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Cardiovascular Risk Profiling in Blacks: Don't Forget the Lipids

DAVID S. KOUNTZ, M.D.
University of Medicine and Dentistry of New Jersey
­Robert Wood Johnson Medical School,
New Brunswick, N.J.

SUSAN L. LEVINE, M.D.
University of Connecticut Health Center
Farmington, Connecticut

As a population, blacks have one of the highest rates of coronary artery disease (CAD) in the world.¹ Evidence from the National Hospital Discharge Survey (NHDS) suggests that CAD has an earlier onset and is particularly severe in this group. The median age at death from myocardial infarction is five years lower in blacks than in whites, and the mortality rate is higher in all age groups less than 70 years.²

Are these data surprising? For some of us, the answer is "yes"--we tend to focus on stroke risk in blacks and the linear association with hypertension. Indeed, many of us overlook other risk factors--particularly lipid disorders--because we learned from the National Health and Nutrition Examination Survey database that blacks have higher mean high-density lipoprotein (HDL) cholesterol levels than their white counterparts, despite having similar mean levels of total and low-density lipoprotein (LDL) cholesterol levels.³ Indeed, the control of blood pressure in this population is often so problematic that it dominates our attention during the office visit.

Tragically, identification of hypercholesterolemia, in many instances, is influenced by the race of the patient. Data collected in a Rochester, N.Y., family medicine residency training program⁴ suggested that, after controlling for age, sex, insurance status, socioeconomic status, number of visits and other cardiovascular risk factors, blacks were less likely than whites to have been screened for cholesterol levels. Among those who were screened and were found to have a cholesterol level greater than 240 mg per dL (6.20 mmol per L), minorities were less likely than whites to receive a diagnosis of hypercholesterolemia.⁴

While patient awareness and concern about cholesterol have increased, studies suggest that there is less awareness and concern among black patients.⁵ Results of a study in an inner-city clinic show that almost 50 percent of black patients had hyperlipidemia and were not receiving interventional treatment.⁶ Similarly, unpublished data from Fong and Ward suggest that over 40 percent of black patients with hypertension who were seen in Rochester, N.Y., had hyperlipidemia. Based on guidelines of the National Cholesterol Education Program II (NCEP II), more than one half of these patients would be candidates for pharmacologic therapy.⁷

We know less about the effects of the use of inhibitors of 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCoA) in black patients. In the Expanded Clinical Evaluation of Lovastatin (EXCEL) study,⁸ only 459 of 8,245 patients (5.5 percent) were black. The percentage of involvement of blacks was even lower in the landmark prospective Scandinavian Simvastatin Survival Study (4S) and West of Scotland Study. Clinicians should be aware that there is similar efficacy of "statins" in blacks compared with whites but a higher incidence of creatine kinase levels in the upper limit of normal. In the EXCEL substudy, there was no increased risk for myopathy or rhabdomyolysis.⁸

Blacks remain a group at significant risk for CAD. While HDL cholesterol levels appear to be higher in blacks than in whites, elevated total and LDL cholesterol levels still need to be treated in black patients, because we know from the results of the Multiple Risk Factor Intervention Trial⁹ that elevations of these levels are predictive of coronary events. It remains unclear to what extent HDL confers cardiovascular protection. The higher incidence of CAD and underuse of invasive cardiovascular procedures suggest that more emphasis be placed on risk factor reduction. While more long-term studies in blacks are necessary to show that lowering total LDL cholesterol levels translates into actual reductions in clinical CAD events and mortality reductions, there is enough evidence from other groups to intervene aggressively with dietary and pharmacologic interventions.

This information should serve as a call-to-arms for all physicians, especially those of us in primary care. Make it a point to ask your black patients about a family history of lipid disorders and check lipid profiles according to age guidelines, with special vigilance in those with other cardiovascular risk factors. If you are in a clinic setting, assign a staff member, medical student or resident to review charts to assess compliance with NCEP guidelines in all patients. And, if you are so inclined, participate in clinical trials of cholesterol-lowering agents, enrolling black (and other minority) patients to expand our knowledge base of efficacy and safety of these agents in this population. Unless and until we consciously take these steps, the disparity in identification and treatment of this easily modifiable risk factor will persist.

Dr. Kountz is associate professor and chief in the Division of Primary Care at the University of Medicine and Dentistry of New Jersey­Robert Wood Johnson Medical School, New Brunswick, N.J. Dr. Levine is assistant professor in the Department of Medicine at the University of Connecticut Health Center, Farmington.

