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Impact of a Targeted Intervention on Lipid-Lowering Therapy in Patients With Coronary Artery Disease in the Hospital Setting
Clifton R. Lacy, MD;
Dong-Churl Suh, PhD;
Joseph A. Barone, PharmD;
Maureen Bueno, PhD;
Deana Moylan, PharmD;
Carla Swartz, BS;
Ramanasri V. Kudipudi, MD;
John B. Kostis, MD
Arch Intern Med. 2002;162:468-473.
ABSTRACT
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Background Although lipid-lowering therapy according to the National Cholesterol
Education Program guidelines decreases mortality and morbidity in patients
with coronary artery disease (CAD), significant undertreatment of hyperlipidemia
continues to occur. This study was designed to determine the impact of an
intervention targeted at improving the use of lipid-lowering therapy in patients
with CAD in the hospital setting.
Methods Cardiac case managers prompted physicians to obtain lipid profiles for
patients with CAD who were not receiving lipid-lowering therapy on admission
and initiate lipid-lowering therapy for patients with a low-density lipoprotein
level of 130 mg/dL (3.37 mmol/L) or higher during hospitalization. The study
population comprised 813 patients with CAD admitted for percutaneous transluminal
coronary angioplasty, coronary artery bypass grafting, or myocardial infarction.
A retrospective chart review of lipid testing and treatment rates was conducted
in 300 patients in the preintervention period, and a prospective review of
rates was conducted in 513 patients during the intervention period.
Results The percentage of patients with CAD not receiving lipid-lowering therapy
on admission who had fractionated lipid profiles obtained during hospitalization
increased from 27% preintervention to 89% during intervention (odds ratio,
18.27; 95% confidence interval, 11.61-28.74; P<.001).
The percentage of patients with a low-density lipoprotein level of 130 mg/dL
or higher for whom lipid-lowering therapy was initiated during hospitalization
increased from 17% preintervention to 82% during intervention (odds ratio,
24.50; 95% confidence interval, 7.33-81.83; P<.001).
Conclusions The intervention provided by specialized cardiac case managers significantly
increased physicians' adherence to the National Cholesterol Education Program
treatment guidelines. The results of the present study suggest that intervention
programs of this nature could produce a significant positive impact on cardiovascular
outcomes if implemented nationally.
INTRODUCTION
CORONARY ARTERY disease (CAD) is a leading cause of mortality in the
United States, responsible for a half million deaths in 1996 and contributing
to substantial morbidity.1 For 1999, it was
estimated that 1.1 million Americans would have a new (650 000 people)
or recurrent (450 000 people) myocardial infarction (MI), with one third
of those events resulting in a fatality.1
Elevated serum cholesterol level is a known risk factor for CAD, and
reducing cholesterol slows the progression of coronary artery lesions and
decreases coronary event rates.2 Findings from
recent studies have confirmed that lipid lowering in the secondary prevention
of coronary disease significantly reduces coronary disease–related morbidity
and mortality.3-4
The National Cholesterol Education Program (NCEP) recommends that lipoprotein
profiles be obtained for patients with CAD immediately following hospital
admission and lipid-lowering therapy be initiated in conjunction with maximal
nonpharmaceutical therapy for patients with a low-density lipoprotein (LDL)
level of 130 mg/dL (3.37 mmol/L) or higher to achieve a target LDL cholesterol
level of 100 mg/dL (2.59 mmol/L) or lower.2, 5-6
Success in meeting NCEP goals for the management of cholesterol could significantly
reduce morbidity and mortality associated with CAD. Despite the benefit of
lipid-lowering therapy and the comprehensive scope and wide dissemination
of the NCEP guidelines, many patients with CAD remain inadequately treated
for elevated serum cholesterol level and fail to achieve the beneficial outcomes
associated with the NCEP guidelines.7-16
Interventions to increase adherence to the NCEP guidelines have been
examined for outpatients with CAD. Implementation of an individualized intensive
multifactor risk reduction program resulted in a significant improvement in
LDL cholesterol levels and reductions in cardiac events and hospitalizations
in patients with CAD compared with standard care.17
Various team and multidisciplinary approaches have been initiated in
outpatient clinical settings to reduce risk of CAD including interventions
by nurse and pharmacist with physician supervision,18
physician and pharmacist,19 nurse alone,20-21 or pharmacist alone.22
These programs were successful in demonstrating reductions in lipid levels.
