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Disparities in the Diagnosis and Pharmacologic Treatment of High Serum Cholesterol by Race and Ethnicity
Data From the Third National Health and Nutrition Examination Survey
Karin Nelson, MD, MSHS;
Keith Norris, MD;
Carol M. Mangione, MD, MSPH
Arch Intern Med. 2002;162:929-935.
ABSTRACT
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Background Serum cholesterol is one of the most important modifiable risk factors
for coronary artery disease. There are conflicting data on racial and ethnic
variation in the treatment of high cholesterol.
Methods We analyzed data from the Third National Health and Nutrition Examination
Survey, a nationally representative cross-sectional survey conducted between
1988 and 1994. Participants included 7679 white, 4467 African American, and
4113 Mexican American adults older than 25 years who completed the household
adult questionnaire. The adjusted odds of serum cholesterol screening and
of taking a prescription medication to lower serum cholesterol among African
Americans and Mexican Americans were compared with those of whites, controlling
for differences in age, sex, income, educational level, insurance status,
comorbid illness, and having a regular source of health care.
Results African Americans and Mexican Americans were significantly less likely
than whites to report ever having had their blood cholesterol checked (odds
ratio, 0.7 for both; P<.001). Among individuals
with high cholesterol who were told to take a medication, African Americans
(P<.001) and Mexican Americans (P = .05) were less likely than whites to be taking a cholesterol-lowering
agent (odds ratios, 0.3 and 0.5, respectively). Individuals who reported being
told they had high cholesterol had significantly higher serum cholesterol
measurements (from the laboratory examination) than those who reported being
told their cholesterol was not high (234 vs 198 mg/dL [6.05 vs 5.12 mmol/L]; P<.001).
Conclusions African Americans and Mexican Americans were less likely to report serum
cholesterol screening than whites. Even when identified as having high cholesterol
that required medication, African Americans and Mexican Americans were less
likely than whites to be taking cholesterol-lowering agents.
INTRODUCTION
RECENT DECLINES in death rates from coronary heart disease (CHD) have
been more significant in whites than in minority populations in the United
States.1-3 Many
studies4-8
have shown that Latinos and African Americans receive less aggressive treatment
for CHD than do whites. However, there are conflicting data on racial and
ethnic variation in the primary prevention of CHD. Elevated serum cholesterol
is one of the most important modifiable risk factors for CHD,9-11
and treating hypercholesterolemia lowers the risk of developing disease.12-16
Given the strength of this evidence, the National Cholesterol Education Program
recommends measuring the serum cholesterol in all adults older than 20 years
at least once every 5 years.9
Previous studies have documented low rates of treatment for elevated
cholesterol levels17-22
and variation in management by physician23-28
and patient29-37
characteristics. In the San Antonio Heart Study, Mexican Americans were less
likely than whites to be aware of and to be undergoing treatment for high
cholesterol.38-39 In the 1988-1990
Behavioral Risk Factor Surveillance System (BRFSS), African Americans and
Latinos were less likely than whites to report cholesterol screening.40-41 Paradoxically, in the same study,
African Americans and Latinos were more likely than whites to report taking
a prescription medication for high cholesterol.41
In the Cardiovascular Health Study,42 among
a cohort 65 years or older, only 20% of eligible individuals were treated
for high cholesterol and no treatment difference was noted between whites
and African Americans. These reports conflict with data from the Atherosclerosis
Risk in Communities study43 and the Heart and
Estrogen/Progestin Replacement Study,34 in
which African Americans were less likely than whites to receive lipid-lowering
medication.
The last national study41 examining differences
in treatment for hypercholesterolemia by race and ethnicity used the 1988-1990
BRFSS data. This study may not fully reflect the change in treatment patterns
after the approval of the 3-hydroxy-3-methylglutaryl coenzyme A reductase
inhibitors (the "statins") in 1987.17 The use
of data from the Third National Health and Nutrition Examination Survey (NHANES
III), collected between 1988 and 1994, permits further examination of time
trends in treatment as the statins became widely used. To accurately assess
treatment for high blood cholesterol, detailed medication information obtained
by review of actual medication bottles collected during NHANES III will be
analyzed. With these nationally representative data, the purpose of our study
is to examine the effect of race and ethnicity on the receipt of cholesterol
screening and on the treatment of high serum cholesterol.
