Barriers, facilitators, and solutions to familial hypercholesterolemia treatment

Background

Familial hypercholesterolemia (FH) is an inherited lipid disorder that confers high risk for premature cardiovascular disease but remains undertreated. Causes are multifactorial and multilevel, ranging from underprescribing (at the clinician-level) to medication nonadherence (at the patient-level). We evaluated patient and clinician stakeholder barriers and facilitators for treatment of FH to explore possible solutions to the problem.

Methods and results

Semi-structured interviews and focus groups guided by the Practical, Robust, Implementation and Sustainability Model (PRISM), were conducted with 33 patients and 17 clinician stakeholders across three healthcare systems. A total of14 patients and 9 clinician stakeholders participated in on-site focus groups and the remainder were individual interviews. Transcripts were coded using an iterative process to create a static codebook. We characterized patient and clinician stakeholder barriers into three categories: medical care-, medication-, and life-related. Feasibility of brainstormed solutions varied and was not always representative of the needs of all stakeholders. Patients suggested a need for childhood screening for FH and doctors being persistent about the importance of treating FH, creation of a patient peer group, data transparency, advocacy, and policy changes that would enable patients to receive better treatment. Clinician stakeholders suggested the need for clinical champions. Both groups of stakeholders discussed the need for education about FH.

Conclusions

Proposed solutions to improve treatment of FH proffered by participants in this study included resources for both patients and clinician stakeholders that clarify cardiovascular disease risks from FH, develop programs to screen for and identify FH at younger ages, and foster open conversations between patients and clinicians about treatment.

Treatment Preferences in Germany Differ Among Apheresis Patients with Severe Hypercholesterolemia

BACKGROUND

Severe hypercholesterolemia is a major risk factor of death in patients with coronary heart disease. New adjunctive drug therapies (proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors) have gained approval in Europe and the USA.

OBJECTIVE

In this empirical study, we documented preferences regarding adjuvant drug therapy in apheresis-treated patients with severe familial hypercholesterolemia.

METHODS

We conducted a systematic literature search to identify patient-relevant outcomes in patients with severe hypercholesterolemia currently undergoing apheresis. Data were used to generate a semi-structured qualitative interview that enabled seven patient-relevant characteristics with three levels each to be identified. For the discrete choice experiment, an experimental design (7 × 3) was generated using NGene Software that consisted of 96 choices divided into eight blocks. The survey was conducted between November 2015 and April 2016 using computer-assisted personal interviews.

RESULTS

The survey was completed by 348 patients (64.9% male). The random parameter logit estimation showed predominance for the attribute 'reduction of LDL-C (low-density lipoprotein cholesterol) level'. 'Risk of myopathy' and 'frequency of apheresis' dominated next. Within the random parameter logit estimation, all coefficients were significant (P ≤ 0.01). The latent class analysis identified three patient groups. The first group (126 patients) found 'reduction of LDL-C level in blood' to be most important. This group focused solely on this treatment outcome independently of apheresis frequency or additional injections. The second group (106 patients) focused on three attributes: 'frequency of apheresis', 'risk of myopathy', and 'reduction of LDL-C level in blood'. Respondents clearly considered a high frequency of apheresis to have a negative impact. The third group (116 patients) demonstrated the highest preference for apheresis. These patients have adjusted to apheresis for > 10 years.

CONCLUSION

Regarding patient preference, clinical efficacy seems to dominate. Hence, 'reduction of LDC-C in blood' was ranked highest above patient-relevant modes of administration and adverse effects. In the patient groups identified, reduction of apheresis was important for only a subsegment (30%) of patients. Another 30% wanted effective LDL-C reduction by whatever means necessary. Most strikingly, another 30% preferred higher frequencies of apheresis.

