ORIGINAL ARTICLES

 

Perceptions about the management of dyslipidaemia among physicians in Jamaica and Trinidad

 

Percepciones acerca del tratamiento de la dislipidemia entre los médicos en Jamaica y Trinidad

 

 

HA Monsanto; M Prann; JG Quijada

Medical Department, Merck Sharp and Dohme (IA) Corporation, PO Box 3689, Carolina, Puerto Rico 00984-3689

Correspondence

 

 

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ABSTRACT

BACKGROUND: Proper management of dyslipidaemia in patients may reduce morbidity and mortality related to coronary heart disease.
OBJECTIVE: To determine physician perceptions of the management of dyslipidaemia in Jamaica and Trinidad.
METHODS: Personal interviews were conducted from March to May, 2005, by an independent research firm using a structured questionnaire.
RESULTS: A total of 111 interviews were conducted, 61 in Jamaica and 50 in Trinidad. Respondents were mostly primary care physicians (PCP) or internal medicine physicians (76.5%) and 58% were in private practice. The most important factors for prescribing a drug for dyslipidaemia were related to efficacy (76%), safety (59%) and price (36%). The majority (92%) reported using treatment guidelines. The National Cholesterol Education Program (NCEP) guidelines were the most widely mentioned by physicians but there were reports of using guidelines from other organizations and physician groups. Nearly a third of all physicians, most of whom were PCPs, had not heard of the NCEP. The LDL-C level at which drug therapy should be started and the LDL-C treatment goals were higher among Jamaican physicians.
CONCLUSIONS: Physicians are aware of the existence of treatment guidelines for dyslipidaemia. How-ever, the source and adherence to the guidelines varies according to country and specialty. Information about the proper management of dyslipidaemia must be reinforced by professional societies and government agencies.

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RESUMEN

ANTECEDENTES: El tratamiento apropiado de la dislipidemia en pacientes puede reducir la morbilidad y la mortalidad en relación con la cardiopatía coronaria.
OBJETIVO: Determinar las percepciones de los médicos con respecto al tratamiento de la dislipidemia en Jamaica y Trinidad.
MÉTODOS: Se llevaron a cabo entrevistas personales de marzo a mayo, 2005, por una empresa de investigación independiente, utilizando un cuestionario estructurado.
RESULTADOS: Se llevaron a cabo un total de 111 entrevistas – 61 en Jamaica y 50 en Trinidad. Los entrevistados fueron en su mayoría médicos de atención primaria (MAP), o médicos de medicina interna (MMI) (76.5%) y el 58% estaban en la práctica privada. Se relacionaron los factores más importantes para prescribir una droga para la dislipidemia estuvieron relacionados con la eficacia (76%), la seguridad (59%) y el precio (36%). La mayoría (92%) reportó el uso de pautas para el tratamiento. Las pautas del Programa Nacional de Educación sobre el Colesterol (PNEC) fueron las más ampliamente mencionadas por los médicos, pero hubo reportes de uso de pautas provenientes de otras organizaciones y grupos médicos. Casi un tercio de todos los médicos – la mayor parte de quien eran MAPs – no había oído hablar del PNEC. El nivel de colesterol de lipoproteína de baja densidad (CLBD) a que debe empezarse la terapia medicamentosa, y los objetivos del tratamiento de CLBD, fueron más altos entre los médicos jamaicanos.
CONCLUSIONES: Los médicos tienen conciencia de la existencia de pautas para el tratamiento de la dislipidemia. Sin embargo, la fuente y la adhesión a las pautas varían según el país y la especialidad. La información sobre el tratamiento adecuado de la dislipidemia debe ser reforzada por las sociedades profesionales y agencias del gobierno.

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INTRODUCTION

Cardiovascular disease is among the leading causes of death in Caribbean countries. In 1999, cardiovascular diseases were the second leading cause of death in Jamaica, with a mortality rate of 84.6 per 100 000 population (1). In Trinidad and Tobago, cardiovascular diseases accounted for 38% and 43% of the deaths in men and women, respectively, in 1997 (1).

