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.