Familial hypercholesterolaemia reduces the quality of life of patients not reaching treatment targets

INTRODUCTION

Familial hypercholesterolaemia (FH) is the most common monogenic disorder associated with premature cardiovascular disease. If untreated, life expectancy in heterozygous FH patients is shortened by 20-30 years compared with the general population. Nevertheless, treatment goals are only met in approximately 50% of patients. This comparative study examined the quality of life (QoL) impact of FH in patients who had and had not reached the target of treatment.

METHODS

Two qualitative focus group interviews were carried out with a total of ten FH patients. A semi-structured interview guide included questions identified in a preceding literature study. The data were analysed using a medical anthropological approach.

RESULTS

While having FH did not have much impact on well-treated patients' QoL, patients who had not reached the treatment target had markedly more concerns. They had experienced severe side-effects and worried about their own and their relatives' health. They were concerned about the long-term impact of not being effectively treated including the risk that coronary heart disease could cause their premature death or disability and inability to care for their children, in particular. The women had issues with stigma and self-efficacy.

CONCLUSIONS

The QoL impact of FH is related to treatment efficacy. These findings need to be addressed in the management of FH patients. Particular attention should be paid to those who are not presently reaching the target of treatment.

FUNDING

The study was funded by a research grant from Amgen.

TRIAL REGISTRATION

not relevant.

How do index patients participating in genetic screening programmes for familial hypercholesterolemia (FH) interpret their DNA results? A UK-based qualitative interview study

OBJECTIVE

To explore patients' interpretations of their DNA results for familial hypercholesterolemia (FH).

METHODS

In-depth interviews were conducted with patients from two lipid clinics in Scotland, who were offered genetic testing as part of a nationwide cascade screening service.

RESULTS

Patients were receptive to taking part in genetic screening and most expected a positive result. Receiving a molecular diagnosis of FH could provide reassurance to patients that diet and lifestyle factors were not the primary causes of their condition. Patients who received inconclusive results tended to interpret this as meaning that their high cholesterol was not genetic, which could induce feelings of uncertainty and self-blame. With the exception of newly diagnosed patients, for whom a positive result could provide a useful rationale for initiating statins, most perceived DNA screening to be of little relevance to their own medication use or their own approaches to lifestyle management.

CONCLUSIONS

Index patients are likely to view DNA screening for FH as non-threatening. Receiving a positive DNA result can be reassuring for patients. Patients may not, however, interpret inconclusive DNA results correctly.

PRACTICE IMPLICATIONS

Health professionals need to ensure FH index patients are prepared to receive, and fully understand, inconclusive DNA results.

Can multiple lifestyle behaviours be improved in people with familial hypercholesterolemia? Results of a parallel randomised controlled trial

OBJECTIVE

To evaluate the efficacy of an individualised tailored lifestyle intervention on physical activity, dietary intake, smoking and compliance to statin therapy in people with Familial Hypercholesterolemia (FH).

METHODS

Adults with FH (n = 340) were randomly assigned to a usual care control group or an intervention group. The intervention consisted of web-based tailored lifestyle advice and face-to-face counselling. Physical activity, fat, fruit and vegetable intake, smoking and compliance to statin therapy were self-reported at baseline and after 12 months. Regression analyses were conducted to examine between-group differences. Intervention reach, dose and fidelity were assessed.

RESULTS

In both groups, non-significant improvements in all lifestyle behaviours were found. Post-hoc analyses showed a significant decrease in saturated fat intake among women in the intervention group (β = -1.03; CI -1.98/-0.03). In the intervention group, 95% received a log on account, of which 49% logged on and completed one module. Nearly all participants received face-to-face counselling and on average, 4.2 telephone booster calls. Intervention fidelity was low.

CONCLUSIONS

Individually tailored feedback is not superior to no intervention regarding changes in multiple lifestyle behaviours in people with FH. A higher received dose of computer-tailored interventions should be achieved by uplifting the website and reducing the burden of screening questionnaires. Counsellor training should be more extensive.

TRIAL REGISTRATION

Dutch Trial Register NTR1899.

