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Diabetes Care 28:2942-2944, 2005
© 2005 by the American Diabetes Association, Inc.

Epidemiology/Health Services/Psychosocial Research
Brief Report

Lack of Effect of Guideline Changes on LDL Cholesterol Reporting and Control for Diabetes Visits in the U.S., 1995–2004

Y. Richard Wang, MD, PHD1,2, G. Caleb Alexander, MD, MS3,4,5 and David O. Meltzer, MD, PHD3,4,5,6

1 Public Policy Department, AstraZeneca Pharmaceuticals, Wilmington, Delaware
2 Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
3 MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
4 Robert Wood Johnson Clinical Scholars Program, University of Chicago, Chicago, Illinois
5 Department of Medicine, University of Chicago Hospitals, Chicago, Illinois
6 Harris School for Public Policy, University of Chicago, Chicago, Illinois

Address correspondence and reprint requests to Y. Richard Wang, MD, PhD, Public Policy Department, AstraZeneca Pharmaceuticals, FOC 3 CE 417, 1800 Concord Pike, Wilmington, DE 19850-5437. E-mail: y.richard.wang{at}astrazeneca.com

Abbreviations: ADA, American Diabetes Association • ATP III, Adult Treatment Panel III • CHD, coronary heart disease • NDTI, National Disease and Therapeutic Index


   INTRODUCTION
TOP
 INTRODUCTION
RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
 References
 
We studied the effects of guideline changes on LDL cholesterol reporting and control for diabetes visits compared with coronary heart disease (CHD) visits in the U.S. between 1995 and 2004. In January 1998, the American Diabetes Association (ADA) advocated an LDL cholesterol goal of <100 mg/dl for patients with diabetes (1). Subsequently, in May 2001, the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults published its third report (Adult Treatment Panel III [ATP III]) that designated diabetes as a CHD risk equivalent, with the same LDL cholesterol goal of <100 mg/dl (2).


   RESEARCH DESIGN AND METHODS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
RESULTS
 CONCLUSIONS
 References
 
The publication of the ADA and ATP III guidelines provides an opportunity to assess the effect of guideline changes on LDL cholesterol reporting and control for diabetes visits. The publication of guidelines does not ensure timely communication to the practicing physician let alone the adoption into patient care. As the treatment strategy for CHD remained unchanged (2), we used CHD visits as the control group for the time trends of LDL cholesterol reporting and control.

We used the National Disease and Therapeutic Index (NDTI) (3), an ongoing survey of U.S. office-based physicians conducted by IMS Health providing nationally representative diagnostic and treatment data, to analyze the national trends of LDL cholesterol reporting and control for diabetes and CHD visits by year between 1995 and 2004. The NDTI has been previously used to report national disease diagnostic and treatment trends (4–6). In one study (6), it was compared with the National Ambulatory Care Medical Survey and yielded similar but less volatile time trends, benefiting from its larger sample size. Variables recorded in the NDTI include demographics, blood pressure, cholesterol levels, diagnoses, and recommended drug therapy. LDL cholesterol was reported as the "most recent result available," which can be a pre- or posttreatment value.

Diabetes and CHD visits were identified using ICD-9-CM codes 250 (diabetes mellitus) and 410–414 (acute myocardial infarction, other acute or subacute forms of ischemic heart disease, old myocardial infarction, angina pectoris, and other forms of chronic ischemic heart disease), respectively (7). Visits by people <20 years of age or by people diagnosed with both diabetes and CHD were excluded.

We defined the rate of LDL cholesterol reporting as the percent of visits with LDL cholesterol reported. We defined the rate of LDL cholesterol control as the percent of those LDL cholesterol reported that were <100 mg/dl. Using sample weights in the NDTI, these rates were weighted to reflect national patterns of clinical practice, accounting for the probability of sampling based on physician specialty and geographic area as well as adjusting for nonresponse.


   RESULTS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
CONCLUSIONS
 References
 
After excluding 3,953 visits with both diabetes and CHD, we identified 98,443 diabetes visits (without CHD) and 43,361 CHD visits (without diabetes) in the 1995–2004 NDTI. The latter two represented an estimated 346 million diabetes visits and 158 million CHD visits.

In 1995, the rate of LDL cholesterol reporting was 21% of diabetes visits and 23% of CHD visits (Fig. 1A). Both rates increased similarly over time to 43% of diabetes visits and 48% of CHD visits in 2004. Neither of the guidelines increased LDL cholesterol reporting for diabetes visits relative to CHD.



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  		Figure 1— A: Difference in the annual rate of LDL cholesterol reporting between diabetes and coronary heart disease visits in the U.S., 1995–2004. The ADA guidelines were published in January 1998; the ATP III guidelines were published in May 2001. B: Difference in the annual rate of LDL cholesterol control between diabetes and coronary heart disease visits in the U.S., 1995–2004. The ADA guidelines were published in January 1998; the ATP III guidelines were published in May 2001.

 
In 1995, the rate of LDL cholesterol control was 4% higher for diabetes visits than for CHD (Fig. 1B). LDL cholesterol control increased for both diseases over time (but at a slower speed for diabetes) to 44% of diabetes visits and 55% of CHD visits in 2004, with an absolute difference of 11%. Despite the publication of new guidelines in 1998 and 2001, diabetes lagged behind CHD visits in LDL cholesterol control after 1998.


