PRIMARY CARE CLINICIAN COMPLIANCE WITH CHOLESTEROL TREATMENT GUIDELINES

Objective: To determine the rate and predictors of clinician compliance with treatment guidelines for high cholesterol in a primary care practice and establish quality assurance thresholds for monitoring patient management. Design: Retrospective chart audit one year after high (> 240 mg/dL) cholesterol level. Patients: 257 (243 after exclusions) consecutive patients with serum cholesterol levels greater than 240 mg/dL. Setting: Primary care practice of group-model university-based HMO. Interventions: None. Measurements and main results: In the one-year interval following the index elevated cholesterol level, 67% of 243 patients had received documented dietary counseling, 53% had had a follow-up cholesterol test, and 8% were started on drug treatment. Only two patients (1.8%) without a history of hypercholesterolemia prior to the index level were started on drug treatment, compared with 18 patients (15%) with such a history. The odds (and 95% confidence intervals) of patient dietary counseling increased twofold (1.35 to 2.95) for each 25-mg/dL increment in serum cholesterol, and by 1.45 times (1.12 to 1.87) for each additional coronary risk factor. Patients who had high cholesterol levels obtained as isolated determinations had 2.46 times (1.32 to 4.64) higher odds of being followed by counseling than did those whose levels had been obtained as part of a chemistry panel. Conclusions: Compliance with National Cholesterol Education Panel guidelines for dietary counseling, but not drug therapy, was higher in this setting than in other published compliance studies. Quality assurance monitoring of compliance with dietary counseling and obtaining lipid measurements using a threshold approach are suggested. A similar approach to drug therapy of hypercholesterolemia appears premature.