Identifying the Barriers among Primary Care Providers in Cholesterol Screening, lack of guidelines utilizations. Quantitative Annotated Bibliography

Identifying the Barriers among Primary Care Providers in Cholesterol Screening, lack of guidelines utilizations. Quantitative Annotated Bibliography

South University

Nursing Research Methods

Identifying the Barriers among Primary Care Providers in Cholesterol Screening, lack of guidelines utilizations. Quantitative Annotated Bibliography

Identifying the Barriers among Primary Care Providers in Cholesterol Screening

Grant, D. S. L., Scott, R. D., Harrison, T. N., Cheetham, T. C., Chang, S. C., Hsu, J. W. Y., … Reynolds, K. (2018). Trends in Lipid Screening Among Adults in an Integrated Health Care Delivery System, 2009-2015. Journal of managed care & specialty pharmacy, 24(11), 1090-1101.

Grant et al (2018) conducted a Quasi-experimental time series. The purpose of the study was to evaluate trends in lipids screenings of adults 20 years and older in a large multi-ethnic population in a single health plan based in Kaiser Permanente Southern California. The study utilized a sample size of 4.2 million members of variation of income and education over the age of 20. The study utilized a control group categorized into 3 groups based on the ACC/AHA guidelines. In the first group patients with ASCVD, in the second group patients with had diabetes mellitus none diagnosed with ASCVD, the last group included patients with neither condition. The data was timeframe was between 2009-2015, and data collected on September 30th, 2015 revealed,  N=3,946,512 excluding members less than 20 years of age without 12 months previous membership N=1,458.720. Results exhibited higher lipid rate was observable in patients without insurance especially on patients with ASCVD and DM. Lastly, it resulted also indicated that patients that had ASCVD were 5.3%-5.8 %, 7.3%-7.9% of patients had DM, while 86.6%-87.0% had neither condition in the population age 20-39. The study was limited to a single health plan based in Southern California with non-direct contact with patient and providers. To determine the reason for screening or non-screening. Furthermore, patients were misclassified during the screening process.

Lowenstern, A., Li, S., Navar, A. M., Virani, S., Lee, L. V., Louie, M. J., & Wang, T. Y. (2018). Does clinician-reported lipid guideline adoption translate to guideline-adherent care? An evaluation of the Patient and Provider Assessment of Lipid Management (PALM) registry. American heart journal, 200, 118-124.

Lowenstern et al (2018) directed a quasi-experimental predictable study to evaluate clinician’s management of hyperlipidemia in a hypothetical manner. The sample size patient enrollment was between May 27, 2015-Sept 12, 2015, in which 7938 patients and 744 physicians were enrolled. The PALM method asked 744 clinicians on how to treat 4 hypothetical patients’ scenarios. The sites require to completed surveys for 80% of participant physician’s prior to patient enrollment. Patients were included in the PALM registry if they had prior ASCVD, active treatment with a statin or eligible for treatment. The palm population was of 6839 and 2297 fit criteria for 4 hypothetical scenarios. The scenarios involved patients with diabetes mellitus, high risk, high LDL, low-risk high LDL, and high LDL despite adherence to high-intensity statins. The study demonstrated that the majority of the cardiologist reported adoption to the 2013 ACC/AHA guidelines. Although the response to the hypothetical scenario did not correlate to lipid management decision when risk calculator was utilized more guidelines adherence was noticeable. Finally, there was mixed management in patients with elevated LDL in the absence of high ASCVD as well as in patients with high LDL and high intensity was used. Physicians demonstrated high utilization of statins in patients with diabetes mellitus and high risk of ASCVD on hypothetical scenarios, but guidelines proved many practices still underutilized the use of statins. The study based exhibited statistical analysis of enrolled patients were classified base on hypothetical scenarios. Patients with Diabetes Mellitus were 14962, high LDL and high-Risk ASCVD greater than 7.5%, high-Risk LDL was greater than 130mg/dl, n=457 and low risk (ASCVD risk <7.5%, but high LDL (130-189mg/dl) n 344. The limitations identified during the study included none available data from clinician management decisions at the time of the clinic appointment, and the study was unable to assess if lipids levels were taken before or after statin initiation in some patient’s scenarios.

