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Variation in local policies and guidelines for cholesterol management: national survey

^a Directorate of Public Health and Health Policy, Lambeth, Southwark, and Lewisham Health Authority, London SE1 7NT, ^b Department of Public Health Medicine, UMDS, St Thomas's Hospital, London SE1 7EH

Raised serum cholesterol concentrations are known to be an important risk factor for coronary heart disease. In 1993 an authoritative systematic review of effective cholesterol management was disseminated to health authorities and boards throughout the United Kingdom.¹ The review recommended that population cholesterol screening should be discouraged and cholesterol lowering treatment targeted at those patients at highest overall risk of coronary heart disease according to a range of risk factors. In 1994 we conducted a national survey to assess variations in local cholesterol management policies and clinical guidelines and the extent to which they reflected the recommendations.

Methods

and results

A questionnaire was sent to the director of public health (or chief administrative medical officer) of all 151 health authorities or boards in the United Kingdom. Respondents were also asked to submit copies of local clinical guidelines. The responses were analysed using EPIINFO 6.1.

Completed questionnaires were received from 142 (94%) of the authorities. Only 70 reported the existence of a local written policy or guidelines covering cholesterol management, though 26 reported that policies were under development. Of the 70 with existing policies 55 reported that they included clinical criteria for cholesterol testing in general practice, referral to a dietitian or lipidologist, and hyperlipidaemia management--that is, they included clinical guidelines. However, only 34 reported a collaborative approach to developing such policies--for example, with family health services authorities, general practitioners, laboratories, and pharmacists. Only 13 had procedures for monitoring the implementation of the policies.

Of the 40 guidelines submitted, 37 advocated selective testing of individuals at high overall risk of coronary heart disease (as recommended in the review bulletin), rather than screening whole populations. Nevertheless, there was much variation in the risk factors specified and how they were defined. Seven guidelines discussed the concept of "high overall risk" but failed to specify any risk factors. Three guidelines did not mention pre-existing coronary heart disease, two did not mention a family history of hyperlipidaemia or premature coronary heart disease, and one suggested that cholesterol testing should be extended to "women without risk factors." Only one guideline proposed the use of a composite risk factor scoring system. The age range recommended for testing also varied greatly: the lower limit varied from 16 to 35 years and the upper from 55 to 70. The cholesterol lowering management criteria also showed striking variation (table 1). Although 35 of the 40 submitted guidelines gave clinical criteria for cholesterol lowering drug treatment, there was much variation in the advice given.

Table 1--Variation in cholesterol lowering management criteria in guidelines submitted
by 40 authorities
-----------------------------------------------------------------------------------------------------------------
                                                                                  No of guidelines in which
Element in recommendations                                                         element was included
-----------------------------------------------------------------------------------------------------------------
Specific management regimens according to degree of overall risk                        Specified in 23
Repeat cholesterol measurement before treatment                                       Recommended in 31
Full lipid profile before treatment                                                   Recommended in 28
Upper limit of "acceptable" total cholesterol level                                 Specified in 32; varied from
                                                                                  5.2 to 6.5 mmol/l (median 5.2)
Total cholesterol level at which dietitian should be consulted                      Specified in 15; varied from
                                                                                  6.5 to 8.0 mmol/l (median 7.8)
Total cholesterol level at which referral to lipid clinic should be                 Specified in 14; varied from
  considered                                                                      6.5 to 10 mmol/l (median 7.8)
Total cholesterol level at which drugs should be considered                         Specified in 28; varied from
                                                                                  6.5 to 10 mmol/l (median 7.8)

Comment

This study revealed great variation and inconsistency in local criteria for cholesterol testing and treatment throughout the United Kingdom, despite the previous widely disseminated review recommendations. Only about half of responding districts had developed policies or guidelines, and only about half of those had done so collaboratively.

In view of the high potential cost of cholesterol management for large numbers of patients there is a need to make priorities based on clear criteria for both testing and treatment.² For testing, this requires an explicit definition of each risk factor and of the various combinations comprising "high overall risk." For treatment, it requires explicit criteria based on overall risk status (not merely serum cholesterol concentration), agreed in accordance with current evidence of cost effectiveness. Clear, explicit guidelines, developed collaboratively with those who will be using them, have been shown to facilitate, albeit not to guarantee, more consistent practice.³ All health authorities, through their directors of public health working with general practitioners, physicians, and lipidologists, should ensure that suitable local policies and guidelines for cholesterol management are agreed, disseminated, and monitored.

We thank members of the cardiovascular working group of the Faculty of Public Health Medicine on whose behalf the study was undertaken, and Mary Matthews of the health promotion office at the faculty for her administrative help.

Funding: None.

Conflict of interest: None.

1. Cholesterol Screening and Treatment. Effective health care bulletin No 6. Leeds: University of Leeds, 1993.
2. Pharoah PDP, Hollingworth W. Cost effectiveness of lowering cholesterol concentration with statins in patients with and without pre-existing coronary heart disease: life table method applied to health authority population. BMJ 1996;312:1443-8. [Abstract/Free Full Text]
3. Implementing Clinical Guidelines. Effective health care bulletin No 8. Leeds: University of Leeds, 1994.

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