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A Community-Wide Survey of Physician Practices and Attitudes Toward Cholesterol Management in Patients With Recent Acute Myocardial Infarction
Jorge Yarzebski, MD, MPH;
Carmen F. Bujor, MD;
Robert J. Goldberg, PhD;
Frederick Spencer, MD;
Darleen Lessard, MS;
Joel M. Gore, MD
Arch Intern Med. 2002;162:797-804.
ABSTRACT
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Background Physicians' current attitudes and practices toward the management of
high cholesterol levels in patients with recent acute myocardial infarction
are not well defined.
Objective To examine threshold levels of serum cholesterol and other factors that
influence physicians' decision to prescribe lipid-lowering drugs and initiate
dietary therapy in patients with recent acute myocardial infarction.
Methods Community-wide questionnaire survey of general internists, cardiologists,
and family physicians practicing in the Worcester, Mass, metropolitan area.
Results Among the 257 responding physicians, lipid-lowering drug therapy was
more likely to be initiated in younger patients at lower total serum and low-density
lipoprotein (LDL) cholesterol levels than in older patients (P = .03). Younger physicians were more likely to initiate dietary and
lipid-lowering drug therapy at lower total and LDL cholesterol levels than
their older counterparts. Younger physicians also considered LDL cholesterol
level the most important factor in initiating lipid-lowering drug therapy
in contrast to older physicians who favored total cholesterol level (P = .001). General practice physicians were more likely
to initiate dietary therapy at lower total cholesterol levels, but tended
to initiate lipid-lowering drug therapy at higher total and LDL cholesterol
levels compared with internists and cardiologists. Physicians reported that
the most important factors that interfere with patients' use of lipid-lowering
medication were concerns about medication costs, issues related to polypharmacy,
and failure to recognize the importance of lipid-lowering drugs. Several physician-associated
factors, including perceived importance of other cardiac drugs and provider
responsibility, were associated with the nonuse of lipid-lowering medications.
Conclusion Educational and practice-based efforts remain necessary to remove potential
barriers to the implementation of effective long-term cholesterol management
in patients with recent acute myocardial infarction.
INTRODUCTION
EVIDENCE ACCRUED from randomized trials has demonstrated that lowering
elevated serum cholesterol levels significantly reduces the risk of nonfatal
myocardial infarction (MI) and death attributed to coronary heart disease
(CHD) in high-risk healthy individuals and those with established CHD.1-2 Hyperlipidemia thereby represents an
important modifiable risk factor for the development and progression of CHD
in many individuals.
These results and other accumulated evidence have led to a series of
published guidelines by the National Cholesterol Education Program (NCEP)
for the more effective management of persons with elevated serum lipid levels,
including specific recommendations for aggressive lipid lowering in patients
with CHD.3 The NCEP–Adult Treatment Panel
(ATP) II guidelines emphasize that patients with any manifestation of cardiovascular
disease should reduce their low-density lipoprotein (LDL) cholesterol levels
below 100 mg/dL (<2.59 mmol/L).3 Accordingly,
one of the performance measures of the National Committee for Quality Assurance
(NCQA) will reflect the extent of effective cholesterol management in patients
with CHD.4 Managed care organizations looking
for NCQA accreditation must act in accordance with the latest Health Plan
Employer Data and Information Set (HEDIS) mandate to assess and report the
percentage of patients with a major CHD event in whom elevated serum LDL levels
have been lowered within 1 year of hospitalization.4
Despite this background, physicians' adoption of and adherence to the
NCEP-ATP II guidelines have been less than optimal, especially in patients
with CHD.5-6 Several surveys indicate
that fewer than half of patients with CHD have received active dietary or
pharmacologic cholesterol-lowering interventions.5, 7
In patients with recent acute MI, this issue is further complicated by the
controversy surrounding the appropriate timing of cholesterol management as
well as the cholesterol level at which to begin dietary or medication therapy.8
Relatively little information is known about the reasons for patients
not receiving therapy with cardiac medications in general and hypolipidemic
agents in particular.9 In addition, limited
information exists about patients' and providers' attitudes and beliefs toward
the efficacy of lipid-lowering medications and dietary therapy for patients
after recent acute MI.6 Information on current
physician attitudes and practices toward lipid-lowering interventions is essential
for identifying obstacles to optimal preventive and treatment strategies in
these high-risk patients.
