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Low-Density Lipoprotein Cholesterol Levels in Coronary Artery Disease Patients: Opportunities for Improvement
Gary J Martin1, Meron Teklu2, Edwin Mandieka3
1Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
Insights
This study found significant variation in LDL-C control among patients with cardiovascular disease. Physician treatment patterns for statin therapy present opportunities for quality improvement interventions.
Area of Science:
- Cardiovascular Medicine
- Pharmacotherapy
- Health Services Research
Background:
- Assessing low-density lipoprotein cholesterol (LDL-C) control is crucial for managing cardiovascular disease (CAD).
- Identifying undertreated patient populations and understanding factors influencing LDL-C control are essential for improving patient outcomes.
- Variability in treatment strategies can impact the effectiveness of LDL-C lowering therapies.
Purpose of the Study:
- To characterize the level of LDL-C control in a large patient cohort with established cardiovascular disease.
- To identify patient demographics and clinical factors associated with undertreatment or suboptimal LDL-C control.
- To explore variations in LDL-C management among healthcare providers within a multihospital system.
Main Methods:
- Retrospective analysis of 15,111 patients with CAD from a large multihospital system (January 2017-September 2019).
- Inclusion criteria: age <90, at least two CAD-related encounters before first LDL-C measurement, and a minimum six-month follow-up.
- Linear regression used to analyze the impact of statin intensity and patient characteristics on the last recorded LDL-C level.
Main Results:
- Mean follow-up LDL-C was 75.6 mg/dL, with 45.5% of patients on high-intensity statin therapy.
- Higher LDL-C levels were associated with female sex, younger age, Black race, high poverty zip codes, Medicaid insurance, and angina diagnosis.
- Significant variation in mean LDL-C (47-102 mg/dL) was observed among clinicians treating over 10 patients.
Conclusions:
- Substantial variability exists in LDL-C control among patients with similar indications for treatment within the health system.
- Physician-level variations in treatment present a key area for quality improvement initiatives.
- The study methodology is reproducible, offering a framework for other centers to identify patient and physician-level improvement opportunities.
Background:
We sought to characterize the level of LDL-C control and identify opportunities for improvement and characteristics of patients who were undertreated.
Methods:
Study patients were from a large multihospital system, age <90, with documentation of at least two encounters with a CAD diagnosis or procedure before a first measured LDL-C level and a last recorded LDL-C measurement over a minimum six-month (median = 22 months, IQR = 15-26 months) follow-up from January 2017 to September 2019. Linear regression analysis for last recorded LDL-C level was used to analyze the effects of statin intensity and patient characteristics.
Results:
Among 15,111 eligible patients, mean age was 68.4 (SD = 10.8), 68.7% were male, and 79.4% were non-Hispanic White. At follow-up, 87.8% of patients were prescribed a statin, 9.7% were on ezetimibe, and 0.5% were on a PCSK9 inhibitor. Mean LDL-C at follow-up was 75.6 mg/dL and 45.5% of patients were on high-intensity treatment. Higher LDL-C values were associated with female sex, younger patients, non-Hispanic Black patients, high poverty or out of state zip code, Medicaid, or angina as the qualifying diagnosis. For 332 clinicians with >10 patients in the cohort, mean last recorded LDL-C values ranged from 47 to 102 mg/dL.
Conclusions:
There were important variations in LDL-C control between patients in our health system with the same indication for treatment. Variation in treatment among physicians is an area ripe for quality improvement interventions. This study may be easily reproduced by other medical centers and used for highlighting both patient and physician opportunities for improvement.
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