Hyperlipidaemia : an evaluation of management and attitudes among doctors and knowledge and attitudes in the population

An evaluation of management and attitudes among doctors and knowledge and attitudes in the population Coronary heart disease (CHD) is the main cause of death in the western world, and hyperlipidaemia is one of the major risk factors. Lipids have been the focus of much discussion among both doctors and the public. Successful management of patients with hyperlipidaemia requires a common view among doctors, and also information about attitudes and knowledge of the subject in the population. This study was aimed at comparing management and attitudes among doctors of different specialties over time, in northern and southern Europe, and finding which factors influence general practitioners' decisions to prescribe lipid-lowering drugs. It was also aimed at evaluating over time the knowledge of cardiovascular risk factors, including hyperlipidaemia attitudes to lifestyle changes, and the role of primary health-care in an urban population.

Questionnaires were sent in 1990 and 1995 to general practitioners (GPs), occupational health doctors (OH doctors) and doctors in internal medicine wards (internists) in Stockholm, and also to the public. In 1995 they were also sent to GPs and internists in Sicily. In a clinical judgement analysis study (CJA), questionnaires were sent to GPs in Stockholm in 1997.

Doctors studied in 1990 (response rate), 1995 (response rate) were: GPs 146 (81%), 181 (67%), OH doctors 147 (68%), 121(50%), internists 157 (61%), 143 (58%). 1000 persons aged 40-64 years were included, and 75% (67%) responded. In 1995, 332 Sicilian GPs (46%) and 357 internists (59%) were included. GPs participating in the 1997 CJA-study were 60, with 38 responders.

In 1990, treatment was initiated by OH doctors at lower levels of total cholesterol than by the other two groups in primary and secondary prevention. Mean cholesterol levels for treatment with 95% confidence interval for change 1995-1990 (CI) were for GPs 7,01 mmol/L (-0.81, -0.35), for OH doctors 6.70 (-0.77, -0.23) and for internists 6,66 (-1.06, -0.53). The mean cholesterol levels for primary prevention were increased among GPs to 8.04 (0.07, 0.49) and among OH doctors to 7.84 (0.16, 0.67). Among the internists, the cholesterol level for treatment was unchanged, 7.42 mmol/L (-0.23, 0.3). The OH doctors had a positive attitude to screening healthy individuals. There were differences in views and management practice between doctors in Sicily and doctors in Stockholm. Doctors tested lipids at first visits in Sicily but not in Stockholm. Treatment was initiated at lower levels of cholesterol in Sicily, with no differences between GPs and internists.

Knowledge in the population in 1990 about causative cardiovascular risk factors was good, but poor about healthy eating. Interest in hyperlipidaemia declined between 1990 and 1995, while the expectations that the doctors take an interest in patients' lifestyles and in preventive work remained the same.

In 1997, using CJA with authentic written case descriptions of patients, all with a blood cholesterol >5.5 mmol/L, and with variations in seven other variables, we found that the doctors used very different strategies for drug prescription concerning patients with hypercholesterolaemia. A fairly large group of the GPs did not include CHD in their judgements, in contrast to the guidelines. Insights into one's own strategies were good.

Differences in management and attitudes to high lipid values among groups of doctors lead to contradictory information being given to patients. Therefore, consensus is important when implementing national guidelines. Secondary preventive treatment was improved, in line with the guidelines, but the decrease in interest in primary prevention is of concern, as there is an increase in some risk factors that may end the present downward trend in the incidence of CHD. The trust of the population in the primary health-care for preventive tasks shown in this study should be utilized.