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December 2004, Vol 94, No. 12 | American Journal of Public Health 2112-2117
© 2004 American Public Health Association

RESEARCH AND PRACTICE

Is Lipid-Lowering Therapy Underused by African Americans at High Risk of Coronary Heart Disease Within the VA Health Care System?

LeChauncy D. Woodard, MD, MPH, Nancy R. Kressin, PhD and Laura A. Petersen, MD, MPH

LeChauncy D. Woodard and Laura A. Petersen are with the Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey Veterans Affairs Medical Center, and Section for Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Tex. Nancy R. Kressin is with the Center for Health Quality, Outcomes and Economic Research, Bedford Veterans Affairs Medical Center, Bedford, Mass, and the Health Services Department, Boston University School of Public Health, Boston, Mass.

Correspondence: Requests for reprints should be sent to LeChauncy D. Woodard, MD, MPH, Health Services Research and Development (152), Houston Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030 (e-mail: lwoodard{at}bcm.tmc.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 

Objectives. We examined whether racial differences exist in cholesterol monitoring, use of lipid-lowering agents, and achievement of guideline-recommended low-density lipoprotein (LDL) levels for secondary prevention of coronary heart disease.

Methods. We reviewed charts for 1045 African American and White patients with coronary heart disease at 5 Veterans Affairs (VA) hospitals.

Results. Lipid levels were obtained in 67.0% of patients. Whites and African Americans had similar screening rates and mean lipid levels. Among the 544 ideal candidates for therapy, rates of treatment and achievement of target LDL levels were similar.

Conclusions. We found no disparities in cholesterol management. This absence of disparities may be the result of VA quality improvement initiatives or prescription coverage through the VA health care system.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 References
 
Coronary heart disease causes more than 500000 deaths annually in the United States.1 Although studies indicate a reduction in coronary heart disease mortality across all ethnic groups, this decline has been less significant in African Americans.2 Researchers have examined numerous potential causes of this disparity, including the more frequent occurrence of coronary heart disease risk factors seen in the African American population.3–5 One of the most significant of these coronary risk factors is hypercholesterolemia. The association between hypercholesterolemia and coronary heart disease has been well established and is consistent across gender, race/ethnicity, and age.6–13 Several clinical trials conclusively demonstrated that lowering total cholesterol and low-density lipoprotein (LDL) levels in patients with coronary heart disease resulted in substantial reductions in recurrent ischemia, mortality, and need for revascularization procedures.14–19 These findings and clinical guidelines established by the National Cholesterol Education Program (NCEP)20 indicate that vigorous cholesterol management is required in patients with coronary heart disease.

Despite widespread dissemination of the NCEP guidelines and clear evidence that appropriate cholesterol management favorably affects coronary heart disease morbidity and mortality, hypercholesterolemia remains inadequately diagnosed and treated. Studies have indicated that 33–50% of patients with known coronary heart disease do not receive screening with comprehensive lipid panels.21–23 Rates of treatment with cholesterol-lowering therapy are similarly low, with only one third of appropriate patients receiving lipid-lowering medications.24 Other studies have revealed that 25% or fewer patients achieve target LDL levels.21,22,25,26

Studies of the influence of patient race on the management of hypercholesterolemia have provided inconsistent results. In population-based surveys conducted from 1985–1994, African Americans reported lower rates of awareness, screening, and treatment of high cholesterol than Whites.27–29 By contrast, more recent data from the 1996 Medical Expenditure Study and the Cardiovascular Health Study showed no differences between African American and White patients in rates of cholesterol screening and treatment.30,31 Although these studies provided valuable information about recent trends in the diagnosis and treatment of hypercholesterolemia, they largely focused on primary prevention. Therefore, they do not adequately reflect treatment of patients with coronary heart disease who are at highest risk for recurrent events. Given that African Americans have a greater risk of death from coronary heart disease than Whites and that cholesterol lowering confers substantial survival benefits, it is imperative to identify whether disparities in cholesterol monitoring and treatment exist, particularly among the high-risk group of patients with established disease.

