The recent release of the updated guidelines

OVERCOMING BARRIERS TO BETTER LIPID MANAGEMENT IN WOMEN Lori Mosca, MD, PhD, MPH* ABSTRACT Most physicians are knowledgeable of the effective treatment strategies for the primary and secondary prevention of cardiovascular disease; unfortunately, these practices are currently underutilized. This article discusses specific barriers to effective risk factor management that involve the patient, physician, health system, and society. While some of these barriers impact men and women, some are specific to women. Potential barriers to appropriate lipid management and strategies to overcome those barriers also are presented. An important patient-related barrier is insufficient awareness of, or information about, the importance of cardiovascular disease as a cause of morbidity and mortality in women. Because several physician and health-system barriers center on the lack of reimbursement for preventive measures, examples of successful preventive programs implemented in health systems are provided. Efforts toward risk reduction management in women must target awareness, knowledge, skills, and self-efficacy. (Advanced Studies in Medicine 2002;2(11):416-421) *Director, Preventive Cardiology, New York Presbyterian Hospital, New York, New York. Address correspondence to: Lori Mosca, MD, PhD, MPH, Director, Preventive Cardiology, New York Presbyterian Hospital, 622 West 168th Street, PH10-203B, New York, NY 10032. The recent release of the updated guidelines by the third Adult Treatment Panel (ATP III) of the National Cholesterol Education Program is an important tool for physicians in optimizing lipid management in hyperlipidemic patients. 1 These new guidelines emphasize the importance of primary prevention with lifestyle changes, including diet, exercise, and weight control. In addition, target low-density lipoprotein cholesterol (LDL-C) goals are now defined as <100 mg/dl for patients with established cardiovascular disease (CVD) as well as those patients considered a coronary heart disease (CHD) risk equivalent. These new guidelines will greatly expand the number of people, including women, in need of lipid-lowering therapy and therapeutic lifestyle changes to 36 million people, almost 3 times the current number of people prescribed a lipid-lowering drug. 1,2 Currently, data show that reducing LDL-C decreases the risk of CVD, and low high-density lipoprotein cholesterol (HDL-C) and high triglycerides are predictive of risk. Despite the strong data to support treatment strategies for the prevention of CVD, these methods are not uniformly applied. In women, the gender differences in CVD may signal a knowledge gap of the risks for CVD, especially those risks specific to women. Moreover, gender-specific barriers to widespread implementation of lipid guidelines in women may exist. Little is known about what methods are most effective to improve lipid management in women. This article discusses a variety of barriers to the widespread implementation of better lipid manage- 416 Vol. 2, No. 11 July 2002

ment for women. Categories of barriers include patient, physician, health system, and society/policy. In addition, methods and opportunities to overcome these barriers are presented. RISK FACTORS FOR CVD Approximately 300 variables are associated with CHD 3 ; however, intervention studies that prove altering a risk marker actually lowers risk are limited to only a few major risk factors. Several major modifiable and nonmodifiable risk factors account for the majority of CVD risk (Table 1). Preventive efforts should be focused on each modifiable major risk factor, since any factor alone can produce CVD if left untreated. 4 Risk factors for CHD tend to exist concurrently, and their combined impact is usually multiplicative rather than additive. 5,6 Most CHD is caused by hypertension, dyslipidemia, smoking, and diabetes. When these risk factors exist concurrently, the impact on CHD risk is great. With each additional risk factor, the risk for CVD and all-cause mortality substantially increases. 5,6 PREVENTION OF CVD CVD is largely preventable. As stated in the ATP III guidelines, primary prevention represents the greatest opportunity for reducing the public health burden of CHD in the United States. 1 The risk of developing CVD varies among people, making the individualization of prevention strategies paramount. In general, preventive strategies have maximal benefit if implemented aggressively for those patients at highest risk. 1 Absolute risk assessment determines the probability that an individual with a certain set of criteria (or risk factors) will develop a disease within a fixed period of time. The consideration of multiple risk factors strengthens the calculation of absolute risk and helps to identify which population subset will experience the most CVD events. 