Using an electronic medical record to identify opportunities to improve compliance with cholesterol guidelines

OBJECTIVE: To use an electronic medical record to measure rates of compliance with the National Cholesterol Education Program (NCEP) cholesterol guidelines for secondary prevention, to characterize the patterns of noncompliance, and to identify patient and physician-specific correlates of noncompliance. DESIGN. Cross-sectional descriptive analysis of data extracted from an electronic medical record. SETTING: Nineteen primary care clinics affiliated with a tertiary academic medical center. PATIENTS: All patients who visited their primary care physician in the preceding year who met criteria for secondary prevention of hypercholesterolemia. INTERVENTIONS: None. The main outcome was rate of compliance with NCEP cholesterol guidelines. MAIN RESULTS: Of 2,019 patients who qualified for secondary prevention, only 31% were in compliance with NCEP recommendations, although 44% were on lipid-lowering therapy. There was no low-density lipoprotein cholesterol (LDL-C) on record within the last three years for 771 (38%), and another 809 (40%) had a recent LDL-C that was above the recommended target of 100 mg/dL. Of the latter group, 374 (46%) were not on a statin, including 188 patients with an LDL-C > 130 mg/dL. Compliance among secondary prevention patients with cerebrovascular or peripheral vascular disease, but not coronary disease, was even lower: 19% versus 36%, P < .0001. Most of the additional noncompliant patients never had an LDL-C checked. Patient-specific factors associated with compliance included having seen a cardiologist (45% vs 21%); having had a recent admission for myocardial infarction, unstable angina, or angina (41% vs 26%); being male (37% vs 24%); and being white (34% vs 26%). Patients over 79 and under 50 years old also were less likely to be compliant (22% vs 34% for 50-79 year olds). There were no significant differences in compliance rates based on physician-specific factors, such as level of training, gender, or panel size. CONCLUSION: We found poor compliance with nationally published and well-accepted guidelines on diagnosing and treating hypercholesterolemia in secondary prevention patients. Compliance was unrelated to physician or physician-specific characteristics, but it was especially low for women, African Americans, patients without a cardiologist, and patients with cerebrovascular and peripheral vascular disease.