We examined a cohort of 1045 veterans with established coronary heart disease to determine whether racial differences exist in cholesterol management for secondary prevention of coronary heart disease. Importantly, prior studies of racial disparities in health care use may have been confounded by unequal access to health care services, such as preventive health screening and prescription medications. Hyperlipidemia is asymptomatic, and lipid-lowering agents are expensive. Thus, patients with limited incomes may choose not to comply with lipid-lowering therapy. Therefore, because the effects of medication costs and insurance access are minimized in the Veterans Affairs (VA) health care system, VA hospitals provide an ideal setting to examine racial disparities in treatment.32


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 References
 
Study Design and Population
Data were collected from baseline surveys and medical records of patients who participated in a study that examined differences between African American and White patients in attitudes regarding use of invasive cardiac procedures.33 To establish a prospective cohort of patients who were likely to have coronary heart disease, we screened the results of all cardiac nuclear imaging studies performed at 5 VA hospital sites (Atlanta/Decatur, Ga, Durham, NC, Houston, Tex, Pittsburgh, Pa, and St. Louis, Mo) between August 1, 1999, and January 31, 2001. We initially identified 5278 patients who underwent a nuclear imaging study. Of these, 2335 (44%) met criteria for a positive study. A study was positive if there was any evidence of reversible cardiac ischemia. We excluded 961 patients for the following reasons: 456 (20%) could not be contacted to enroll them in the study; 78 (3%) had impaired mental status; 32 (1%) were in another research study determining their cardiac treatment; 102 (4%) were not African American or White; 189 (8%) underwent a cardiac procedure in the preceding 6 months; 5 (<1%) were not veterans; and 99 (4%) were excluded for miscellaneous other reasons (e.g., patient died before study enrollment). After these exclusions, 1374 patients with positive imaging studies remained. Of these, 329 refused to participate, did not return their informed consent, or requested questionnaires but did not return them. Thus, 1045 patients were included in the final cohort, representing a 76% response rate (1045/1374=76%). Of the 1045 participants, 236 were African American and 809 were White. Ninety-eight percent of patients in our study were men, reflecting the predominantly male population served by the Department of Veterans Affairs. This sample size provided 80% power to detect a 10% difference in the use of lipid-lowering agents between African American and White patients.

We examined racial differences in cholesterol monitoring and treatment for secondary prevention of coronary heart disease. Because every participant had a diagnosis of coronary heart disease, all were deemed appropriate for secondary prevention. We examined computerized medical records to determine documented lipid levels, appropriateness for treatment with lipid-lowering therapy, medication use, contraindications to lipid-lowering medications, and coexisting medical conditions. Total cholesterol and LDL levels documented within 3 months before enrollment or during any in-patient admission after enrollment were included in this analysis. Participants completed baseline surveys to provide demographic data.

Guidelines for Cholesterol Management
Appropriate diagnosis and treatment of hypercholesterolemia was based on the NCEP Adult Treatment Panel II guidelines, which were in effect at the time of study enrollment.20 These guidelines stated that for secondary prevention in patients with coronary heart disease, lipid levels should be obtained for all patients, and therapy should be initiated on the basis of LDL cholesterol levels. The target of therapy in these patients is an LDL level of 100 mg/dL or less. Liver disease and allergy to lipid-lowering agents are absolute contraindications to the use of hydroxymethylglutaryl-CoA reductase inhibitor (statin) therapy for management of hypercholesterolemia, and age younger than 35 years old, dementia, and terminal illness are relative contraindications. Therefore, candidates were considered ideal for treatment if they had an LDL cholesterol level exceeding 100 mg/dL or were receiving lipid-lowering therapy during the study period, were at least 35 years old, and did not have a diagnosis of dementia, alcohol abuse (a significant contributor to liver disease), cirrhosis, terminal illness, or lipid-lowering agent allergy.

Study Variables
The independent variable was self-reported race. The dependent variables were cholesterol monitoring, treatment with lipid-lowering agents, and achievement of target LDL levels. We ascertained use of the following classes of lipid-lowering agents: hydroxymethylglutaryl-CoA reductase inhibitors, fibrates, bile acid resins, and niacin. These medication classes were combined into a dichotomous (treatment yes or no) variable.

Data Collection
Registered nurses with extensive cardiology and chart review experience abstracted data from the medical records. Patient demographics; documented lipid values; relevant laboratory values; and data on lipid-lowering agent use, adverse reaction to lipid-lowering agents, and comorbid medical conditions, including coronary heart disease risk factors, were collected on all patients.