Experiences of guilt and shame in patients with familial hypercholesterolemia: a qualitative interview study

OBJECTIVE

To explore patients' experiences of guilt and shame with regard to how they manage familial hypercholesterolemia.

METHODS

We interviewed 40 men and women diagnosed with heterozygous familial hypercholesterolemia. Data were analyzed by systematic text condensation inspired by Giorgi's phenomenological method.

RESULTS

Participants disclosed their condition as inherited and not caused by an unhealthy lifestyle. They could experience guilt or shame if they violated their own standards for dietary management, or if a cholesterol test was not favorable. Participants had experienced health professionals who they felt had a moralizing attitude when counseling on lifestyle and diets. One group took this as a sign of care. Another group conveyed experiences of being humiliated in consultations.

CONCLUSION

Patients with familial hypercholesterolemia may experience guilt and shame related to how they manage their condition. Health professionals' counseling about lifestyle and diet may induce guilt and shame in patients.

PRACTICE IMPLICATIONS

Health professionals should be sensitive to a patient's readiness for counseling in order to diminish the risk of unintentionally inducing guilt and shame in patients.

Disease knowledge and adherence to treatment in patients with familial hypercholesterolemia

BACKGROUND

Familial hypercholesterolemia (FH) is one of the most common genetic metabolic disorders and is associated with a high risk of premature coronary heart disease. Primary prevention directed at lifestyle changes, combined with preventive medical treatment, is the most important way to reduce the risk of coronary heart disease in individuals with FH. Knowledge about the condition and adherence to drug treatment may facilitate reaching treatment goals.

OBJECTIVE

The purpose of this study was to describe disease knowledge and adherence to treatment in patients with FH.

SUBJECTS AND METHODS

Seventy-four patients, more than 18 years of age, with FH were asked to participate. A questionnaire on disease knowledge about FH and adherence to drug treatment was sent to the patients. Response rate was 92% (n = 68). Drug treatment, laboratory results, blood pressure, and smoking were also documented.

RESULTS

Most patients knew about cholesterol, prevention, and the reason for drug treatment but were less informed about the risk of genetic transmission and family history. No significant correlation was found between knowledge and low-density lipoprotein cholesterol level. A significant, negative correlation between adherence and low-density lipoprotein cholesterol level was found (r = -.354, P < .01).

CONCLUSIONS

Patients with FH had scant understanding about the risk of genetic transmission and family history. High adherence to drug prescription has significant correlation to low-density lipoprotein cholesterol level.

Familial hypercholesterolemia: ethical, practical and psychological problems from the perspective of patients

The main aim of the study was to explore the extent to which familial hypercholesterolemia (FH) influences the life of the patients affected. The study employed a qualitative analysis of semi-structured interviews with 23 outpatients who were being treated following a diagnosis of heterozygous FH at a tertiary hospital in Göteborg, Sweden. Some interviewees reported concerns related to their medication and feelings of guilt when not complying with treatment recommendations. However, none of the respondents expressed sustained emotional distress or would have preferred to be ignorant of their diagnosis. Apart from being more observant about food intake, their awareness of FH did not appear to have had a substantial impact on their way of life. In fact, those who did not suffer from any other diseases generally regarded themselves as healthy. Discussing the genetic constitution with family members with whom they had close contact was natural, but informing distant family members was not.

The Meaning of Quality of Life Among Patients With Familial Hypercholesterolemia

BACKGROUND

Living with a genetic predisposition to disease may influence quality of life. The presence of premature disease can lead to an increased focus on family history and genetic predisposition.

OBJECTIVE

The purpose of this study was to describe quality of life in patients with the genetic disease, familial hypercholesterolemia, who are at an increased risk of premature coronary heart disease.

METHODS

Interviews from 12 adult patients with FH were analyzed using constant comparative analysis. The findings of this qualitative study revealed that for patients, quality of life was equated with harmony in life, the core category. Attaining harmony in life presumes satisfaction and togetherness. Cognizance of the threat of coronary heart disease and impending mortality is balanced by the support of togetherness and satisfaction that builds harmony in life.

