|Year : 2021 | Volume
| Issue : 4 | Page : 187-192
Clinical inertia in lipid screening and prescribing statins for primary prevention: Experience from a low-to-middle income country
Anne Thushara Matthias1, Mathotage Satheisha Nihari Padmasiri1, Batheegama Gamarachchige Gayasha Kavindi Somathilake1, Nethrani Sameera Wijesekara Pathirana2
1 Department of Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka
2 University Medical Unit, Colombo South Teaching Hospital, Colombo, Sri Lanka
|Date of Submission||22-Jun-2021|
|Date of Acceptance||20-Nov-2021|
|Date of Web Publication||31-Dec-2021|
Dr. Anne Thushara Matthias
Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda
Source of Support: None, Conflict of Interest: None
Introduction: Most adults who should be screened for dyslipidemia do not undergo lipid testing in low- to middle-income countries due to lack of resources and clinical inertia. Those eligible for statin therapy for cardiovascular disease (CVD) prevention are under treated possibly due to clinical inertia. This study aimed to find out the present lipid screening practices and prescribing of statins for primary prevention in a low- to middle-income country.
Methods: This study was conducted at medical wards of Colombo South Teaching Hospital in patients with a first-time acute coronary syndrome (ACS), who have not been on treatment with statins and not diagnosed with dyslipidemia prior to this admission. Eligibility for lipid screening was assessed using U.S. preventive services task force recommendations. CVD risk prior to ACS was assessed by QRISK2 score. Lipid profile was done within 24 h.
Results: Out of 125 participants, 70.4% had a QRISK2 >10 and were eligible for statins prior to their first episode of ACS. Eighty-four percent have not had a lipid screening and 91.4% were not aware of the need for it. 54.4% were not aware that the elevation of certain types of cholesterol leads to ACS. Of 125 patients (100 males/25 females), mean age 55.78 (26–82). Body mass index >23kg/m2 in 65.6%. 65.6% had some lipid abnormality. Total cholesterol >200 in 29.6%, low-density lipoprotein cholesterol >130 in 28.8%, triglyceride >150 in 31.2%, high-density lipoprotein cholesterol suboptimal in 67.2%.
Discussion: Lipid screening is suboptimal. Most patients who were eligible for statins based on their CVD risk prior to their first episode of ACS, were not receiving statins prior to their first ACS. Patients should have their CVD risk estimated and statins should be given to eligible patients for prevention of ACS.
Keywords: Acute coronary syndrome, cardiovascular disease risk, cardiovascular disease, dyslipidemia, lipid, lipoproteins, South Asia, Sri Lanka
|How to cite this article:|
Matthias AT, Nihari Padmasiri MS, Kavindi Somathilake BG, Wijesekara Pathirana NS. Clinical inertia in lipid screening and prescribing statins for primary prevention: Experience from a low-to-middle income country. Int J Non-Commun Dis 2021;6:187-92
|How to cite this URL:|
Matthias AT, Nihari Padmasiri MS, Kavindi Somathilake BG, Wijesekara Pathirana NS. Clinical inertia in lipid screening and prescribing statins for primary prevention: Experience from a low-to-middle income country. Int J Non-Commun Dis [serial online] 2021 [cited 2022 Aug 17];6:187-92. Available from: https://www.ijncd.org/text.asp?2021/6/4/187/334615
| Introduction|| |
Acute coronary syndrome (ACS) in the Asia-Pacific region accounts for around half of the global burden. With the current demographic transition and increase in life expectancy, incidence of noncommunicable diseases (NCD), including ACS is on the rise in Sri Lanka. In Sri Lanka, from the year 2005 to 2010, there was a 29% increase in hospitalization due to ischemic heart disease (IHD). The well-established risk factors for cardiovascular disease (CVD) are smoking, abnormal lipids, hypertension, diabetes, abdominal obesity, psychosocial factors, reduced consumption of fruits, vegetables, alcohol abuse and physical activity. Dyslipidemia is a major risk factor for CVD. Elevated levels of total cholesterol, low-density lipoprotein cholesterol (TC and LDL-C), elevated levels of triglycerides (TG) and low density of high-density lipoprotein cholesterol (HDL-C) are risk factors for IHD.