However, to our knowledge, there have been no studies analyzing the impact
of intervention by cardiac case managers on lipid management in inpatients
with CAD. The purpose of the present study was to determine the impact of
an intervention initiated by cardiac case managers on lipid testing and treatment
according to the NCEP guidelines for patients with CAD in the hospital setting.
PATIENTS AND METHODS
PATIENTS
This study included patients with CAD admitted to Robert Wood Johnson
University Hospital, New Brunswick, NJ, for percutaneous transluminal coronary
angioplasty (PTCA), coronary artery bypass grafting (CABG), or acute MI. The
medical records of 300 patients who were admitted to the study hospital for
the above indications from July 1996 through June 1997 were consecutively
selected and reviewed for physicians' diagnosis and treatment of hypercholesterolemia
before implementation of the intervention (preintervention phase). During
the intervention period, 513 consecutive patients who were admitted to the
study hospital for the above indications from October 1997 through March 1998
were identified, and their lipid testing results and treatment were prospectively
assessed (intervention phase).
DATA COLLECTION
Patient demographics and clinical variables were collected from medical
records and laboratory reports. Demographic variables included age, sex, marital
status, race, and health insurance type. Clinical variables included admission
diagnosis, lipid profile (if obtained), and the use (or not) of lipid-lowering
medication(s) on admission. Lipid risk profiles were obtained within 24 hours
of onset of MI in the subset of patients with infarction. Total cholesterol
and high-density lipoprotein cholesterol levels have been shown to remain
at or near baseline levels during the first 24 to 48 hours after infarction.2, 23-24 Information recorded
for analysis included whether lipid-lowering drug therapy was initiated during
hospitalization and if the patient was discharged with a prescription for
such an agent.
INTERVENTION PROGRAM
Figure 1 presents the study
process with points of intervention by specialized cardiac case managers.
When patients were admitted for PTCA, CABG, or MI, cardiac case managers reviewed
the medical records for the use of lipid-lowering therapy on admission. Patients
who were receiving lipid-lowering agents prior to admission were excluded
from the intervention. Physicians with patients not receiving lipid-lowering
therapy were prompted by the cardiac case managers to obtain a fractionated
lipid risk profile as part of the admission blood testing. For patients with
an LDL level of 130 mg/dL or higher, cardiac case managers contacted the physician
and recommended that lipid-lowering therapy be initiated before discharge
if no contraindication existed.
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Figure 1. Process algorithm for patients
with coronary artery disease who were admitted for percutaneous transluminal
coronary angioplasty, coronary artery bypass grafting, or myocardial infarction.
Testing and treatment interventions indicate periods when cardiac case managers
prompted physicians to test or treat lipid levels according to the National
Cholesterol Education Program guidelines.
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DATA ANALYSIS
Data were analyzed using a stepwise procedure based on a cascade (as
shown in Figure 1) to determine
(1) the percentage of patients with CAD who were not receiving lipid-lowering
therapy prior to admission; (2) the percentage of those patients with CAD
not receiving lipid-lowering therapy who had lipid profiles obtained during
admission; (3) the percentage of patients with CAD admitted with an LDL level
of 130 mg/dL or higher; and (4) the percentage of admitted patients with an
LDL level of 130 mg/dL or higher for whom lipid-lowering drug therapy was
initiated during hospitalization.
Baseline characteristics of patients were compared to determine the
significance of differences using a  2 test for discrete variables
and a t test for continuous variables.25
A Wilcoxon rank sum test was applied to determine differences in LDL levels
of patients with hyperlipidemia in the preintervention and postintervention
phases.26
The impact of the intervention on the outcomes of interest at each step
of data analysis (eg, the percentage of lipid profiles obtained and the percentage
of patients who received lipid-lowering therapy) was analyzed using a partitioning 2 test.27 Odds ratios (ORs) with 95%
confidence intervals (CIs) were also calculated for the probability of the
occurrence of such outcomes postintervention vs preintervention. All statistical
analyses were performed using SAS statistical software (SAS Institute Inc,
Cary, NC).