PARTICIPANTS AND METHODS
NHANES III was conducted by the National Center for Health Statistics
at 89 survey locations between 1988 and 1994.44-45
The survey is a cross-sectional nationally representative sample of the US
civilian noninstitutionalized population. NHANES III used a stratified multistage
probability cluster design with oversampling of Mexican Americans, African
Americans, and persons older than 60 years.46
The survey consists of multiple components, including a household interview,
a physical examination, and laboratory tests.
A total of 16 884 people older than 25 years completed the household
adult questionnaire. Given guidelines recommending a serum cholesterol measurement
every 5 years beginning at the age of 20 years,1
we limited our sample to those 25 years or older. Respondents were asked to
identify themselves as white, black, Mexican American, or other. We excluded
those individuals (n = 625) identified as other race, including those of Hispanic
origin who did not identify themselves as Mexican American.
Respondents were asked a series of questions regarding serum cholesterol
screening and treatment in the household adult questionnaire. Of the subjects
older than 25 years, 96% (n = 15 686) answered these questions and compose
the sample for this study. All respondents were asked: "Have you ever had
your cholesterol checked?" If respondents answered yes, they were asked: "Have
you ever been told by a doctor or other health professional that your blood
cholesterol level was high?" If they reported being told their blood cholesterol
level was high, they were asked: "Because of your high blood cholesterol,
have you ever been told by a doctor or other health professional to take prescribed
medication?"
If a respondent reported taking any prescription medicine, the interviewer
asked to see the medication container to record the name of the product. If
the container was not available, the interviewer probed for the medication
name. Medication data were available for 14 655 individuals. Lipid-lowering
agents identified included cholestyramine, clofibrate, cholestipol, gemfibrozil,
lovastatin, niacin, and probucol. If a person reported taking 1 or more of
these medications, the person was considered to be taking a lipid-lowering
agent. Laboratory data were obtained from respondents at the mobile examination
center and were available for 10 820 participants. Coronary heart disease
risk factors, including hypertension, diabetes mellitus, coronary artery disease,
and smoking, were based on self-report. Participants were considered smokers
if they reported smoking at least 100 cigarettes during their lifetime and
were current smokers.
Data were weighted to account for the unequal probability of selection
that resulted from the survey cluster design, nonresponse, and oversampling
of certain target populations.46-47
Statistical analysis was performed using computer software (Stata, version
6.0)48 to take into account the complex sampling
design. Sampling weights were used to calculate population estimates, and
sampling strata and primary sampling units were accounted for to estimate
variances and to test for significant differences. All results are presented
as unweighted counts and weighted percentages and odds ratios.
Bivariate analyses were performed to assess the significance of associations
between race and ethnicity and receipt of cholesterol screening, being told
your serum cholesterol level was high, being told to take a cholesterol-lowering
medication, and taking a cholesterol-lowering medication. Multivariate analyses
were performed to examine the association of race and ethnicity on the receipt
of cholesterol screening and on taking a cholesterol-lowering medication,
accounting for the independent effects of sociodemographic factors (age, sex,
income, and educational level), health insurance coverage, comorbid disease
(diabetes mellitus, hypertension, CHD, and tobacco use), and having a regular
source of care. Multicollinearity was assessed using correlation coefficients
between the independent variables. None of the correlation coefficients between
independent variables were greater than 0.6.
RESULTS
Of all adults older than 25 years, 63% reported that they had their
cholesterol level checked at least once (Table 1). Mexican Americans and African Americans were much less
likely to report serum cholesterol screening compared with whites (37% and
50%, respectively, vs 66%; P<.001). The unadjusted
and adjusted odds ratios and predicted percentages for receipt of cholesterol
screening are displayed in Table 2.
The difference in screening by race and ethnicity persists in a multivariate
analysis controlling for the independent effect of sociodemographic factors,
type of health insurance, comorbid illness, and having a regular source of
care. Those who were poor, less educated, uninsured, or smokers were also
less likely to report the receipt of cholesterol screening.
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Table 1. Bivariate Correlates With Cholesterol Monitoring and Receipt
of Treatment*
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Table 2. Characteristics of Individuals Reporting Cholesterol Screening*
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Overall, 35% of those who had their cholesterol level checked were told
the value was high (Table 1).
