High serum cholesterol is a risk factor for coronary

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1 Impact of a Low-Cost Intervention to Increase Cholesterol Awareness Among Older Patients Maureen Murdoch, MD, MPH, Sheila A. Sheridan, MS, RN, CNS, Monica Lavin Doeden, MS, RD, Timothy J. Wilt, MD, MPH, and Hanna Bloomfield Rubins, MD, MPH Objective: To evaluate the effectiveness of a low-cost, readily exportable intervention to increase cholesterol awareness among older patients and to assess physician compliance with National Cholesterol Education Program (NCEP) population-based guidelines to reduce cholesterol risk. Design: Pre- and postinterventional study. Setting and participants: Patients receiving care at the Minneapolis Veterans Affairs Medical Center primary care clinic who had been screened for high cholesterol in the previous 16 months. Intervention: The intervention consisted of educational posters and patient brochures placed throughout the clinic, computer-generated feedback letters sent to patients following cholesterol measurement, and an education program to familiarize internal medicine residents with NCEP guidelines. Outcome measures: A questionnaire assessed participants cholesterol awareness (ie, ability to correctly characterize their cholesterol status as desirable or undesirable), ability to recall their cholesterol level, and physicians compliance with NCEP guidelines. Results: 232 patients completed the questionnaire before the intervention was implemented (baseline) and 351 patients completed the questionnaire postintervention. The percentage of respondents who remembered having their cholesterol measured and who remembered being told their test results increased by 6 and 9 percentage points, respectively (P = 0.04), after the intervention. The percentage of respondents who remembered being given advice on how to reduce dietary fat and cholesterol also increased, but not significantly (7 percentage points, P = 0.16). Cholesterol awareness was low at baseline (50%) and did not improve after the intervention (51%, P = 0.86). Residents compliance with 2 of the NCEP guidelines improved modestly after the intervention. Conclusion: Further research is needed to identify effective, low-cost, easily implemented methods to improve cholesterol awareness in older patients. High serum cholesterol is a risk factor for coronary heart disease (CHD) [1]. To reduce the population risk for CHD, the National Cholesterol Education Program (NCEP) expert panel advocates a dual strategy for lowering blood cholesterol levels: a patient-based approach, which seeks to clinically identify and treat high-risk individuals [2,3], and a population-based approach, which encourages the general public to modify life habits with the aim of reducing CHD risk factors [1]. This population-based approach is believed to offer greater public health benefits [4,5] than a strategy that seeks only to identify high-risk patients in the clinical setting. Improving patients cholesterol awareness (eg, patients awareness of their cholesterol level and the risks associated with it) is a cornerstone of the NCEP s population-based strategy. Accordingly, NCEP guidelines recommend that physicians screen all adults for high cholesterol, explain to patients the implications of their cholesterol test results, and encourage all patients to follow a Step I diet [1] regardless of their serum cholesterol level or risk-factor profile. In a number of studies, this triad of strategies has been shown to improve subjects cholesterol awareness [6], positively alter their diets and exercise habits [5,7 10], and result in sustained serum cholesterol reductions between 2% and 10% [8,9,11 14]. Becoming cholesterol-aware by itself has been shown to result in favorable changes in both subjects serum cholesterol levels [15,16] and their overall CHD risk-profiles [17]. Most programs successful in improving cholesterol awareness Maureen Murdoch, MD, MPH, Minneapolis Veterans Affairs Center for Chronic Disease Outcomes Research, Minneapolis, MN; Sheila A. Sheridan, MS, RN, CNS, Clinical Nurse Specialist, Primary Care, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN; Monica Lavin Doeden, MS, RD, Clinical Dietitian, Minneapolis Veterans Affairs Medical Center; Timothy J. Wilt, MD, MPH, Associate Professor of Medicine, Minneapolis Veterans Affairs Center for Chronic Disease Outcomes Research; and Hanna Bloomfield Rubins, MD, MPH, Associate Professor, Internal Medicine, Chief, Section of General Internal Medicine, Minneapolis Veterans Affairs Medical Center. Vol. 7, No. 4 JCOM April

