Application of ACC/AHA Cholesterol Treatment Guidelines on a Community Health Center Population
Deepak Honaganahalli, MD, MPH
Honaganahalli D. Application of ACC/AHA cholesterol treatment guidelines on a community health center population. Consultant. 2016;56(10 Suppl):S14-S16.
ABSTRACT: This article discusses the application of the ACC/AHA guidelines to a sample population so as to determine whether potential opportunities exist for optimal treatment in 4 statin-treatment groups. Gender has been incorporated as a variable to determine whether any bias is associated with it. The article also discusses the steps taken to address the application of the ACC/AHA guidelines with a team-based care model at our practice.
KEYWORDS: Dyslipidemia, atherosclerotic cardiovascular disease, low-density lipoprotein cholesterol, cholesterol treatment guidelines, diabetes mellitus, statins
Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of mortality and morbidity in United States, with nearly one-third of all-cause mortality attributed to heart disease and stroke.1 Despite major advances in the treatment of heart disease and stroke, disparities exist in the death rate among subpopulations, especially men and African Americans.1 In 2014, the American College of Cardiology (ACC) and the American Heart Association (AHA) published updated guidelines for the treatment of cholesterol levels to reduce the rate of ASCVD.2 It established a risk-based algorithm for the treatment of patients who are at high risk for ASCVD.2,3
This article discusses the application of the ACC/AHA guidelines to a sample population so as to determine whether potential opportunities exist for optimal treatment in 4 statin-treatment groups. Gender has been incorporated as a variable to determine whether any bias is associated with it. The article also discusses the steps taken to address the application of the ACC/AHA guidelines with a team-based care model at our practice.
We applied ACC/AHA guidelines to all the patients seen by one physician in the week of November 11 through November 15, 2013, and in the week of January 13 through January 17 2014. A total of 102 patient visits occurred during those times. Data gathering and analysis was done in June 2015. Among those 102 patient visits, 3 men and 4 women were seen in both of those weeks and were excluded from the study; likewise, 2 men and 2 women died of causes unrelated to ASCVD and were excluded.
Retrospectively, we collected demographic characteristics, medical history, vital signs, treatment history, and laboratory data on the remaining 91 patients. These patients were categorized and analyzed based on the 4 statin groups suggested in the ACC/AHA guidelines. In each of those 4 categories, we analyzed whether patients were treated with optimal intensity and dose of statin, and also investigated whether gender bias existed in the treatment of these patients.
Among the 91 patients meeting inclusion criteria who had been seen during those 2 weeks, 42 were men and 49 were women. Of them, 28 men and 26 women qualified to be on statin therapy. The 4 ACC/AHA categories indicated for statin therapy are discussed below. Because the sample sizes were small with subsequently small expected values, we applied the Fisher exact test to evaluate our objective.
Category 1, patients with a low-density lipoprotein cholesterol (LDL-C) level greater than 190 mg/dL. Three patients had an LDL-C level greater than 190 mg/dL, 1 man and 2 women (P = 1.0; odds ratio [OR], 0). Of note, 2 patients had an LDL-C level of 185 mg/dL and were not included in the analysis; moreover, LDL-C levels were missing in 4 patients, and 4 more patients’ LDL-C level was unable to be calculated due to an elevated triglyceride level.
Category 2, patients with ASCVD. Eighteen patients had ASCVD, 9 men and 9 women. Among them, 6 men and 2 women were on an appropriate dose of a statin, and 3 men and 7 women either were being suboptimally treated or were not being treated at all with statins as per the ACC/AHA guidelines (P = .1524; OR, 7; 95% confidence interval [CI], 0.8612, 56.8968).
Category 3, patients with diabetes. Among 91 patients, data were missing about the presence of diabetes in 1 patient. Twenty-three patients had diabetes, 7 men and 16 women. Among them, 3 men and 2 women were on an appropriate dose of a statin, and 4 men and 11 women either were being suboptimally treated or were not being treated at all with statins. Three women who had diabetes were outside of the age group delineated in the ACC/AHA guidelines for this category and thus were excluded from analysis (P = .2898; OR, 4.125; 95% CI, 0.4932, 34.5004).