7 However, appreciating risk and implementing prevention strategies do not always go hand in hand. Also, secondary preventive measures are equally important in patients with existing CHD. 1 BARRIERS TO EFFECTIVE LIPID MANAGEMENT Specific barriers to better lipid management are multifaceted and may include patient, physician, health system, and societal/policy barriers. Potential barriers, including those that apply specifically to women, for each of these categories are listed in Table 2. PATIENT BARRIERS Patient barriers to appropriate lipid management can stem from intrinsic or extrinsic origins. Intrinsic barriers can include the patient s motivation and acceptance of interventions, self-esteem, and other inner resources (eg, knowledge and self-management skills). Extrinsic barriers for patients include limited access or no access to health care/insurance, socioeconomic limitations that make almost any therapy cost prohibitive, and poor or nonexistent social support systems. 8 An important patient-related barrier that may not be well recognized is a general lack of awareness in many women about the serious consequences of CVD. In a recent national survey, nearly 1000 women who were 25 years or older were queried regarding their perceptions and understanding of the greatest health problems facing women today. Cancer, particularly breast cancer, was noted as the greatest health problem for women by 61% of respondents and as the leading cause of death by 50% of respondents. As shown in Figure 1, heart disease or stroke was identified as the leading Table 1. Risk Factors for Coronary Heart Disease Modifiable High LDL-C Low HDL-C High triglycerides High blood pressure Smoking Obesity High-fat diet Physical inactivity Nonmodifiable Age Premature menopause Gender Family history of premature heart disease Diabetes mellitus LDL-C = low-density lipoprotein cholesterol; HDL-C = high-density lipoprotein cholesterol. Advanced Studies in Medicine 417

health problem by only 8% of women and as the leading cause of death by only 31% of women. 9 However, in 1998, heart disease ranked as the number 1 cause of death of women in the United States, accounting for more than 500 000 deaths, while 250 000 women died of all forms of cancer combined. 10 Women suffering from CVD risk factors often know that healthy lifestyle changes are required; however, for a variety of reasons, making these changes can be difficult for many women. Results of a recent survey indicate a difference between men and women in barriers to making lifestyle changes. This study surveyed 186 men and 107 women participating in a preventive cardiology program about priorities and barriers to lifestyle changes. The top priorities identified for lifestyle changes, regardless of gender, were increasing exercise and improving nutrition. Significantly more women rated self-esteem as the number 1 barrier and stress as the second barrier to lifestyle changes as compared to men (P.035). Conversely, men rated time and stress as the number 1 and 2 barriers, respectively. Money, knowledge, and skills also were rated as more important barriers by women than by men. 11 Lifestyle changes, such as the implementation of an exercise program, are critical in a program of effective lipid management. Exercise of moderate intensity at least 3 times to 5 times per week can reduce the likelihood of developing diabetes, reduce blood pressure, and improve lipid profiles. 12 As many as one fourth of the adults in the United States are sedentary, with one third of women not engaging in any leisure-time physical activity. 12 Women cite varying reasons for not engaging in regular physical activity, including lack of time, dislike for exercise and sweating, laziness, and lack of facilities and equipment, as well as embarrassment and being too heavy, age, fatigue, bad weather, and orthopedic problems or injuries. 8 These patient-related barriers demonstrate the need for more focused public education regarding the risk of CVD. The American Heart Association (AHA) Web site includes patient-focused information regarding women and heart disease. Specifically, a program called Take Wellness to Heart allows women to register for informative e-mail notes and links to news features regarding heart disease and women. 13 An additional education program sponsored by the AHA is The Cholesterol Low Down. While not specifically for women, this program offers a variety of methods for delivery of CVD educational materials. 14 Many of the serious health risks for women are highly publicized, with patient advocates bringing educational messages to the public (eg, breast cancer). The success of these campaigns is seen in the perceived risk of death from breast cancer as compared to the actual risk. 9 To effectively manage women with risk factors for CVD, physicians and health care providers must not only understand patient-related barriers but also assist their female patients in overcoming these barriers. When dealing with intrinsic risk factors, physicians should assess a woman s level of motivation and amount of education about CVD risk factors. 