Of those with high cholesterol, 22% were told to take medication. Of those
told to take medication for high cholesterol, 46% were documented to be taking
a cholesterol-lowering agent during the month before the survey. Most individuals
were taking either lovastatin or gemfibrozil (data not shown). Of those who
were told to take prescription medication, Mexican Americans and African Americans
were less likely than whites to be taking medication to control high blood
cholesterol (28% and 29%, respectively, vs 49%; P<.001). Table 3 displays the unadjusted and adjusted
odds ratios and predicted percentages for taking a cholesterol-lowering medication
among those who were told to take medication. The difference in taking a cholesterol-lowering
medication by race and ethnicity persists after adjusting for other sociodemographic
factors, type of health insurance, comorbid illness, and having a regular
source of care. As expected, other factors that were associated with taking
a cholesterol-lowering agent included a previous history of coronary artery
disease, having diabetes mellitus, and reporting a regular source of care.
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Table 3. Characteristics of Individuals Taking Cholesterol-Lowering
Medications*
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To assess the validity of the self-report of high cholesterol, we compared
mean cholesterol levels for those who reported being told they had high cholesterol
with those who were told they did not have high cholesterol. The mean total
serum cholesterol level of those who reported being told their cholesterol
level was high was 234 mg/dL (6.05 mmol/L) compared with 198 mg/dL (5.12 mmol/L)
for those who were told their cholesterol level was not high (P<.001). The mean cholesterol level did not significantly (P = .13) differ by race or ethnicity among those who were
told their serum cholesterol was high (data not shown). In addition, 99% (n
= 298) of the individuals who were taking a cholesterol-lowering medication
reported being told that their cholesterol was high and that they should be
taking a cholesterol-lowering medication.
COMMENT
African Americans and Mexican Americans were less likely than whites
to report ever having been screened for high cholesterol, and of those who
were told to take a prescription medication, were less likely to be taking
a cholesterol-lowering agent. Our results add important information to the
growing literature on racial and ethnic variation in the treatment of CHD.
Hypercholesterolemia is an important risk factor in the development of CHD,
and recent national data49 suggest that the
proportion of individuals with an elevated cholesterol level is similar across
different racial and ethnic groups. Although the death rate from CHD is lower
among Latinos, declines in mortality have occurred to a smaller degree among
Latinos than whites.3 Among African Americans,
CHD mortality is higher and declines have also been less than in the white
population.2 The difference in primary prevention
we describe could contribute to this variation in disease rates.
The strength of our study is the use of data designed to provide accurate
estimates about African Americans and Mexican Americans. Collected through
1994, data from NHANES III represent the most current nationally representative
data on the treatment of high blood cholesterol after the introduction and
widespread use of the statins. In addition, estimates about pharmacologic
treatment were made from direct review of medication bottles.
Cholesterol screening rates have steadily increased during the past
20 years. In 1983, only 35% of adults reported that they had their cholesterol
level checked, compared with 65% in 1990.20, 50
Consistent with these national surveys, we found that 63% of adults older
than 25 years reported having undergone a serum cholesterol test. Our results
of the racial and ethnic variation in screening rates are consistent with
data from the 1988-1990 BRFSS.41 However, we
report a lower rate of cholesterol screening for Mexican Americans than found
for Hispanic individuals in the BRFSS (42% vs 58%). The higher screening rate
for Hispanic individuals in the BRFSS is not adjusted to account for insurance
status or income. In our study, income and insurance status were strong correlates
for cholesterol screening. It is possible that differences in income and insurance
status could explain the observed variation in screening rates between the
2 studies.
In our analyses, differences in screening for high cholesterol by race
and ethnicity persist after accounting for the independent effects of income,
educational level, health insurance status, comorbid disease, and having a
regular source of care. These results suggest that lower rates of cholesterol
screening in African Americans and Mexican Americans are not solely a result
of problems with health care access. Potential explanations for the observed
differences may include unmeasured socioeconomic or clinical factors, patient
preferences, or physician characteristics, such as knowledge of screening
recommendations or bias.
Although the first National Cholesterol Education Program guidelines
were released in 198851 and the statins were
approved for use in 1987,17 NHANES III data
were collected before the publication of the most definitive primary and secondary
prevention trials.52-55
Recent studies56-58
have demonstrated a modest increase in the use of cholesterol-lowering agents
since the publication of these landmark studies. In NHANES III, we estimated
that 2.5% of US adults older than 25 years were undergoing treatment with
a lipid-lowering agent (data not shown), consistent with other national surveys.20 The period for NHANES III may account for the low
rate of screening and treatment for hypercholesterolemia overall, but would
not explain the variation in treatment by race and ethnicity that we have
demonstrated.
In the only previous analysis41 of nationally
representative data, African Americans and Hispanic individuals were more
likely to report that they were taking a lipid-lowering agent than were whites.
These data were based on self-report and not on review of medication bottles.