RESULTS
PATIENT CHARACTERISTICS
The demographics of preintervention group (n = 300) and intervention
group (n = 513) are presented in Table 1. The preintervention group comprised 100 patients admitted for
MI, 100 admitted for CABG, and 100 admitted for PTCA; the intervention group
comprised 134 patients admitted for MI, 96 patients admitted for CABG, and
283 patients admitted for PTCA. The mean age in both groups was 64 years,
and the percentage of male patients in the preintervention and intervention
phases were 72% and 70%, respectively.
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Table 1. Characteristics of Study Patients*
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The percentage of patients admitted for PTCA, CABG, and MI was significantly
different between preintervention and intervention groups (P = .001). However, LDL levels of patients in the preintervention group
were not statistically different from those of patients in the intervention
group. In the subset of patients who met NCEP requirements for lipid-lowering
therapy, there was also no significant difference in LDL levels when comparing
preintervention and intervention phases.
LIPID-LOWERING THERAPY
The number of patients in each category and ORs with 95% CIs are presented
in Table 2. Intervention resulted
in significant increases in the percentage of patients who had a fractionated
lipid profile obtained during hospitalization in all subgroups of patients
with CAD, with an overall increase from 27% to 89% (OR, 18.27; 95% CI, 11.61-28.74; P<.001).
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Table 2. Number and Percentage of Patients by Reason for Admission
Before and After Intervention*
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In addition, a significant overall increase was observed in the initiation
of lipid-lowering therapy in patients with LDL levels of 130 mg/dL or higher
from 17% to 82% (OR, 24.50; 95% CI, 7.33-81.83; P<.001).
The cardiac case management intervention significantly increased percentages
of both lipid profile acquisition and lipid-lowering drug therapy initiation
for eligible admitted patients (Figure 2).
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Figure 2. Changes in major study parameters
before and during intervention. Case management intervention significantly
increased the rates of (1) fractionated lipid profile obtained during hospitalization
for patients with coronary artery disease not receiving lipid-lowering therapy
on admission and (2) lipid-lowering therapy initiated during hospitalization
for patients with an elevated low-density lipoprotein (LDL) level ( 130
mg/dL [3.37 mmol/L]).
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Lipid profile acquisition and treatment initiation were evaluated according
to the patients' reason for admission. Of the patients admitted for PTCA,
lipid profile acquisition increased from 40% to 88% (OR, 9.31; 95% CI, 4.60-18.86; P<.001), and initiation of lipid-lowering therapy for
patients with LDL levels higher than 130 mg/dL increased from 27% to 72% (OR,
7.11; 95% CI, 1.61-31.35; P = .005).
The percentage of patients admitted for CABG who had an lipid profile
obtained during hospitalization increased significa ntly from 29% to 90% following
intervention (OR, 23.21; 95% CI, 9.10-59.21; P<.001).
The percentage of patients in this group started on lipid-lowering therapy
for an LDL level higher than 130 mg/dL increased from 10% to 89% (OR, 69.00;
95% CI, 6.32-753.61; P<.001).
For patients admitted with acute MI, lipid profile acquisition increased
significantly from 17% to 89% of patients (OR, 32.04; 95% CI, 13.88-73.93; P<.001). Initiation of lipid-lowering drug therapy increased
from 0% of patients who met criteria for such treatment to 100% (P<.001) following cardiac case manager intervention.
Regardless of the reason for admission, lipid profiles were obtained
for 90% of patients admitted for PTCA, CABG, or MI during the intervention
period (Figure 3). However, the
largest change in adherence to lipid-lowering therapy was observed in patients
admitted for MI. No patient with an LDL level higher than 130 mg/dL admitted
for MI was started on a therapy with a lipid-lowering agent in the preintervention
period, but treatment was initiated in 100% of such patients during the intervention
period. In patients admitted for CABG and PTCA, treatment was initiated in
10% and 27%, respectively, of those with elevated LDL levels before intervention
and initiated in 89% and 72%, respectively, of such patients during intervention.
