Discussion
Established CVD and FH are both associated with major adverse
cardiovascular morbidity and mortality. Aggressive lowering of LDL-C has
been shown to reduce the risk of cardiovascular events and mortality in
both of these groups (28, 18. 19). Despite the use of
high intensity statin therapy, many patients do not achieve the
recommended LDL-C level. The addition of second and third-line therapies
has been shown to reduce residual cardiovascular risk.(28, 18, 19). Reminders to physicians to adhere to CPG
treatment targets was recently shown to result in more patients
achieving the recommended LDL-C in both patients with established CVD
and FH (11).
This analysis of the GOAL Canada study(11) compared
management by specialists and PCPs with respect to their following of
the guidelines recommendations. The proportion of patients enrolled by
specialists and PCPs turned out to be very close, a serendipitous
outcome, which provided an excellent opportunity for this comparison. No
difference in the achievement of the recommended LDL-C level or
reduction in the LDL-C during follow up was seen between the specialist
and PCP groups and this finding was further supported on the
multivariable analysis.
A number of important care gaps were identified. At baseline, a
significant proportion of patients were not treated with any statin
therapy which suggests a knowledge gap and physician unfamiliarity with
establishing and maintaining statin use, while dealing with potential
statin intolerance. What was even more surprising is that the proportion
of patients not on statin therapy was significantly greater among
specialists. One can speculate that perhaps the patients followed by
specialists were more likely to have statin tolerability issues. On the
other hand, specialists were more likely to use recommended additional
therapy such as ezetimibe and/or PCSK9i. However, there was no
difference between the specialists and PCP groups in lowering of the
LDL-C during follow up or in the proportion of patients achieving the
recommended LDL-C level, despite this greater use. Previous comparisons
using administrative database for diabetes care, also revealed a care
gap of similar proportions between specialist and PCP care.(29)
Additional evidence of a knowledge gap is revealed by physician
responses regarding why recommended therapy was not being used.The second most common reason for not following the guidelines was that
additional therapy was not needed despite the LDL-C being clearly above
the recommended level. This is the clearest example of a knowledge gap
or a manifestation of treatment inertia for both groups of physicians
and requires additional per-to-peer education. Patient intolerance was
the most frequent response by specialists and PCPs and raises a question
of how well patients are informed about their personal cost of
non-adherence. Given there was no significant difference in this
response between PCPs and specialists, strongly suggests how difficult
patient non-adherence will be to address.
A response by physicians confirming that additional recommended therapy
will be prescribed at the next visit was more frequent with PCPs and is
an example of an action gap indicating treatment inertia coupled with a
realization that adherence with guidelines improves care. Addressing the
challenges that have prevented physicians from optimizing therapy before
the reminder is important in closing the care gap.