Prevention is a key public health strategy in controlling any NCD. The modification of risk factors significantly reduces morbidity and mortality from heart disease. With regards to early identification of dyslipidemia, the U.S. Preventive Services Task Force (USPSTF) recommendation states screening of men over 35 years and older, screening of women aged above 45 years and older and for men and women who are aged between 20–35 and 20–45 respectively if they are at increased risk of coronary heart disease (CHD). Though it is recommended in clinical practice in Sri Lanka not many adults undergo lipid screening. All Sri Lankans benefit from the free health care policy of the government. The health system of Sri Lanka is increasingly burdened by the high burden of NCDs and the growing out of pocket expenditure for chronic diseases. Routine screening for dyslipidemia by healthy individuals is rarely carried out in the government sector due to overcrowding and long waiting times to get tests done. Healthy life style centers established by the Ministry of Health of Sri Lanka, provides people the opportunity to get their lipids screened. Yet, these centers have limited hours of operation, are not widely distributed and at present don't have the capacity for carrying out lipid profile. A small proportion of individuals who have health insurance schemes or adequate personal funds do the routine screening for lipids and other NCD such as diabetes in the private sector. This study aimed to find out the present trends in lipid screening in Sri Lanka in a group of hospitalized patients with first time ACS prior to the development of ACS and if not screened the reasons for not screening. Identifying the reasons for not routinely screening for dyslipidemia will have public health benefit as dyslipidemia is a preventable risk factor for ACS.
Recently, there has been a trend toward becoming more liberal with statin prescribing for primary prevention of CVD. The National Institute for Health and Care Excellence (NICE) guideline in 2020 advocates for the use of statin in primary prevention if the individuals have a 10% or >10- year risk of developing CVD using the QRISK 2 assessment tool.,, There is a notion that statin prescribing in primary prevention make otherwise healthy individuals appear sick but it reduces CVD risk and it is important at an individual level. Statins are not expensive, and the side effects are small. Despite a large evidence base supporting the efficacy of statins in primary prevention, there is a paucity of data regarding the prevalence of statin prescribing for primary prevention in Sri Lanka. To our knowledge no similar studies have been performed in Sri Lanka. This study was carried out with the aim of calculating the CVD risk of patients prior to the development of the first ACS and checking to see based on that risk whether they were given statins if they were eligible for statins for primary prevention. Identifying the usage of statins as a mode of primary prevention in this group of patients would reflect the usage of statins for primary prevention.
| Methods|| |
A cross-sectional study on patients with ACS admitted to Colombo South Teaching Hospital was carried out. Colombo South Teaching Hospital is one of the two public sector tertiary care teaching hospitals at the center of Colombo. It has a bed strength of 1110.
All admissions to the unit fulfilling the inclusion criteria was recruited and clerked according to usual ward protocols. All patients with first time ACS were recruited. All who have had a prior ACS were excluded. All patients who were on statins at the time of data collection was also excluded [Figure 1].
A trained medical graduate obtained information about demographic factors, socioeconomic status (education, income), lifestyle (smoking, physical activity) personal and family history of CVD, and risk factors (hypertension and diabetes mellitus). Information about prior lipid screening was inquired from the patient.
Whether the patient has been given statins or is on stains at the time of study was asked from the patients and also confirmed with medical records of the patients. Height, weight, and waist and hip circumferences were determined by a standardized protocol.
A lipid profile on recruited patients was taken within 24 h of the onset of ACS. Acute myocardial infarction can alter serum lipid levels, but these changes occur after 48 h.
The USPSTF recommendations on lipid screening was used to see how many patients should have been screened. It states screening of men over 35 years and older, women aged above 45 years and older for lipid disorders, men and women who are aged between 20–35 and 20–45 respectively if they are at increased risk of CHD. The increased risk is determined by certain factors predetermined such as diabetes, personal history of CHD or noncoronary atherosclerosis (e.g., abdominal aortic aneurysm, peripheral artery disease, carotid artery stenosis), family history, tobacco use, hypertension, obesity (body mass index of 30 kg per m2 or greater).
To assess the eligibility for statins NICE 2020 Dyslipidemia guidelines were used. To assess the patient's CVD risk the QRISK2 was used.