Proper management of dyslipidaemia may reduce morbidity and mortality due to coronary heart disease (CHD). Many studies have shown that high serum concentrations of LDL cholesterol (LDL-C) are a major risk factor for CHD and that lowering LDL-C levels will reduce the risk for major coronary events (2).

In the United States of America (USA), the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Cholesterol in Adults has published guidelines for lipid management based on CHD risk assessment and stratification (3). The guidelines are revised periodically to reflect improved understanding of dyslipidaemia and its association with CHD, improved understanding of other CHD risk factors, technical advances and advances in therapy (4). European professional societies have also developed guidelines on cardiovascular disease prevention in clinical practice which recognize the importance of lipid management (5).

Guidelines are meant to serve as a tool for clinical decision-making for the treatment of conditions such as dyslipidaemia but they do not substitute for the individual professional judgment of the practitioner. However, since they are developed by a panel of experts based on a thorough review of scientific studies on the topic being addressed, it is expected that practitioners become aware and adhere to them. Level of awareness and adherence to guidelines may be influenced by several factors and may be important in achieving optimal patient outcomes.

Dyslipidaemia is an important, modifiable CHD risk factor which has been the subject of several guidelines. Guidelines for the management of dyslipidaemia appear to have had a beneficial effect on the population of the USA based on data from the National Health Examination Survey (NHES) and the National Health and Nutrition Examination Surveys (NHANES) (4). However, physician awareness and adherence to guidelines continues to be an issue. A survey commissioned by the National Lipid Association in 2004 revealed that, although most physicians indicated a high degree of familiarity with and adherence to the guidelines (81%), a substantially lower percentage (46%) believed that physicians "in general" were familiar with and adherent to the guidelines (6). Furthermore, it has been found that the degree of consensus among physicians about their patient care decisions with regard to the management of hyper-cholesterolaemia varies considerably on an individual basis (7). Physician beliefs in more aggressive management strategies have resulted in better mean total cholesterol values in high risk patients over a period of time (8).

The objective of this study was to determine physician perceptions of the management of dyslipidaemia in patients in Jamaica and Trinidad. The specific objectives were: 1) to describe physician awareness and perceived importance of guidelines for the treatment of dyslipidaemia, 2) to describe the first line alternatives for treating dyslipidaemia and the current practices for monitoring and evaluating patients with dyslipidaemia and 3) to determine the LDL-C levels physicians use in order to start drug treatments and the LDL-C goals according to patient risk level.

 

SUBJECTS AND METHODS

Personal interviews were conducted among a random sample of physicians from March to May, 2005, by an independent research firm using a structured questionnaire. Physicians were selected consecutively on the basis of his/her consent to participate in the interview until the target sample size was achieved. The physician sample included primary care providers (general medicine and family practitioners), internists, cardiologists and endocrinologists. Participation was voluntary and a monetary compensation was provided.

 

RESULTS

Description of the sample

One hundred and eleven physicians were interviewed, 61 (55%) in Jamaica and 50 (45%) in Trinidad. The mean years of practice reported by the physicians were 21 years for the physicians in Jamaica and 26 years for those in Trinidad. Nearly 60% of the total sample reported having a private practice only (59% in Jamaica and 56% in Trinidad) while 42% reported having both a public and a private practice (41% in Jamaica and 44% in Trinidad).

The distribution of physicians by specialty was similar in both countries. Internists comprised one third of the total sample (30% in Jamaica, 36% in Trinidad) while generalists accounted for nearly one-quarter of the sample (23% in Jamaica and 26% in Trinidad) and family practitioners for 20% (21% in Jamaica and 18% in Trinidad). Cardiologists and endocrinologists accounted for 18% and 5% of the total sample, respectively (20% and 7% in Jamaica and 16% and 4% in Trinidad, respectively).