CONCLUSION

When caring for patients with familial hypercholesterolemia, it is important to meet each patient on his or her own level, and to support balance and their choices for maintaining or regaining harmony in life.

Children and statins

Use of statins is increasing among children with familial hypercholesterolaemia who previously have had to take unpalatable resins. In a selected group with no controls, children taking statins had similar scores for quality of life and anxiety as normative scores. The question that remains is how to improve dietary and disease information.

CONCLUSION

Children with familial hypercholesterolaemia who are taking statins have no reduction in quality of life or increase in anxiety.

Quality of life, anxiety and concerns among statin-treated children with familial hypercholesterolaemia and their parents

AIM

To assess the quality of life, anxiety and concerns among statin-treated children with familial hypercholesterolaemia (FH) and their parents.

METHODS

69 FH children on statin therapy and 87 parents (51 families) participated in this study. Quality of life of the children, and anxiety levels of both the children and their parents, were investigated using self-report questionnaires. In addition, a questionnaire was designed to evaluate FH-specific concerns of these children and their parents on six different topics: 1, knowledge about FH; 2, experience of the disease; 3, family communication; 4, screening; 5, diet; and 6, experience of medication therapy.

RESULTS

FH children and their parents reported no problems with regard to quality of life and anxiety. In contrast, the FH survey showed specific FH-related concerns. One-third of the children thought that FH can be cured, and 44% of the children suffered from the fact they have FH, but taking medication makes them feel safer (62%). The majority of the children kept a low cholesterol diet and more than 50% took care not to eat too much fat. Almost 38% of the parents experienced FH as a burden to their family and 79% suffered because their child had FH.

CONCLUSION

These findings show that statin-treated children with FH and their parents did not report affected psychosocial functioning, but did show specific FH-related concerns.

Psychological impact of genetic testing for familial hypercholesterolemia within a previously aware population: A randomized controlled trial

This trial tests the hypothesis that confirming a clinical diagnosis of familial hypercholesterolemia (FH) by finding a genetic mutation reduces patients' perceptions of control over the disease and adherence to risk-reducing behaviors. Three hundred forty-one families, comprising 341 hypercholesterolemia probands and 128 adult relatives, were randomized to one of two groups: (a) routine clinical diagnosis; (b) routine clinical diagnosis plus genetic testing (mutation searching in probands and direct gene testing in relatives). The main outcome measures were perceptions of control over hypercholesterolemia, adherence to cholesterol-lowering medication, diet, physical activity, and smoking. There was no support for the main hypothesis: finding a mutation had no impact on perceived control or adherence to risk-reducing behavior (all P-values > 0.10). While all groups believed that lowering cholesterol was an effective way of reducing the risk of a heart attack, participants in whom a mutation was found believed less strongly in the efficacy of diet in reducing their cholesterol level (P = 0.02 at 6 months) and showed a trend in believing more strongly in the efficacy of cholesterol-lowering medication (P = 0.06 at 6 months). In conclusion, finding a mutation to confirm a clinical diagnosis of FH in a previously aware population does not reduce perceptions of control or adherence to risk-reducing behaviors. The pattern of findings leads to the new hypothesis that genetic testing does not affect the extent to which people feel they have control over a condition, but does affect their perceptions of how control is most effectively achieved. Further work is needed to determine whether similar results will be obtained in populations with little previous awareness of their risks.

How disturbing is it to be approached for a genetic cascade screening programme for familial hypercholesterolaemia? Psychological impact and screenees' views

OBJECTIVES

To assess the screenees' views on, and the psychological impact of, a family-based genetic screening programme for familial hypercholesterolaemia (FH) and to evaluate non-participation.

METHODS

Self-administered questionnaires were filled out at the time of screening and after communication of the test result. Non-participants were interviewed by phone.

