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Diabetes Care 26:1633-1634, 2003
© 2003 by the American Diabetes Association, Inc.

Editorials
Editorial

The Need to Improve

Richard W. Bergstrom, MD

From the Portland Diabetes and Endocrinology Center, Portland, Oregon

In this issue of Diabetes Care, Massing et al. (1) present the results of their review of Medicare claims from 13,660 diabetic patients who received regular outpatient care from a primary care physician (n = 1,749). During a 24-month period, 31% received no lipid profile, 24% received only one lipid profile, and 45% of the diabetic patients received two or more lipid profiles. Further analysis revealed that Caucasians compared with African Americans were 1.6 times more likely to receive a lipid panel, and patients with stroke or heart failure were also less likely to receive a lipid profile.

There are clinical decisions pertaining to lipid screening made by the primary care physician that are not captured with Medicare claims data and may partially account for an under-representation of the adherence rates. One situation is a patient’s refusal to obtain a lipid profile. Another situation, which is rare, is the individual with a total cholesterol <100 mg/dl. In this case, the primary care physician may not request a full fasting lipid profile because the calculated LDL cholesterol goal will be <100 mg/dl and the additional information would not affect a clinical decision. The final clinical situation that has a practical application for diabetic patients is utilizing a direct LDL cholesterol measurement (2). The direct LDL cholesterol’s Current Procedural Terminology (CPT) code is 83721, and this code was not used in the analysis by Massing et al. (1). The practical application of a direct LDL cholesterol measurement is that the sample can be obtained in a nonfasting state, unlike the calculated LDL cholesterol, which requires at least a 10-h fast. This is one solution to the difficult situation in which a diabetic patient treated with insulin has an office visit at 4:00 P.M. and must maintain a prolonged fast to obtain an accurate calculated LDL cholesterol measurement. Another indication for the direct LDL cholesterol measurement is if the serum triglyceride level exceeds 400 mg/dl. Even if these three situations were incorporated in the Medicare claims data analysis, I suspect the adherence rate would still be low.

The finding of Massing et al. of a low rate of adherence to the American Diabetes Association’s recommendations for lipid testing in diabetic patients is concerning and underscores the need for improvement. Improvement is important because coronary heart disease is a major cause of mortality and morbidity in diabetic populations (3). Furthermore, trials have confirmed the proven benefit of lipid treatment (4,5). A screening lipid test is only the initial step in cardiovascular risk modification and lipid treatment. The finding (1) that 31% of the Medicare population with diabetes did not receive a screening lipid profile in a 2-year period is unfortunate because these individuals were effectively excluded from the opportunity to benefit from the advances in cardiovascular risk modification and lipid treatment. Thus, it is imperative that the adherence rate for lipid screening be improved.

Ironically, the rate of lipid screening in this audit (1) could suggest improvement, since earlier surveys have recorded even lower rates of lipid screening (6–8). Studies have documented an improving trend for awareness and adherence to lipid testing (9,10), which is the result of several factors. One factor is the contribution of various organizations to educate and reinforce the relevance of lipid screening and treatment (10). The continued reporting in the medical literature of adherence rates drives further improvement because the published rates call upon health care providers to exceed these published rates in their own practice. These publications are also the stimulus to develop solutions to exceed these rates. There are several systems that have been developed and utilized to improve the adherence rate for lipid screening (11,12). Incorporation of these systems into practice of large groups of practitioners and the busy practitioner who sees patients every 8–12 min, regardless of the patient’s medical complexity, may result in further improvements in the rates of lipid screening.

Another area that needs improvement is the racial disparity for lipid testing. Massing et al. observed that Caucasians compared with African Americans were 1.6 times more likely to receive a lipid panel. The racial disparity persisted after controlling the variable, access to health care. The racial disparity in cholesterol screening has been reported in other surveys (13). This finding is paradoxical because the group that may be the "most vulnerable" has the one of the lowest rates of lipid testing. A racial disparity has been demonstrated in other health care services, such as influenza vaccination (14), diabetic end-stage real disease (15), coronary artery revascularization procedures (16), and early detection of cancer (17). The continued documentation of this racial disparity in the quality of health care for preventive services suggests that these observations are not aberrant findings. I believe further research and investigation is warranted to determine the factors that contribute to racial disparity for lipid testing.

