Results
A total of 177 physicians (102 PCPs and 75 specialists) enrolled 2009
patients; Ontario contributed more than any other province with the top
4 being Ontario, BC, Quebec, and Alberta. The number of patients
enrolled by specialists and PCPs was equal.
Patients enrolled by specialists were slightly older, more frequently
female and Caucasian (77% vs. 65%, p=0.0001) and with other
differences in clinical characteristics summarized in Table 1.
Specialists had less patients on statin therapy and bile acid
sequestrants but more patients on aspirin and other antiplatelet
therapies as well as beta blockers (Table 1). Patients treated by
specialists had slightly lower total cholesterol and triglycerides but
no difference in LDL-C or non-HDL-C levels (Table 1).
At baseline and during the follow up, the specialists tended to use less
statins (Figure 1) but more additional and recommended non-statin
therapy (Figure 1). PCPs used more of other, non-guideline recommended
lipid lowering therapies such as niacin or fibrate as compared to
specialists (10% vs. 6%, p=0.007).
The mean LDL was 3.3 mmol/L at baseline (visit 1) and decreased
significantly to 2.4 and 2.2 mmol/L respectively during the follow up in
visits 2 and 3 (11) , there was no difference in the
extent of decrease between specialists and PCPs (Figure 2). The
proportion of patients achieving the CCS recommended LDL-C level of
< 2.0 mmol/L (primary endpoint) increased significantly to
41.7% and 50.8% in visits 2 and 3 respectively (11)and was similar between specialists and PCPs (Figure 3).
Physician responses as to why they were not following guidelines with
respect to additional therapy of ezetimibe and/or PCSK9i are summarized
in Figure 4; physicians did not provide reasons for not following the
guidelines for each patient. The two most frequent reasons provided were
patient refusal (more common by specialists) and additional therapy not
perceived to be needed. Importantly, both groups of physicians (more
often PCPs than specialists) stated that additional therapy would be
prescribed at the next visit. Cost, as a reason for not following the
guidelines was more commonly sited by PCPs while co-morbidities, patient
intolerance, or social constraint was more frequently cited by
specialists (Figure 4).
Multivariable analysis identified female gender, history of FH and
chronic kidney disease as being associated with a lower likelihood of
achieving recommended LDL-C level while age, coronary artery disease and
diabetes as being predictors of achieving the recommended level. Care by
a specialist vs. PCP was not significantly associated with achieving the
recommended LDL-C level (1.02 [95% CI: 0.87-1.20] p=0.80). The use
of any recommended lipid lowering therapy was the strongest indicator of
achieving LDL-C < 2.0 mmol/L with the odds ration and 95% CI
for statin 3.10 (2.54-3.78, p <.0001), ezetimibe 1.71
(1.46-2.01, p <.0001) and PCSK9i 17.21 (13.69-21.63, p
<.0001).