   CONCLUSIONS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
References
 
Our results indicate that although LDL cholesterol reporting and control for diabetes and CHD visits improved continuously between 1995 and 2004, neither the 1998 ADA guidelines nor the 2001 ATP III guidelines increased LDL cholesterol control for diabetes relative to CHD. In fact, LDL cholesterol control in patients with diabetes started to lag behind CHD after 1998. This finding is surprising considering public health efforts to promote comprehensive diabetes care (8) and the recognition of ATP III as the gold standard for CHD prevention and its wide dissemination in the medical community. On the other hand, it is consistent with recent reports (9–13) of inadequate LDL cholesterol control in patients with diabetes despite progress in screening, suggesting that treatment is more of a problem than screening in diabetic patients. This finding is also consistent with previous reports (14,15) that the publication of reports by the Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure had little direct impact on clinical practice.

Several limitations associated with the use of the NDTI should be considered in interpreting our results. First, sicker individuals are more likely to see physicians and are therefore overrepresented. Secondly, our defined LDL cholesterol reporting may underestimate LDL cholesterol screening due to underreporting. Thirdly, we could not differentiate between type 1 and 2 diabetes, even though the former may or may not require LDL cholesterol control <100 mg/dl. To address these concerns, we examined the trends of LDL cholesterol reporting and control for diabetes visits over time and used CHD visits as a control group. Finally, although LDL cholesterol reporting and control may be influenced by a number of factors such as demographics, geographic location, and insurance coverage, they were not the focus of this brief report.


   Acknowledgments
 
This research was supported by AstraZeneca Pharmaceuticals (Y.R.W.), the MacLean Center for Clinical Medical Ethics at the University of Chicago (G.C.A.), and the Centers for Disease Control, Chicago Center of Excellence in Health Promotion Economics (1 P30 CD000147-01 to D.O.M.).

We thank Lisa Croll for administrative assistance.


   Footnotes
 
G.C.A. has received grant/research support from AstraZeneca.

A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

Received for publication June 2, 2005. Accepted for publication August 24, 2005.


   References
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
 References
 

  1. American Diabetes Association: Management of dyslipidemia in adults with diabetes. Diabetes Care21 :179 –182,1998[Medline]
  2. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults: Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA285 :2486 –2497,2001[Free Full Text]
  3. IMS Health: NDTI Diagnosis Reference File, 1995 to 2004. Plymouth Meeting, PA, IMS Health, 1995 to 2004
  4. Munnangi S, Sonnenberg A: Time trends of physician visits and treatment patterns of peptic ulcer disease in the United States. Arch Intern Med157 :1489 –1494,1997[Abstract]
  5. Stafford RS, Blumenthal D, Pasternak RC: Variations in cholesterol management practices of U.S. physicians. J Am Coll Cardiol29 :139 –146,1997[Abstract]
  6. Stafford RS, Radley DC: The underutilization of cardiac medications of proven benefit, 1990–2002. J Am Coll Cardiol41 :56 –61,2003[Abstract/Free Full Text]
  7. Practice Management Information Corporation: ICD-9-CM: International Classification of Diseases, 9th revision, Clinical Modifications. Vol. 1, 5th ed., hospital ed. Los Angeles, CA, Practice Management Information Corporation,1999
  8. National Committee for Quality Assurance: New collaborative diabetes initiative could change the face of diabetes care in America [article online],1997 . Available from http://www.ncqa.org/communications/news/diabrel.htm. Accessed 2 May 2005
  9. Massing MW, Foley KA, Sueta CA, Chowdhury M, Biggs DP, Alexander CM, Simpson RJ: Trends in lipid management among patients with coronary artery disease: has diabetes received the attention it deserves? Diabetes Care26 :991 –997,2003[Abstract/Free Full Text]
  10. Beaton AJ, Nag SS, Gunter MJ, Gleeson JM, Sajjan SS, Alexander CM: Adequacy of glycemic, lipid, and blood pressure management for patients with diabetes in a managed care setting. Diabetes Care27 :694 –698,2004[Abstract/Free Full Text]
  11. Pladevall M, Tunceli K, Elston-Lafata J, Simpkins J, Divine G, Kamal-Bahl SJ, Nag SS, Sajjan SG, Alexander CM: Trends in lipid management among patients with diabetes (Abstract). Diabetes53 (Suppl. 2) :A232 ,2004
  12. Fuke D, Hunt J, Siemienszuk J, Estoup M, Carroll M, Payne N, Touchette D: Cholesterol management of patients with diabetes in a primary care practice-based research network. Am J Manag Care10 :1301 –1336,2004
  13. Bergenstal RM, Nag SS, Reusch JEB, Sajjan SG, Alexander CM: Macrovascular risk factors in patients with diabetes: physician treatment strategies and extent of control. Endocrine Practice11 :172 –179,2005
  14. Hill MN, Levine DM, Whelton PK: Awareness, use, and impact of the 1984 Joint National Committee consensus report on high blood pressure. Am J Public Health78 :1190 –1194,1988[Abstract/Free Full Text]
  15. Siegel D, Lopez J: Trends in antihypertensive drug use in the United States: do the JNC V recommendations affect prescribing? Fifth Joint National Commission on the Detection, Evaluation, and Treatment of High Blood Pressure. JAMA278 :1745 –1748,1997[Abstract]

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