The required sample size with an estimated prevalence of 30% CVD, at 95% significance level and a 10% margin of error was 81. We recruited 125 participants as the funding received allowed us to test the lipid profile of 125 patients.
A descriptive analysis was carried out with the use of correlations, associations and graphical interpretations. Statistical methods, Pearson's Chi-square test and Mann–Whitney U test were used to find the associations and correlations between variables in this study. IBM SPSS Statistics - Version 20 and R Software - Version 3.3.3 and RStudio - Version 1.3.959 was used.
| Results|| |
The sample consisted of 125 patients. The baseline characteristics are given in [Table 1].
In patients with ACS, high levels of TC (>200 mg/dL) were found in 29.6% and 70.4% of the patients had their TC level <200 mg/dL, high levels of low-density cholesterol (LDL-C) (>130 mg/dL) were found in 28.8%, high levels of TG (>150 mg/dL) were found in 31.2% and low levels of high-density cholesterol (HDL-C) (<40 mg/dL) were found in 67.2%.
Mean cholesterol, TG, HDL, and LDL were not statistically significant between male and female groups.
Lipid screening in adults
Cumulatively 123 patients of the population were eligible for lipid screening but 105 of them have not had their lipid screening done according to the USPSTF recommendations [Table 2].
Out of the sample, 84% haven't had their lipid profiles checked before. The reasons for not having done a previous screening are lack of awareness about the benefit of a routine lipid profile, lack of money, and lack of time with percentage of 91.4%, 5.71%, and 2.85%, respectively.
Out of the 16% who had their lipid profiles checked, the initial lipid profile readings had been in normal range according to what they have been informed by health-care professionals.
Usage of statin as primary prevention
The majority 70.4% had their Q2 risk above 10, which would have made them eligible for initiation of statin therapy prior to the development of ACS [Table 3].
|Table 3: National Institute for Health and Care Excellence recommendation for primary prevention of cardiovascular disease|
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Awareness about dyslipidemia
54.4% of our sample were not aware that the elevation of certain types of cholesterol leads to ACS. The educations level did not have a significant influence on the awareness at a confidence level of 95%. (Pearson Chi-square = 0.214, P = 0.899).
| Discussion|| |
Despite the international guidelines encouraging the use of statins for primary prevention, a large gap exists between guideline recommendations and day today clinical practice in the usage of statins for primary prevention. 70.4% of our study population who should have received statins had not been given statins. This high percentage of patients eligible for statins but not receiving statins is disappointing. In the PALM registry it was revealed that in primary prevention 71.9% of those eligible for stains did not receive stains. Even for a lower middle income country (LMIC) like Sri Lanka statin is a cost effective way of reducing the burden of dyslipidemia which will in turn reduced the burden of NCDs.
Underutilization of statins as primary prevention to prevent CVD could be due to many reasons. Lack of awareness about guideline recommendations and inadequate screening for dyslipidemia are some reasons. Sri Lanka does not have local lipid guidelines for primary prevention and lipid management is done according to international guidelines. More emphasis needs to be on encouraging statins for primary prevention as statins in primary prevention has shown statistically significant reductions in cardiovascular morbidity., To encourage the use of statins, provider and patient education about guidelines recommendations should be done. Educational programs should highlight the benefits of adding statins to those with high CVD risk. The professional colleges and associations need to have continuous medical education programs to update the physicians with the aim of reducing clinical inertia in prescribing statins to those who deserve it.
To encourage use of statins, the CVD risk should be calculated using standard formulas such as QRISK2. Still the use of screening tools such as QRISK2 by medical professionals may be restricted by lack of adequate allocated time per patient in the state sector due to overcrowding of hospitals and lack of awareness in state sector hospitals in Sri Lanka.
Several other reasons could contribute to under utilization of statins in South Asian countries. Ignoring the proven efficacy of statins and exaggerated concerns of safety and undue reliance on antiplatelets are some of them. All these problems can be addressed with educational programs to enhance the use of statins for patients deserving statins for primary prevention.