2 CHOLESTEROL AWARENESS have targeted young, healthy adults [8,9,13 17]. Although the association between CHD and cholesterol is weaker in adults older than 60 years, an elevated cholesterol level remains an important risk factor modifiable by diet in the older population [1,18]. Moreover, as CHD occurs at a dramatically higher rate in older persons [1], small reductions in risk may translate into large reductions in the absolute number of adverse events [18]. A 1% reduction in CHD mortality among persons aged 65 or older would result in 4300 fewer deaths per year in the United States [1]. In this study, we evaluated the effectiveness of a low-cost, readily exportable intervention to increase cholesterol awareness among older veterans enrolled in an ambulatory care clinic. Additional objectives were to examine the effect of the intervention on residents compliance with the NCEP guidelines and to describe correlates of cholesterol awareness among study participants. Methods and Materials Setting and Participants The Minneapolis Veterans Affairs Medical Center (MVAMC) is a 267-bed teaching hospital affiliated with the University of Minnesota School of Medicine. The MVAMC provides both primary and tertiary care to approximately 40,000 men and 2000 women and has more than 300,000 outpatient visits and approximately 15,000 hospitalizations each year. The MVAMC s primary care clinic, the largest longitudinal primary care clinic in the Veterans Affairs system, provides care to approximately 10,000 veterans who are predominantly older than 60 years, male, and, consistent with statewide demographics, white. Most women veterans who use MVAMC services receive their care through a specialized women s health clinic. The primary care clinic is staffed by 4 full-time staff physicians and 79 internal medicine residents. Each resident provides longitudinal care to groups of 50 to 100 patients as part of their ambulatory skills training. Patients enrolled in the MVAMC primary care clinic who received primary care from an internal medicine resident and had a serum cholesterol measurement at least once since their enrollment were eligible for the study. Because the MVAMC does not offer multichannel testing, physicians must specifically order serum cholesterol tests. Before and following the intervention, 400 patients were selected to receive surveys; patients were selected randomly from the resident clinic rolls using a computer-generated program. Patient overlap between groups was negligible. Patients were excluded if they were concurrently enrolled in a cholesterol-lowering intervention trial (because such trials often require subjects to be blinded to their cholesterol levels), if they had died since their last cholesterol measurement, if they had moved and left no forwarding address, or if their last cholesterol measurement had occurred more than 16 months prior to the intervention. The latter exclusion was made to ensure that the preintervention and postintervention study periods were equivalent in length. After applying the exclusion criteria, 232 patients in the preintervention group and 351 patients in the postintervention group were eligible for survey. A total of 144 patients (36%) were excluded from the preintervention group because their serum cholesterol had been measured more than 16 months prior to the intervention. These subjects were excluded from the main analyses but were still surveyed to look for secular trends in cholesterol awareness. Intervention The intervention lasted 16 months and was launched during a Cholesterol Awareness kick-off month (April 1996). During that month, posters were displayed in the MVAMC primary care clinic asking patients if they knew their cholesterol count and encouraging them to talk with their physician if they did not. Brochures containing information about diet and cholesterol-lowering options were also displayed and available to take home. Lectures to familiarize residents with the NCEP population-based guidelines were presented as part of the residents ambulatory skills curriculum. A number of studies suggest that primary preventive care is most reliably provided when its delivery is not dependent upon physicians [19 24]. Hence, the centerpiece of the intervention involved a computer-generated feedback letter that was sent automatically to any patient who had his or her cholesterol level checked by a clinic resident during the study period. Patients whose serum cholesterol levels were measured in other clinics were not mailed feedback letters. In part, this restriction was imposed to make sure we did not inadvertently break blinding for subjects enrolled in cholesterollowering trials. The feedback letter was personalized for each patient and was mailed no later than 1 month after cholesterol testing. In accordance with the NCEP s populationbased guidelines, the letter provided patients with their most recent cholesterol level, explained the test s meaning in terms of cardiac risk, and provided 7 dietary suggestions that would bring them into compliance with a Step I diet. The letter also provided sources of additional information, including the telephone number of a dietitian and the name and telephone number of the patient s primary care physician. The letter was written at the 8th-grade level and had a Flesch Reading Ease score [25] of 62%. Assessment of Program Effectiveness A 19-item, confidential survey similar to one used previously [26] was mailed to the homes of participants in the preintervention group in January An identical survey was mailed to the postintervention group 16 months after the intervention 32 JCOM April 2000 Vol. 7, No. 4