The purpose of our questionnaire survey in a community sample of physicians
was to identify factors that influence treatment practices and providers'
attitudes toward cholesterol management in patients with recent acute MI.
The results of this study provide insights to current physician practice patterns
in the secondary prevention of CHD, particularly in regard to effective lipid
management.
PATIENTS AND METHODS
STUDY SAMPLE
We invited all internal medicine, family practice, and cardiology physicians
practicing in the Worcester (Mass) Standard Metropolitan Statistical Area
(SMSA) (1990 census estimate was 437 000) to participate in a mailed
questionnaire survey of their attitudes and practices toward the use of various
lipid-lowering management strategies in patients with recent acute MI. Physicians
practicing in the Worcester SMSA were identified through a medical directory
and from hospital listings of physicians who had admitting privileges to greater
Worcester hospitals. A total of 457 physicians were identified as either practicing
in the Worcester SMSA and/or having admitting privileges at area hospitals.
We excluded 32 physicians who had moved out of the area or died, 4 retired
physicians, and 25 physicians who indicated that they were not actively treating
patients with CHD at the time that the survey took place. The survey was mailed
to 396 physicians in the fall of 1999. Two repeat mailings were sent to initial
survey nonrespondents. A small monetary incentive ($10) was offered to physicians
who completed the survey. This study was approved by the institutional review
board from the University of Massachusetts Medical School, Worcester.
The questionnaire asked detailed questions about physicians' routine
practices toward the management of elevated cholesterol levels for the secondary
prevention of CHD and the levels of total serum and LDL cholesterol at which
they usually initiate dietary and lipid-lowering drug therapy in patients
with evidence of recent acute MI. Separate questions were asked according
to different patient age groups (50-64 years, 65-74 years, and  75 years).
In the survey we did not specify the cholesterol cut points (eg, <200 mg/dL
[<5.18 mmol/L], 200-239 mg/dL [5.18-6.19 mmol/L], and 240 mg/dL [6.22
mmol/L]) commonly used to denote gradation of CHD risk and to guide treatment
strategies. Instead, we asked the physicians to indicate at what level of
serum cholesterol and/or LDL cholesterol they usually initiate dietary or
lipid-lowering drug therapy in previously described age groups. We asked physicians
about the importance of different lipid fractions in making decisions about
the initiation of lipid-lowering drug therapy and the relative importance
of decreasing LDL levels compared with increasing high-density lipoprotein
levels in the secondary prevention of CHD in patients with recent acute MI.
We also asked physicians which type of lipid-lowering agent they would usually
initially prescribe in patients with recent acute MI and elevated serum cholesterol
levels according to different patient age groups. Surveyed individuals were
then asked to rank the importance of a number of patient and physician-related
factors in influencing treatment with lipid-lowering drug therapy.
Information about physician characteristics including age, sex, specialty,
and type of practice was collected. Physicians in the specialties of general
and family practice, internal medicine, and cardiology were considered to
be the ones most likely to care for patients with recent acute MI and were
the primary groups targeted for our survey. Because of study size limitations
and possible differences in reported attitudes and practices toward the various
factors under study, the study sample was categorized into the following 2
groups for purposes of analysis according to practice type: primary care and
family practice physicians (30%) and internal medicine and cardiologists (70%).
DATA ANALYSIS
Differences in the distribution of physicians' attitudes and practices
toward cholesterol management in the treatment of patients with recent acute
MI and high serum cholesterol levels according to specialty and age were examined
with  2 tests of statistical significance for discrete variables.