8 In Table 2. Potential Barriers to Appropriate Lipid Management in Women Patient Barriers " Childbearing potential and use of prescription medicines " Poor self-esteem/self-efficacy " Lack of education/knowledge " Misperception of cardiovascular risk " Competing priorities " Fear of pharmacologic agents " Lack of key spokeswomen/advocates " Cost of therapy " Lack of or limited access to health care " Poor social support systems Physician Barriers " Lack of education/training on benefits of CVD prevention " Lack of education resources for patients " Lack of acceptance of established lipid-lowering therapies in women " Problem-based practice versus preventive medicine " Lack of leadership on the benefits of prevention " Lack of confidence to counsel patients on lifestyle changes " Time constraints and competing priorities " Therapeutic intervention preferred over medical intervention " Poor specialist-generalist communication Health System Barriers " Women s health care is fragmented " Lack of resources for women-centered programs " Lack of infrastructure for preventive measures Society/Policy Barriers " Lack of education regarding women s risk " Poor cooperation among reimbursement agencies and health care professionals for patient educational programs Some barriers apply to more than 1 category. CVD = cardiovascular disease. 418 Vol. 2, No. 11 July 2002

addition, the role of self-esteem should be addressed. External barriers should be addressed with creative problem solving and messages that are consistent and persistent. Women of childbearing potential may fear the use of lipid-lowering agents; however, administering bile acid sequestrants in this patient population is safe and effective. Regardless of the type of patientrelated barrier, some women should be referred to specialists when appropriate. PHYSICIAN BARRIERS Both primary-care physicians and cardiovascular specialists face time constraints in their practices and, therefore, may focus on acute problems rather than on preventive medicine. 15 Reimbursement for acute-care services is traditionally greater than reimbursement for less acute services such as risk factor management. 15 However, preventive medicine is cost effective, as recently demonstrated in many studies for several diseases. Although physicians treating women may be aware of practice guidelines for lipid management, they may not perceive themselves as adequately trained in counseling on lifestyle changes such as smoking cessation and nutrition or on the appropriate use of lipid-lowering agents. 15 Also, the chain of preventive care is often disrupted between primary-care physicians and spe- Figure 1. Perceptions of Health Problems and Leading Causes of Death Versus Actual Causes of Death AIDS = acquired immunodeficiency syndrome; COPD = chronic obstructive pulmonary disease. Reprinted with permission from Mosca L, Jones WK, King KB, Ouyang P, Redberg RF, Hill MN. Awareness, perception, and knowledge of heart disease risk and prevention among women in the United States. American Heart Association Women s Heart Disease and Stroke Campaign Task Force. Arch Fam Med. 2000;9(6):506-515. Advanced Studies in Medicine 419

cialty-care physicians. 15 Health care delivery, especially for women, is often fragmented by different specialist and generalist physicians, which may contribute to a patient-education gap. And specialists, such as cardiologists and cardiac surgeons, may not perceive risk-factor management as part of their responsibilities. In order to present a consistent and strong message regarding management of risk factors, specialists and generalists must support each others efforts in patient education. 15 Ancillary health care personnel, such as physician assistants, nurses, and pharmacists, also should play a role in breaking down these barriers. Physicians or other health care workers should avoid being judgmental when counseling women about lifestyle changes and serve as a supportive patient advocate. As shown in Figure 2, only 30% of patients report that their physician discusses heart disease with them, but more than 75% of patients indicate they would feel comfortable talking with their physician about preventive health options. 9 Addressing these physician barriers requires changes not only in the physician s treatment of patients at risk of CVD but also in the health care delivery system s treatment of such interventions. The AHA s Get with the Guidelines, an acute-care, hospital-based program focusing on the management of risk factors for CVD patients, offers continuing education for health care practitioners and encourages interaction among cardiologists, neurologists, primary-care physicians, nurses, and pharmacists. 