Physicians stated that they see a mean of 82 patients per week (77 patients per week in Jamaica and 89 patients per week in Trinidad), one third of whom (32%) reportedly have dyslipidaemia. Physicians in Trinidad reported having a higher percentage of patients with dyslipidaemia (40%) than physicians in Jamaica (26%).

Use of Medications for Dyslipidaemia

Overall, nearly nine out of ten physicians (87%) mentioned statins as the ‘top-of-mind’ (the first that came to mind) medication category for the treatment of dyslipidaemia, with no substantial differences among countries (Jamaica 85%, Trinidad 90%) or among specialties. Efficacy and safety were the two most important factors that physicians considered when prescribing a statin (Table 1). Differences were observed by country and specialty. Physicians in Jamaica overwhelmingly selected efficacy over other factors while physicians in Trinidad attributed the same importance to efficacy and safety. This preference was also observed across specialties. Availability of the medication was more an issue for physicians in Trinidad than in Jamaica.

 

 

Monitoring Patients with Dyslipidaemia

Ninety-two per cent of physicians stated that they monitored patients with dyslipidaemia by using blood tests, 85% in Jamaica and 100% in Trinidad. However, there were differences by country in the types of tests recommended. In Jamaica, 65% of physicians used a lipid panel and 31% used both a lipid panel and a liver function test. In Trinidad, 62% of physicians reported ordering a lipid panel while 32% reported ordering a lipid panel and a liver function test. In Jamaica, PCPs and cardiologists were less likely to use both tests than internists and endocrinologists (60% and 58% vs 73% and 75%, respectively), while in Trinidad PCPs and internists were less likely to use both tests than specialists (32% and 33% vs 50%, respectively).

The frequency at which tests are ordered did not vary substantially by country. The most frequent interval mentioned by physicians in Jamaica and Trinidad was every 2–3 months (48% and 58%, respectively), followed by every three to six months (28% and 22%, respectively). There were no substantial differences observed by specialty within countries. Blood test monitoring frequency varied by patient risk level. Physicians reported ordering these tests more frequently as the level of risk increased. High risk patients are ordered blood tests monthly or every two to three months by nearly three quarters of physicians in both countries, while low risk patients are ordered these tests yearly by nearly 70% of physicians.

A similar pattern was observed for follow-up physician visits. High risk patients were asked to come back to the office monthly or every 2 to 3 months by more than 80% of physicians, while low risk patients were asked to come back yearly or every 3 to 6 months by more than 90% of physicians. No differences were observed by country regarding frequency of physician visits.

Use of Guidelines for the Management of Dyslipidaemia

Nine of ten respondents reported using guidelines for determining risk levels and/or options for the treatment of patients with dyslipidaemia (93% in Jamaica and 90% in Trinidad). The trend was similar for specialties in both countries except for PCPs in Trinidad where 18% reported no use of guidelines. Physicians were also asked which guidelines they used. This yielded over 30 organization names which were then classified into organizations based in the USA, Europe and locally. The great majority of physicians (78%) reported using guidelines developed by organizations in the USA, followed by 9% from European organizations and 7% from local organizations. There were variations among countries with regard to the use of local guidelines. Seventeen per cent of physicians in Jamaica reported using local guidelines in contrast to 2% in Trinidad.

Awareness of the National Cholesterol Education Program (NCEP) of the National Institutes of Health was widespread among physicians interviewed. Seventy-two per cent of the total sample reported having heard about the programme, 74% in Jamaica and 70% in Trinidad. Awareness was substantially lower among PCPs than among specialties in both countries (56% in Jamaica and 50% in Trinidad). Nine of ten physicians who used the guidelines developed by the NCEP found them "important" or "very important". This was consistent among countries, with 91% of physicians in Jamaica and 86% in Trinidad reporting that they were "important" or "very important". One in five of PCPs in Jamaica and one in three internists in Trinidad rated the NCEP guidelines as "somewhat important" or "interesting but not relevant." Cardiologists in Jamaica (8%) and Trinidad (14%) rated the guidelines as "somewhat important."