3 was initiated. Data collection procedures were the same for each survey wave, and mailings followed Dillman s procedures [27]. The survey assessed the participants cholesterol awareness and ability to recall the number value of their last cholesterol measurement. Participants were considered to be cholesterol-aware if they correctly identified their cholesterol level as being desirable (ie, less than 200 mg/dl) or undesirable (ie, greater than 200 mg/dl). The rationale for using 2 cholesterol categories has been described elsewhere [26]. Participants were considered to have recalled their cholesterol number accurately if they were within 10 mg/dl of the laboratory-measured value. The survey also asked participants about personal characteristics anticipated to be associated with cholesterol awareness and accurate cholesterol number recall. Using the Health Beliefs Model [28] as a framework, we hypothesized that participants would be more likely to be cholesterol-aware or to accurately recall their cholesterol number if they reported having higher perceived susceptibility to the ill effects of high cholesterol, fewer perceived barriers to reducing the amount of cholesterol and fat in their diets, higher perceived benefits from reducing their serum cholesterol levels through diet, and certain sociodemographic characteristics such as older age or more years of education [4,29]. Also in accordance with the Health Beliefs Model, we expected that participants who reported having received cues to action [28] to reduce their dietary fat and cholesterol would be more likely to be cholesterol-aware and to accurately remember their cholesterol number. Cues to action assessed by the survey included whether participants said they were being treated with cholesterol-lowering medications and whether they had a spouse or other family members with high cholesterol. Several cues to action assessed by the questionnaire also assessed physicians compliance with the NCEP population-based guidelines (as remembered by the participants). For example, participants were asked if their cholesterol level had been measured by a physician in the past year or ever, if they had been notified of their cholesterol test results, if they had been given general information on how to reduce the amount of fat and cholesterol in their diets, or if they had been more specifically advised to follow a low-fat, low-cholesterol diet as part of a treatment plan. The validity of characterizing these items under the cues to action component of the Health Beliefs Model was supported by a factor analysis of participants responses (analysis available on request). We assessed participants perceived benefits from reducing dietary fat and cholesterol using a 4-item scale developed specifically for this study. This dietary benefits scale has satisfactory psychometric properties, including a Cronbach alpha [30] of 0.79; scores may range from 4 to 20, with higher scores representing greater perceived benefits (data available on request). Both the intervention and the survey protocol were approved by the MVAMC Subcommittee on Human Subjects. Validation and Demographic Measures Information on participants age, sex, race, and most recently measured serum cholesterol level were obtained using the MVAMC Decentralized Hospital Computer Program database. Cholesterol levels were measured from serum samples using Kodak EKTACHEM (r) clinical chemistry slides and run on a stationary Kodak EKTACHEM (r) 700XR automated chemistry analyzer. The MVAMC participates in the VA/National Centers for Disease Control and Prevention s National Cholesterol Standardization and Certification Program and consistently exceeds the standards of the VA National Reference Center for Cholesterol Standardization. Analysis The main analyses examined the effectiveness (as opposed to the efficacy) of the intervention using an intention-to-treat paradigm. For the main analyses, differences in preintervention and postintervention participants characteristics, cholesterol awareness, and cholesterol number recall were compared using Pearson s chi-square test