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Am Fam Physician. 1998;57(6):1412-1414

An elevated cholesterol level (greater than 240 mg per dL) is an established risk factor for coronary artery disease; however, 60 percent of all deaths from coronary heart disease occur among persons with lower cholesterol levels. Since 1991, the National Cholesterol Education Panel (NCEP) has encouraged physicians to screen patients for hyperlipidemia and provide dietary counseling in order to reduce the risk for heart disease. The NCEP recommends that physicians inform patients of their cholesterol test results in a clear, understandable manner and encourage all patients, regardless of concurrent risk factors, to reduce their fat intake. Previous studies have shown that patients who were screened for high blood cholesterol and were informed of their cholesterol status were more motivated to modify other cardiac risk factors and to reduce their serum cholesterol levels. Murdoch and Wilt surveyed patients within a year of their cholesterol measurement to assess compliance with the NCEP guidelines.

Any patient at a midwestern Veterans Affairs hospital who had a cholesterol level checked by a physician's order between January 1993 and 1994 was eligible for the study. Multiphasic blood screening was not done at that institution during the study period, so cholesterol testing could only be performed if specifically requested by a physician. A total of 250 patients (125 men and 125 women) who had cholesterol screening were randomly selected by a computer-generated list. A 17-item questionnaire was mailed to study participants within one year of their last cholesterol measurement. The participants were asked to identify their cholesterol status in two different ways: as a category (i.e., desirable versus undesirable) and as the actual number. Respondents were also asked to estimate their perceived risk of coronary artery disease due to high cholesterol levels, their overall health perceptions, their other cardiac risk factors, if they had been prescribed a specific cholesterol-lowering diet and if a physician had told them their actual cholesterol number.

Eighty-three percent of study participants responded to the survey. The average age of the participants was 61 years for the men and 55 years for the women. The mean length of time between the survey and respondents' last cholesterol measurement was 4.4 months. Almost all respondents (99 percent) either agreed or strongly agreed that a high cholesterol level increases the risk for coronary heart disease, and the majority (76 percent of men and 83 percent of women) believed that lowering their cholesterol level would decrease their personal risk of coronary disease.

When asked if a physician had checked their cholesterol level in the past year, 60 percent of the men and 65 percent of the women answered affirmatively. Yet only 50 percent of men and 55 percent of women stated that they were told their cholesterol results by a physician. Less than one half of the study participants said they were given dietary instructions by a physician.

Twenty-eight percent of the men and 37 percent of the women said they knew their cholesterol number, but only 40 percent of the numbers they reported were accurate. Overall, only 19 percent of the survey respondents accurately reported their cholesterol level.

Respondents were more likely to accurately recall their cholesterol numbers if they remembered being told their test results or remembered receiving dietary advice. Female gender and more years of education were correlated with cholesterol awareness.

The authors conclude that physician compliance with the NCEP guidelines is poor. Even among better-educated patients, knowledge of the importance of cholesterol level and the need for dietary intervention was found to be significantly lacking. Physicians should endeavor to improve patient awareness by following up cholesterol screening with meaningful feedback and by being diligent in prescribing dietary therapy.

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Copyright © 1998 by the American Academy of Family Physicians.

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