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Figure 3. Percentage of patients who underwent
lipid testing or for whom lipid therapy was initiated for each subset of study
patients (those admitted for percutaneous transluminal coronary angioplasty
[PTCA], coronary artery bypass grafting [CABG], or myocardial infarction [MI]).
Intervention increased the rates of lipid testing performed and treatment
initiated in patients with a low-density lipoprotein (LDL) level of 130 mg/dL
(3.37 mmol/L) or higher.
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The results of intervention were also analyzed according to patients'
age. Among patients younger than 65 years, the percentage of fractionated
lipid profiles obtained increased from 33% before intervention to 88% during
intervention (P = .001) (Figure 4). While 21% of patients with elevated levels of LDL in
this age category were treated for hyperlipidemia before intervention, 89%
received treatment during intervention. A similar trend was seen in patients
65 years or older. The percentage of patients in this subgroup that had fractionated
lipid profiles obtained increased from 25% to 75% (P
= .001), and the percentage of patients for whom lipid-lowering therapy was
initiated increased from 0% to 90% (P = .001).
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Figure 4. Changes in lipid testing and initiation
of lipid-lowering therapy during hospitalization by age before and during
the intervention phase. Intervention increased the percentage of patients
(those younger than 65 years and those 65 years or older) who had lipid profiles
obtained and low-density lipoprotein (LDL) levels treated if 130 mg/dL (3.37
mmol/L) or higher.
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Effects of intervention also were evaluated by sex and race (Figure 5). In the preintervention period,
lipid profiles were obtained for 32% of the men and only 13% of the women.
During intervention, lipid profiles were obtained in 89% of the men and 88%
of the women. Before intervention, 19% of the men and 0% of the women were
receiving lipid-lowering therapy. During intervention, lipid-lowering therapy
was more frequently initiated in men with elevated LDL levels (86%) than in
women (73%).
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Figure 5. Female and male patients who had
lipid testing performed and who had lipid-lowering therapy initiated for a
low-density lipoprotein (LDL) level of 130 mg/dL (3.37 mmol/L) or higher before
and during the intervention period.
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About 27% of the white patients and 21% of all other study patients
underwent lipid testing in the preintervention period (Figure 6). During intervention, however, 89% of the white patients
and 89% of all other patients underwent lipid testing. During the preintervention
period, while only 5% of the white patients who met criteria for lipid-lowering
therapy had such treatment, 50% of all other patients received treatment with
lipid-lowering agents. During the cardiac case manager intervention period,
80% of the white patients and 92% of all other study patients eligible for
therapy were started on treatment with lipid-lowering agents.
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Figure 6. Patients stratified by race. An
increased percentage of both white and other patients had lipid testing performed
and lipid treatment initiated for low-density lipoprotein (LDL) levels of
130 mg/dL (3.37 mmol/L) or higher during the intervention phase compared with
preintervention.
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COMMENT
This study clearly demonstrates that a targeted, cardiac case manager–based
intervention significantly improves rates of lipid testing and initiation
of lipid-lowering treatment in patients with CAD in the hospital setting.
Cardiac case managers successfully prompted physicians to initiate lipid-lowering
therapy for patients with LDL levels of 130 mg/dL or higher.
The intervention increased the percentage of patients tested for hyperlipidemia
from 27% to 89% and, ultimately, the use of lipid-lowering therapy from 17%
to 82% of patients with elevated lipid levels. These improvements are statistically
significant and clinically important. This study provides evidence that implementation
of a targeted intervention can improve physicians' treatment of hyperlipidemia
in patients with CAD, thus increasing compliance with the NCEP guidelines.