Data Analysis
We used Statistical Analysis Software (SAS), Version 8.2 (SAS Institute Inc., Cary, NC) to perform statistical analyses. Simple descriptive statistics were used to describe the study population. We used {chi}2 and t tests to assess racial differences in cholesterol monitoring and the use of lipid-lowering agents where appropriate. We assessed lipid-lowering agent use in the entire population and in ideal candidates only. For the ideal candidate analysis, patients with contraindications to lipid-lowering agent use were excluded regardless of whether they were already receiving therapy.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 References
 
Patient Characteristics
The cohort consisted of 236 African American and 809 White patients. Table 1Go displays the characteristics of these patients by race. African Americans were more likely than Whites to be younger and unmarried (both P<.01), but there was no difference between the two groups in educational level attained. African American patients were more likely than White patients to have a history of hypertension (85.7% vs 76.2%, respectively; P=.002). African American participants were less likely than White participants to have had a prior myocardial infarction or cerebrovascular accident, hypercholesterolemia, chronic obstructive pulmonary disease, prior coronary artery bypass graft surgery, or prior percutaneous coronary intervention (all P<.05). The two groups had similar rates of smoking, angina, and peripheral arterial disease.


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  		TABLE 1— Characteristics of African American and White Patients With Coronary Heart Disease Who Underwent Cardiac Nuclear Imaging Studies (n = 1045): 5 VA Hospitals, August 1, 1999, through January 31, 2001
 
Cholesterol Screening
Table 2Go displays cholesterol screening information for the two groups. African American and White patients were equally likely to receive cholesterol monitoring. There were no differences between the two groups in rates of documented total cholesterol and LDL values. Similarly, there were no differences between African Americans and Whites in the percentage of patients receiving any cholesterol (total cholesterol or LDL) monitoring (64.8% vs 67.6%, respectively; P=.42). These results indicate that, although rates of cholesterol screening are similar between African Americans and Whites, approximately one third of all patients with established coronary heart disease did not receive appropriate cholesterol monitoring in the time interval we examined. Of those patients receiving cholesterol screening, African American and White patients had similar mean total cholesterol values (194.0 mg/dL vs 188.7 mg/dL, respectively; P=.13) and mean LDL values (118.2 mg/dL vs 112.4 mg/dL, respectively; P=.27).


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  		TABLE 2— Comparison of Cholesterol Measurements in African American and White Patients With Coronary Heart Disease Who Underwent Cardiac Nuclear Imaging Studies (n = 1045): 5 VA Hospitals, August 1, 1999, through January 31, 2001
 
Use of Lipid-Lowering Therapy
Table 3Go displays the use of lipid-lowering therapy in the two groups. We initially assessed overall use of lipid-lowering medications in the entire sample, without exclusions for ideal candidates. Among all patients in our cohort, African Americans were less likely than Whites to receive treatment with lipid-lowering agents (46.2% vs 59.6%, respectively; P=.0003). We also assessed the use of lipid-lowering medications in subsets of patients with specific cardiovascular disease diagnoses. Among patients with a history of angina or prior cerebrovascular accident, African Americans were less likely than Whites to receive lipid-lowering therapy. However, when the comparison was restricted to the 544 patients who met the definition of ideal candidate for treatment with lipid-lowering agents, African Americans and Whites were equally likely to receive treatment (96.9% vs 98.9%, respectively; P=.96).


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  		TABLE 3— Use of Lipid-Lowering Agents by African American and White Patients With Coronary Heart Disease Who Underwent Cardiac Nuclear Imaging Studies: 5 VA Hospitals, August 1, 1999, through January 31, 2001
 
Achieving LDL Goals
Table 4Go displays the mean LDL levels and low rates of achieving guideline-recommended LDL goals among ideal patients receiving lipid-lowering medication. Of those patients who had documented LDL levels, only 40% reached the target LDL of 100 mg/dL or less. However, of these, African American and White patients were equally likely to achieve target LDL levels (32.8% vs 41.4%, respectively; P=.21). Mean LDL levels of African American and White patients who successfully reached the LDL goal of 100 mg/dL or less were 81.9 mg/dL versus 76.7 mg/dL, respectively; P=.20. Mean LDL levels for those who failed to achieve target LDL levels were significantly higher than guideline-recommended levels of 100 mg/dL overall but did not differ by race (141.9 mg/dL vs 134.7 mg/dL, respectively; P=.18).