Analysis of variance and t tests were used for the
analysis of between-group differences for continuous variables. The Mantel-Haenszel 2 test was used to assess the significance of between-group differences
for trends in various lipid-related factors. A logistic regression analysis
was used to examine the association of physician-related characteristics (age,
sex, specialty, and affiliation with an health maintenance organization [HMO])
with patient and physician factors that may influence the use of lipid-lowering
drug therapy while controlling for potentially confounding factors.
RESULTS
The present report is based on information provided by 257 physicians,
which yielded an overall questionnaire response rate of 65%. The average age
of the responding physicians was 49 years. No significant age differences
were noted between responding physicians of different specialties or types
of practice. Approximately three fourths (73%) of the sample were men; 5%
were in general practice, 25% in family practice, 59% in internal medicine,
and 11% reported their specialty as cardiology. Of the study sample, 43% were
in private practice, 16% were affiliated with an academic hospital, 20% were
affiliated with a community hospital, and 21% practiced in an HMO; 72% of
the sample were board certified. Because the survey was confidential and extremely
limited information was available about the targeted physician sample, we
were unable to compare the characteristics of responding physicians with those
of nonrespondents.
INITIATION OF DIETARY AND LIPID-LOWERING DRUG THERAPY ACCORDING TO
PHYSICIAN AGE AND SPECIALTY
Responding physicians reported that lipid-lowering drug therapy was
more frequently initiated at similar total (mean, 201 mg/dL [5.21 mmol/L])
and LDL (mean, 122 mg/dL [3.16 mmol/L]) cholesterol levels than dietary therapy
(mean total cholesterol and LDL cholesterol levels, 200 and 122 mg/dL [5.18
and 3.16 mmol/L], respectively), regardless of physician age or patient age
group targeted. Patient age modestly affected physicians' threshold level
for initiating dietary and lipid-lowering therapies; older patients were permitted
higher total and LDL cholesterol levels prior to the initiation of treatment.
However, the impact of physician age on these treatment practices was more
striking. Physicians 55 years and older were much more liberal than their
younger counterparts in their threshold levels for treatment, allowing significantly
higher LDL levels prior to the initiation of dietary or lipid-lowering drug
therapy (P = .02) (Figure 1).
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Figure 1. Average levels of total serum
cholesterol and low-density lipoprotein (LDL) cholesterol for initiation of
dietary therapy and lipid-lowering drug therapy following hospital discharge
for recent myocardial infarction according to patient and physician age.
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About the influence of physician specialty on reported practice patterns,
internists and cardiologists started dietary therapy at lower LDL levels and
lipid-lowering drug therapy at lower total cholesterol and LDL levels compared
with their colleagues in general or family practice (Figure 2). Because different cholesterol management practices may
exist between internists and cardiologists, we carried out an additional subgroup
analysis comparing these 2 physician groups. The results of this analysis
showed that compared with internists, cardiologists started dietary therapy
at slightly lower total cholesterol levels (204 mg/dL [5.28 mmol/L] vs 207
mg/dL [5.36 mmol/L]), but at higher LDL concentrations (121 mg/dL [3.13 mmol/L]
vs 116 mg/dL [3.00 mmol/L]). Cardiologists started lipid-lowering drug therapy
at higher total cholesterol levels than those used by internists (214 mg/dL
[5.54 mmol/L] vs 204 mg/dL [5.28 mmol/L]), but each group initiated lipid-lowering
drug therapy at the same LDL level (120 mg/dL [3.11 mmol/L]).
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Figure 2. Average levels of total serum
cholesterol and low-density lipoprotein (LDL) cholesterol for initiation of
dietary therapy and lipid-lowering drug therapy following hospital discharge
for recent myocardial infarction according to patient age and physician specialty.
