Exploring the gap between National Cholesterol Education Program guidelines and clinical practice in secondary care: results of a cross-sectional study involving over 10 000 patients followed in different specialty settings across Italy

Rapezzi, Claudio; Biagini, Elena; Bellis, P. De; Cafiero, M; Velussi, Mario; Ceriello, Antonio; Cooke, Robin M. T.; Schweiger, Carlo

doi:10.2459/jcm.0b013e3282f56513

Cited by 16 publications

(10 citation statements)

References 44 publications

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“…2 Despite specific and updated CPG, many patients fail to reach guideline-recommended levels. [3][4][5][6][7][8][9][10] GOAL Canada 11 reported that physician education based on the reminder system significantly improved care as measured by the proportion of patients achieving the recommended LDL-C level in relation to a greater utilization of recommended 2 lipid-lowering therapies. CPG recommendations do not typically distinguish between the respective roles of primary care physicians (PCPs) or specialists; further, it is not known whether the adoption of guidelines, pattern of management and specific strategies for lowering LDL-C are different for these groups of physicians.…”

Section: Conclusion: Despite Minor Differences In the Clinical Profile Of Their Patients Bothmentioning

confidence: 99%

“…The 2016 Canadian Cardiovascular Society clinical practice guidelines (CPG) recommend initiation of LDL‐C lowering with high‐intensity statin therapy and the addition of ezetimibe or a PCSK9i as needed if LDL‐C is not lowered by at least 50% or to a level below 2.0 mmol/L in patients with established CVD or FH 2 . Despite specific and updated CPG, many patients fail to reach guideline‐recommended levels 3‐10 . GOAL Canada 11 reported that physician education based on the reminder system significantly improved care as measured by the proportion of patients achieving the recommended LDL‐C level in relation to a greater utilization of recommended 2 lipid‐lowering therapies.…”

Section: Introductionmentioning

confidence: 99%

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Does management of lipid lowering differ between specialists and primary care: Insights from GOAL Canada

et al. 2020

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Background We studied whether significant differences in care gaps exist between specialists and primary care physicians (PCPs). Methods GOAL Canada enrolled patients with CVD or familial hypercholesterolemia (FH) and LDL‐C > 2.0 mmol/L despite maximally tolerated statin therapy. During follow‐up, physicians received online reminders of treatment recommendations based on Canadian Guidelines. Results A total of 177 physicians (58% PCPs) enrolled 2009 patients; approximately half of the patients were enrolled by each physician group. Patients enrolled by specialists were slightly older (mean age 63 years vs 62), female (45% vs 40%), Caucasian (77% vs 65%), and had a slightly higher systolic pressure and lower heart rate. Patients enrolled by specialists had less frequent history of FH, diabetes, hypertension, chronic kidney disease and liver disease but more frequent history of coronary artery disease, atrial fibrillation and premature family history of CVD. There was no significant baseline difference in LDL‐C, HDL‐C or non‐HDL‐C, although total cholesterol and triglycerides were slightly higher in patients managed by PCPs. At baseline, PCPs were more likely to use statins (80% vs 73%, P = .0002) and other therapies such as niacin or fibrate (10% vs 6%, P = .0006) but similar use of ezetimibe (24% vs 27%, P = .15). At the end of follow‐up, specialists used less statins (70% vs 77%, P = .0005) and other therapies (6% vs 10%, P = .007) but more ezetimibe (45% vs 38%, P = .01) and the same frequency of PCSK9i (28% vs 27%, P = .65). The proportion of patients achieving the recommended LDL‐C level of 2.0 mmol/L or below (primary endpoint) was similar at last available visit between specialists and PCPs (44% vs 42%, P = .32). Conclusion Despite minor differences in the clinical profile of their patients, both PCPs and specialists actively participate in the management of lipid‐lowering therapy in high‐risk CVD patients and experience similar challenges and care gaps.

