Prevalence and treatment of dyslipidemia in canadian primary care: A retrospective cohort analysis

doi:10.1016/j.clinthera.2007.04.009

Clinical Therapeutics

Volume 29, Issue 4, April 2007, Pages 742-750

https://doi.org/10.1016/j.clinthera.2007.04.009 Get rights and content

Abstract

Background:

Dyslipidemia is an important modifiable risk factor for cardiovascular disease (CVD). Studies suggest that dyslipidemia is underdiagnosed and undertreated in Canada.

Objective:

The objective of this study was to describe dyslipidemia prevalence, patient characteristics, and lipid-lowering treatment (LLT) patterns in a cohort representing Canadian primary care practice.

Methods:

In this retrospective cohort analysis, the Southwestern Ontario database (which comprises data from >150,000 adult patients in rural and urban primary care practices) was used as the data source. Male and female patients with data available from 4 physician visits were included; data were captured quarterly between April 2000 and December 2003 and included demographic and lifestyle information, CVD risk factors, and cardiovascular drug treatments. Data gathered included clinical diagnoses at each visit, symptoms corroborating the diagnoses, clinical data (eg, blood pressure, smoking status, height, weight, fitness level), medications (including name, dose, duration, and quantity prescribed), and diagnostic test results and laboratory analyses. For the purposes of this study, a patient was considered to have dyslipidemia if ≥1 of the following conditions was met: (1) physician-diagnosed hyperlipidemia or hypercholes terolemia; (2) at least 1 measurement of low-density lipoprotein cholesterol (LDL-C) or total cholesterol: high-density lipoprotein cholesterol (TC:HDL-C) ratio greater than the recommended targets based on 10-year coronary artery disease (CAD) risk; and/or (3) at least 1 prescription for a lipid-lowering drug.

Results:

A total of 49,667 patients were included in the study cohort. Dyslipidemia was identified in 6961 (14.0%) patients. Of patients with dyslipidemia, more were untreated (63.2%) than treated (36.7%) with LLTs, with women receiving treatment less often than men (P < 0.001). Of those treated, 47.2% had disease that was not adequately controlled, with fewer treated women having controlled disease than treated men (P < 0.017). Patients with dyslipidemia fell mostly into very-high-risk (45.7%) or low-risk (31.1 %) categories for CAD. A total of 73.0% of treated patients were prescribed monotherapy with a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin); of starin prescriptions, most were for atorvastatin (51.8%) or simvastatin (29.4%). Initial LDL-C levels and initial TC:HDL-C ratios were statistically similar between patients prescribed atorvastatin and those prescribed simvastatin.

Conclusion:

Based on the results of this retrospective cohort analysis, dyslipidemia prevalence in Canadian primary care is high, and despite clinical evidence and treatment guidelines, dyslipidemia is largely untreated in family practice, suggesting a gap in care.

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Cited by (37)