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IMPORTANCE OF LIPID FRACTIONS IN INITIATING TREATMENT
Most physicians reported LDL cholesterol to be the most important lipid
fraction they consider in initiating lipid-lowering drug therapy in patients
with recent acute MI. Almost 90% of internists and cardiologists and more
than 95% of younger physicians (<45 years) identified LDL as the most important
factor affecting their decision to proceed with lipid-lowering drug treatment.
This observation is in contrast to older physicians (55 years) in whom
a substantial proportion identified total cholesterol or high-density lipoprotein
as more important lipid parameters used in their decision to start therapy
(P = .001). Consistent with these results, in asking
physicians about the relative importance of either decreasing LDL cholesterol
levels, or increasing serum high-density lipoprotein cholesterol levels, two
thirds reported that decreasing LDL levels was more important.
LIPID-LOWERING TREATMENT PREFERENCES
Most physicians (86%) reported that they would consider both dietary
and drug therapy as the initial form of therapy to lower serum cholesterol
levels in patients with recent acute MI. Fewer than 1% of physicians reported
that they would initially treat these patients with only lipid-lowering drug
therapy, while 13% would consider only dietary therapy as the initial form
of treatment. Most responding physicians (97%) indicated that for both men
and women with a recent acute MI and elevated cholesterol levels they would
initially prescribe statins as the lipid-lowering medication of choice.
PATIENT FACTORS THAT MAY PREVENT THE USE OF LIPID-LOWERING DRUG THERAPY
In asking physicians about a variety of patient-related factors that
may interfere with the successful implementation of lipid-lowering drug therapy
in patients with recent acute MI and elevated serum cholesterol levels, the
most important factor influencing whether lipid-lowering drug therapy was
begun was patients' concerns about the costs of medication (Figure 3). Patients believing that they could lower their cholesterol
levels without drugs, believing that they were already taking too many other
drugs, and not understanding the importance of lipid-lowering drugs were also
noted as important contributory factors. Of lesser importance were troublesome
adverse effects, the belief that other cardiac drugs were more important,
and patient compliance.
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Figure 3. Patient factors that prevent the
more widespread use of lipid-lowering drug therapy.
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PHYSICIAN FACTORS THAT MAY PREVENT THE USE OF LIPID-LOWERING DRUG THERAPY
In asking the surveyed sample to indicate which physician-related factors
influence the prescribing of lipid-lowering medication, the most influential
factor reported was the belief that physicians do not adequately inform their
patients about the use of these medications or encourage their use (Figure 4). Other contributory factors included
the belief that other drugs used in the management of CHD were more important
and confusion over which provider was responsible for the patient's lipid
management. Of lesser importance was the belief that cholesterol management
was unchallenging or unexciting. Although the least influential factor measured,
nearly 50% of physicians surveyed felt that nonprescription of therapy was
affected by the fact that physicians were not convinced of the benefits of
lipid-lowering agents.
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Figure 4. Physician factors that prevent
the more widespread use of lipid-lowering drug therapy.
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PHYSICIAN CHARACTERISTICS ASSOCIATED WITH THE USE OF LIPID-LOWERING
DRUG THERAPY
We also examined the association of several physician characteristics,
including age, sex, specialty, and HMO affiliation, with previously described
factors (Figure 3 and Figure 4) that could influence the use of lipid-lowering drug therapy.
We carried out a logistic regression analysis in which we examined the association
of these physician characteristics with selected outcomes while controlling
for the effect of each other factor. The following physician characteristics
were significantly related to beliefs about the use of lipid-lowering drug
therapy: older physicians were less likely than younger physicians to be concerned
if patients think that other cardiac medications are more important (odds
ratio [OR], 0.29; 95% confidence interval [CI], 0.13-0.65). Men were more
likely than women to think that patients believe that they can lower their
cholesterol levels without drugs (OR, 2.2; 95% CI, 1.2-4.3). Internists and
cardiologists were significantly less likely to believe that physicians are
not convinced of the benefits of lipid-lowering drug therapy for patients
with CHD (OR, 0.41; 95% CI, 0.18-0.94). Physicians affiliated with HMOs were
more likely to believe that physicians do not adequately inform their patients
about the use of lipid-lowering drugs or encourage them to take these medications
(OR, 2.0; 95% CI, 1.0-4.0).
