冠心病患者血脂检查可能有1/3为不必要

根据《美国医学会杂志》7月1日在线发表的一项大规模分析结果，可能有多达三分之一的冠心病患者在低密度脂蛋白胆固醇(LDL-C)已达标且没有接受进一步强化治疗的情况下仍接受了血脂复查(JAMA Intern. Med. 2013 July 1 [doi: 10.1001/jamainternmed. 2013.8198])。

主要研究者、休斯敦Michael E. DeBakey退伍军人事务部(VA)医疗中心的Salim S. Virani医生指出，这些患者已经在接受强化治疗，对其进行血脂复查的做法可能反映了对医疗资源的过度使用或浪费。


Salim Virani医生

这项研究纳入的近2.8万例冠心病患者共接受了12,686次“多余的”血脂检查，平均每次检查的费用为16美元。“也就是说，一家VA医院每年就因此多花了20万美元，而且这还没有算上患者接受检查的时间成本和医务人员分析结果并告知患者所花的时间。”

在这项研究中，Virani医生及其同事确定了27,947例正在服用降脂药物并且LDL-C已达标(＜100 mg/dl)的冠心病患者。受试者的平均年龄为73岁，多数为白人。高血压患病率为86%，44%合并糖尿病。这些受试者的血脂控制情况良好，具有理想的基线LDL-C(70 mg/dl)、高密度脂蛋白胆固醇(HDL-C，43 mg/dl)、甘油三酯(123 mg/dl)和非HDL-C(94 mg/dl)水平。72%的受试者正在服用他汀类药物。

研究者发现，共有9,200例患者在没有进一步强化治疗的情况下在11个月内接受了血脂复查。这排除了试图将LDL-C进一步降至70 mg/ml以下的那些患者。在这9,200例患者中，“血脂复查很可能并不伴随任何临床举措”，因此是多余的。

共有34%的血脂复查是在前一次检查后6个月内进行的，80%是在9个月内进行的。复查结果与前一次检查结果“非常相似”，这也表明“并不是因为用药或治疗性生活方式干预的改变而复查血脂”。

一项纳入其中13,114例具有最佳LDL-C水平(＜70 mg/dl)患者的敏感性分析显示，62%的患者接受了血脂复查，表明这种多余的检查在此类患者中也是司空见惯的。

该研究还显示，合并高血压或糖尿病的患者最可能接受血脂复查，提示“医务人员有对病情复杂患者实施更多实验室检查的倾向”，而且反映出医务人员更愿意对此类患者进行综合性实验室检查(包含血脂检查)而不是针对某个临床问题进行检查(例如在评估糖尿病控制情况时仅检查糖化血红蛋白指标)。

这项研究的局限性在于，女性、少数族裔受试者所占比例较低，因此研究结果可能无法外推至这些人群。

Virani医生报告称无相关利益冲突，一名合著者报告称与多家药企有关联。

随刊述评：医疗资源的浪费

Chesterfield创新治疗中心的Joseph P. Drozda Jr.博士在随刊述评中指出，这项构思巧妙的研究“传递给我们一个重要信息，即医疗系统中可能存在一种普遍的浪费，然而由于其费用很低而未被我们注意到” (JAMA Intern. Med. 2013 July 1 [doi: 10.1001/jamainternmed.2013.6808])。他强调：“要想显著降低医疗支出，就必须在这类单价低但数量大的检查或操作项目上减少浪费。”


Joseph Drozda博士

Drozda博士报告称无相关利益冲突。

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By: MARY ANN MOON, Cardiology News Digital Network

As many as one-third of patients with coronary heart disease who have met target low-density lipoprotein cholesterol levels undergo repeat lipid testing within months, without any further intensification of treatment, according to a large analysis published online July 1 in JAMA Internal Medicine.

Such patients are already being treated aggressively, and repeat lipid testing in them likely represents an overuse or waste of health care resources, said Dr. Salim S. Virani of the Health Policy and Quality Program, Michael E. DeBakey VA Medical Center Health Services Research and Development Center of Excellence, Houston, and his associates.
 
In a study involving nearly 28,000 CHD patients who made a primary care visit to a Veterans Affairs medical center or community-based outpatient clinic during a 1-year period, 12,686 such "redundant" lipid panels were performed at an average cost of about $16 each. "This is equivalent to $203,990 in annual costs for one VA network, and does not take into account the cost of the patient’s time to undergo lipid testing and the cost of the provider’s time to manage these results and notify the patient," the investigators said.

"Our results highlight areas to target for future quality improvement initiatives," they noted.

In the study, Dr. Virani and his colleagues identified 27,947 patients with CHD who were taking a variety of lipid-lowering medications and who had attained the guideline-recommended low-density lipoprotein (LDL) cholesterol target of less than 100 mg/dL. The mean age of these study subjects was 73 years, and most were white men. The prevalence of hypertension was 86%, and that of diabetes was 44%.

The study subjects had well-controlled lipid levels, with excellent mean baseline levels of LDL cholesterol (70 mg/dL), non-HDL cholesterol (94 mg/dL), triglycerides (123 mg/dL), and HDL cholesterol (43 mg/dL). Most (72%) were taking statins.

A total of 9,200 underwent repeat lipid panels within 11 months, without any intensification of their treatment. This ruled out any patients who might have been attempting to reach an even lower LDL cholesterol target of less than 70 mg/dL.

In these 9,200 patients, "it is likely that repeat lipid testing was performed without any clinical action," and therefore was redundant, the researchers said (JAMA Intern. Med. 2013 July 1 [doi: 10.1001/jamainternmed. 2013.8198]).

A total of 34% of the repeat lipid tests were done within 6 months of an index test, and 80% were done within 9 months. Their results were "strikingly similar" to those of the index lipid panels, which also "argues against major medication or therapeutic lifestyle changes as the drivers of repeat lipid testing."

A sensitivity analysis involving a subset of 13,114 patients who had optimal (below 70 mg/dL) LDL levels showed that 62% underwent repeat lipid testing, confirming that redundancy was commonplace even in these patients.

Patients who had concomitant hypertension or diabetes were the most likely to undergo repeat lipid panels, which "points toward a tendency of health care providers to order frequent laboratory testing in complex patients. Frequent lipid testing in these patients likely represents providers’ practice to order comprehensive laboratory tests (including lipid levels) rather than focusing on one clinical issue (e.g., ordering only glycated hemoglobin measurement to assess diabetes control)," Dr. Virani and his associates said.

"Repeat lipid testing likely provides a sense of comfort to the providers that they are being vigilant in following up on their patients with CHD, although a repeat lipid panel may not be indicated," they added.

Their study was limited in that it included few women, and minority races/ethnicities were underrepresented. The findings therefore may not be generalizable to these groups, the investigators said.

Dr. Virani reported no financial conflicts of interest; one of his associates reported ties to numerous industry sources.

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Wasteful use of health care resources

This well-conceived study "delivers an important message regarding a type of waste that is likely widespread in health care and that goes under the radar because it involves a low-cost test," said Dr. Joseph P. Drozda Jr.

"It is precisely these low-cost, high-volume tests and procedures that need to be addressed if significant savings from reduction of waste are to be realized," he noted.

Dr. Drozda is at the Center for Innovative Care in Chesterfield, Mo. He reported no relevant financial conflicts of interest. These remarks were taken from his invited commentary accompanying Dr. Virani’s report (JAMA Intern. Med. 2013 July 1 [doi: 10.1001/jamainternmed.2013.6808]).