with continuity correction [31], the Mantel-Haenszel test for linear association [31], or Student s t test [31], as appropriate. Similarly, Pearson s chi-square test with continuity correction, Student s t test, or Cornfield s odds ratio [31] were used to identify potential correlates of cholesterol awareness and accurate number recall on bivariable analyses. Forward, stepwise logistic regression [32] was used to assess the independent contribution of study variables, including group status (ie, preintervention versus postintervention), to cholesterol awareness and number recall while controlling for potentially important covariates and potential confounders. The independent efficacy of the automated feedback letter in improving cholesterol awareness was examined in a post-hoc, exploratory fashion. Names of participants enrolled in the postintervention group were cross-checked against lists of individuals who had been mailed the feedback letter. Appropriate bivariable analyses were then used to compare cholesterol awareness, accurate number recall, and remembered action cues between those who had received the letter and those who had not. All analyses were conducted using SPSS for Windows, version 6.0. Results Eighty-nine percent of eligible participants in the preintervention group and 80% of those in the postintervention group returned questionnaires (P = 0.01). Nonrespondents were on Vol. 7, No. 4 JCOM April

4 CHOLESTEROL AWARENESS Table 1. Characteristics of Survey Respondents Preintervention Group Postintervention Group (n = 206) (n = 281) P Value Mean age, yr (SD) 69.0 (8.8) 68.6 (10.0) 0.59 Male gender, % White, % Education, % Less than 12 years High school graduate College or beyond * No. of months since last cholesterol test, mean (SD) 5.9 (4.7) 10.8 (3.5) < Coronary heart disease risk factors, % Family history of early myocardial infarction Hypertension Personal diagnosis of heart disease Peripheral vascular disease Stroke Diabetes Current smoker Ranked health as good or better, % Mean serum cholesterol level, mg/dl (SD) (37.6) (36.7) 0.10 Takes cholesterol-lowering medications, % Dietary benefits scale scores, mean (SD) 16.6 (2.2) 16.7 (2.2) 0.74 SD = standard deviation. *Mantel-Haenszel test for linear association. average 3 years younger than respondents (P < 0.001) and had received cholesterol tests 3.8 months more recently (P = 0.003). However, respondents and nonrespondents did not differ in terms of sex, race, or cholesterol level. Nonrespondents were also as likely as respondents to have received an automated feedback letter. Baseline characteristics of the respondents are listed in Table 1. As expected based on clinic demographics, virtually all were male and white. The pre- and postintervention groups were closely matched in terms of age, risk factors for CHD, and education. Postintervention participants were significantly more likely to say they took cholesterol-lowering medications, and more time had elapsed since their last serum cholesterol measurement. Scores on the dietary benefits scale were high for both groups, ranging from 9 to 20 with a mean of almost 17 (highest possible score = 20). Also, more than 54% of respondents in both groups either agreed or strongly agreed that it would be no problem for them to reduce the amount of fat and cholesterol in their diets (P = 0.86, data not shown). The Figure shows the impact of the intervention on respondents cholesterol awareness and cholesterol number recall. Resident physicians compliance with the NCEP population-based guidelines, as remembered by study participants, is also shown. The absolute percentage of respondents who said a physician had measured their serum cholesterol level increased by 6 percentage points after the intervention, and the percentage of respondents who said they had been notified of their cholesterol test results increased by 9 percentage points. However, the percentage of respondents who could accurately recall their cholesterol number declined from 23% to 17% after the intervention (P = 0.17), and cholesterol awareness remained essentially unchanged (P = 0.86). Of all continuously measured variables, only 2 correlated with cholesterol awareness. Cholesterol-aware respondents were on average 2.2 years younger than cholesterol-unaware respondents (P = 0.006), and respondents who recalled their cholesterol number accurately had received a cholesterol test more recently (7.5 months versus 9.0 months, P = 0.01). Individual serum cholesterol levels were specifically not associated with either cholesterol awareness or accurate cholesterol number recall. Table 2 shows the association between cholesterol awareness, accurate number recall, and selected categorically measured respondent characteristics. Of all Health Beliefs Model components measured by the survey, only physicianinitiated action cues that were remembered by respondents 34 JCOM April 2000 Vol. 7, No. 4

