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127. Compliance with LDL-Cholesterol Guidelines in Veterans with Ischemic Heart Disease: Do Visits to a Cardiologist Make a Difference?

JA Rothendler, Center for Health Quality, Outcomes and Economic Research; BA Kader, Center for Health Quality, Outcomes and Economic Research; BH Chang, Center for Health Quality, Outcomes and Economic Research; KL Sloan, VA Puget Sound Health Care System; AE Sales, VA Puget Sound Health Care System

Objectives: Previous reports have suggested that certain types of cardiac-related guidelines are more likely to be implemented when a cardiologist is involved with the patients' care. In patients with ischemic heart disease (IHD), National Cholesterol Education Program guidelines set a goal for low density lipoprotein (LDL) cholesterol of <=100 mg/dL. In this study, we sought to determine whether there is a relationship between visits to a cardiologist and compliance with LDL guidelines.

Methods: As part of a QUERI-sponsored study on lipid management, we studied LDL levels in 3029 veterans in VISN 1 who had diagnoses of IHD during FY1997 based of one or more of the following: A) diagnoses of coronary bypass surgery or coronary angioplasty, B) inpatient diagnoses of acute myocardial infarction or unstable angina, or C) inpatient diagnoses of old myocardial infarcts or other forms of stable IHD. These criteria were chosen to optimize diagnostic specificity for IHD. The patients also had at least one outpatient visit during both FY1998 and FY1999 to clinic stops associated with the provision of "primary care", "cholesterol screening" or cardiology.

For each patient, we obtained the last LDL level recorded from 10/1/97 through 12/31/1999 and grouped these into three categories for analysis: <=100, 101-129 and >=130 mg/dL. Clinic visits associated with a cardiology stop code in conjunction with an "evaluation and management" (E&M) cpt-4 code were determined for each patient for FY1998-1999. We also calculated the total number of "non-cardiology" clinic visits for stop codes associated with the provision of primary care or cholesterol screening in conjunction with an E&M code. For those with recorded LDL levels, the association between cardiology clinic visits and LDL level was estimated first by a chi-square test and then by a proportional odds model controlling for age, gender and number of non-cardiology visits.

Results: LDL levels were available on 2924 patients (96.5%). Those who had at least one cardiology visit (n=2091 patients, mean of 6.6 visits/patient) were more likely to have LDL<=100 mg/dL (51% vs. 39%) and less likely to have LDL>=130 mg/dL (15% vs. 27%) compared to patients who had no cardiology visits (p=.0001 for chi-square test). After adjusting for age, gender and number of non-cardiology visits, the odds ratio of having an LDL<=100 mg/dL was 1.77 (p= .0001) for patients who had at least one cardiology visit vs. those who had none.

Conclusions: Having at least one E&M cardiology clinic visit over two years was associated with better compliance with LDL guidelines for the IHD patients in this study. Most of the patients with cardiology visits were seen at least six times over the two-year span, suggesting ongoing care by a cardiologist.

Impact: Adequate control of LDL cholesterol is important in preventing subsequent ischemic events in those with pre-existing IHD. The finding that outpatient cardiology visits in patients with IHD is associated with better compliance with LDL guidelines raises important issues regarding the mechanisms by which hyperlipidemia is diagnosed and treated in the VHA, especially in regard to the role of primary care providers.