Using data from a medication bottle review, Mexican Americans and African
Americans in NHANES III were less likely to actually be taking a cholesterol-lowering
agent among those who were told to take medication. It is reassuring that
we did not find any racial or ethnic variation in the report of physician
recommendation for nonpharmacologic interventions to lower serum cholesterol
(data not shown) or to take a medication for high cholesterol.
Our results regarding lower treatment rates of high blood cholesterol
among African Americans are consistent with 2 previous studies. In the Atherosclerosis
Risk in Communities study,43 Nieto and colleagues
observed a cohort of individuals in 4 US communities and assessed cholesterol
treatment through medication bottle review. They found that of those with
high cholesterol, 28% of whites and 20% of African Americans were undergoing
treatment.43 In the Heart and Estrogen/Progestin
Replacement Study,59 a large secondary prevention
trial of estrogen replacement therapy, a high percentage of women were taking
cholesterol-lowering agents. However, even among clinical trial participants,
white women were still more likely to be treated for hypercholesterolemia
compared with African American women (71% vs 52%).34
We found that less than half of the individuals who reported being told
by a physician to take a lipid-lowering agent were actually taking medication
to treat high cholesterol, suggesting either a low likelihood of starting
a recommended therapy or, as documented by previous studies,60-61
a high discontinuation rate. The observed racial and ethnic differences in
pharmacologic treatment could reflect concerns about cost or differences in
coverage for prescription medications62 that
were not measured in NHANES III. Patient- or physician-level health beliefs,
social norms, and differential knowledge regarding the benefits of treatment
of high cholesterol may also play a role. Differences in treatment rates could
also reflect lack of patient trust or ineffective communication between the
physician and patient regarding treatment.
Our results also highlight the importance of access to preventive services
for the primary prevention of CHD and are consistent with previous reports63-64 on limited access to preventive care
among the uninsured. In this study, having a regular source of care was one
of the strongest predictors for reporting cholesterol screening and for taking
a cholesterol-lowering medication. The uninsured were significantly less likely
to report ever having their cholesterol level checked. Although we did find
fewer uninsured individuals taking a cholesterol-lowering medication, the
limited sample size did not provide enough power to detect a statistically
significant difference in prescription drug use by insurance categories.
The main limitation of this study is the self-report of cholesterol
screening. We performed several validity checks of the self-reported screening
data. Of those taking a lipid-lowering agent, 99% reported that they had their
cholesterol checked and were told that they required medication. In addition,
individuals who reported being told their cholesterol was elevated had a significantly
higher measured serum cholesterol from the laboratory examination compared
with those who were told that their cholesterol was not high. Previous studies65-67 suggest that individuals
underreport cholesterol screening, although there is no evidence that African
Americans or Mexican Americans are more likely to underreport screening than
whites. To diminish the racial and ethnic differences we describe, the rate
of underreporting would have to be significantly different among these populations.
This description of racial and ethnic variation in the primary prevention
of CHD adds important information to the growing literature on disparities
in health care in the United States. African Americans and Mexican Americans
are less likely than whites to report cholesterol screening and, if indicated,
are less likely to be taking a cholesterol-lowering medication. Further research
is needed to understand the interaction of patient, physician, and organizational
factors that contribute to this variation to address this disparity in the
primary prevention of CHD. To understand differences in the treatment of high
cholesterol, identifying patient preferences and barriers to adherence for
lipid-lowering agents, such as trust in physician recommendations and knowledge
about the benefits of treatment, will be essential. In addition, larger studies
of secondary prevention are needed to understand if these racial disparities
exist in higher-risk populations.
AUTHOR INFORMATION
Accepted for publication August 29, 2001.
This study was supported in part by grant U54RR14616 from the Research
Centers in Minority Institutions, National Center for Research Resources,
National Institutes of Health, Bethesda, Md.
Corresponding author and reprints: Karin Nelson, MD, MSHS, VA Puget
Sound Health Care System, 1660 S Columbian Way, Mail Stop S-111-GIMC, Seattle,
WA 98108-1597 (e-mail: karin.nelson{at}med.va.gov).
From the VA Puget Sound Health Care System, Department of Medicine,
University of Washington, Seattle (Dr Nelson); the Department of Internal
Medicine, Charles Drew University/University of California, Los Angeles, UCLA
School of Medicine (Dr Norris); the Division of General Internal Medicine
and Health Services Research, University of California, Los Angeles, UCLA
School of Medicine (Dr Mangione); and RAND Health, Santa Monica, Calif (Dr
Mangione).
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