Qualitative Annotated Bibliography

Carratala-Munuera, C., Gil-Guillen, V. F., Orozco-Beltran, D., Maiques-Galan, A., Lago-Deibe, F., Lobos-Bejarano, J. M., Lopez-Pineda, A. (2015). Barriers to improved dyslipidemia control: Delphi survey of a multidisciplinary panel. Family Practice, 32 (6), 672-680. doi:10.1093/fampra/cmv038

Carratala et al. (2015) conducted a qualitative case study. Study objectives focus on the barriers that make it difficult for health care professionals to achieve better control for dyslipidemia in Spain. The sample took place in different regions of Spain which included 149 members from medicine, nursing, and health care management fields were randomly selected and invited to participate. But no sample size was calculated because there was an absence of agreement within the expert sample size and no criteria in which a sample size choice could be judged. The observational study used the Delphi technique in a questionnaire survey. The survey suggests that the best way to control dyslipidemia is through the promotion of shared decision making, setting of treatment goal, promotion of the use of dyslipidemia indicators and tool for the calculation of cardiovascular risk. The key barriers identified were lack of knowledge of patients, lack of communication between patient and provider and lack of motivation between both. The response rate was 81% for Kappa index in the first round agreement: 0.12; 95% CL:-0.44 to 0.68; P=1, in the non-agreement round 0.38; 95% CL: -0.02 to 0.58; P =0.687. In the second round agreement: 0.12; 95% CL:-0.27 to 0.52; P=0.219, in the part of the non-agreement:0.23; 95% CL-0.18 to 0.64; P =0.727. The global results after both rounds and between the three groups showed 7 consensus statements that lower the limit to 90%. Agreement index of 33% (95%CL; 18.9-47.7). The only limitations identified by the authors was the use of a structured questionnaire which suggests that this method may hinder elaboration of the problems and the possibility of experts suggesting other options.

Samah Alageel, Martin C. Gulliford, Lisa McDermott and Alison J. Wright. (2018).BMC Family Practice. Implementing multiple health behavior change interventions for cardiovascular risk reduction in primary care: a qualitative study. 19:171https://doi.org/10.1186/s12875-018-0860-0.

Alageel et al. (2018) conducted a qualitative study using elaborated interviews. This interviews were conducted within healthcare workers current implementing the National Health System Program in London. This study aimed to identify barriers and facilitators to implement new behaviors, health care screenings and methods to prevent and identify patients at risk for CVD within primary care settings. Cardiovascular risk management for prevention of cardiac complications can be achieve by interventions and medications, these have the potential to reduce risk factors and provide health benefits. As previous studies have showed; High cholesterol levels is a well-defined risk factor for cardiovascular disease, and it is associated with unhealthy diet, lack of physical activity, pre- existing illness and genetic abnormalities. High cholesterol can be lowered by implementing multiple health behavior changes at the Primary level of care as suboptimal intervention. The potential of regular primary care evaluation provide opportunities to support behavior changes interventions. In many countries behavior change interventions are delivered by primary care providers, however no enough evidence showed improvements on MHBC reducing CVD and decreasing mortality rates among primary care preventions.

The study utilized qualitative research methodology, applying data analysis form interviews performed to Primary Care Providers, who were implementing MHBC under the NHSHC programme. Participants were selected from 23 general practice from two socio economic deprived and ethnically diverse inner-city in London. Interview were conducted face to face during the months of July-August of 2016, interview was conducted with provider consent and lasted 30-90 minutes, the main topic was to identify barriers and facilitators for implementing MHBC in primary care settings. The majority of the providers were females and currently using the program since was introduced, however no difference in geographic or ethnic were observe. Some of the participants concern were; how much patients understand about healthy lifestyle; lack of confidence from providers and frustration about implementing MHBC interventions; lack of patient- provider encounter time, concluding that there is not enough time during visits to go over patient education and health check during one consultation. As all the interviews were conducted, the study was able to identify several factors impacting negatively the implementation of the MHBC interventions for CVD reductions, the author pointed out the importance of facilitating provider trainings, easy guidelines and methods to follow as well as introducing electronic based interventions to facilitate behavior changes.