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  		TABLE 4— Comparison of LDL Levels Among Ideal African American and White Candidates Receiving Lipid-Lowering Therapy: 5 VA Hospitals, August 1, 1999, through January 31, 2001
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
References
 
We assessed cholesterol management in African American and White patients with coronary heart disease who were receiving care within the VA health care system. African American and White patients were equally likely to receive cholesterol screening, although overall rates of screening did not reach the level recommended by guidelines in either group. Although White patients were more likely to have a documented diagnosis of hypercholesterolemia, there were no significant differences in measured lipid levels between the two groups. In the subset of 544 patients who were ideal candidates for treatment according to an accepted national guideline, African American patients were equally likely to receive lipid-lowering therapy, and nearly all of the patients identified as appropriate for treatment received medications. However, among ideal patients receiving lipid-lowering medications, only 40% of patients overall achieved target LDL levels. Thus, our findings highlight the need for improvement in cholesterol screening and the achievement of guideline-recommended LDL levels for all patients once screening is performed.

Our study extended prior work, which examined the provision of guideline-based treatment of hypercholesterolemia in two important ways. First, we assessed the association of patient race with receiving cholesterol screening and treatment in patients with established coronary heart disease. Given the high mortality rate in this population, the survival benefit associated with appropriate use of lipid-lowering therapy was particularly large in this group of patients. Second, we conducted this study in the VA health care system, where access to care is not limited by insurance status, thereby diminishing the effect of insurance coverage for medical care or prescription drug costs as a potential confounder in the analysis. Because hydroxymethylglutaryl-CoA reductase inhibitors may be one of the most costly prescription medications, cost as a potential barrier is an important confounder in prior studies of racial disparities in such treatment.

Consistent with other health care settings, our findings indicated that rates of cholesterol monitoring were inappropriately low in the VA system between 1999 and 2001, with approximately one third of coronary heart disease patients not receiving any form of cholesterol screening, and 44% not receiving LDL screening. Although screening rates were low in the VA health care system, some studies have demonstrated that rates in non-VA settings are even lower, ranging from 44% to 50%.22,23 These findings suggest that NCEP guidelines recommending lipid panels in all patients with coronary heart disease are not followed in clinical practice and may be an area in which future quality improvement efforts are warranted.

Although the reasons for low rates of screening have not been fully elucidated, prior work has suggested that cholesterol management practices may be influenced by a variety of factors, including physician specialty, physician and patient age, insurance status, comorbid conditions, perception of cardiovascular risk, and knowledge and acceptance of NCEP guidelines.34 These factors contribute to the widely documented under-use of cholesterol screening. Obviously, low screening rates are a significant barrier to identifying candidates for therapy and to initiating treatment when appropriate. Given that documentation of cholesterol levels is a significant predictor of treatment with lipid-lowering therapy,22 the effect of suboptimal screening practices is heightened.

In contrast to earlier studies showing significant underuse of lipid-lowering therapy in patients with coronary heart disease,21,22,24 nearly all patients in our cohort who were deemed ideal for treatment had received cholesterol-lowering medications. This finding suggests that when appropriate candidates are identified in the VA health care setting, lipid-lowering therapy is initiated in accordance with NCEP guidelines. One reason for the absence of disparities in our findings may relate to determinants of health care access, such as education and insurance status. Lower levels of education and lack of insurance have been shown to predict poorer rates of cholesterol screening.30 Patients in our sample had similar education levels and received medical care within the VA system where barriers such as inadequate access to care and medication costs are minimized. Other potential reasons are the dissemination of practice guidelines, current quality monitoring, and centralized quality standards in the VA health care system that may promote high quality care.35–38 Although patients were generally receiving treatment, only 40% of ideal patients receiving lipid-lowering medications achieved target LDL levels. Although low, this treatment success rate exceeds that seen in non-VA settings where success rates of 9–25% have been documented.21,22,25,26

Our results differ somewhat from those of prior studies that have documented disparities in other forms of care for coronary heart disease patients treated in the VA health care system.39–43 The absence of consistent disparities in our findings, in contrast to those of studies that have documented racial differences in invasive cardiac procedure use,39–44 suggests that disparities may vary according to the type of care provided. Our findings may reflect that national guidelines regarding the management of hypercholesterolemia are more widely disseminated compared with guidelines for invasive cardiac procedure use or that quality improvement efforts within the VA health care system have been more successful in primary and preventive care.

