EDITORIALS
Hypercholesterolemia: needs of physicians
The current
educational
Patrick E. McBride, MD, MPH, Mary Beth Plane, PhD, and Gail Underbakke, RD, MS. Madison, Wis.
Physicians play a vital role in public health efforts to reduce the burden of coronary artery disease (CAD) and atherosclerosis1 by identifying and treating highrisk patients. As a result of this role, physicians are the target of national initiatives to increase the identification and management of patients with high blood cholesterol levels.2-4 With the release of the National Cholesterol Education Program (NCEP) guidelines in 1987, patients with blood cholesterol levels greater than 6.2 mmol/L (240 mg/dl) are considered to have high blood cholesterol values. The guidelines recommend that individuals with high blood cholesterol levels, particularly those with multiple risk factors for CAD, undergo assessment by a physician and be considered candidates for dietary or medical therapy.2 The NCEP and the American Heart Association (AHA) developed campaigns beginning in 1987 to educate physicians about the new guidelines. Surveys conducted before the NCEP to assess physician attitudes, knowledge, and self-reported practices indicated that they did not generally agree with national consensus recommendations.5-7 A 1986 survey of primary care physicians in New Hampshire indicated that 47 % of physicians thought that a cholesterol level needed to be higher than 7.75 mmol/L (300 mg/dl) to be considered high risk.? More recently, Schucker et a1.8 reported that in the third wave of a national survey of physicians conducted by the National Institutes of Health (NIH) in 1990, most physicians agree with the NCEP guidelines for di-
From vision
the Departments of Cardiology,
of Family University
Medicine and Practice of Wisconsin Medical
and Medicine, School.
Di-
Supported in part by the American Heart Association-Wisconsin Affiliate, a Public Health Service Preventive Cardiology Academic Award (lK07 HL01936-01) from the National Heart, Lung, and Blood Institute, National Institutes of Health, and the University of Wisconsin Medical School. Received
for publication
Reprint requests: Patrick and Practice, University Madison, WI 53715-1896. 4/l/34517
Aug.
5, 1991;
E. McBride, of Wisconsin
accepted
Sept.
20,
1991.
MD, Department of Family Medicine Medical School, 777 S. Mills St.,
etary and drug treatment of patients with borderline and high-risk cholesterol levels. The NIH surveys found that the percentage of physicians who considered cholesterol to be a significant risk for CAD had increased from 39 % in 1983 to 64 % in 1986; by 1990, 99 % of physicians surveyed thought total cholesterol was an important clinical marker for heart disease. The median range of blood cholesterol levels for drug treatment declined from 8.79 to 9.28 mmol/L (340 to 359 mg/dl) in 1983 to 7.76 to 8.25 mmol/L (300 to 319 mg/dl) in 19867ys and in 1990 descended to 6.21 to 6.7 mmol/L (240 to 259 mg/dl), consistent with the guidelines. Bostick et al9 looked at physician practice in heart disease prevention and found that hypertension was treated more often with nonpharmacologic methods, smoking cessation activities increased, and treatment of high blood cholesterol was initiated at lower levels in 1989 compared with 1987.g The number of prescriptions for cholesterol-lowering medication in the United States has increased nearly fivefold from 1983 to 1988,l” an indication of more frequent treatment of high blood cholesterol levels. Although physician knowledge and attitudes toward cholesterol management are changing, studies indicate that management of elevated cholesterol levels in primary care practice continues to be well below recommended practice guidelines.l’-l4 Given the changing perspectives of physicians, we developed this survey to provide an update for current physician cholesterol education programs. The survey examined current attitudes, knowledge, and self-reported educational needs of Wisconsin physicians, including those in family practice, general practice, and internal medicine including cardiolWY. METHODS
A mailing list purchased from the State Medical Society of Wisconsin identified physicians registered with the society as family physicians, internists, or general practitioners. Surveys were sent to 2301 physicians to reach all members of these specialties in the state. Data obtained from the society indicate that family physicians made up 817
818
McBride,
Plane, and Underbakke
Table I. Physician tion guidelines
estimates
American
of own useof NCEP prevenEstimates
Treatment
Mean
Cholesterol level for diagnosis of high risk (mmol/L) (n = 801) % Time diet changes reduce cholesterol to treatment goal levels (n = 852) MO of diet therapy trial before initiating drug therapy (n = 850) Level of cholesterol at which to initiate drug therapy for patient with two risk factors/not responsive to diet therapy (mmol/L) (n = 797)
6.37 36
Physicians reporting use of guidelines, 77 “1. There was no difference in these measures by physician
0.67 19
4.6
2
6.19
0.57
specialty.