5 Preintervention group (n = 206) Postintervention group (n = 281) Percentage of respondents Figure. Physician compliance with National Cholesterol Education Program guidelines (as remembered by patients) and patient cholesterol awareness before and after intervention. 0 Remembered having cholesterol measured Remembered being told test results Remembered receiving dietary advice Were cholesterol aware Recalled cholesterol number accurately (eg, being tested for high cholesterol, being told test results, or being treated for high cholesterol) were significantly and positively associated with cholesterol awareness and accurate number recall. Group status (preintervention versus postintervention group) was not associated with either parameter. Group status and variables statistically significantly associated with cholesterol awareness and accurate number recall on bivariable analyses were submitted to forward, stepwise logistic regression. As with bivariable analyses, group status did not correlate significantly with either cholesterol awareness or accurate cholesterol number recall. Only 65% of postintervention participants were mailed an automated feedback letter. As might be expected given the study s protocol, the most common reason participants were not mailed a feedback letter was that their cholesterol level had been measured in a different clinic (90% of those not receiving a letter). For the remaining 10%, we could not ascertain why no letter had been sent. To determine if receiving a feedback letter was independently correlated with either compliance with NCEP population-based guidelines or cholesterol awareness, we conducted a series of exploratory, bivariable analyses (Table 3). Letter recipients in the postintervention group were significantly more likely than nonrecipients to say that their cholesterol level had been measured, that they had been told their test results, and that they had been given general cholesterollowering dietary information. Nonetheless, letter recipients and nonrecipients did not differ significantly in terms of cholesterol awareness or cholesterol number recall. The characteristics of preintervention participants excluded from the main analysis because their serum cholesterol had been measured more than 16 months prior to the intervention did not differ significantly from eligible preintervention participants. In terms of age, sex, race, years of education, serum cholesterol, and CHD risk factors, they were well matched (data not shown). Ineligible participants were, however, significantly less likely to say they were taking cholesterol-lowering medications (6% versus 26%, P < 0.001). They were also significantly less likely than eligible preintervention participants to say they had ever had their cholesterol level tested (77%), been told their test results (50%), or received dietary information (44%) (P values for all differences 0.03). Only 32% of the ineligible participants were cholesterol-aware, and just 6% recalled their cholesterol number accurately. Even when these ineligible participants were combined with eligible participants in a sensitivity analysis, we failed to find a significant improvement in postintervention participants cholesterol awareness or number recall (data not shown). Likewise, whether or not these participants were included, the same predictors of cholesterol awareness and cholesterol number recall emerged from stepwise logistic regression with similar effect sizes and levels of statistical significance as reported in Table 2. Intervention Costs Actual prices associated with the intervention were not calculated, but labor costs included a one-time input of Vol. 7, No. 4 JCOM April

6 CHOLESTEROL AWARENESS Table 2. Association Between Selected Respondent Characteristics, Cholesterol Awareness, and Accurate Cholesterol Number Recall UNIVARIABLE RESULTS Cholesterol Awareness* Cholesterol Number Recall Variable Odds Ratio (95% CI) P Value Odds Ratio (95% CI) P Value Remembered being told test results 4.18 ( ) < ( ) < Remembered receiving general dietary information 2.51 ( ) < ( ) Remembered having cholesterol level measured 2.44 ( ) < ( ) At least some college education 1.96 ( ) ( ) 0.11 Remembered being recommended a cholesterol ( ) ( ) lowering diet as part of a treatment plan Takes cholesterol-lowering medications 1.68 ( ) ( ) 0.05 Postintervention group status 1.05 ( ) ( ) 0.17 MULTIVARIABLE RESULTS Cholesterol Awareness Cholesterol Number Recall Adjusted Odds Ratio Adjusted Odds Ratio Variable (95% CI) P Value (95% CI) P Value Remembered being told test results 2.93 ( ) < ( ) < At least some college education 2.09 ( ) Remembered receiving