Several limitations should be considered when interpreting our results. First, data were collected during the 3 months before study enrollment and during any inpatient admission that followed enrollment. Thus, cholesterol levels for patients who may have been screened outside of this defined period were not included in the analysis. However, we examined treatment of patients with coronary heart disease who were actively accessing the health care system for evaluation of ischemic symptoms. Therefore, we believe this setting is one in which a comprehensive risk factor assessment, including measurement of lipid levels, was warranted. Second, data used in this analysis were obtained for a study assessing racial differences in patient attitudes regarding use of invasive cardiac procedures. Therefore, patients who underwent cardiac procedures during the 6 months before study enrollment were not included in our cohort. Third, 98% of our study cohort was male, reflecting the predominantly male patient population receiving treatment within the VA system. Thus, our findings are not necessarily generalizable to women. Finally, because we examined patients with documented coronary heart disease, our findings cannot be generalized to patients who have coronary heart disease that has not yet been diagnosed.

In summary, in this assessment of cholesterol monitoring and treatment of African American and White patients with coronary heart disease in the VA health care system, we found that African American and White patients were equally likely to receive cholesterol monitoring, although rates of screening were low in both groups. When examining ideal candidates for therapy, African American and White patients were equally likely to receive treatment and to achieve target LDL levels. Quality improvement efforts directed at increasing rates of screening and achievement of guideline-recommended cholesterol levels may prove beneficial in ensuring that patients with coronary heart disease receive maximal benefit from lipid-lowering therapy.


   Acknowledgments
 
L. D. Woodard was supported by a grant from the Health Resources and Services Administration (HSR&D grant 1 T32 PE 10031–01) at the time that this research was conducted. This research was supported by grants from the Department of Veterans Affairs (VA) Health Services Research and Development Service HSR&D (grant ECV 97–022.2, N. R. Kressin, principal investigator) and the American Heart Association and the Pharmaceutical Roundtable (grant 9970113N, N. R. Kressin, principal investigator). L. A. Petersen was an awardee in the Research Career Development Award Program of the VA HSR&D Service (grant RCD 95–306) at the time that this research was conducted, and she is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar. This material is the result of work supported with resources and the use of facilities at the Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey VA Medical Center and the Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center.

We thank Colleen Gastonguay and the other dedicated nurses who reviewed medical charts for this study, Megan Amuan and Michelle B. Orner for their assistance in statistical programming, and the veteran patients who generously participated in the study.

Human Participant Protection
This study was approved by the institutional review board for Human Subject Research at Baylor College of Medicine and the Department of Veterans Affairs Research and Development Committee at all participating Veterans Affairs Medical Centers. All patients gave informed consent to participate in the study.


   Footnotes
 
Note. The views expressed in this article are solely those of the authors and do not necessarily represent those of the Department of Veterans Affairs.

Contributors
L. D. Woodard originated the study, developed the data analysis plan, and led the writing of the article. N. R. Kressin obtained project funding, participated in data acquisition, and supervised the data analyses. L. A. Petersen participated in data acquisition, assisted with study design, and helped develop the data analysis plan. All authors helped to conceptualize ideas, analyze and interpret the findings, and review drafts of the article.

Peer Reviewed

Accepted for publication November 5, 2003.


   References
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 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 
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S. W. Gao, D. K. Oliver, N. Das, F. P. Hurst, K. L. Lentine, L. Y. Agodoa, E. S. Sawyers, and K. C. Abbott
Assessment of Racial Disparities in Chronic Kidney Disease Stage 3 and 4 Care in the Department of Defense Health System
Clin. J. Am. Soc. Nephrol., March 1, 2008; 3(2): 442 - 449.
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A. M. Davis, L. M. Vinci, T. M. Okwuosa, A. R. Chase, and E. S. Huang
Cardiovascular Health Disparities: A Systematic Review of Health Care Interventions
Med Care Res Rev, October 1, 2007; 64(5_suppl): 29S - 100S.
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