Guidelines Not Necessarily Guiding Physician Behavior, Study Says

August 31, 1998

DALLAS, September 1 -- An ounce of prevention may be worth a pound of cure, but many people with heart disease may not even get that much, say researchers in a report in today's Circulation: Journal of the American Heart Association. Researchers evaluated the hospital charts of 225 cardiac care unit patients to determine how physicians at an academic hospital followed the latest National Cholesterol Education Program (NCEP) guidelines. The guidelines were created to help physicians screen those at high risk for heart attack and who may benefit from cholesterol-lowering medication. Researchers also examined whether doctors evaluated patients for major risk factors such as cigarette use, prior heart attack and family history of heart disease.

The scientists found that a surprisingly small percentage of patients were screened for some of the most important risk factors. Moreover, even fewer were provided with adequate follow-up treatment. Researchers also found that physicians followed NCEP guidelines incorrectly half of the time when evaluating the need for drug treatment for high cholesterol.

"There is a significant gap between the guidelines produced by experts and what the real world clinical practice of physicians shows," says the study's lead author, Joseph P. Frolkis, M.D., Ph.D., staff physician, Cleveland Clinic Foundation in Cleveland, Ohio. "It's true for cancer guidelines. It's true for diabetes guidelines. It's true for heart disease guidelines."

Of the eight possible risk factors listed in the 1993 NCEP guidelines -- personal history of heart disease or atherosclerosis, high blood pressure, diabetes, cigarette use, family history of premature heart attack, and menopausal status and status of hormone replacement therapy for women -- medical professionals screened, on average, for 2.4 risk factors.

Interns performed best, a finding Frolkis says is expected since they are supposed to take the most thorough history from patients. But even interns only inquired about two risk factors -- cigarette smoking and known heart disease -- greater than 70 percent of the time.

Of the 71 people in the study who reported that they smoked, only 3 of them were told to quit. Only one person was encouraged to exercise more.

"Cigarette smoking is the largest preventable cause of death there is, and even though patients are being asked about it, they're not being counseled to quit," says Frolkis. "Often, physicians aren't confident in their ability to counsel about prevention, having had little instruction in this aspect of medical care during their training."

The study found that physicians appeared to use blood levels of total cholesterol to decide whether to prescribe cholesterol-lowering drugs to patients. Frolkis says that those measurements alone are not enough and that NCEP guidelines rely on risk factor status as well in order to decide how to treat people.

"These levels are not valid markers for NCEP-guided criteria for such decisions," Frolkis says. "Additionally, our data call into question whether physicians are following the logical orderly progression of clinical decision-making inherent in the guidelines. They seemed to be influenced by total and LDL, 'bad,' cholesterol levels, which are questionable surrogates for NCEP-directed care."

When physicians found an LDL cholesterol measurement -- a key factor in starting cholesterol-lowering treatment -- was not necessary by NCEP guidelines, it was not obtained 76 percent of the time. However, when NCEP guidelines indicated an LDL measurement should be done, there was only a 50-50 chance it would be, says Frolkis.

Risk factor screening rates for interns were: cigarette use (89 percent), known heart disease (74 percent), high blood pressure (68 percent), high cholesterol (59 percent), family history of heart disease (56 percent), diabetes (37 percent), postmenopausal hormone replacement therapy (11 percent), and premature menopause (1 percent).

"If you gave physicians a quiz on these guidelines, they'd do very well, so it's not a matter of them not having the knowledge," says Frolkis. "But sometimes, that information just doesn't translate into how things are done in the real world.

"There is a negative incentive for doctors to perform preventative procedures. It's time consuming at a time when we're asked to see more patients in less time. In many cases, these procedures aren't reimbursable. Even with high-risk patients, risk factor assessment is not being performed, and when it is, appropriate counseling isn't being done."

In the study, race, sex, household income and type of medical insurance had no impact on whether patients received cholesterol-lowering drugs. "For a population as demographically diverse as ours, this negative finding was reassuring," says Frolkis.

Co-authors are Stephen J. Zyzanski, Ph.D.; Jonathan M. Schwartz, M.B.A.; and Pamela S. Suhan, R.N., M.B.A.

American Heart Association

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