general dietary information 1.81 ( ) 0.02 Months since last cholesterol measurement 0.94 ( ) Remembered being recommended cholesterol ( ) 0.01 lowering diet as part of a treatment plan CI = confidence interval; = variable not in model. *Respondents were considered to be aware of their cholesterol status if they correctly categorized it as desirable or undesirable. Respondents were considered to have accurately recalled their cholesterol level if they reported a number within 10 mg/dl of their last serum cholesterol measurement. In addition to the variables listed here, both models were adjusted for respondents age, months since last cholesterol test, whether they took cholesterol-lowering medications, and group status (preintervention versus postintervention). The model for cholesterol awareness was also adjusted for college education. approximately 25 hours of computer programming to develop the automated feedback system. Ongoing labor costs included approximately 5 minutes of clerical time and 30 minutes of administrative time each month. The administrator was responsible for overseeing the printing of letters and the stuffing of envelopes. Envelopes were stuffed using an automated machine already owned by the institution, and wear and tear on the machine plus electricity costs associated with its use for the project were negligible. For each letter sent, the paper, printing, and envelope costs totaled about 7 cents. Postage was 27 cents per letter. The costs of preparing the cholesterol awareness lectures were considered neutral, as resident education is an expected component of all staff physicians jobs. Had cholesterol awareness lectures not been prepared, staff would have been expected to produce other lectures instead. Discussion The percentage of participants screened for high cholesterol at MVAMC s primary care clinic who remembered such screening or who remembered being told their cholesterol test results increased modestly after an education program for residents and an automated feedback system for patients were implemented. However, as a whole, neither participants cholesterol awareness nor their cholesterol number recall improved. Recipients of feedback letters were more likely than nonrecipients to say that they had been provided general cholesterol-lowering dietary information, but the overall percentage of participants in the postintervention group who said they had received such information did not change significantly using an intention-to-treat analysis. Surprisingly few of the participant characteristics we studied were associated with cholesterol awareness. Indicators of 36 JCOM April 2000 Vol. 7, No. 4

7 Table 3. Effect of Automated Feedback Letter on Compliance with NCEP Guidelines, Cholesterol Awareness, and Cholesterol Number Recall Letter Recipients Nonrecipients Postintervention Subjects Who: (n = 182) (n = 99) Odds Ratio (95% CI) P Value Remembered having cholesterol measured ( ) Remembered being told test results ( ) 0.03 Remembered receiving general dietary information ( ) Were cholesterol-aware* ( ) 0.66 Recalled cholesterol level accurately ( ) 0.99 CI = confidence interval. *Respondents were considered to be aware of their cholesterol if they correctly categorized it as desirable or undesirable. Respondents were considered to have accurately recalled their cholesterol level if they reported a number within 10 mg/dl of their last serum cholesterol measurement. high risk for CHD, for example, were not correlated with better cholesterol awareness, regardless of whether we examined clinical parameters (eg, a past history of myocardial infarction or a high serum cholesterol level) or participants perceived personal risks. Correlates of cholesterol awareness that have been reported by other investigators, such as age, smoking status, weight [4,6], diabetes mellitus [6], hypertension [6], or family history of myocardial infarction [4], failed to achieve statistical significance here. Likewise, despite a large body of literature correlating components of the Health Beliefs Model [28] to patient knowledge [33], only 2 cues to action telling patients their serum cholesterol and providing some sort of dietary information increased the odds that participants would be cholesterol-aware or that they would recall their cholesterol number accurately. These findings are consistent with earlier work conducted at our institution [26] and suggest that correlates of cholesterol awareness may differ systematically across older and younger age-groups. Most programs successful in improving cholesterol awareness have included considerably younger and healthier subjects [8,9,13 17]; improving cholesterol awareness in older groups may be more challenging. For example, cholesterol awareness depends not only on being