Category 4, patients with pooled ASCVD risk greater than 7.5%. Forty-six patients had pooled ASCVD risk greater than 7.5%, which was calculated using an ACC/AHA smartphone app.3 Among these 46 patients, 26 were men and 20 were women. We were not able to calculate the risk of 2 patients because of missing data, and 15 patients were outside the age limit as specified in the risk calculator. Of note, most of the patients in this category also had either diabetes or ASCVD (P = 1.0; OR, .9832; 95% CI, 0.2892, 3.3422).
Table 1 shows the patients who had multiple covariates and their treatment history. Almost 60% of study patients would qualify for statin use—approximately two-thirds of the men and half the women. Among patients who qualified for statin use, almost two-thirds were either suboptimally treated with statins or not treated at all with statins (P = .7831; OR, 1.222; 95% CI, 0.4035, 3.7019).
Most of our study patients either had an ASCVD risk greater than 7.5%, an ASCVD risk greater than 7.5 plus an ASCVD diagnosis, or an ASCVD risk greater than 7.5% plus a diabetes diagnosis.
Although in Table 2 it appears that, overall, patients with ASCVD plus an ASCVD risk greater than 7.5 were most likely to be on optimum treatment (P = 1.0; OR, 1.33; 95% CI, 0.1132, 15.7047) and that patients with diabetes plus and ASCVD risk greater than 7.5% were suboptimally treated or not treated, the results were not statistically significant.
When gender is considered, it appears that female patients were treated optimally if they had an ASCVD risk greater than 7.5% (P = .3261; OR, 0.25; 95% CI, 0.0343, 1.8235) and were least likely to be treated if they had diabetes plus an ASCVD risk greater than 7.5%. Male patients appeared to have been treated with an optimal dose and intensity of statin if they had ASCVD plus an ASCVD risk greater than 7.5% and suboptimally or not treated if they had diabetes plus an ASCVD risk greater than 7.5%. Again, however, these results were not statistically significant, and no evidence exists of a relationship between gender and treatment.
This is an observational study of a small group of patients from a single provider, which limits its generalizability and the ability to determine whether a gender bias was present. It was unknown whether patient visits included a discussion of cholesterol. Moreover, a comparison between the different guidelines was not made to determine whether there had been a missed opportunity for treatment. These patients were seen in November 2013 and January 2014, and the guidelines were released in November 2013; thus it may have been too soon for the practice penetration of the guidelines in primary care.
While the sample size is small and the results are inconclusive, this could be looked upon as a hypothesis-generating study, and larger population studies would be required to determine whether treatment bias and gender bias exists. We chose the ACC/AHA guidelines due to the ease of calculating the ASCVD risk using a smartphone app, algorithm-based medication initiation and dose titration, and 4 clear subsets of patients. Our patient population has numerous unique health care barriers and challenges. It becomes challenging for primary care providers to address all the contingent issues in a single visit due to a potentially wide variety of causes, confounders that are outside the scope of this study.
Given these results, and because of time constraints, we used pharmacists to co-manage these chronic medical conditions. The pharmacists completed an online certification course and 40 hours of onsite training for cardiovascular risk evaluation and management of hyperlipidemia. We started a cardiovascular risk management clinic run by pharmacists under the physician supervision. This helped to evaluate these patients more thoroughly and recommend statins based on the ACC/AHA guidelines, as well as to spend more time with patients addressing barriers, monitoring for adherence and complications, and educating about medications and healthy lifestyle changes.
Having a physician supervisor who is a certified lipidologist on site helps to address the challenges that arise and reduces the burden on our primary care providers, who can now spend time managing other routine or acute primary care health problems. Patients benefit from this model by receiving evidence-based standard medical care at an affordable cost, and also are able to spend more time with their health care provider to address questions and barriers to care. We also used population health management tools to identify these patients and to start on appropriate treatment. We are hopeful that these initiatives help fill the gap in providing optimal medical therapy for this population.
Deepak Honaganahalli, MD, MPH, is a board-certified internist at Peak Vista Community Health Centers in Colorado Springs, Colorado, and an assistant clinical professor of medicine at the University of Colorado School of Medicine in Aurora.
- Keenan NL, Shaw KM; Centers for Disease Control and Prevention (CDC). Coronary heart disease and stroke deaths—United States, 2006. MMWR Suppl. 2011;60(1):62-66.
- Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 suppl 2):S1-S45.
- Goff DC Jr, Lloyd-Jones DM, Bennett G, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 suppl 2):S49-S75.