How many adults have their cholesterol level checked? How many with high cholesterol receive treatment and lower their cholesterol to a healthy level?

Almost three-quarters (73%) of community-dwelling adults surveyed in 2003 had their cholesterol levels measured within the past five years, an increase of 6 percentage points from 1998. Among the states, this rate ranged from 65 percent to 82 percent in 2003. Among heart attack and stroke survivors with high cholesterol, only 15 percent achieved control of their cholesterol in 1999–2002, although there was a substantial increase in treatment from 1988–1994.

Why is this important?

• High cholesterol is a major modifiable risk factor for coronary heart disease (CHD), the number-one cause of death in the United States. The total economic cost of CHD is $143 billion, including medical costs and societal costs such as lost productivity (Thom et al. 2006).
• Almost one-half of U.S. adults have high cholesterol, and almost 40 percent have high levels of "bad" low-density lipoprotein (LDL) cholesterol.
• Experts recommend that physicians screen adults for lipid disorders, including high cholesterol, every five years starting at age 20 (NCEP 2001), or starting at age 35 for men and age 45 for women and among younger adults who have other risk factors (USPSTF 2002).
• Those identified as having high cholesterol can reduce their risk for CHD by making lifestyle changes (e.g., diet and exercise) and, when appropriate, by taking medication to lower LDL cholesterol levels (Costa et al. 2006; Grundy et al. 2004; NCEP 2001).
• Among individuals who have suffered a heart attack or stroke, 87 percent have high levels of LDL cholesterol and are at high risk for recurrent coronary events (Muntner et al. 2006). Controlling cholesterol is especially beneficial among these high-risk individuals (Costa et al. 2006; Grundy et al. 2004; NCEP 2001).

Findings

• As of 2003, more than one-quarter of community-dwelling adults (ages 18 and older) had not had their cholesterol levels checked within the past five years, an improvement from 1998 when one-third had not been tested as recommended. Cholesterol testing was substantially higher among middle-age and elderly adults compared with younger adults.
• In the state with the best performance (Rhode Island) in 2003, one of five adults had not had their cholesterol checked in the past five years. In the state with the worst performance (Utah), one of three had not been tested in five years.
• Among heart attack and stroke survivors with high cholesterol, who are at high risk for repeat coronary events, two of five had not been diagnosed with high cholesterol and thus were not aware of their condition during 1999–2002.
• The use of cholesterol-lowering medication increased substantially (by 45 percentage points) from 1988–1994 to 1999–2002 among heart attack and stroke survivors who were aware of their high cholesterol. Nevertheless, 85 percent of all heart attack and stroke survivors with high cholesterol did not have their "bad" cholesterol under control during 1999–2002.

Implications

• The improvement trends in cholesterol testing suggest that the nation might meet the Healthy People 2010 goal of 80 percent for this measure (DHHS 2000).
• Increasing cholesterol control among high-risk individuals equal to that achieved among heart attack survivors in the best-performing health plans (61% in 2004) might prevent up 7,200 premature deaths and save up to $88 million in medical costs annually (NCQA 2005).

Improvement Ideas and Resources

To improve the quality of care for patients at risk for CHD, the American Heart Association notes that a "physician-patient partnership must be forged, on the physician's part by assessing and communicating risk and by co-developing with the patient a plan of preventive action" (Pearson et al. 2002). The following interventions were associated with improvements in LDL cholesterol levels or control among high-risk patients in some studies:

• a multifaceted intervention consisting of an educational workshop for primary care providers, the influence of opinion leaders, and the use of prompts including progress notes, patient letters, and chart reminders (Bloomfield et al. 2005);
• contacting primary care physicians of patients hospitalized for coronary care to recommend assessment of lipid profiles and cholesterol-lowering therapy after discharge (Hilleman et al. 2004; Hilleman et al. 2001); and
• involving clinical pharmacists in prescribing and monitoring adherence to cholesterol-lowering medication in ambulatory care (Ellis et al. 2000; Olson et al. 2005; Straka et al. 2005; Till et al. 2003).

Measure:

• For cholesterol screening charts, the denominator includes community-dwelling adults ages 18 and older. The numerator is the subset of the denominator population who could recall whether they had their blood cholesterol checked within the past five years (AHRQ 2006).
• For the chart depicting cholesterol awareness, treatment, and control, the denominator includes community-dwelling adults ages 20 and older who either had an LDL cholesterol level of 100 mg/dL or higher on a standardized laboratory test or reported taking cholesterol-lowering medication in the past two weeks. The numerator contains the subset of the denominator who reported that a health professional diagnosed them with hypercholesterolemia (awareness), that they were taking cholesterol-lowering medication (treatment), or who had cholesterol level less than 100 mg/dl on standardized laboratory test (control), consistent with guidelines of the National Cholesterol Education Program (Grundy et al. 2004; NCEP 2001).