For patients with both CAD and high serum lipid levels, the NCEP treatment
guidelines encourage the measurement of serum cholesterol immediately following
hospital admission, as well as the initiation of lipid-lowering therapy while
patients are hospitalized. However, despite promulgation of the NCEP guidelines,
there has been insufficient compliance in the treatment of elevated lipid
levels. A notable number of eligible patients do not receive appropriate treatment,11-12,16, 28 resulting
in the subsequent failure to prevent secondary coronary events in patients
with established coronary disease.7-10,13-15
The benefits of lipid-lowering therapy in patients with CAD have been
well demonstrated. Lipid-lowering therapy extends survival, improves quality
of life, decreases the need for interventional procedures, and reduces the
incidence of subsequent cardiac events in patients with CAD.4, 29-32
Therefore, it is recommended that lipid-lowering therapy be initiated as a
secondary prevention to reduce the risk of recurrent acute coronary disease
events when LDL cholesterol levels are higher than 130 mg/dL.
A recent study found that of patients with CAD, fewer than half were
discharged on appropriate lipid-lowering treatment, indicating that a significant
proportion of high-risk inpatients continues to be undertreated.7
Another study also found that physicians follow guidelines for obtaining LDL
levels only about 50% of the time, concluding that a significant number of
eligible patients are not appropriately treated.14
In addition, fewer than one third of patients who require treatment for high
cholesterol levels actually receive treatment,10, 16
and 62% of patients with CAD who meet criteria for initiating lipid-lowering
therapy receive prescriptions for cholesterol-lowering medications.33
Lack of compliance with guidelines may indicate deficiencies in physician
knowledge, implementation problems, lack of physicians' consensus regarding
treatment strategies, or problems with patient compliance. The successful
treatment rate of lipid-lowering therapy was highest for patients admitted
for MI, followed by that for CABG and then by that for PTCA. Longer inpatient
hospital stay (longest for patients admitted for MI, followed by that for
CABG and then by that for PTCA) provided greater opportunity for lipid-lowering
therapy to be initiated.
A previous study found that patients with 2 or more cardiac risk factors
were more likely to be treated, while men, blacks, persons in lower socioeconomic
groups, and persons aged between 20 and 34 years were less likely to be treated.34 However, our study found that female patients were
undertreated compared with their male counterparts. There was also a slight
difference between whites and other races in initiation of treatment during
the intervention phase of this study; although, before intervention, fewer
white patients were being treated for hyperlipidemia than patients of other
races.
Many studies have evaluated attempts to increase adherence to the NCEP
guidelines using various intervention strategies in the outpatient setting.
Coronary artery disease risk factors could be effectively reduced when either
nurses or pharmacists, with physicians' supervision, used a stepped-care protocol
based on the NCEP guidelines.18 Teamwork between
physicians and pharmacists has been successful in lowering total cholesterol
levels and increasing the prescription rate of lipid-lowering agents according
to NCEP recommendations.19, 22
Other studies have found that nurses can provide safe, cost-effective, compliance-enhancing
care for dyslipidemia.20-21,35
It has been suggested that the addition of lipid-lowering drug therapy before
hospital release may be advantageous in terms of compliance.36
This study demonstrated that joint efforts by physicians and cardiac
case managers are effective in improving appropriate use of lipid-lowering
therapy. Interventions of this nature implemented nationally can produce a
significant positive impact on cardiovascular outcomes. Although this study
demonstrated the positive impact of a targeted cardiac case manager intervention
on lipid-lowering therapy, these data may not be representative of the whole
US population because the data were collected from a single institution. This
study also examined only physicians' in-hospital adherence to the NCEP guidelines
for lipid testing and initiation of treatment prompted by cardiac case managers
rather than long-term intervention effects on physicians' treatment behavior
and patients' outcomes.
CONCLUSIONS
The findings from this study demonstrate that a targeted cardiac case
manager–based intervention program can significantly improve adherence
to national guidelines for lipid testing and initiation of lipid-lowering
therapy in hospitalized patients with CAD. Significant improvements were observed
in both frequency of lipid testing and appropriate initiation of lipid-lowering
therapy. Programs of this nature implemented nationally can result in a significant
positive impact on clinical and economic cardiovascular outcomes.
AUTHOR INFORMATION
Accepted for publication July 2, 2001.
Corresponding author and reprints: Clifton R. Lacy, MD, Division
of Cardiovascular Diseases and Hypertension, University of Medicine and Dentistry
of New Jersey–Robert Wood Johnson Medical School, 1 Robert Wood Johnson
Pl, New Brunswick, NJ 08903-0019 (e-mail: lacycr{at}umdnj.edu).