RESULTS

Of the people approached for screening, 2% did not participated. These 2% were not interested, had already been clinically diagnosed, or were afraid of insurance consequences. 677 screenees participated, of whom 215 (32%) tested FH positive. Less than 5% of the screenees were critical of the approach and the information provided. 20% of the screenees expressed feelings of social pressure. Effects on mood were minimal to absent, as were general 'quality of life' effects.

CONCLUSIONS

Screening for FH is highly acceptable to screenees, although social pressure is prevalent. Only a small percentage of people being approached did not participate.

Familial hypercholesterolaemia and quality of life in family members

BACKGROUND

Awareness of genetic disease in the family may influence quality of life. The purpose of this study was to describe quality of life among nonaffected members of families with familial hypercholesterolaemia. All were aware of the risk for coronary heart disease. Their quality of life was compared with a reference group and with the patients with familial hypercholesterolaemia themselves.

METHODS

Names of family members (n = 129) were given by the patients with familial hypercholesterolaemia. A randomly selected reference group (n = 1485) and patients with familial hypercholesterolaemia (n = 185) were included for comparison. They all completed the questionnaire Quality of Life Index, the Hospital Anxiety and Depression Scale, and the Mastery Scale measuring coping. Family members and patients with familial hypercholesterolaemia also completed a questionnaire on health and lipids.

RESULTS

Family members were more satisfied with family life, mean 22.1 +/- 3.5 (SD), and psychological/spiritual life, 22.9 +/- 4.0, than the reference group, 21.4 +/- 4.3 and 21.1 +/- 4.8, respectively; this was particularly expressed among partners, P < 0.05. Of family members, 91% were anxious about the patient with familial hypercholesterolaemia developing coronary heart disease.

CONCLUSIONS

Family members have as good a quality of life as members of the reference group, but they were anxious about the patient with familial hypercholesterolaemia developing coronary heart disease.

Quality of life in patients with familial hypercholesterolaemia

OBJECTIVES

The primary aim of this study was to analyse quality of life in adult patients with familial hypercholesterolaemia (FH), a genetic disorder with increased risk of coronary heart disease (CHD). Secondary aims were to find explanatory factors for quality of life and anxiety.

DESIGN

A descriptive cross-sectional design was used.

SETTING

Outpatients from lipid clinics at two university hospitals in Sweden were included. Patients with heterozygous FH and a randomly selected control group participated by filling out questionnaires.

SUBJECTS

Two hundred and eighty patients with heterozygous FH above 18 years of age were asked, and 212 of whom 185 were free of overt CHD, participated. Of a control group of 2980 persons 1485 were included for comparison.

METHODS

We used Likert-type questionnaires: the Quality of Life Index (QLI) consisting of four subscales, the Hospital Anxiety and Depression Scale (HAD), the Mastery Scale measuring coping and a questionnaire on health and lipids constructed for FH patients.

RESULTS

Patients with FH were significantly more satisfied with overall quality of life 21.8 +/- 0.3 (SEM) vs. controls 21.1 +/- 0.1 and this was also the case in three of four subscales, all differences P < 0.05. Anxiety about getting CHD was expressed amongst 86% of the patients with FH.

CONCLUSIONS

Quality of life amongst patients with FH was at least as good as in controls but they were worried about getting CHD.

Stratification of risk in children with familial hypercholesterolemia with focus on psychosocial issues

AIM

This paper discusses the clinical implications of making a diagnosis of familial hypercholesterolemia (FH) in children and data on psychosocial issues.

DATA SUMMARY

The case for treating FH in children is based on pathophysiological considerations. Some authors claim that treatment may be harmful, partly because the psychosocial risks have not been assessed. The available data indicate that psychological distress does not seem to be a problem in testing and treating most children for FH, although a few may develop social and emotional problems, experience family conflicts, or have problems with the diet or bile acid binding resins.