Limitations:

The chart on awareness, treatment, and control does not include all high-risk individuals eligible for secondary prevention, nor does it depict primary prevention among individuals who do not yet have CHD. The measures do not include individuals with diagnosed hypercholesterolemia who have controlled their cholesterol through lifestyle modification.

Source:

• National screening rates were compiled by the Agency for Healthcare Research and Quality (AHRQ 2006) based on responses to the National Health Interview Survey, a nationally representative household interview survey of the U.S. civilian, noninstitutionalized population.
• State rates were compiled by the National Center for Chronic Disease Prevention and Health Promotion using data from the Behavioral Risk Factor Surveillance System, a telephone survey that is representative of the civilian, noninstitutionalized adult population in each state (NDDC 2005).
• Disease awareness and control rates were compiled by researchers at Tulane University (Muntner et al. 2006) using data from the National Health and Nutrition Examination Survey, a nationally representative survey of the civilian, noninstitutionalized U.S. population. Participants are interviewed in their homes, undergo a medical examination, and provide samples for standardized laboratory analysis.

References:

* Indicates source of data used in the chart(s).* AHRQ (Agency for Healthcare Research and Quality). 2006. National Healthcare Quality Report, 2005. Rockville, Md.: Agency for Healthcare Research and Quality. Bloomfield, H. E., D. B. Nelson, M. van Ryn et al. 2005. A Trial of Education, Prompts, and Opinion Leaders to Improve Prescription of Lipid Modifying Therapy by Primary Care Physicians for Patients with Ischemic Heart Disease. Quality and Safety in Health Care 14 (4): 258–63. Costa, J., M. Borges, C. David et al. 2006. Efficacy of Lipid Lowering Drug Treatment for Diabetic and Non-Diabetic Patients: Meta-Analysis of Randomised Controlled Trials. BMJ. 332 (7550):1115–24.Ellis, S. L., B. L. Carter, D. C. Malone et al. 2000. Clinical and Economic Impact of Ambulatory Care Clinical Pharmacists in Management of Dyslipidemia in Older Adults: The IMPROVE study. Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers. Pharmacotherapy 20 (12): 1508–16. Grundy, S. M., J. I. Cleeman, C. N. Merz et al. 2004. Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 110 (2): 227–39.Hilleman, D. E., M. A. Faulkner, and M. S. Monaghan. 2004. Cost of a Pharmacist-Directed Intervention to Increase Treatment of Hypercholesterolemia. Pharmacotherapy 24 (8): 1077–83. Hilleman, D. E., M. S. Monaghan, C. L. Ashby et al. 2001. Physician-Prompting Statin Therapy Intervention Improves Outcomes in Patients with Coronary Heart Disease. Pharmacotherapy 21 (11): 1415–21. * Muntner, P., K. B. Desalvo, R. P. Wildman et al. 2006. Trends in the Prevalence, Awareness, Treatment, and Control of Cardiovascular Disease Risk Factors Among Noninstitutionalized Patients with a History of Myocardial Infarction and Stroke. American Journal of Epidemiology 163 (10): 913–20. NCEP (National Cholesterol Education Program). 2001. Executive Summary of the 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). Journal of the American Medical Association 285(19): 2486–97. NCQA (National Committee for Quality Assurance). 2005. The State of Health Care Quality, 2005. Washington, D.C.: National Committee for Quality Assurance. * NDDC (National Center for Chronic Disease Prevention & Health Promotion). 2005. Behavioral Risk Factor Surveillance System. Atlanta, Ga.: Centers for Disease Control and Prevention. Olson, K. L., J. Rasmussen, B. G. Sandhoff et al. 2005. Lipid Management in Patients with Coronary Artery Disease by a Clinical Pharmacy Service in a Group Model Health Maintenance Organization. Archives of Internal Medicine 165 (1): 49–54. Straka, R. J., R. Taheri, S. L. Cooper et al. 2005. Achieving Cholesterol Target in a Managed Care Organization (ACTION) Trial. Pharmacotherapy 25 (3): 360–71. Thom, T., N. Haase, W. Rosamond et al. 2006. Heart Disease and Stroke Statistics—2006 Update: A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 113 (6): e85–151. Till, L. T., J. C. Voris, and J. B. Horst. 2003. Assessment of Clinical Pharmacist Management of Lipid-Lowering Therapy in a Primary Care Setting. Journal of Managed Care Pharmacy 9 (3): 269–73. USPSTF (U.S. Preventive Services Task Force). 2002. Screening for Lipid Disorders in Adults: Recommendations and Rationale. American Family Physician 65(2): 273–6.