GOAL Canada: Physician Education and Support Can Improve Patient Management
2020, CJC Open
Despite the widespread use of statins, approximately 40% to 50% of Canadian patients with known cardiovascular disease do not achieve the low-density lipoprotein cholesterol (LDL-C) goal. Guidelines Oriented Approach to Lipid lowering (GOAL) is an investigator-initiated study aiming to ascertain the use of second- and third-line therapy and its impact on LDL-C goal achievement in a real-world setting.
GOAL enrolled patients with clinical vascular disease or familial hypercholesterolemia and LDL-C > 2.0 mmol/L despite maximally tolerated statin therapy. During follow-up, physicians managed patients as clinically indicated but with online reminders of guideline recommendations.
Of 2009 patients enrolled (median age 63 years, 42% were female), baseline total cholesterol was 5.5 ± 1.4 mmol/L, LDL-C was 3.3 ± 1.3 mmol/L, non–high-density lipoprotein cholesterol was 4.1 ± 1.4 mmol/L, high-density lipoprotein cholesterol was 1.3 ± 0.4 mmol/L, and triglycerides were 2.0 ± 1.5 mmol/L. Lipid-lowering therapy used at baseline was statin therapy in 76% (with 24% statin intolerant) and ezetimibe in 25%. During follow-up, the proportion of patients achieving an LDL-C level of < 2.0 mmol/L increased significantly to 50.8% as a result of additional lipid-lowering therapy. Patients achieving the recommended LDL-C level were more likely to not be statin intolerant (83.8% vs 70.7%, P < 0.0001) and to be taking a high-efficacy type and dose of statin (52.4% vs 35.9%, P < 0.0001). The 3 top reasons for not using the recommended therapy with ezetimibe were patient refusal in 33%, not needed in 22%, and intolerance in 20%, whereas for PCSK9i the reasons were cost in 26%, not needed in 27%, or patient refusal in 25%.
The results indicate the feasibility of optimizing management, resulting in achievement of the guideline-recommended LDL-C level. This has the potential to translate into reductions in cardiovascular morbidity and mortality of Canadian patients.
Malgré l’utilisation répandue des statines, environ 40 à 50 % des patients canadiens atteints d’une maladie cardiovasculaire connue n’atteignent pas les taux cibles de cholestérol à lipoprotéines de basse densité (C-LDL). L’étude GOAL (Guidelines Oriented Approach to Lipid lowering) est une étude entreprise par un chercheur afin d’évaluer, en contexte réel, l’utilisation de traitements de deuxième et de troisième intention et les effets de ceux-ci sur l’atteinte des taux cibles de C-LDL.
Des patients atteints d’une maladie vasculaire clinique ou d’une hypercholestérolémie familiale, présentant un taux de C-LDL > 2,0 mmol/l malgré un traitement par une statine à la dose maximale tolérée, ont été inscrits à l’étude GOAL. Pendant la période de suivi, les médecins prenaient en charge le traitement de leurs patients selon les besoins cliniques, mais en recevant par voie électronique des rappels des recommandations formulées dans les lignes directrices.
Chez les 2009 patients inscrits à l’étude (âge médian : 63 ans; femmes : 42 %), les taux initiaux moyens étaient les suivants : cholestérol total initial : 5,5 ± 1,4 mmol/l, C-LDL : 3,3 ± 1,3 mmol/l, C non HDL (autre que le cholestérol à lipoprotéines de haute densité) : 4,1 ± 1,4 mmol/l, C-HDL (des lipoprotéines de haute densité) : 1,3 ± 0,4 mmol/l et triglycérides : 2,0 ± 1,5 mmol/l. Le traitement hypolipidémiant utilisé au début de l’étude était composé d’une statine chez 76 % des participants (24 % des patients ne toléraient pas les statines) et d’ézétimibe chez 25 %. Pendant la période de suivi, la proportion de patients atteignant un taux de C-LDL < 2,0 mmol/l a augmenté de façon significative, jusqu’à atteindre 50,8 %, en raison de l’utilisation d’hypolipidémiants additionnels. Les patients atteignant les taux cibles de C-LDL étaient plus susceptibles de ne pas être intolérants aux statines (83,8 % vs 70,7 %, p < 0,0001) et de prendre un type et une dose de statine hautement efficaces (52,4 % vs 35,9 %, p < 0,0001). Les trois principales raisons évoquées pour expliquer le fait de n’avoir pas eu recours au traitement recommandé par l’ézétimibe étaient le refus du patient (33 %), l’absence de besoin (22 %) et l’intolérance (20 %), alors que dans le cas des inhibiteurs de la PCSK9, les raisons données étaient plutôt le coût élevé (26 %), l’absence de besoin (27 %) et le refus du patient (25 %).
Les résultats de cette étude montrent la faisabilité de l’optimisation de la prise en charge, qui entraîne l’atteinte des taux de C-LDL recommandés dans les lignes directrices. Ces résultats pourraient se traduire par des réductions de la morbidité et de la mortalité d’origine cardiovasculaire chez les patients canadiens.
Estimating the benefits of patient and physician adherence to cardiovascular prevention guidelines: The myhealthcheckup survey
2011, Canadian Journal of Cardiology
Citation Excerpt :
These data are also comparable to those from other Canadian surveys. Among those individuals treated for dyslipidemia in a 2000-2003 Southwestern Ontario survey conducted in physician offices,31 47% had LDL-C or a TC/HDL-C ratio above treatment targets, compared with 48% among MHC participants. The success in reaching hypertension treatment targets in the MyHealthCheckup study (63%) was also similar to the results observed in the much larger, randomly sampled Ontario Survey on the Prevalence and Control of Hypertension (65.7%).32