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Section: Conclusion: Despite Minor Differences In the Clinical Profile Of Their Patients Bothmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Does management of lipid lowering differ between specialists and primary care: Insights from GOAL Canada

et al. 2020

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“…However, an analysis performed in the following years in Canada showed a sharp rise in serious adverse effects on hospitalizations due to hyperkalemia and the development of renal failure [55]. Similarly, high risk patients with previous myocardial infarction were less treated with statins than low risk patients in a large retrospective cohort study in Canada as well as in Italy [46,56]. Such ‘treatment paradox’, where high‐risk patients are often not adequately treated, may be also found among elderly hypertensives, since polypharmacy appeared to be a possible determinant of the poor blood pressure control in these patients [57,58].…”

Section: Underprescribing Of Cardiovascular Drugs In Polypharmacymentioning

confidence: 99%

The challenge of polypharmacy in cardiovascular medicine

Volpe

Chin²,

Paneni³

2010

Fundamemntal Clinical Pharma

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Albeit great efforts in reducing the burden of cardiovascular diseases (CVD), their prevalence continues to grow worldwide. Among the causes for this rising burden, the upcoming pandemic of obesity and diabetes further enhances the estimates of CV mortality and healthcare costs over the next decades. Nevertheless, advances in CVD treatment has increased life-expectancy, and future perspectives announce a growing aging population, with increasing comorbid conditions predisposing to CVD. Despite the emphasis on primary prevention, CV risk factors are still poorly controlled and a further need for CV drugs is upcoming. In chronic CVD such as hypertension, ischemic heart disease (IHD) and heart failure, the progressive use of multiple drugs is common and is recommended by international guidelines. However, the chronic use of five or more medications, defined as polypharmacy, has shown to be neither always efficacious nor safe. Polypharmacy is associated with an increased morbidity and costs. The use of multiple medications often leads to inappropriate drug use, underprescription, low adherence and side effects. In order to overcome these issues, a fixed-dose combination pill ('polypill') for the prevention of CVD has been recently proposed. A hypothetical meta-analysis estimated for this strategy a reduction of IHD and stroke by 88 and 80% respectively in people aged 55 or over. Such polypill can be cost effective and increase patient adherence. However, large randomized trials are required to define its impact on clinical outcomes. This review will focus on challenges of polypharmacy in CV medicine, illustrating potential options to face this emerging crisis.

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“…time constraints, job satisfaction, turnover) 13–14 and health policy issues (e.g. access to care, reimbursement) 15–16 .…”

Section: Introductionmentioning

confidence: 99%

Improving Clinician Self-Efficacy Does Not Increase Asthma Guideline Use by Primary Care Clinicians

Cloutier

Tennen

Wakefield

et al. 2012

Academic Pediatrics

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Objectives The association between changes in clinician self-efficacy and readiness to change and implementation of an asthma management program (Easy Breathing©) was examined. Methods A 36 month randomized, controlled trial was conducted involving 24 pediatric practices (88 clinicians). Randomized clinicians received interventions designed to enhance clinician self-efficacy and readiness to change which were measured at baseline and 3 years. Interventions consisted of an educational toolbox, seminars, teleconferences, mini-fellowships, opinion leader visits, clinician-specific feedback, and pay for performance. The primary outcome was program utilization (number of children enrolled in Easy Breathing/year); secondary outcomes included development of a written treatment plan and severity-appropriate therapy. Results At baseline, clinicians enrolled 149 ± 147 (mean ± SD) children/clinician/year; 84% of children had a written treatment plan and 77% of plans used severity-appropriate therapy. At baseline, higher self-efficacy scores were associated with greater program utilization (Relative Rate (RR) 1.34 (95% Confidence Interval 1.04, 1.72), p=0.04) but not treatment plan development (RR 0.63 (0.29, 1.35), p=.23) or anti-inflammatory use (RR 1.76 (0.92, 3.35), p=.09). Intervention clinicians participated in 17 interventions over 36 months. At study end, self-efficacy scores increased in intervention clinicians compared to control clinicians (p=0.01) and more clinicians were in an action stage of change (p=0.001) but these changes were not associated with changes in primary or secondary outcomes. Conclusions Self-efficacy scores correlated with program use at baseline and increased in the intervention arm but these increases were not associated with greater program-related activities. Self-efficacy may be necessary but not sufficient for behavior change.

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Exploring the gap between National Cholesterol Education Program guidelines and clinical practice in secondary care: results of a cross-sectional study involving over 10 000 patients followed in different specialty settings across Italy

Cited by 16 publications

References 44 publications

Does management of lipid lowering differ between specialists and primary care: Insights from GOAL Canada

Does management of lipid lowering differ between specialists and primary care: Insights from GOAL Canada

The challenge of polypharmacy in cardiovascular medicine

Improving Clinician Self-Efficacy Does Not Increase Asthma Guideline Use by Primary Care Clinicians

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