From the Center for Disease Management and Clinical Outcomes, University
of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical
School, New Brunswick (Drs Lacy, Bueno, Moylan, Kudipudi, and Kostis and Ms
Swartz); Robert Wood Johnson University Hospital, New Brunswick, NJ (Drs Lacy,
Bueno, and Kostis); and Rutgers–The State University of New Jersey,
College of Pharmacy, Piscataway (Drs Lacy, Suh, and Barone).
REFERENCES
| |
1. American Heart Association. Heart and Stroke Statistical Update. Dallas, Tex: American Heart Association; 1999.
2. Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults. Summary of the second report of the National Cholesterol Education
Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High
Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA. 1993;269:3015-3023.
FREE FULL TEXT
3. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary
heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;344:1383-1389.
FULL TEXT
|
ISI
| PUBMED
4. Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction
in patients with average cholesterol levels. N Engl J Med. 1996;335:1001-1009.
FREE FULL TEXT
5. National Heart Lung and Blood Institute. Cholesterol Lowering in the Patient With Coronary
Heart Disease. Baltimore, Md: National Institutes of Health; 1997.
6. National Heart Lung and Blood Institute. Second Report of the Expert Panel on Detection, Evaluation,
and Treatment of High Blood Cholesterol in Adults. Baltimore, Md: National Institutes of Health; 1993.
7. Fonarow G, French W, Parsons L, Sun H, Malmgren J. Use of lipid-lowering medications at discharge in patients with acute
myocardial infarction: data from the National Registry of Myocardial Infarction
3. Circulation. 2001;103:38-44.
FREE FULL TEXT
8. Rossouw JE, Lewis B, Rifkind BM. The value of lowering cholesterol after myocardial infarction. N Engl J Med. 1990;323:1112-1119.
ISI
| PUBMED
9. Goldberg RJ, Ockene IS, Yarzebski J, Savageau J, Gore JM. Use of lipid-lowering medication in patients with acute myocardial
infarction (Worcester Heart Attack Study). Am J Cardiol. 1997;79:1095-1097.
FULL TEXT
|
ISI
| PUBMED
10. Cohen MV, Byrne M-J, Levine B, Gutowski T, Adelson R. Low rate of treatment of hypercholesterolemia by cardiologists in patients
with suspected and proven coronary artery disease. Circulation. 1991;83:1294-1304.
FREE FULL TEXT
11. Schrott HG, Bittner V, Vittinghoff E, Herrington DM, Hulley S for the HERS Research Group. Adherence to National Cholesterol Education Program treatment goals
in postmenopausal women with heart disease. JAMA. 1997;277:1281-1286.
FREE FULL TEXT
12. Troein M, Gardell B, Selander S, Rastam L. Guidelines and reported practice for the treatment of hypertension
and hypercholesterolaemia. J Intern Med. 1997;242:173-178.
FULL TEXT
|
ISI
| PUBMED
13. Rifai N, Neufeld E, Ahlstrom P, Rimm E, D'Angelo L, Hicks JM. Failure of current guidelines for cholesterol screening in urban African-American
adolescents. Pediatrics. 1996;98:383-388.
FREE FULL TEXT
14. Frolkis JP, Zyzanski SJ, Schwartz JM, Suhan PS. Physician noncompliance with the 1993 National Cholesterol Education
Program (NCEP-ATPII) guidelines. Circulation. 1998;98:851-855.
FREE FULL TEXT
15. Elasy TA, Mehler PS. Secondary prevention practices after acute myocardial infarction in
a large city hospital. Am J Cardiol. 1998;82:987-989.
FULL TEXT
|
ISI
| PUBMED
16. Majumdar SR, Gurwitz JH, Soumerai SB. Undertreatment of hyperlipidemia in the secondary prevention of coronary
artery disease. J Gen Intern Med. 1999;14:711-717.
FULL TEXT
|
ISI
| PUBMED
17. Haskell WL, Alderman EL, Fair JM, et al. Effects of intensive multiple risk factor reduction on coronary atherosclerosis
and clinical cardiac events in men and women with coronary artery disease:
the Stanford Coronary Risk Intervention Project (SCRIP). Circulation. 1994;89:975-990.