COMMENT
To our knowledge, no previously published study has systematically examined
physicians' attitudes and practices toward the use of dietary and lipid-lowering
drug therapy in patients after hospital discharge for recent acute MI, particularly
from the more generalizable perspective of community-based providers. The
results of our community survey of physicians suggest that older physicians
were less likely to implement recommended guidelines for the treatment of
high cholesterol levels in patients with recent acute MI. Surveyed physicians
also reported that they would treat younger patients with recent acute MI
more aggressively with both dietary changes and lipid-lowering drug therapies
than older patients. In addition, internal medicine and cardiology physicians
reported being more aggressive with the use of lipid-lowering drug therapy
(ie, initiating treatment at both lower total serum and LDL cholesterol levels)
than other physician specialties. Across all physician and patient age groups,
treatments to lower serum cholesterol were in the range of what may be conventionally
considered to be desirable or borderline desirable levels of total and LDL
serum cholesterol. We also found that the 3-hydroxy-3-methylglutaryl coenzyme
A reductase inhibitors (statins) were the overwhelming drug of choice for
the management of hyperlipidemia. A number of patient and provider factors
were reported to be associated with the use (or nonuse) of lipid-lowering
medications.
Hyperlipidemia represents an important modifiable risk factor in the
development and progression of CHD.10-13
During the past decade, particularly with the development and application
of new lipid-lowering regimens, treatment of dyslipidemia has emerged as a
powerful approach for the prevention of initial and recurrent CHD events.
Several large-scale randomized clinical trials have demonstrated the merits
of intensive lipid-lowering drug therapy in the secondary prevention of CHD
with reductions in associated morbidity and mortality approaching upwards
of 50%.14 Patients with established CHD and
lipid abnormalities represent an important high-risk subgroup because their
risk of dying is significantly greater than that of patients with comparable
risk factors but without a known history of CHD.15
In response to compelling evidence for the benefits of cholesterol-lowering
therapy, considerable efforts have been made in developing and promoting clinical
guidelines for the screening and treatment of lipid abnormalities.3 Specific guidelines for cholesterol testing, dietary
counseling, and pharmacologic treatment have been provided by the NCEP-ATP
I (1988)16 and NCEP-ATP II (1993).3 The NCEP-ATP II guidelines placed particularly strong
emphasis on the secondary prevention of CHD as well as on LDL cholesterol
as the primary lipid treatment target.3 The
recently released third report of the Expert Panel on Detection, Evaluation,
and Treatment of High Blood Cholesterol in Adults (ATP III) continues to emphasize
that intensive lipid-lowering treatment should be maintained in the management
of patients with CHD.17
At the time that we conducted our physician survey, the NCEP guidelines
for patients with CHD recommended obtaining a fasting lipid profile.3 If LDL cholesterol level was above 100 mg/dL (2.59
mmol/L), then initiation of dietary therapy was recommended; if the LDL cholesterol
level remained above 130 mg/dL (3.37 mmol/L) after 6 to 12 weeks of dietary
therapy, initiation of drug therapy was recommended. Dietary therapy and lifestyle
changes should be considered in patients with an LDL cholesterol level between
100 and 129 mg/dL (2.59-3.34 mmol/L); the decision to initiate lipid-lowering
drug therapy was left up to the physician's discretion according to his or
her clinical judgment.3-4 The
most recent ATP III recommendations emphasize again that the goal of lipid-lowering
drug therapy in patients with CHD should be to achieve an LDL cholesterol
level lower than 100 mg/dL (2.59 mmol/L). An important recommendation in ATP
III is that men and women should be treated similarly.