The management of cardiovascular risk factors such as hypertension and dyslipidemia is poorly described in many communities, and the benefits associated with tighter control remain unknown. We used data from the 2007 MyHealthCheckup survey to document the treatment gaps and estimated the potential benefits of better adherence to recommended guidelines.
Cardiovascular risk factors, lifestyle habits, and prescribed medications were evaluated among Canadian adults recruited primarily in pharmacies. The Cardiovascular Life Expectancy Model was used to estimate the potential benefits of optimally treating hypertension or dyslipidemia (defined as not smoking, regular physical activity, an acceptable body weight, and maximal medication as needed).
Among 2674 screened individuals, 1266 (47%) were receiving pharmacotherapy for either dyslipidemia or hypertension, including 772 (61%) and 656 (63%), respectively, who remained above treatment targets. Among those above lipid or blood pressure targets, 27% and 22%, respectively, were optimally treated. The average increased life expectancy or life-years gained associated with making appropriate lifestyle changes included 2.2 to 4.7 years from smoking cessation, 0.7 to 1.1 years from regular exercise, and 0.4 to 0.7 years from weight reduction. The life-years gained following better risk factor treatment included maximal pharmacotherapy for elevated blood pressure (0.6-0.8), low-density lipoprotein cholesterol (0.5-0.6), and the ratio of total cholesterol to high-density lipoprotein cholesterol (0.3-0.4). Years of life free of cardiovascular disease would be similarly increased.
Better treatment of cardiovascular risk factors could result in a substantial reduction in morbidity and mortality among Canadians. Given current physician prescribing and patient habits, lifestyle modification should be considered a priority before additional medications are prescribed.
La gestion des facteurs de risque cardiovasculaire comme l'hypertension et la dyslipidémie est décrite de façon insatisfaisante dans plusieurs communautés, et les bénéfices associés à un contrôle plus strict demeurent inconnus. Nous avons utilisé les données de 2007 de l'enquête MonBilanSanté pour documenter les écarts de traitement et nous avons évalué les bénéfices potentiels d'une meilleure adhésion aux lignes directrices recommandées.
Les facteurs de risque cardiovasculaire, les habitudes de vie et la médication prescrite étaient évalués chez des adultes canadiens recrutés essentiellement dans les pharmacies. Le Cardiovascular Life Expectancy Model était utilisé pour évaluer les bénéfices potentiels d'un traitement optimal de l'hypertension ou de la dyslipidémie (défini par l'abstinence de fumer, l'activité physique régulière, un poids corporel acceptable et une médication maximale au besoin).
Parmi les 2674 sujets sélectionnés, 1266 (47 %) recevaient une pharmacothérapie pour une dyslipidémie ou une hypertension, soit 772 (61 %) et 656 (63 %) respectivement, ce qui demeure supérieur aux objectifs de traitement. Chez ceux dont les objectifs lipidiques et de pression artérielle sont supérieurs, 27 % et 22 % respectivement étaient traités de façon optimale. L'augmentation moyenne de l'espérance de vie ou le gain d'années de vie associées à des changements appropriés du style de vie incluait l'abandon du tabac (2,2 – 4,7), l'exercice régulier (0,7 – 1,1) et la perte de poids (0,4 – 0,7). Le gain d'années de vie augmente après un meilleur traitement du facteur de risque a inclus une pharmacothérapie maximale pour une pression artérielle élevée (0,6 – 0,8), un cholestérol LDL (0,5 – 0,6) et un ratio CT/C-HDL (0,3 – 0,4). Les années de vie sans maladie cardiovasculaire augmenteraient de façon similaire.
Un meilleur traitement des facteurs de risque cardiovasculaire aboutirait à une réduction substantielle de la morbidité et de la mortalité chez les Canadiens. Compte tenu des ordonnances médicales actuelles et des habitudes de vie des patients, une modification du style de vie devrait être prioritairement envisagée avant l'ajout d'une médication.
Use of a treatment optimization algorithm involving statin-ezetimibe combination aids in achievement of guideline-based low-density lipoprotein targets in patients with dyslipidemia at high vascular risk guideline-based undertaking to improve dyslipidemia management in Canada (GUIDANC)
2011, Canadian Journal of Cardiology
Despite the well-established benefits of strategies to reduce low-density lipoprotein cholesterol (LDL-C), many patients fail to achieve the guideline recommended targets. The objective of this study was to evaluate the impact of an enhanced 26-week algorithm-based treatment optimization strategy, involving titration of statin monotherapy and/or combination therapy with statin and ezetimibe, on achievement of guideline-based LDL-C targets in patients at high risk for atherosclerotic disease.