screened and being told one s test results but also on remembering those test results [29]. Studies have shown that patients forget more than half of all physician instructions almost immediately after receiving them [34,35], and the higher prevalence of dementia in the elderly [36] may magnify this effect. This is consistent with our finding that participants with more recent tests for high cholesterol were more likely to accurately recall their cholesterol number than participants tested less recently. Older adults have expressed a preference for printed cholesterol information [37], perhaps because verbally communicated health information is hard to remember, especially over time. An exploratory analysis showed that postintervention subjects who received an automated feedback letter were more likely than nonrecipients to remember being told their cholesterol test results and to remember receiving general dietary advice. Given the reasonably strong association between these 2 parameters and cholesterol awareness, we might have expected a corresponding increase in cholesterol awareness had everyone in the postintervention group received a feedback letter. However, remembering being told one s cholesterol test results and remembering receiving general dietary advice accounted for only a tiny proportion of the variance in cholesterol awareness. Based on our data, we estimate that even if 100% of the postintervention subjects had been mailed feedback letters, at best only 57% would have become cholesterol-aware. It is unlikely, therefore, that we have missed a clinically important intervention effect or that confounding constructs and levels of constructs [38] materially affected our results. Eligible participants in the preintervention group had more recent cholesterol measurements than those in the postintervention group, raising concern that this discrepancy may have masked or diminished a true intervention effect. However, even in a sensitivity analysis in which all preintervention participants were analyzed, we saw no significant improvement in the postintervention groups cholesterol awareness. Likewise, while the recency of participants last cholesterol measurement correlated significantly with the participants ability to recall their cholesterol number accurately, it did not correlate with their being cholesterol-aware. This was true both in the primary analysis and in the sensitivity analysis. To further address this issue, we conducted a tertiary analysis in which we matched preintervention and postintervention participants by the recency of their last cholesterol measurement. Once again we found no evidence for an intervention effect on cholesterol awareness. We feel confident, therefore, that we did not make a type II error by excluding these ineligible participants from the main analysis. Vol. 7, No. 4 JCOM April

8 CHOLESTEROL AWARENESS All adults in the population regardless of their personal risk-profile or age are eligible for and intended to benefit from the NCEP population-based strategy for cholesterol risk reduction [1]. However, improving cholesterol awareness, an important aspect of this strategy, may be more difficult in older agegroups. If an automated feedback letter that capitalizes on older adults preferences for written cholesterol information does not improve their cholesterol awareness, what strategies might? Besides focusing on younger adults, successful programs have generally used more intensive, personalized, and costly methods to improve cholesterol awareness [8,9,13,15 17]. Had we adopted similar methods, we might have achieved similar gains. Whether more expensive interventions would work in an older population and whether such expenses could be justified are questions for future research. Clearly, if we are to design effective interventions for older adults, we must first identify better predictors of cholesterol awareness. To the best of our knowledge, this study is the first to specifically examine the cholesterol awareness of older adults; however, the generalizabilty of our findings to older women, nonveterans, or ethnic minorities is uncertain. To extend understanding of cholesterol awareness, we encourage other investigators to include older adults in their research. The authors thank James Hodges, PhD, for his statistical assistance, MVAMC Information Resources Management personnel, and Dick Inman, Warren Samuelson, Dawn Brooks, Reed Wold, and Cathy Rivard for their assistance in developing and supporting the automated feedback system. Authors address: Center for Chronic Disease Outcomes Research, One Veterans Drive, Minneapolis, MN 55417, References 1. Report of the Expert Panel on Population Strategies for Blood Cholesterol Reduction. 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