FREE FULL TEXT
18. Harris DE, Record NB, Gipson GW, Pearson TA. Lipid lowering in a multidisciplinary clinic compared with primary
physician management. Am J Cardiol. 1998;81:929-933.
FULL TEXT
|
ISI
| PUBMED
19. Bogden PE, Koontz LM, Williamson P, Abbott RD. The physician and pharmacist team: an effective approach to cholesterol
reduction. J Gen Intern Med. 1997;12:158-164.
FULL TEXT
|
ISI
| PUBMED
20. Blair TP, Bryant FJ, Bocuzzi S. Treatment of hypercholesterolemia by a clinical nurse using a stepped-care
protocol in a nonvolunteer population. Arch Intern Med. 1988;148:1046-1048.
FREE FULL TEXT
21. Miller NH, Thomas RJ, Superko RH, Ghandour G, Tayor CB, DeBusk RF. Lipid-lowering therapy in post-MI patients: efficacy of a nurse-managed
intervention [abstract]. Circulation. 1991;84(suppl II):II-328.
22. Carson JJ. Pharmacist-coordinated program to improve use of pharmacotherapies
for reducing risk of coronary artery disease in low-income adults. Am J Health Syst Pharm. 1999;56:2319-2324.
FREE FULL TEXT
23. Gaziano J, Hennekens C, Satterfield S, et al. Clinical utilities of lipid and lipoprotein levels during hospitalization
for acute myocardial infarction. Vasc Med. 1999;4:227-231.
FREE FULL TEXT
24. Gore JM, Goldberg RJ, Matsumoto AS, Castelli WP, McNamara PM, Dalen JE. Validity of serum total cholesterol level obtained within 24 hours
of acute myocardial infarction. Am J Cardiol. 1984;54:722-725.
FULL TEXT
|
ISI
| PUBMED
25. Rosner B. Fundamentals of Biostatistics. 4th ed. Belmont, Calif: Duxbury Press; 1995.
26. Pett MA. Nonparametric Statistics for Health Care Research. Thousand Oaks, Calif: Sage Publications; 1997.
27. Agresti A. Categorical Data Analysis. New York, NY: John Wiley & Sons; 1990.
28. Sueta CA, Chowdhury M, Boccuzzi SJ, et al. Analysis of the degree of undertreatment of hyperlipidemia and congestive
heart failure secondary to coronary artery disease. Am J Cardiol. 1999;83:1303-1307.
FULL TEXT
|
ISI
| PUBMED
29. The Long-Term Intervention with Pravastatin in Ischemic Disease (LIPID)
Study Group. Prevention of cardiovascular events and death with pravastatin in patients
with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med. 1998;339:1349-1357.
FREE FULL TEXT
30. Smith S, Blair S, Criqui M. Preventing heart attack and death in patients with coronary heart disease. Circulation. 1995;92:2-4.
31. Smith S. Risk reduction therapy: the challenge to change. Circulation. 1996;93:2205-2211.
FREE FULL TEXT
32. Grundy SM. Statin trials and goals of cholesterol-lowering therapy. Circulation. 1998;97:1436-1439.
FREE FULL TEXT
33. Danias PG, O'Mahony S, Radford MJ, Korman L, Silverman DI. Serum cholesterol levels are underevaluated and undertreated. Am J Cardiol. 1998;81:1353-1356.
FULL TEXT
|
ISI
| PUBMED
34. Giles WH, Anda RF, Jones DH, Serdulla MK, Merritt RK, DeStefano F. Recent trends in the identification and treatment of high blood cholesterol
by physicians: progress and missed opportunities. JAMA. 1993;269:1133-1138.
FREE FULL TEXT
35. Stoy DB. Pharmacotherapy for hypercholesterolemia: guidelines and nursing perspectives. J Cardiovasc Nurs. 1991;5:34-43.
PUBMED
36. Gotto AM. Cholesterol management in theory and practice. Circulation. 1997;96:4424-4430.
FREE FULL TEXT
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