In this national (172-physician) quality enhancement research initiative involving 2334 Canadian men and women (median age, 65 years) at high vascular risk who were not at the guideline-recommended LDL-C target despite statin therapy, 36.6% and 45.5% of patients achieved an LDL-C <2.0 mmol/L at visit 2 and visit 3, respectively, using the treatment optimization algorithm. The percentage of patients achieving the 2009 Canadian Cardiovascular Society (CCS)-recommended target of either LDL-C <2.0 mmol/L or a 50% or greater reduction from baseline increased from 6.8% at visit 1 to 43.3% at visit 2 and to 52.1% at visit 3. Attainment of LDL-C targets increased significantly with consecutive visits (P < .001). Use of ezetimibe in combination with statin therapy was associated with greater target achievement.
Use of a structured treatment optimization algorithm, based on titration of statin dosages and incorporation of ezetimibe therapy when required, enabled the majority of high-risk patients to achieve guideline-recommended targets, thereby narrowing the care gap that exists in dyslipidemia management.
En dépit des bénéfices bien établis des stratégies pour réduire le cholestérol à lipoprotéines de faible densité (LDL), plusieurs patients ne parviennent pas aux objectifs des recommandations. Le but de cette étude était l'évaluation de l'impact d'une stratégie d'un algorithme d'optimisation de traitement de 26 semaines impliquant le titrage d'une statine en monothérapie, et/ou traitement associant la statine à l'ézétimibe, selon l'atteinte des objectifs des recommandations de base en matière de LDL chez les patients à risque élevé de maladie athérosclérotique.
Dans cette initiative nationale (172 médecins) de l'amélioration de la qualité de la recherche impliquant 2 334 hommes et femmes canadiens (âge moyen de 65 ans) à risque vasculaire élevé, ne respectant pas les objectifs des recommandations en matière de cholestérol LDL malgré un traitement aux statines, 36,6 % et 45,5 % des patients ont atteint un taux de cholestérol LDL < 2,0 mmol/l à la 2^e visite et à la 3^e visite, respectivement, d'après l'algorithme d'optimisation du traitement. Le pourcentage de patients ayant atteint les objectifs recommandés par la Société canadienne de cardiologie (SCC) 2009, soit un LDL < 2,0 mmol/l ou une réduction minimale de 50 % par rapport à la situation initiale augmentait de 6,8 % à la 1^re visite, à 43,3 % à la 2^e visite et à 52 % à la 3^e visite. L'obtention des objectifs de cholestérol LDL augmentait significativement lors des visites consécutives (P < 0,001). L'utilisation de l'ézétémibe combinée au traitement aux statines était associée à une atteinte plus grande des objectifs.
L'utilisation structurée d'un algorithme d'optimisation de traitement, basé sur le titrage de la dose des statines et l'introduction d'un traitement à l'ézétimibe, lorsque nécessaire, permettait à la majorité des patients à risque élevé d'atteindre les objectifs des recommandations, réduisant ainsi l'écart actuel dans la gestion des soins de la dyslipidémie.
Economic evaluation of high-dose (80 mg/day) atorvastatin treatment compared with standard-dose (20 mg/day to 40 mg/day) simvastatin treatment in Canada based on the Incremental Decrease in End-Points Through Aggressive Lipid-Lowering (IDEAL) trial
2009, Canadian Journal of Cardiology
The Incremental Decrease in End-Points Through Aggressive Lipid-Lowering (IDEAL) trial demonstrated incremental cardiovascular benefit of treatment with high-dose atorvastatin (80 mg/ day) versus standard-dose simvastatin (20 mg/day to 40 mg/day) in 8888 patients with a previous myocardial infarction (MI) over a median follow-up period of 4.8 years.
To assess the cost-effectiveness of high-dose atorvastatin versus standard-dose simvastatin treatment in patients with a history of MI from a Canadian societal perspective.
In a within-trial analysis, end point-related events, resources used and productivity losses occurring during the IDEAL trial were aggregated by treatment arm on an intention-to-treat basis to calculate the incremental cost per event avoided. Additionally, quality-adjusted survival was projected using a lifetime Markov model. Transition probabilities, workdays lost, use of study medication and cardiovascular hospitalization rates were based on IDEAL trial data. Hospitalization, study medication and productivity costs were included. Probabilistic and deterministic sensitivity analyses were performed.
Compared with standard-dose simvastatin, atorvastatin 80 mg led to 0.099 fewer events per patient and cost savings over 4.8 years of treatment. Over a lifetime horizon, atorvastatin 80 mg led to 0.023 quality-adjusted life years (QALYs) gained per patient at an incremental cost of $26,795/QALY gained. The incremental cost-effectiveness ratio remained below $50,000/QALY in 78% of 1000 simulations. Exclusion of indirect costs resulted in an incremental cost-effectiveness ratio of $38,834/QALY. Results were relatively sensitive to baseline age, but robust with respect to sex, baseline low-density lipoprotein cholesterol levels, diabetes status and hospitalization costs.