REFERENCES

1. Gillum RF. Coronary heart disease in black populations, I: morbidity and mortality. Am Heart J 1982; 104:839-51.
2. Roig E, Castaner A, Simmons B, Patel R, Ford E, Cooper R. In-hospital mortality rates from acute myocardial infarction by race in U.S. hospitals: findings from the National Hospital Discharge Summary. Circulation 1987;76:280-8.
3. Linn S, Carroll M, Johnson C, Fulwood R, Kalsbeek WD, Briefel R. High-density lipoprotein cholesterol and alcohol consumption in US white and black adults: data from NHANES II. Am J Public Health 1993;83:811-6.
4. Naumburg E, Franks P, Bell B, Gold M, Engerman J. Racial differentials in the identification of hypercholesterolemia. J Fam Pract 1993;36:425-30.
5. Factors related to cholesterol screening and cholesterol level awareness-United States. MMWR Morb Mortal Wkly Rep 1990;39:633-7.
6. Foster P, Jackson M. Distribution of lipoprotein phenotypes, cholesterol, and lipids in inner-city blacks. J Natl Med Assoc 1993;85:211-5.
7. National Cholesterol Education Panel. Second report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 1993;269:3015-23.
8. Prisant LM, Downton M, Watkins LO, Schnaper H, Bradford RH, Chremos AN, et al. Efficacy and tolerability of lovastatin in 459 African-Americans with hypercholesterolemia. Am J Cardiol 1996;78:420-4.
9. Multiple Risk Factor Intervention Group. Risk factor changes and mortality results. JAMA 1982;248: 1465-77.

Medicare-Financed Home Health Care

MICHELE L. MARZIANO, M.D.
Mid-Atlantic Permanente Medical Group, P.C.,
Rockville, Maryland

CHARLES A. CEFALU, M.D.
Louisiana State University Medical Center,
New Orleans

Until recently, Medicare-financed home health care has escaped negative public opinion and cost-cutting. It is an area of health care that has grown at a phenomenal pace, because there is no out-of-pocket deductible or co-payment for the beneficiary except for medical equipment items. Moreover, services have been provided and reimbursed to Medicare home health agencies (HHAs) at cost for every major service rendered with no cap per patient. The growth of Medicare HHAs has been so tremendous that a moratorium was placed on starting new HHAs for a period of time in 1997. The guidelines for obtaining Medicare-funded home health care are broad enough that most, if not all, homebound patients with Medicare Part A qualify. As outlined by Montauk in this issue of American Family Physician,¹ a multitude of services are covered.

See Article in this issue.

To control acute hospital costs, the Health Care Financing Administration, with authorization from the federal government, changed reimbursement from cost to the Prospective Payment System in the early 1980s. Faced with declining Medicare reimbursement with no change in overhead, acute care hospitals reduced the average length of stay for Medicare patients while depending on Medicare HHAs and skilled nursing units to provide posthospital or subacute care. A crisis may be looming for physicians, acute care hospitals, HHAs, patients and their families at some point in 1999 when reimbursement for Medicare-sponsored home health care also switches from cost to the Prospective Payment System. Like acute care hospitals, subacute nursing units and HHAs will be forced to reduce overhead to maintain financial viability. Feeling the squeeze from HHAs, patients and families, physicians will be placed in a tenuous situation to monitor homebound patients more closely without support services.

As Montauk points out,¹ about 25 percent of claims submitted to Medicare on behalf of beneficiaries may be inappropriate. Physicians are held liable for the home health care forms of Medicare that they sign each day. However, many physicians may not be aware of the requirement for a specific skilled need that must be met before the patient is eligible for the service. For example, physical therapy for general conditioning is not a specific skilled need. In some instances, the busy physician is approached by an HHA or a friend of the patient to request Medicare-financed home health care. Occasionally, the physician may even be asked to sign a retroactive authorization for Medicare-financed home health care that was instituted by an interested party, to sign a form on a patient that he or she has never seen, or to sign a form on a service authorized by another physician.

The services provided by Medicare-financed home health care are so comprehensive that families love it. The attending physician may find himself or herself in a difficult situation on the one hand of authorizing termination of the service when it is no longer necessary, yet feeling pressured by family members to continue the service. Physicians can protect themselves by becoming familiar with the specific Medicare home health guidelines mentioned in this editorial. They should also make an inquiry by telephone with any questions regarding the requested service. Physicians can play an important part in home health care by helping with the care plan in coordination with the home health care team and by being available when the team has questions.²

Physicians can become more involved in the administrative aspects of home health care. A physician can serve as medical director for a home health care agency. As medical director, a physician has many responsibilities, including taking part in the agency utilization review, pharmacy and research.³ Physicians can also join the American Academy of Home Care Physicians.

Clearly, home health care is an important aspect of care for elderly persons. Geriatric patients prefer to live at home where they have an improved sense of well-being. Because patients are grateful for the services provided by home health care, physicians need to play an active role and keep up-to-date on the criteria for Medicare-financed home health care.

Dr. Marziano is a family physician with Kaiser Permanente, Mid-Atlantic Permanente Medical Group, P.C., Rockville, Md. She completed a fellowship in geriatric medicine at Georgetown University Medical Center/Providence Hospital, Washington, D.C. Dr. Cefalu is a professor and chief of geriatric medicine in the Department of Family Medicine at Louisiana State University Medical Center, New Orleans. He completed a fellowship in geriatric medicine as well as a master of science in epidemiology at Bowman Gray School of Medicine in Winston-Salem, N.C.

REFERENCES

1. Montauk SL. Home health care. Am Fam Physician 1998;58:1608-14.
2. American Medical Association Home Care Advisory Panel. Guidelines for the medical management of the home care patient. Arch Fam Med 1993;2:194-206.
3. Keenan JM, Hepburn KW. The role of physician in home health care. Clin Geriatr Med 1991;7:665-74.

Copyright © 1998 by the American Academy of Family Physicians.
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