Does Management of Lipid Lowering Differ Between Specialists and Primary
Care: Insights from GOAL Canada.
Background: We studied whether significant differences in care gaps
exist between specialists and PCPs. Methods: GOAL Canada enrolled
patients with CVD or familial hypercholesterolemia (FH) and LDL-C
> 2.0 mmol/L despite maximally tolerated statin therapy.
During follow-up, physicians received online reminders of treatment
recommendations based on Canadian Guidelines. Results: A total of 177
physicians (58% PCPs) enrolled 2009 patients; approximately half of the
patients were enrolled by each physician group. Patients enrolled by
specialists were slightly older (mean age 63 years vs. 62), female (45%
vs. 40%), Caucasian (77% vs. 65%), and had a slightly higher systolic
pressure and lower heart rate. Patients enrolled by specialists had less
frequent history of familial hypercholesterolemia, diabetes,
hypertension, chronic kidney disease and liver disease but more frequent
history of coronary artery disease, atrial fibrillation and premature
family history of CVD. There was no significant baseline difference in
LDL-C, HDL-C, or non-HDL-c, although total cholesterol and triglycerides
were slightly higher in patients managed by PCPs. At baseline, PCPs were
more likely to use statins (80% vs.73%, p=0.0002) and other therapies
such as niacin or fibrate (10% vs. 6%, p=0.0006) but similar use of
ezetimibe (24% vs. 27%, p=0.15). At the end of follow up, specialists
used less statins (70% vs. 77%, p=0.0005) and other therapies (6% vs.
10%, p=0.007) but more ezetimibe (45% vs. 38%, p=0.01) and the same
frequency of PCSK9i (28% vs. 27%, p=0.65). The proportion of patients
achieving the recommended LDL-C level of 2.0 mmol/L or below (primary
endpoint) was similar at last available visit between specialists and
PCPs (44% vs. 42%, p=0.32). Conclusion: Despite minor differences in
the clinical profile of their patients, both PCPs and specialists
actively participate in the management of lipid lowering therapy in high
risk CVD patients and experience similar challenges and care gaps.