk despite similar calculated risk for women versus men. Educational interventions for physicians are needed to improve the quality of CVD preventive care and lower morbidity and mortality from CVD for men and women.

Cardiovascular disease risk reduction in the Behavioral Risk Factor Surveillance System

BACKGROUND

Cardiovascular disease (CVD) risk-reduction practices are suboptimal in populations at high risk for CVD, and this problem may be worse in women than in men.

METHODS

In 2003, CVD risk-reduction practices were compared between men and women after stratification by CVD risk status (high, intermediate, low) in a cross-sectional analysis of the 1999 Behavioral Risk Factor Surveillance System (BRFSS), a random-digit telephone survey of state population-based samples of the civilian non-institutionalized population of adults. This analysis included persons aged >40 years who answered questions regarding lipid and blood pressure screening, recommendations for lifestyle modification, that is, exercise and reduced fat intake, and aspirin use. Risk status was defined according to Adult Treatment Panel III definitions.

RESULTS

In the 97,387 adults included in this analysis, high CVD risk was associated with lipid and blood pressure screening, lifestyle modification, and aspirin use in both men and women compared to intermediate-risk and low-risk (p <0.001). Among high-risk adults, men and women reported similar frequency of blood pressure and cholesterol measurement and physician advice on lifestyle modification; among intermediate- and low-risk adults, women reported slightly more frequent screening and lifestyle modification than men (p <0.001). In all CVD risk categories, women reported significantly less aspirin use than in men (p <0.001).

CONCLUSIONS

Among people at high risk for CVD, women report lifestyle modification more often than men, while men report use of aspirin more often than women. These findings may assist with targeting interventions to reduce CVD risk to the unique needs of men and women.