Footnotes

Address correspondence to Richard W. Bergstrom, MD, Portland Diabetes and Endocrinology Center, 1130 NW 22nd, Portland, OR 97210. E-mail: bergstrom5{at}aol.com.

References

  1. Massing MW, Henley NS, Carter-Edwards L, Schenck AP, Simpson RJ: Lipid testing among patients with diabetes who receive diabetes care from primary care physicians. Diabetes Care 26:1369–1373, 2003[Abstract/Free Full Text]
  2. Hirany S, Li D, Jialal I: A more valid measurement of low-density lipoprotein in diabetic patients. Am J Med 102:48–53, 1997[Medline]
  3. Laakso M: Hyperglycemia and cardiovascular disease in type 2 diabetes. Diabetes 48:937–942, 1999[Abstract]
  4. Gotto AM: Lipid management in diabetic patients: lessons from prevention trials. Am J Med 112:19S–26S, 2002
  5. Heart Protection Study Collaborative Group: MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 360:7–22, 2002[Medline]
  6. Weiner JP, Parente ST, Garnick DW, Fowles J, Lawthers AG, Palmer H: Variation in office-based quality: a claims-based profile of care provided to Medicare patients with diabetes. JAMA 273:1503–1508, 1995[Abstract]
  7. Frolkis JP, Zyzanski SJ, Schwartz JM, Suhan PS: Physician noncompliance with the 1993 National Cholesterol Education Program (NCEP-ATPII) Guidelines. Circulation 98:851–855, 1998[Abstract/Free Full Text]
  8. Headrick LA, Speroff T, Pelecanos HI, Cebul RD: Efforts to improve compliance with the National Cholesterol Education Program Guidelines: results of a randomized controlled trial. Arch Intern Med 152:2490–2496, 1992[Abstract]
  9. Pieper RM, Arnett DK, McGovern PG, Shahar E, Blackburn H, Luepker RV: Trends in cholesterol knowledge and screening and hypercholesterolemia awareness and treatment, 1980–1992. Arch Intern Med 157:2326–2332, 1997[Abstract]
  10. Cleeman JI, Lenfant C: The National Cholesterol Education Program: progress and prospects. JAMA 280:2099–2104, 1998[Abstract/Free Full Text]
  11. Maviglia SM, Teich JM, Fiskio J, Bates DW: Using an electronic medical record to identify opportunities to improve compliance with cholesterol guidelines. J Gen Intern Med 16:531–537, 2001[Medline]
  12. Gottlieb NH, Huang PP, Blozis SA, Guo JL, Murphy-Smith M: The impact of Put Prevention into Practice on selected clinical preventive services in five Texas sites. Am J Prev Med 21:35–40, 2001[Medline]
  13. Brown DW, Giles WH, Greenlund KJ, Croft JB: Disparities in cholesterol screening: falling short of a national health objective. Preventive Medicine 33:517–522, 2001[Medline]
  14. Schneider EC, Cleary PD, Zaslvasky AM, Epstein AM: Racial disparity in influenza vaccination. Does managed care narrow the gap between African Americans and whites? JAMA 286:1455–1460, 2001[Abstract/Free Full Text]
  15. Brancati F, Whittle JC, Whelton PK, Seidler AJ, Klag MJ: The excess incidence of diabetic end-stage renal disease among blacks. JAMA 268:3079–3084, 1992[Abstract]
  16. Peterson ED, Shaw LK, DeLong ER, Pryor DB, Califf RM, Mark DB: Racial variation in the use of coronary-revascularization procedures. N Engl J Med 336:480–486, 1997[Abstract/Free Full Text]
  17. Roetzheim RG, Pal N, Tennant C, Voti L, Ayanian JZ, Schwabe A, Krischer JP: Effects of health insurance and race on early detection of cancer. J National Cancer Inst 91:1409–1415, 1999[Abstract/Free Full Text]

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