CONCLUSIONS

Parental preferences and the psychosocial function of the child should be considered and a complete assessment should be made of the potential risk of coronary heart disease (CHD) on the basis of established CHD risk factors. Boys and girls with total cholesterol concentrations of > 7.0 mmol/L and a family history of early CHD (first or second degree relatives with CHD, in males before the age of 40 and in females before the age of 50 years), and boys with cholesterol concentrations of > 10.0 mmol/L regardless of family history, should be considered at high risk and start dietary treatment as early as possible (preferable before the age of ten years). Girls at high risk may start statins by the age of 18 years, whereas starting statins should be considered in boys between the ages of 10 and 18 years. Children with FH at low to moderate risk of CHD may wait until adulthood or start treatment depending on an individualized evaluation.

[Attitude of patients toward detection of hereditary disease. Heterozygote familial hypercholesterolemia]

Molecular biology has enabled us to identify apparently healthy persons at high risk of genetic disease. The purpose of the present study was to examine attitudes to detection of disease and the present well-being in persons at risk of disease with a modifiable outcome-heterozygous Familial Hypercholesterolaemia (heFH). A questionnaire collecting information on impact on well-being and on attitudes to screening family members for heFH was mailed to heFH index patients and hypercholesterolaemic relatives. Anxiety was expressed by 44%, fear of ischaemic heart disease by 37% and diminished well-being by 13% of respondents. Six percent regretted that they were aware of their diagnosis, and 84% were in favour of screening their family. We conclude that a substantial proportion of persons with heFH experience anxiety due to heFH. A small minority regret being informed of the diagnosis of heFH, however, and a majority are in favour of family screening.

[Is the detection of familial hypercholesterolemia in children indicated? Occasionally, yes]

Searching for familial hypercholesterolaemia (FH) in children is useful only if efficacious treatment is to be administered shortly and if there are relatives with ischaemic heart disease at very early ages. In all other cases, the (psychological) drawbacks probably outweigh the doubtful benefit of early intervention. The search for the major homozygous form of FH begins with cholesterol assay in both parents, in the absence of FH in either of them, the above-named restrictions apply.

Dietary adherence in children with familial hypercholesterolemia

We examined nutritional and psychosocial factors associated with adherence to the recommended diet (< or = 30% of energy from fat and < 10% from saturated fat) in children with familial hypercholesterolemia. Ninety-eight boys and 74 girls aged 7-17 y treated for > or = 18 mo responded to a quantitative food-frequency questionnaire that was self- (ages 13-17 y) or dietitian-(ages 7-12 y) administered. One hundred nine subjects also completed a weighed food record. Psychosocial assessments included the Child Behavior Checklist, Youth Self Report, and Children's Global Assessment Scale. The weighed record showed better adherence to dietary guidelines than the food-frequency questionnaire, but energy intake was underestimated. Low energy reporters had a healthier diet than the rest with the weighed record. According to the questionnaire, energy intake was underreported in only 9% of subjects and was not associated with a healthier diet, thus, further analyses were based on the questionnaire. Intakes of vitamin C (P = 0.0001), folate (P = 0.0001), riboflavin (P = 0.03), thiamine (P = 0.0001), and magnesium (P = 0.0001) per megajoule increased as quartile of total fat intake (as a % of total energy) decreased, reflecting increased intakes of cereals (P = 0.002), pasta (P = 0.01), fruit (P = 0.0001), pure meat (not minced or meat products; P = 0.047), skim milk (P = 0.0001), and skim cheese (P = 0.005). Energy and sugar (% of total energy) intakes were not significantly different across all fat intakes; energy density decreased with decreasing fat quartile. Overall psychosocial function score and parental educational level were associated with lower fat intake in multivariate analysis, explaining 11% of the variance in fat intake. We conclude that adherence to fat restriction among children treated for familial hypercholesterolemia is associated with increased micronutrient density, decreased energy density, and psychosocial factors that facilitate adherence.