To validate awareness and adherence to the guidelines established by the NCEP, physicians were asked about specific components of these guidelines. Almost 90% of the respondents reported being aware of the therapeutic lifestyle changes that are suggested by the NCEP guidelines as a component for the management of dyslipidaemia. Awareness did not differ by country but more PCPs than specialists were unaware of this concept in both countries.

Physicians were also asked the LDL-C level at which to initiate treatment and to reach their goal according to risk levels. The risk levels used are those defined in the NCEP guidelines (3), mainly low risk (individuals with no or one coronary heart disease (CHD) risk factor), moderate risk (individuals with two or more risk factors plus a less than ten per cent risk for heart attack within ten years), moderately high risk (individuals who have two or more CHD risk factors together with a ten to twenty per cent risk for a heart attack within ten years), and high risk (individuals who have CHD) or disease of the blood vessels to the brain or extremities, or diabetes, or multiple (two or more) risk factors that give them a greater than twenty per cent chance of having a heart attack within ten years).

As shown in Tables 2 and 3, LDL-C levels to initiate treatment and to reach treatment goals varied by country. Physicians in Jamaica consistently reported higher levels than their counterparts in Trinidad to initiate treatment and to reach treatment goals. As expected, the mean LDL-C level to initiate treatment was lower as the risk level increased in both countries. However, there was greater variation among physicians in Jamaica than in Trinidad. There was only a three-point difference in the mean level reported by Trinidad physicians to initiate treatment between the moderate/low risk patients and the high/moderately high risk patients. Generally, physicians in both countries initiated treatment at LDL-C levels that are lower than those recommended by the NCEP to patients at moderate and low risk. LDL-C treatment goals were consistently within the recommendations set forth by the NCEP in both countries.

 

 

 

 

Figures 1 and 2 show the LDL-C levels reported to initiate treatment by country, specialty and level of risk. Cardiologists and endocrinologists tended to start patients at a lower LDL-C level than their counterparts, regardless of country. As shown, PCPs did not discriminate much when to initiate treatment in patients regardless of risk level, but specialists seemed to be more aware of the differences in risk levels as they relate to when to initiate treatment. With regard to LDL-C treatment goals, the expected pattern of lower LDL-C goals for higher risk patients was observed with no substantial variations within physician specialties.

 

 

 

 

DISCUSSION

LDL-C levels to initiate treatment and to reach treatment goals were found to vary by country. This may be attributed to the use of different guidelines. Adherence to NCEP guidelines was observed for achieving treatment goals but not to initiate drug treatment. This may be influenced by the degree of exposure to the guidelines in professional meetings and literature. It has been shown that a key strategy to improve the outcomes in patients with acute coronary syndrome is the proper management of secondary prevention initiatives, such as aspirin, beta blockers, statins and ACE inhibitors (9). Poor adherence to guidelines may, thus, be perceived as a problem in terms of quality of care (7).

This study has several limitations. The sample of physicians may not be representative of the total physician population. Although the sample was selected randomly from a list of physicians obtained by the external contractor, physicians who were not willing to participate were substituted by the next physician on the list. We did not have access to this information and, therefore, cannot calculate the non-response rate. We were also unable to compare the proportion of physicians by specialty with the actual distribution in each of the countries. Due to the study design (structured interview) and the nature of the questions (physician perceptions), there is the potential for recall bias in that they may not remember with certainty some of the information asked. There is also the potential that physicians responded based on the social desirability of the responses according to the objectives of the study.

In conclusion, physicians in Jamaica and Trinidad are aware of the existence of treatment guidelines for dyslipidaemia. However, the source and adherence to the guidelines vary according to country and specialty. The differences in physician perceptions about the management of dyslipidaemia by country and specialty could be explained by factors associated with the medical training of physicians and the country’s healthcare system. Physician beliefs about the benefits of treatment with lipid lowering drugs may also play a role (8). Further research is needed to determine the reasons for practice variations.