45 %, and generalpractitioners 15% of the primary care providers surveyed. Nearly 5% of these physiciansidentified themselvesascardiologists.The two-page survey was mailed between October 1989and March 1990 a maximum of three times to each physician. This survey was designedto assessphysician attitudes regarding the national guidelines on dietary and drug therapy for high blood cholesterol levels.Physicians were askedto indicate: whether they followed NCEP guidelines in treating patients with high blood cholesterol levels, the level of blood cholesterol they considered“high risk,” the length of time they attempted dietary therapy before prescribing drugs, their drug of first choice for both primary and combined hyperlipidemias, level of cholesterol at which they initiate drug therapy in a patient with two risk factors, knowledge of their own cholesterol levels, and if they controlled the amount of fat and cholesterolin their own diet. The survey also asked about participation in and usefulnessof AHA cholesterol education programs, their preferred methods for future cholesterol education programs, educational topics of interest, and specific practice resourceneeds of the responding physicians. The survey was pretested for content validity by local family physicians and medical school faculty. Survey data were entered into a computer data base twice to verify accuracy, and noncorresponding answers were checked with the original questionnaire. When lowdensity lipoprotein (LDL) levels were reported on questions in which total cholesterol levels were requested, the values were translated into approximately equivalent total
cholesterol values for the analysis (e.g., LDL 4.16 mmol/ L = total cholesterol 6.24 mmol/L). Descriptive statistics were used to summarizethe answersof the entire group of
physicians and of the subgroupsof specialties.Variation subgroups
was examined
by one-way
analysis
ysis. Comments written on questionnaireswere grouped and tallied for further insight into responses. RESULTS
SD
40 % , internists
between
March 1992 Heart Journal
of
variance, t test, and chi square analysis to examine the cholesterol treatment attitudes and overall self-reported educational needsof the physicians. The SPSSX Statistical Packagefor the Social Sciences15 wasusedin the anal-
The overall response rate to the survey was 4l@; (n = 948). The response rates to the individual mailings were 23 % , 8%) and 9%) respectively, with an additional 1% (n = 32) of surveys returned blank because of retirement, change of address, or physician stating that cholesterol treatment is not an area of practice concern. Physicians indicated their practice specialty on the questionnaire. Physicians who identified themselves on the questionnaire as “other” (than the four above-named specialties) were asked to list their specialty and were eliminated from the analysis if not identified as subspecialty internists or primary care physicians. Thirty-one physicians did not indicate a specialty or listed a specialty that does not routinely deal’ with adult cholesterol management (e.g., dermatology and emergency medicine) and were not included in this analysis. After eliminating blank surveys and surveys from physicians who failed to indicate their specialty or who do not routinely deal with cholesterol management, the effective response rate was 38 o/;,(885/2301). Of the 105 physicians who further identified themselves with the state medical society as cardiologists, 43 (41% ) returned surveys. Their responsesare reported but as a group separate from the primary care physicians. Family physicians constitute 48% of the physicians responding to the survey, general practitioners BCr;‘, internists 39 70, and cardiologists 5 % . Use of NCEP guidelines. Most physicians reported being aware of NCEP/AHA guidelines for the treatment of high blood cholesterol levels (87 % ) and 77 90 reported using the guidelines in their practice (Table I). Physicians who reported using national cholesterol guidelines were in practice for fewer years (13.2 vs 16.2; p < 0.01). General practitioners, the group in practice the longest, were the least likely to report using the guidelines (68’%, data not shown), followed by family physicians at 78 % and internists at 76 % . Cardiologists were the most likely to report using the new guidelines (84 % ). The AHA-Wisconsin Affiliate provided education to more than 800 physicians through a faculty speaker’s bureau in 1987 through 1989 as a part of the NCEP and initiated this needs assessmentto update the program content. Twenty-five percent of the responding physicians had participated in this AHA Physician Cholesterol Education Program (PCEP) l-day workshop in Wisconsin. Of those who participated in the PCEP program, 91% stated they used the guidelines in their practice, compared with 72 %
Volume Number
Table
123 3
Physician
education
on hypercholesterolemia
819
II. Cholesterol level estimates:range for treatment decisions % Responding
Hypercholesterolemia: needs of physicians
The current
educational
Patrick E. McBride, MD, MPH, Mary Beth Plane, PhD, and Gail Underbakke, RD, MS. Madison, Wis.