Proposal

In the United States approximately 55% of adults have elevated LDL blood levels, fewer than 50 % of patients with high LDL levels receive treatment, and sequentially 31 million of Americans have total cholesterol levels above 240mg/dl. The prevalence of high cholesterol levels increases depending on income rate, noticing the low-income population with the highest LDL level.  Data showed that one out of every three adults with high cholesterol levels will have the condition under control. It is essential that providers taking action in order to have this current issue under control.

Statement of the Problem, Purpose of the Study and Research Questions.

The purpose of this research is to identify or aim existing Barriers and facilitators on cholesterol screening diagnosis and management within primary care providers? What interventions are effective in improving lipid screening rates in primary care settings? Proper patient-provider education during each encounter will minimize or eliminate the risk of high cholesterol levels. Patient diet modifications , exercise programs , generic testing facilitated during patient-provider encounters will prevent the need for early treatment with statins with further complications such as cardiovascular disease which many cases lead to other comorbidities including death.

According to results of studies that were hold by the World Health Organization, heart diseases are the main cause of morbidity and mortality in the majority of industrial countries. A number of steps, such as data collection, accurate epidemiological information, and cardiovascular risk factors assessment have been identified as the basic measures for the promotion of health and activities to reduce risk factors, improvement of people’s health, and reducing of the mortality level. The American Heart Association also defined a number of risk factors which are conductive to cardiovascular diseases, and elevated LDL (low density lipoproteins) cholesterol levels are among the most widespread of them (ACC/AHA, 20018). The revised 2018 guidelines on screening and management of cholesterol by the American College of Cardiology/American Heart Association (ACC/AHA) allows for more personalized patient management compared to the 2013 guidelines. The new guidelines recommend that healthcare providers conduct a detailed risk assessment and discuss treatment options with patients, recognizing the importance of identifying and managing high LDL levels. These guidelines are not enough without provider and patient partnership to manage high cholesterol. This Study is specific to the adult population with an inclusion criteria of patients older than 18 years of age, patients with or without history of high cholesterol level, patients diagnosed with high cholesterol levels, generic, and

Variables with Operational Definitions:

Variable with Operational Definitions: Two quantitative and two qualitative studies where selected by the author to conduct this research project. The two quantitative articles where quasi-experimental research studies with different sample size .The first study was to evaluate trends in lipids screenings of adults 20 years and older in a large multi-ethnic population in a single health plan based in Southern California with a sample size of 4.2 million Members of variation of income and education over the age of 20. The second quasi-experimental study aimed to evaluate clinician’s management of hyperlipidemia in hypothetical patients’ scenarios with a sample size of 7938 patients 744 physicians enrolled between May 27, 2015-Sept 12,2015 in Cardiologist, endocrine, primary care practice across US. The first qualitative study was aimed to assess the barriers that make it difficult for the health care professionals (physicians, nurses and health are managers) to achieve a better control for dyslipidemia in Spain. For this study 149 members from medicine, nursing and health care management fields were randomly selected and invited to participate in survey. But no simple size was calculated because there was an absence of agreement within the expert sample size and no criteria in which a sample size choice could be judged. The second qualitative study utilized the interview method, fourteen patients with high cholesterol and risk of cardiovascular disease were interviewed, and patterns across patient accounts were identified and analyzed from an ethnographic approach, concluding that Interpretations of high cholesterol and risk of cardiovascular disease are embedded in social relations and everyday life concerns.

Hypothesis:

Studies have shown that through comprehensive multiphase approach involving technology, non-technology, and multimethod inventions, was effective in identifying barriers primary providers encounter with cholesterol screening. While the evidence sources have varied methods and interventions which are reflected over variables measured and discussed, the findings reflect key concepts related to barriers primary providers encounter with cholesterol screening such as; Lack of provider/patient education and communication; Lack of adoption guidelines; Lack of health insurance; lack of E-health software, decision support tool, health information utilization.

