Frequency and correlates of treatment intensification for elevated cholesterol levels in patients with cardiovascular disease

Abstract

Although current performance measures define low-density-lipoprotein cholesterol (LDL-C) levels <100 mg/dL in patients with cardiovascular disease (CVD) as good quality, they provide a snapshot and do not address whether treatment intensification was performed to manage elevated LDL-C levels. We determined the proportion of patients with CVD (n = 22,888) with LDL-C <100 mg/dL and the proportion with uncontrolled LDL-C levels (≥100 mg/dL) who received treatment intensification within the 45-day follow-up in a Veterans Affairs Network. We evaluated facility, provider, and patient correlates of treatment intensification. Low-density-lipoprotein cholesterol levels were at goal in 16,350 (71.4%) patients. An additional 2,093 (one third of those eligible for treatment intensification) received treatment intensification. Controlling for clustering between facilities and patient's illness severity: history of diabetes (odds ratio [OR] 1.15, 95% CI 1.01-1.32), hypertension (OR 1.19, 95% CI 1.01-1.42), good medication adherence (OR 2.20, 95% CI 1.91-2.54), and a higher number of lipid panels (OR 1.20, 95% CI 1.14-1.27) were associated with treatment intensification. Patients older than 75 years (OR 0.65, 95% CI 0.56-0.75) and women (OR 0.66, 95% CI 0.43-1.00) were less likely to receive treatment intensification. Teaching status of the facility, physician or specialist primary care provider, and patient's race were not associated with treatment intensification. Only one third of the CVD patients with elevated LDL-C received treatment intensification. Diabetic and hypertensive patients were more likely to receive treatment intensification, whereas, older patients, female patients, and patients with poor medication adherence were less likely to receive treatment intensification. Our findings highlight areas for quality improvement initiatives.