Physicians play a vital role in public health efforts to reduce the burden of coronary artery disease (CAD) and atherosclerosis1 by identifying and treating highrisk patients. As a result of this role, physicians are the target of national initiatives to increase the identification and management of patients with high blood cholesterol levels.2-4 With the release of the National Cholesterol Education Program (NCEP) guidelines in 1987, patients with blood cholesterol levels greater than 6.2 mmol/L (240 mg/dl) are considered to have high blood cholesterol values. The guidelines recommend that individuals with high blood cholesterol levels, particularly those with multiple risk factors for CAD, undergo assessment by a physician and be considered candidates for dietary or medical therapy.2 The NCEP and the American Heart Association (AHA) developed campaigns beginning in 1987 to educate physicians about the new guidelines. Surveys conducted before the NCEP to assess physician attitudes, knowledge, and self-reported practices indicated that they did not generally agree with national consensus recommendations.5-7 A 1986 survey of primary care physicians in New Hampshire indicated that 47 % of physicians thought that a cholesterol level needed to be higher than 7.75 mmol/L (300 mg/dl) to be considered high risk.? More recently, Schucker et a1.8 reported that in the third wave of a national survey of physicians conducted by the National Institutes of Health (NIH) in 1990, most physicians agree with the NCEP guidelines for di-
From vision
the Departments of Cardiology,
of Family University
Medicine and Practice of Wisconsin Medical
and Medicine, School.
Di-
Supported in part by the American Heart Association-Wisconsin Affiliate, a Public Health Service Preventive Cardiology Academic Award (lK07 HL01936-01) from the National Heart, Lung, and Blood Institute, National Institutes of Health, and the University of Wisconsin Medical School. Received
for publication
Reprint requests: Patrick and Practice, University Madison, WI 53715-1896. 4/l/34517
Aug.
5, 1991;
E. McBride, of Wisconsin
accepted
Sept.
20,
1991.
MD, Department of Family Medicine Medical School, 777 S. Mills St.,
etary and drug treatment of patients with borderline and high-risk cholesterol levels. The NIH surveys found that the percentage of physicians who considered cholesterol to be a significant risk for CAD had increased from 39 % in 1983 to 64 % in 1986; by 1990, 99 % of physicians surveyed thought total cholesterol was an important clinical marker for heart disease. The median range of blood cholesterol levels for drug treatment declined from 8.79 to 9.28 mmol/L (340 to 359 mg/dl) in 1983 to 7.76 to 8.25 mmol/L (300 to 319 mg/dl) in 19867ys and in 1990 descended to 6.21 to 6.7 mmol/L (240 to 259 mg/dl), consistent with the guidelines. Bostick et al9 looked at physician practice in heart disease prevention and found that hypertension was treated more often with nonpharmacologic methods, smoking cessation activities increased, and treatment of high blood cholesterol was initiated at lower levels in 1989 compared with 1987.g The number of prescriptions for cholesterol-lowering medication in the United States has increased nearly fivefold from 1983 to 1988,l” an indication of more frequent treatment of high blood cholesterol levels. Although physician knowledge and attitudes toward cholesterol management are changing, studies indicate that management of elevated cholesterol levels in primary care practice continues to be well below recommended practice guidelines.l’-l4 Given the changing perspectives of physicians, we developed this survey to provide an update for current physician cholesterol education programs. The survey examined current attitudes, knowledge, and self-reported educational needs of Wisconsin physicians, including those in family practice, general practice, and internal medicine including cardiolWY. METHODS
A mailing list purchased from the State Medical Society of Wisconsin identified physicians registered with the society as family physicians, internists, or general practitioners. Surveys were sent to 2301 physicians to reach all members of these specialties in the state. Data obtained from the society indicate that family physicians made up 817
818
McBride,
Plane, and Underbakke
Table I. Physician tion guidelines
estimates
American
of own useof NCEP prevenEstimates
Treatment
Mean
Cholesterol level for diagnosis of high risk (mmol/L) (n = 801) % Time diet changes reduce cholesterol to treatment goal levels (n = 852) MO of diet therapy trial before initiating drug therapy (n = 850) Level of cholesterol at which to initiate drug therapy for patient with two risk factors/not responsive to diet therapy (mmol/L) (n = 797)
6.37 36
Physicians reporting use of guidelines, 77 “1. There was no difference in these measures by physician
0.67 19
4.6
2
6.19
0.57
specialty.