Inadequate screening for dyslipidemia is seen in our study. 85.36% patients who were eligible for lipid screening had not had their lipids screened. The underlying cause for under screening of patients could be many. Firstly there is a shortcoming in the primary care model in Sri Lanka at present. There are several types of institutions that offer primary health care: primary medical care units, hospitals and private practitioners. Patients can choose freely to which provider they go to, from primary care medical unit to tertiary care facilities. It is not mandatory for patients to register with one practitioner and there is no established referral pathway. No institution is responsible for a defined population or area which creates a lack of accountability for patient care. The screening for dyslipidemia happens opportunistically when patients visits either the primary care physicians or tertiary care hospitals for other ailments. Symptoms of dyslipidemia are almost nonexistent except for some skin changes like xanthelesma or xanthomata. So the patients are unlikely to actively seek treatment or screening unless they suffer from symptomatic atherosclerotic CVD and this could be another reason for poor lipid screening.
Secondly, the lack of resources in state sector hospitals and clinics. Lipid profiles are done in government sector hospitals at present but only limited number of hospitals can do it and the number of tests which can be done on a day is limited. In order to improve screening of NCD and its risk factors such as dyslipidemia the Ministry of Health has established healthy life centers/NCD clinics. But currently they do not have facilities to check for lipid profile which will help in diagnosing dyslipidemia. All these issues can be addressed if Sri Lanka has a well-organized primary health care system with proper referral pathways. The Sri Lankan government is in the process of implementing a Sri Lankan Essential Health Services Package (SLESP) which will ensure that necessary steps will be taken at the point of entry into primary care. This will be continued with secondary and tertiary care services. All these services together will do health promotion and early detection and treatment of dyslipidemia. The new proposed Shared Care Cluster System model will help to identify and treat dyslipidemia early as there will be defined catchment area and it will facilitate universal health coverage. The SLESP will make sure there is a define a set of interventions available at each level of primary health care facility including lipid screening.
Thirdly, poor knowledge among patients about dyslipidemia also results them in not getting their lipid profiles done. When inquired from patients, as to why most had not got their lipid profile to detect lipid abnormalities, the commonest reason was the fact they were unaware of the need for lipid testing. Probably they haven't been offered lipid testing by health care professionals. There is clinical inertia on the part of clinicians which needs to be dealt with.
Most of our patients did not know that high cholesterol can lead to heart diseases. A study done previously in Sri Lanka assessing patients knowledge about CVD risk factors, the knowledge was only moderate. Further patient education program need to be conducted to educate the public on screening for dyslipidemia and on risk factors of CVD. This will help in preventing CVDs as there will be active contribution from the patients to screen for their CVD risk factors and if they are diagnosed with dyslipidemia it will improve compliance with drugs and life style modification.,
Strengths and limitations
This study yields valuable insights in to statin usage for primary prevention in a LMIC. The results of the study can be generalized as the study was carried out at a tertiary care hospital in Colombo, the commercial capital of the country. The study center receives patients from all over the country as it is a tertiary care hospital in Colombo with services of subspecialist including two cardiologists. However some limitations are noted. There has been no prior research on the usage of statins for primary prevention in Sri Lanka prior to this study. Hence the study design was developed in a way to capture the population of patients presenting to hospital with the first episode of ACS. The study aimed to find whether these patients were eligible to receive statins prior to this episode in order to determine the usage of statins for primary prevention of CVD. But since no control group is available for comparison we cannot conclude that statins would have prevented this first episode of ACS had the patients been given statins for primary prevention. Longitudinal studies are required to confirm morbidity and mortality benefit of statins in primary prevention.
| Conclusion|| |
There is significant room for improvement in statin utilization among adults eligible for but not on statin therapy in Sri Lanka for primary prevention of CVD. There is indisputable evidence for statins as a mode of primary prevention of ACS. Further efforts need to be taken to identify and treat adults with high CVD risk and commence them on statin therapy we need a more organized screening system for dyslipidemia to combat the burden of dyslipidemia in Sri Lanka.
Availability of data and materials
The datasets used during the current study are available from the corresponding author on reasonable request.
Ethics approval and consent to participate
Ethical approval was from the Ethics review Committee of the XXXX. Informed written consent was taken from the participants.
Financial support and sponsorship
The study was carried out with funding received from the Ceylon College of Physician Grant 2018/2019. The funds were used to do the lipid profile of the participants.
Conflicts of Interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]