16 HEALTH SYSTEM BARRIERS The complexity of the contemporary health care delivery system in the United States may act as a barrier to effective lipid management in patients, regardless of gender. The acute hospital setting may not be conducive to managing risk factors for several reasons, including logistical problems for patient identification and follow-up posed by the hospital environment, no infrastructure for focusing on prevention, and no reimbursement for hospital-based preventive services. 15 However, patient management strategies in the hospital setting may benefit men and women. A task force designed to examine the organization of preventive cardiology services recommended the incorporation of risk factor management for primary and secondary care. 15 Included in these recommendations were the modification of existing cardiology programs to meet patient and health system needs at the local level and the implementation of quality assurance programs that include risk factor management as a key indicator of quality care. Hospital-based programs designed to reduce the risk of CVD have been successful: The Changes for Life cardiac prevention and rehabilitation program was conducted over 12 weeks in 158 patients (106 men and 52 women) presenting with their first symptoms of coronary artery disease. Smoking cessation was achieved by 92% of participants. Other positive impacts included blood pressure controlled to 140/90 mm Hg or lower in 73% of participants, and total cholesterol reduced to 4.8 mmol/l or less in 62% of participants. These patients, normally managed by primary care, reached lifestyle and risk factor targets with a hospital-based program that included psychosocial and vocational support. 17 In an effort to identify people more at risk during a motivational moment, the Columbia Weill Cornell Heart Institute of New York-Presbyterian Hospital implemented an innovative screening and risk-reduction program called the Family Heart Health Passport Figure 2.The Communication Gap Between Patients and Physicians Data from the AHA National Survey in Women. Reprinted with permission from Mosca L, Jones WK, King KB, Ouyang P, Redberg RF, Hill MN. Awareness, perception, and knowledge of heart disease risk and prevention among women in the United States. American Heart Association Women s Heart Disease and Stroke Campaign Task Force. Arch Fam Med. 2000;9(6):506-515. 420 Vol. 2, No. 11 July 2002

Program. This outreach program, which began in October 2001, offers free heart-disease screening for family members of cardiac inpatients, including cholesterol, blood pressure, and glucose screenings as well as educational materials. Patients receive counseling about lifestyle changes and other modifiable risk factors and are referred for physician follow-up as needed. SOCIETY/POLICY BARRIERS The lack of infrastructure and reimbursement for preventive measures are physician and health system barriers but are also representative of policy barriers. Poor reimbursement stems from our culture of urgent care rather than preventive care, of prescribing rather than proscribing. As a society, we may not appreciate the benefits of good health until they are lost. Therefore, preventive services are often not as valued as they should be. In the past, diverse populations have not been included in most CVD research. The establishment of governmental policies to include women and minorities in CVD research will help to raise awareness that CVD is a significant health problem for many people. Governmental policies can also affect reimbursement standards. The formation of alliances among reimbursement agencies, specialists, and primary-care providers has the potential of breaking down some of the policy-related barriers. CONCLUSION Heart disease and stroke currently affect 1 of every 2 women. 10 To achieve maximal benefit from the implementation of lipid management guidelines, such as the ATP III guidelines, improved compliance by patients and members of the health care team is required. To obtain the greatest gain, a multidisciplinary approach should be taken. In addition, individualized patient intervention strategies should improve adherence to a lipid management plan. Recognition of the need for CVD risk reduction by patients, including lifestyle changes and lipid management, is critical to reducing the burden of CVD in men and women. A variety of barriers to achieving these goals exist, and some barriers are gender related. Efforts toward risk-reduction management in women must target self-esteem, stress management, time, knowledge, and skills. REFERENCES 1. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486-2497. 2. Grundy SM. Clinical applications of the ATP III guidelines. LipidManagement Newsletter. National Lipid Education Council Web site. Available at: http://www.lipidhealth. org/content/newsletter/vol6no3/pg1.asp. Accessed April 24, 2002. 3. Poulter N. Coronary heart disease is a multifactorial disease. Am J Hypertens. 1999;12(10 Pt 2):92S-95S. 4. 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