The results of the present study suggest different views and possible
interpretations of these recommendations by our community physicians. Surveyed
physicians reported initiating dietary therapy at lower average total and
LDL cholesterol levels than published recommendations. These physicians also
tolerated higher levels of these serum lipids with advancing patient age.
Despite the publication and widespread dissemination of the NCEP guidelines,
the secondary prevention of CHD through screening and treatment of hyperlipidemia
continues to be an underused clinical approach. Several studies suggest inadequate
adherence of US physicians to existing guidelines11, 14, 18-20
and that the management of high blood cholesterol levels is suboptimal for
both primary care physicians and cardiologists.18, 21-23
Prior studies have shown several factors other than patients' clinical
condition to exert significant influences on cholesterol management.22 These factors include physicians' specialty and age,
geographic region of practice, payment source, and patients' age, sex, and
race. Each of these factors represents potentially modifiable barriers to
increased awareness and more appropriate practice patterns. The results of
our study also suggest potential differences in knowledge and prescribing
practices of generalists compared with specialists in regard to cholesterol
management in patients with recent acute MI and differential use of various
therapeutic strategies. We found internal medicine and cardiology physicians
to be more likely to initiate treatment at lower total cholesterol and LDL
cholesterol levels. Other authors also have found provider specialty to be
an important factor influencing cholesterol management.24-25
A retrospective study of patients with CHD found that cardiologists documented
and treated elevated LDL cholesterol levels more frequently than primary care
physicians.25 On the other hand, in the Stanford
Lipid Research Clinic survey, similar cholesterol-lowering treatment patterns
were found among different medical specialties.26
Physician age was related to the use of different treatment approaches
and threshold for intervention. Younger physicians were more likely to report
initiating lipid-lowering drug therapy in younger patients and in patients
with lower total cholesterol and LDL cholesterol levels. On the other hand,
older physicians reported tolerating significantly higher total and LDL cholesterol
levels before initiating dietary or lipid-lowering drug therapy. Similar findings
were observed in the Stanford Lipid Research Clinic survey,26
suggesting that younger physicians are more likely to adhere to recommended
national guidelines or are more aggressive in their management of patients
with coronary disease.
In addition, younger patients were more likely to be treated aggressively
with both dietary and lipid-lowering drug therapy than older patients. Lipid-lowering
drug therapy was more likely to be initiated at significantly lower total
serum and LDL cholesterol levels for younger patients, regardless of physician
age. These findings are different from the National Ambulatory Medical Care
Survey results in which younger patients with hyperlipidemia were more likely
to be counseled but less likely to receive lipid-lowering medications than
older patients.22 On the other hand, many studies
have found older age to be associated with a lower likelihood of cholesterol
treatment.27-28 Recent findings
from a large national registry of patients hospitalized with acute MI in the
late 1990s indicated that lipid-lowering medications were prescribed at discharge
in fewer than one third of all patients and in fewer than half of high-risk
patients and those with a history of hyperlipidemia.29
In this study, older patients (65-74 years) were significantly less likely
to receive lipid-lowering drug therapy than younger patients.29
The fact that physicians have different thresholds in treating their
patients despite guidelines and/or evidence-based medicine has been recently
described in a random sample of US physicians. In this study, older hypertensive
patients were treated less aggressively by primary care physicians and/or
their treatment was less likely to be intensified even if they exhibited a
persistently elevated blood pressure than younger patients with elevated blood
pressure levels.30 Somewhat analogous to the
findings in our study, the less aggressive management of elderly patients
after acute MI may partially be because the benefits of lipid-lowering drug
therapy in elderly patients with established CHD have not been clearly demonstrated.