: From a Canadian societal perspective, high-dose atorvastatin is cost-effective compared with standard-dose simvastatin in patients with a previous MI.
L’essai IDEAL sur la diminution incrémentielle des points de virage par l’abaissement énergique des lipides a démontré les bienfaits cardiovasculaires incrémentiels du traitement d’atorvastatine à forte dose (80 mg/jour) par rapport au traitement de simvastatine à dose standard (de 20 mg/jour à 40 mg/jour) chez 8 888 patients ayant déjà subi un infarctus du myocarde (IM) pendant une période de suivi médiane de 4,8 ans.
Évaluer le rapport coût-efficacité du traitement d’atorvastatine à forte dose par rapport à celui de simvastatine à dose standard chez des patients ayant des antécédents d’IM selon une perspective sociétale canadienne.
Dans l’analyse de l’essai, les auteurs ont regroupé les événements liés aux points de virage, les ressources utilisées et les pertes de productivité observées pendant l’essai IDEAL selon le volet de traitement et d’après l’intention de traiter afin de calculer le coût incrémentiel par événement évité. De plus, ils ont projeté la survie rajustée à la qualité au moyen du modèle de Markov au cours d’une vie. Ils ont fondé les probabilités de transition, les jours de travail perdus, l’utilisation des médicaments à l’étude et les taux d’hospitalisation en soins cardiovasculaires sur les données de l’essai IDEAL. Enfin, ils ont inclus l’hospitalisation, les médicaments à l’étude et les coûts de productivité et ont effectué des analyses de sensibilité probabilistes et déterministes.
Par rapport à la simvastatine à dose standard, 80 mg/jour d’atorvastatine ont favorisé 0,099 moins d’événements par patient et des économies pendant les 4,8 années du traitement. Dans l’horizon d’une vie, 80 mg d’atorvastatine suscitaient un gain de 0,023 année de vie pondérée par la qualité (AVPQ), à un coût incrémentiel de 26 795 $/AVPQ. Le rapport coût-efficacité incrémentiel est demeuré sous les 50 000 $/AVPQ dans 78% des 1 000 simulations. L’exclusion des coûts indirects a donné un rapport coût-efficacité incrémentiel de 38 834 $/AVPQ. Les résultats étaient relativement sensibles à l’âge de départ, mais robustes pour ce qui est du sexe, des taux de cholestérol à lipoprotéines de basse densité de départ, du statut de diabète et des coûts d’hospitalisation.
D’une perspective sociétale canadienne, l’atorvastatine à forte dose est rentable par rapport à la simvastatine à dose standard chez des patients ayant déjà subi un IM.
Usefulness of Statin-Ezetimibe Combination to Reduce the Care Gap in Dyslipidemia Management in Patients With a High Risk of Atherosclerotic Disease
2009, American Journal of Cardiology
Citation Excerpt :
In this multicenter observational cohort of 2,577 Canadian patients with persistent hypercholesterolemia, 71% of subjects were successful at attaining LDL cholesterol levels <2.5 mmol/L (97 mg/dl) and 41% <2.0 mmol/L (77 mg/dl) through a 26-week comprehensive treatment regime with statins and ezetimibe. Inasmuch as poor LDL cholesterol control is often ascribed to clinical inertia,1–6 the latter finding was reassuring because this lower LDL cholesterol target was advocated in Canada in 200613 while enrollment for this study was still in progress. Nonetheless, the <50% achievement rate underscores the fact that successful dissemination of data from practice-changing trials and evidence-based guideline recommendations and narrowing of the care gap persist as challenges in primary care.
Lowering of low-density lipoprotein (LDL) cholesterol is a fundamental step in the comprehensive management of patients at high risk for cardiovascular events. The combination of a statin with ezetimibe usually provides additional LDL cholesterol lowering compared to statin monotherapy. This open-label observational study evaluated the impact of a 26-week treatment program with uptitration of statin dosages and incorporation of ezetimibe 10 mg therapy in 2,577 men and women (median age 64 years) with hypercholesterolemia and an LDL cholesterol level >2.5 mmol/L (97 mg/dl). Attainment of an LDL cholesterol target of 2.5 mmol/L (97 mg/dl) increased with consecutive visits (63%, 67%, and 71% at the second, third, and final visits, respectively). Current guideline-recommended LDL cholesterol value <2.0 mmol/L (77 mg/dl) was achieved by 36%, 40%, and 41% of the group at the same consecutive follow-up sessions. Median LDL cholesterol decreased from 3.0 mmol/L (116 mg/dl) at baseline to 2.1 mmol/L (81 mg/dl) at the end of the 26-week monitoring period. Favorable changes were concomitantly observed for median total cholesterol (5.1 to 4.1 mmol/L [197 to 159 mg/dl]), total cholesterol/high-density lipoprotein cholesterol ratio (4.2 to 3.3), and triglyceride (1.6 to 1.4 mmol/L [142 to 124 mg/dl]). Of those who attended visit 4, 48% exhibited LDL cholesterol lowering of ≥1 mmol/L (39 mg/dl) compared to baseline levels. In conclusion, an algorithm-based statin uptitration/ezetimibe combination regimen is useful to increase LDL cholesterol lowering where statin monotherapy has not achieved target lipid values.
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Prevalence and treatment of dyslipidemia in canadian primary care: A retrospective cohort analysis