Literature Review

The revised 2018 guidelines on screening and management of cholesterol by the American College of Cardiology/American Heart Association (ACC/AHA) allows for more personalized patient management compared to the 2013 guidelines. The new guidelines recommend that healthcare providers conduct a detailed risk assessment and discuss treatment options with patients, recognizing the importance of identifying and managing high LDL levels. These guidelines are not enough without provider and patient partnership to manage high cholesterol. Per the authors of the literature review in this scholarly paper there are gaps and limitations from primary providers on screen and management of hyperlipidemia. This literature review aims to identify Barriers among Primary Care Providers in Cholesterol Screening. During the review process the author found some common Barriers such as: Lack of patient provider education during patient encounter; Underutilization of informatics or electronic systems to help with patient screening and education; Provider’s none using combination drug therapy for treatment; Non available data from clinician management decision at the time of patient encounter.

  Background and Significance of the Problem or Phenomenon of Interest

Per the Center of Disease Control and Prevention (CDC) In the United States approximately 55% of adults have elevated LDL blood levels, fewer than 50 % of patients with high LDL levels receive treatment, and sequentially 31 million of Americans have total cholesterol levels above 240mg/dl. The prevalence of high cholesterol levels increases depending on income rate, noticing low income population with the highest LDL level.  Data showed that one out of every three adults with high cholesterol levels have the condition under control.  Hyperlipidemia is a recognized risk factor for incident of acute myocardial infarction (AMI) and acute decompensated heart failure (ADHF). High LDL Levels is known to cause 4.5% of death.

High cholesterol itself is not a disease, but it can lead to serious health consequences. Every 40 seconds, an American adult dies from a heart attack, stroke, or related vascular disease. These conditions claim the lives of more than 800,000 Americans each year with 150,000 of them under age 65.According to the Centers for Disease Control and Prevention, 71 million Americans have high cholesterol but 2 in 3 do not have it under control, and that has serious consequences for patients and society as a whole. A report commissioned by the AHA found that in 2010, heart disease cost the U.S. $273 billion in direct medical costs, and projected this would reach $818.1 billion by 2030. The report also found that heart disease will cost the nation billions in lost productivity, increasing from $172 billion in 2010 to $276 billion in 2030.

Method

The search engine that was utilized in order to collect data on this topic was of The Cochrane library, Cinahl, Google Scholar databases, and South University Library. The search included the following key words: Hyperlipidemia in primary care, hyperlipidemia screening in primary care, Cholesterol Screening guidelines/primary care, Barriers cholesterol screening in primary care, Facilitators of hypercholesteremic screening/primary care, patient education on high cholesterol levels in primary care settings.

The inclusion criteria consist of Systematic reviews, Qualitative Case studies, and Randomized Controlled Trials. The information obtained had to be on barriers and facilitators faced in primary care regarding cholesterol screening and the studies had to be published between the years 2015-2020 in the English language. All other articles published before 2015 including Pediatric research and other language than English were excluded. Literature was initially screened for references and application of the barriers and facilitators in cholesterol screening within primary care providers. The findings of the articles were limited to those that applied to the Pico Question and provided information related to barriers and facilitators within primary care regarding cholesterol screening.

When comparing theories, this articles were found to follow under the Middle Range Theories; less abstract, addressing more specific phenomena than do the grand theory, they focus on explanation of the specifics of condition, symptom, diagnosis, or process, and on implementation. This articles emanate from previous practice and existing theory on previous cholesterol screening studies. . While conducting the research the author of this paper found similar models such as the HBM which was established in the 1950s to understand why people were not participating in available programs to detect disease (Champion & Skinner, 2008). Burke et al. (2003) used self-efficacy to understand adherence behavior model. In this study, a self-efficacy scale was developed in order measure cholesterol-lowering diet self-efficacy in people who had been diagnosed with elevated cholesterol at a screening. Treatment adherence behaviors model (Anderson et al. 2011). As previous research shows the most common theoretical frameworks used in understanding aspects of cholesterol screening have been the theory of planned behavior, this was adapted from the theory of reasoned action by Fischbein and Ajzen in 1975 to understand individual motivational factors that influence the likelihood of performing a specific behavior.

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