PDAs, more education help doctors follow cholesterol treatment guidelines

A new study by researchers at Wake Forest University School of Medicine suggests that patients with high cholesterol receive better care when physicians use a variety of tools to learn and apply a clinical practice guideline for treating the condition.

The study, published in the April 13 issue of the Archives of Internal Medicine, tracked the adherence to clinical guidelines at 61 primary care practices. The study aimed to improve the treatment of high cholesterol by having doctors use a personal digital assistant (PDA) to assess the patient's risk of heart disease and recommend treatment. Doctors also received copies of the cholesterol guideline and an introductory lecture on it, attended additional presentations on treating high cholesterol, and received a report on their practices' performance on cholesterol management.

"We wanted to know if we could improve guideline adherence with this multifaceted strategy," said Alain G. Bertoni, M.D., M.P.H., an associate professor in the Departments of Epidemiology & Prevention and Internal Medicine, and lead author on the study. "When you look at previous quality improvement efforts, it appears that single strategies don't work that well."

Clinical guidelines aim to prevent the under- or over-treatment of a disease. Lowering high cholesterol reduces the risk of cardiovascular disease, the leading cause of death in the United States, but the National Cholesterol Education Program Adult Treatment Panel (ATP III) guideline suggests prescribing drugs only under certain conditions. The complexity of the guideline made it the perfect subject for study, Bertoni said.

"The guideline doesn't say if your LDL cholesterol is a specific level, you should treat," he said. "It says you should consider all risk factors before deciding to prescribe a lipid-lowering drug."

For the study, a decision-making tool was programmed into PDAs. The tool calculated the patient's risk of heart disease, and then considered LDL-cholesterol levels before recommending a drug dosage or no treatment at all, according to the ATP III guidelines.

To test the theory that using multiple tools would help physicians adhere to the clinical practice guideline for treating high cholesterol, the researchers randomly assigned the participating practices into two groups. One group of physicians received the ATP III-focused intervention including PDAs and the other group received an intervention which focused more on a guideline for high blood pressure. All providers received education about both guidelines.

In both groups, screening for high cholesterol increased during the study period. The guideline recommends that adults be screened every five years. In the group that used the PDAs, the level of appropriate treatment decisions remained relatively stable, while the incidence of over-treatment decreased. In contrast, in the group that did not use the PDAs, the percentage of cases that received appropriate cholesterol management decreased by nearly nine percent and the occurrence of over-treatment, or the prescribing of drugs even though the guidelines did not recommend it, increased from 4.2 percent to 6.4 percent of cases.

"This is not the final answer yet, but it does suggest that having this multifaceted approach and having a technological tool helping physicians make decisions might make a difference in the future," said David Goff, M.D., Ph.D., a professor in and chairman of the Department of Epidemiology & Prevention, and lead investigator for the study.

The National Heart, Lung and Blood Institute funded this study, which was the first to look at the use of PDAs to aid in adherence to the cholesterol treatment guideline.

Haiying Chen, Ph.D., Patricia Hogan, M.S., O. Lenore Crago, Erica Rosenberger, M.S., Ann Hiott Barham, M.D., and C. Randall Clinch, D.O., M.S., all of the School of Medicine; and Denise E. Bonds, M.D., M.P.H., of the University of Virginia Health System, also contributed to the study.