45 %, and generalpractitioners 15% of the primary care providers surveyed. Nearly 5% of these physiciansidentified themselvesascardiologists.The two-page survey was mailed between October 1989and March 1990 a maximum of three times to each physician. This survey was designedto assessphysician attitudes regarding the national guidelines on dietary and drug therapy for high blood cholesterol levels.Physicians were askedto indicate: whether they followed NCEP guidelines in treating patients with high blood cholesterol levels, the level of blood cholesterol they considered“high risk,” the length of time they attempted dietary therapy before prescribing drugs, their drug of first choice for both primary and combined hyperlipidemias, level of cholesterol at which they initiate drug therapy in a patient with two risk factors, knowledge of their own cholesterol levels, and if they controlled the amount of fat and cholesterolin their own diet. The survey also asked about participation in and usefulnessof AHA cholesterol education programs, their preferred methods for future cholesterol education programs, educational topics of interest, and specific practice resourceneeds of the responding physicians. The survey was pretested for content validity by local family physicians and medical school faculty. Survey data were entered into a computer data base twice to verify accuracy, and noncorresponding answers were checked with the original questionnaire. When lowdensity lipoprotein (LDL) levels were reported on questions in which total cholesterol levels were requested, the values were translated into approximately equivalent total
cholesterol values for the analysis (e.g., LDL 4.16 mmol/ L = total cholesterol 6.24 mmol/L). Descriptive statistics were used to summarizethe answersof the entire group of
physicians and of the subgroupsof specialties.Variation subgroups
was examined
by one-way
analysis
ysis. Comments written on questionnaireswere grouped and tallied for further insight into responses. RESULTS
SD
40 % , internists
between
March 1992 Heart Journal
of
variance, t test, and chi square analysis to examine the cholesterol treatment attitudes and overall self-reported educational needsof the physicians. The SPSSX Statistical Packagefor the Social Sciences15 wasusedin the anal-
The overall response rate to the survey was 4l@; (n = 948). The response rates to the individual mailings were 23 % , 8%) and 9%) respectively, with an additional 1% (n = 32) of surveys returned blank because of retirement, change of address, or physician stating that cholesterol treatment is not an area of practice concern. Physicians indicated their practice specialty on the questionnaire. Physicians who identified themselves on the questionnaire as “other” (than the four above-named specialties) were asked to list their specialty and were eliminated from the analysis if not identified as subspecialty internists or primary care physicians. Thirty-one physicians did not indicate a specialty or listed a specialty that does not routinely deal’ with adult cholesterol management (e.g., dermatology and emergency medicine) and were not included in this analysis. After eliminating blank surveys and surveys from physicians who failed to indicate their specialty or who do not routinely deal with cholesterol management, the effective response rate was 38 o/;,(885/2301). Of the 105 physicians who further identified themselves with the state medical society as cardiologists, 43 (41% ) returned surveys. Their responsesare reported but as a group separate from the primary care physicians. Family physicians constitute 48% of the physicians responding to the survey, general practitioners BCr;‘, internists 39 70, and cardiologists 5 % . Use of NCEP guidelines. Most physicians reported being aware of NCEP/AHA guidelines for the treatment of high blood cholesterol levels (87 % ) and 77 90 reported using the guidelines in their practice (Table I). Physicians who reported using national cholesterol guidelines were in practice for fewer years (13.2 vs 16.2; p < 0.01). General practitioners, the group in practice the longest, were the least likely to report using the guidelines (68’%, data not shown), followed by family physicians at 78 % and internists at 76 % . Cardiologists were the most likely to report using the new guidelines (84 % ). The AHA-Wisconsin Affiliate provided education to more than 800 physicians through a faculty speaker’s bureau in 1987 through 1989 as a part of the NCEP and initiated this needs assessmentto update the program content. Twenty-five percent of the responding physicians had participated in this AHA Physician Cholesterol Education Program (PCEP) l-day workshop in Wisconsin. Of those who participated in the PCEP program, 91% stated they used the guidelines in their practice, compared with 72 %
Volume Number
Table
123 3
Physician
education
on hypercholesterolemia
819
II. Cholesterol level estimates:range for treatment decisions % Responding