Abstract

Background:

Objective:

Methods:

Results:

Conclusion:

Lancet

A method for comparing and combining cost-of-illness studies: An example from cardiovascular disease

Chronic Dis Can.

Recommendations for the management of dyslipidemia and the prevention of cardiovascular disease: Summary ofthe 2003 update

CMAJ

Are Canadian guidelines for cholesterol lowering in high-risk patients optimal?

Can J Cardiol.

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)

JAMA

Cholesterol reduction yields clinical benefit: Impact of statin trials

Circulation

Quantifying effect of statins on low density lipoprotein cholesterol, ischaemic heart disease, and stroke: Systematic review and metaanalysis

BMJ

Impact of guidelines on health care use for the management of dyslipidemia in two Canadian provinces, Alberta and Nova Scotia, from 1990 to 2001

Can J Cardiol.

Management of high blood cholesterol levels in Nova Scotian adults: Comparison with the NCEP II and European clinical practice guidelines

Am J Manag Care.

Application of the 1998 Canadian cholesterol guidelines to a military population: Health benefits and cost effectiveness of improved cholesterol management

Can J Cardiol.

Evidence of suboptimal management of cardiovascular risk in patients with type 2 diabetes mellitus and symptomatic atherosclerosis

CMAJ

Lipid-lowering therapy with statins in high-risk elderly patients: The treatment-risk paradox

JAMA

Comparison of the prevalence of cardiovascular risk factors between Quebec and other Canadian provinces: The Canadian heart health surveys

Ethn Dis