Familial hypercholesterolaemia: a pilot study of parents' and children's concerns

OBJECTIVE

To assess psychosocial concerns of families with familial hypercholesterolaemia.

METHODS

One-hundred-and-fifty-four single or pairs of parents of children age 6 - 16 years responded to a specifically designed questionnaire. One child from each family was interviewed.

RESULTS

Eleven percent of parents thought that their quality of life would have been better had they not known about the disease. None agreed totally that they wished the diagnosis had not been made. However, 20% reported familial conflicts and 8% that their child's emotional or social life had been adversely affected. Conflicts and adverse effects were associated with higher scores on the Child Behaviour Checklist (CBCL). Among the children, worry about cardiovascular disease (affirmed by 22%) was related to male sex and CBCL score.

RELEVANCE

Most families do not indicate that they have experienced psychosocial problems due to familial hypercholesterolaemia. Parental ratings of the child's behavioural adjustment may identify vulnerable children.

Psychosocial function during treatment for familial hypercholesterolemia

OBJECTIVE

To determine whether children treated for familial hypercholesterolemia (FH) have greater psychosocial dysfunction compared with their peers.

CHILDREN

Children were 86 boys and 66 girls 7-16 years of age attending a lipid clinic. They were screened and instructed to follow a diet low in saturated fat and cholesterol 18 months to 9 years earlier (mean, 4 years), and their mean dietary intake, estimated by a quantitative food frequency questionnaire, was within recommended limits. One-fourth had lost a parent or had a parent who had had cardiovascular disease due to FH (parental disease group).

METHODS

Results of the Child Behavior Checklist, Teacher's Report Form, and Youth Self-Report were compared with a population sample. A semistructured interview, the Child Assessment Schedule, was administered to the children with FH and a well-functioning comparison group from the population (epidemiologic cohort; n = 62).

RESULTS

Psychosocial scores were similar in the children with FH and the population sample. The Child Assessment Schedule showed that, compared with the epidemiologic cohort, children with FH did not have increased symptoms in any area of function, and scores for family, mood, and expression of anger were lower (less symptomatic). The prevalence of psychiatric diagnoses was 10%, which was not greater than expected. Children from the parental disease group had higher symptom scores in the areas of school and expression of anger than the rest of the children with FH. Their mean Children's Global Assessment Score (CGAS, which gives average children scores of 70-79) was slightly lower (77 vs 79). Belonging to the parental disease group predicted a lower CGAS in multivariate regression analyses, as did male sex, parental divorce, and low parental educational level. These factors explained up to 19% (95% confidence interval, 9%-31%) of the variance in CGAS.

CONCLUSIONS

We found that the prevalence of psychosocial dysfunction was not greater than expected in children treated for FH. Psychosocial function within the group was associated with the usual demographic characteristics and with the loss or disease of a parent, beyond the period of bereavement or immediately after the event.

Psychological and ethical considerations in screening for disease

Coronary artery disease is the leading cause of death in the United States. Serum cholesterol is a widely used screening test to detect persons at high risk for coronary artery disease, including those with familial hypercholesterolemia. However, universal screening of currently healthy persons is not without risk. Previous experience in screening for sickle cell anemia and hypertension has shown that these risks include misunderstanding of test results, misdiagnosis, labeling, stigmatization, and decreased psychological well-being. Results of screening programs may be misused by industry or insurance companies to exclude individuals from positions or benefits. Consideration of these harms suggests that screening should not be implemented until certain safeguards are in place. Physicians and the public should be educated about the potential risks and benefits of screening. Screening tests should be accurate, reliable, valid, and of demonstrated sensitivity. Informed consent for screening should be obtained. Follow-up surveillance and recommended treatments, including dietary counseling and drug therapy, should be available to all individuals identified as being at high risk regardless of their socioeconomic status. Finally, procedures to protect the right to privacy of individuals and their families should be implemented well in advance of the actual screening.