This study shows that there is room for additional information about the proper management of dyslipidaemia in clinical practice. Professional societies at the local, national and international levels as well as government agencies could play a vital role in developing and adopting these guidelines and disseminating the information to their constituents.

Future studies should compare physician perceptions about guidelines with actual behaviour by examining medical records to evaluate adherence to guidelines and, subsequently, their impact on patient outcomes. This is particularly important considering that recent research has shown that, in spite of the existence of guidelines, LDL-C cholesterol values among USA adults exceeded 2001 NCEP goals and 2004 optional goals for 30% and 35.8% of the adults, respectively (10). Furthermore, since achievement of lipid goals may also be influenced by patient adherence to treatment, it is also of utmost importance to study patient attitudes and beliefs about dyslipidaemia and its treatment. A scale has been developed and validated to be used with physicians and patients for this purpose (11, 12).

 

ACKNOWLEDGEMENTS

We would like to acknowledge the contributions of Mr Juan Charana and Research and Research in collecting the data for this study.

 

REFERENCES

1. Pan American Health Organization. Basic Country Health Profiles for the Americas: Summaries. http://www.paho.org/english/dd/ais/cp_ index.htm (Accessed November 22, 2005).

2. Grundy SM, Cleeman JI, Merz NB, Brewer HB, Clark LT, Hunninghake DB, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation 2004; 110: 227–39.

3. Expert Panel on the Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III Final Report). Circulation 2002; 106: 3143–421.

4. LaRosa JC, Gotto AM. Past, present, and future standards for management of dyslipidaemia. Am J Med 2004; 116: 3S–8S.

5. De Backer G, Ambrosioni E, Borch-Johnsen K, Brotons C, Cifkova R, Dallongeville J et al. European guidelines on cardiovascular disease prevention in clinical practice. European Heart J 2003; 24: 1601–10.

6. Pasternak RC, McKenney JM, Brown WV, Cahill E, Cohen JD. Understanding physician and consumer attitudes concerning cholesterol management: results from the National Lipid Association Surveys. Am J Cardiol 2004; 94(suppl): 9F–15F.

7. Backlund L, Skånér Y, Montgomery H, Bring J, Strender LE. The role of guidelines and the patient’s life-style in GPs’ management of hyper-cholesterolaemia. BMC Family Practice 2004; 5: 3.

8. Franciosi M, Pellegrini F, De Berardis G, Belfiglio M, Di Nardo B, Greenfield S et al. Impact of physicians beliefs and practices on cholesterol levels in patients with type 2 diabetes: A longitudinal assessment. Am Heart J 2005; 149: 104–11.

9. Das R, Kilcullen N, Morrell C, Robinson MB, Barth JH, Hall AS. The British Cardiac Society Working Group definition of myocardial infarction: implications for practice. Heart 2006; 92: 21–6.

10. Persell SD, Lloyd-Jones DM, Baker DW. Implications of changing National Cholesterol Education Program goals for the treatment and control of hypercholesterolemia. J Gen Intern Med 2006; 21:000-000. Online publication date: 6-Jan-2006. http://www.blackwell-synergy. com/toc/jgi/0/0.

11. Foley KA, Vasey J, Alexander CM, Markson LE. Development and validation of the Hyperlipidemia Attitudes and Beliefs in Treatment (HABIT) survey for physicians. J Gen Intern Med 2003; 18: 984–90.

12. Foley KA, Vasey J, Berra K, Alexander CM, Markson LE. The hyperlipidemia attitudes and beliefs in Treatment (HABIT) survey for patients: Results of a validation study. J Cardiovasc Nursing 2005; 20: 35–42.

 

 

Correspondence:
Dr H Monsanto
Merck Sharp and Dohme (IA\ ) Corp, PO Box 3689,
Carolina, Puerto Rico
00984-3689,
e-mail: homero_monsanto@merck.com.

 

 

Presented at the 20th Caribbean Cardiology Conference of the Caribbean Cardiac Society held in Key Biscayne, Florida, July 20–23, 2005.