However, the NCEP guidelines clearly recommend that age alone should not be
a reason to treat hypercholesterolemia less aggressively.31
The present study results indicate that the 3-hydroxy-3-methylglutaryl
coenzyme A reductase inhibitors were overwhelmingly the drug of choice for
the management of elevated serum cholesterol levels (regardless of patient
or physician age or physician specialty). These patterns of medication use
likely reflect physicians' prescribing behavior and are concordant with the
results from several recent studies.22, 32
A shift in physicians' prescribing patterns toward the statin class of lipid-lowering
drugs has been reported by the most recent Cholesterol Awareness Survey.7
The National Heart, Lung, and Blood Institute (NHLBI) sponsored several
national telephone surveys of practicing physicians and the general public
in 1983, 1986, and 1990.33 The most recent
survey (1995) noted more aggressive treatment for patients with CHD consistent
with ATP II recommendations as well as a shift in focus on LDL cholesterol
for treatment decisions.7 These results are
consistent with our study findings in which most of surveyed physicians considered
LDL cholesterol as the most important lipid-related factor to influence management
decisions.
Results of the 1995 NHLBI Cholesterol Awareness Survey indicated that
LDL cholesterol treatment goals were acceptably lower for patients with CHD.
The physicians interviewed in our study indicated that they would initiate
lipid-lowering treatment in patients with recent acute MI at levels of total
and LDL serum cholesterol that may be conventionally considered in the desirable
or borderline desirable range. Their pattern of practice may reflect a more
aggressive attempt to lower elevated total and LDL levels in patients with
recent acute MI. These levels are lower than those reported in the Health
Education and Research Trial (HEART) study in which physicians indicated that
they may not have been aware of or agreed with the specific LDL cholesterol
goal levels for patients with cardiovascular disease.32
This observation emphasizes the importance of physician education in the effective
management of patients with CHD as well as the importance of the dissemination
of national guidelines and study results within the medical community.
The main strength of our study is the inclusion of a large number of
community physicians who were actively treating patients with CHD. By including
physicians from a defined geographic setting, we reduced the likelihood of
selection biases that may be operative in analyzing results from more select
provider populations or from self-selected populations of physicians. Prior
reports from the Worcester Heart Attack Study have reinforced the similarity
of the prescribing practices of physicians in the Worcester SMSA with those
seen in other geographic settings.34 In addition,
findings from this population-based study have suggested that physicians practicing
in the greater Worcester SMSA are sensitive to the results of published clinical
trials and that patients hospitalized with acute MI are more likely to be
treated according to established practice guidelines reflecting an evidence-based
patient management approach.35 However, our
study has several limitations. Despite a relatively high response rate to
our mailed questionnaire, we were unfortunately unable to characterize the
sociodemographic characteristics of nonresponding physicians. Responding physicians
may have differed in regard to their attitudes and practices toward lipid
management compared with nonresponding physicians. Another limitation of our
questionnaire survey is that the results reflect self-reported practices of
physicians, and particular caution must therefore be exercised in extrapolating
to actual prescribing behavior.
In conclusion, more emphasis needs to be placed on the active dissemination
of national guidelines for cholesterol management and recent results of carefully
conducted randomized trials to community-based physicians. Barriers to the
acceptance of new lipid-lowering treatment strategies that have been shown
to be beneficial in the management of patients with CHD need to be identified
and overcome to enhance the effects of secondary prevention of CHD.
AUTHOR INFORMATION
Accepted for publication August 27, 2001.
This study was supported by grant K01 HL 04047 from the National Heart,
Lung, and Blood Institute, Bethesda, Md.
We are indebted to physicians in the Worcester metropolitan area who
completed this questionnaire survey.
Corresponding author and reprints: Jorge Yarzebski, MD, MPH, Department
of Medicine, Division of Cardiovascular Medicine, University of Massachusetts
Medical School, 55 Lake Ave N, Worcester, MA 01655 (e-mail: jorge.yarzebski{at}umassmed.edu).
From the Department of Medicine, Division of Cardiovascular Medicine,
University of Massachusetts Medical School, Worcester.
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