| Citation |
|
Management
of Dyslipidemia in the Primary Care Setting. Washington, DC: VA/DoD
Clinical Practice Guideline Working Group, Veterans Health Administration,
Department of Veterans Affairs and Health Affairs, Department of Defense,
October 2001. Office of Quality and Performance publication 10Q-CPG/Lipids-01. |
| Completion Date:
|
|
August 2001 |
| Release Date:
|
|
September 2001 |
| Source(s):
|
|
Washington
(DC): The Guideline for the Management of Dyslipidemia in the Primary
Care Setting was developed by and for clinicians from the Department
of Veterans Affairs (VA) and the Department of Defense (DoD); 2001. |
| Adaptation: |
|
The guideline draws, in part, from :
- Executive summary of the third report of the National Cholesterol
Education Program (NCEP) expert panel on the detection, evaluation,
and treatment of high blood cholesterol in adults (Adult Treatment
Panel III). (2001). Journal of the American Medical Association.
285(19), 2486-2497.
- Summary of the second report of the national cholesterol education
program (NCEP) expert panel on detection, evaluation, and treatment
of high blood cholesterol in adults. Journal of the American Medical
Association. 269, 3015-3022.
- The U.S. Preventive Services Task Force Guide to Clinical Preventive
Services. Second Edition 1996:15-38.
|
| Guideline Status:
|
|
This is the
current version of the guideline. An update is targeted for 2003.
|
| Developer(s):
|
|
Veterans Health
Administration (VHA), Department of Veterans Affairs (VA) - Federal
Government Agency [U.S.]
Department of Defense (DoD) - Federal Government Agency [US] |
| Funding Source: |
|
United States Government
|
| Committee: |
|
The Management of Dyslipidemia
Working Group |
| Group Composition: |
|
The
list of contributors to this guideline includes nurses, cardiologists,
endocrinologists, internal medicine and primary care physicians, pharmacists,
dieticians and experts in the field of guideline and algorithm development.
|
| Disease Condition: |
|
Dyslipidemia
|
| Category: |
|
Assessment,
Diagnosis, Treatment, Management
|
| Intended Users:
|
|
Clinical Staff
including Physicians; Nurses; Nurse Practitioners; Physician Assistants |
| Target Population:
|
|
Any person with
dyslipidemia who is eligible for care in the VA or DoD health care
delivery system. |
| VHA Contact
Person(s): |
|
VHA :
C. Bernie Good, MD
Associate Professor of Medicine
Pittsburgh VAMC
University Drive C
Pittsburgh, PA 15240
412-688-6113
412-688-6916 (fax)
Chester.good@med.va.gov
|
DoD:
Stephen A. Brietzke, Col, USAF, MC
Consultant for Endocrinology
Department of Medicine USUHS
4301 Jones Bridge Rd.
Bethesda, MD 20814
301-295-3609
301-295-3557 (fax)
sbrietzke@mxa.usuhs.mil |
GOALS/OBJECTIVES
- To describe the
critical decision points in the management of dyslipidemia
- To provide a clear and comprehensive guideline
incorporating current information and practices for practitioners
throughout the DoD and Veterans Health Administration system
- To improve local management of patients
with dyslipidemia and improve patient outcome
|
INTERVENTIONS
AND PRACTICES
The Guideline is a single module, which address
three aspects of lipid-related care:
-
Algorithm, page 1 Dyslipidemia Screening
-
Algorithm, page 2-3 Management of Dyslipidemia
in Primary Care: Primary Prevention
-
Algorithm, page 4 Management of Dyslipidemia
in Primary Care: Secondary Prevention
This guideline also contains appendices that provide more information
on the spectrum of treatment options, and give details on pharmacologic
and other interventions.
-
Appendix 1. Medical Nutrition Therapy
-
Appendix 2. Exercise
-
Appendix 3. Drug Interactions with Bile
Acid Resins, Fibrates, and Niacin
-
Appendix 4. Drug Therapy Summary
-
Appendix 5. Required Percent LDL-C Reductions
to Meet Goals
-
Appendix 6. Drug Selection Based Upon Required
LDL-C Reduction
-
Appendix 7. Costs for Dyslipidemia Drug
Therapy
|
OUTCOMES
CONSIDERED
Rate and degree of progression of dyslipidemia.
|
MAJOR
RECOMMENDATIONS
Presentation of the algorithms is intended to
assist the clinician in reviewing and identifying key points that
are comprehensively discussed in the guideline document.
|
|
CLINICAL ALGORITHMS
A single module, which
address three aspects of lipid-related care, is provided for the
Management of Dyslipidemia in Primary Care
|
TYPE
OF EVIDENCE
The guideline is supported by the literature
in a majority of areas, with evidence-based tables and references
throughout the document. The evidence consists of key clinical randomized
controlled trials and longitudinal studies in the area of dyslipidemia.
Where existing literature is ambiguous or conflicting, or where
scientific data are lacking on an issue, recommendations are based
on the expert panel's opinion and clinical experience. The guideline
contains a bibliography and discussion of the evidence supporting
each recommendation.
|
DESCRIPTION
OF METHODS TO COLLECT EVIDENCE
The literature supporting the decision points
and directives in this guideline is referenced in Evidence Tables
and Discussions. The working group leaders were solicited for input
on focal issues prior to a review of the literature. A search was
carried out using the National Library of Medicine's (NLM) MEDLINE
database. Electronic searches of the Cochrane Controlled Trials
Register (www.update-software.com) were undertaken. Papers selected
for further review were those published in English-language peer-reviewed
journals between 1994 and 1999. Preference was given to papers based
on randomized, controlled clinical trials, or nonrandomized case-control
studies. Studies involving meta-analyses were also reviewed.
Selected articles were identified for inclusion in a table of
information that was provided to each expert participant. The
table of information contained: Title, Author(s), Publication
type, Abstract and Source. Copies of these tables were made available
to all participants. In addition, the assembled experts suggested
numerous additional references. Copies of specific articles were
provided to participants on an as-needed basis. This document
includes references through the year 2001. More recent information
will be included in the next guideline update.
|
METHODS
TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE
Evidence-based practice involves integrating clinical expertise
with the best available clinical evidence derived from systematic
research. The working group reviewed the articles for relevance
and graded the evidence using the rating scheme published in the
U.S. Preventive Services Task Force (U.S. PSTF) Guide to Clinical
Preventive Services, Second Edition (1996), displayed in Table
1. The experts themselves formulated Quality of Evidence (QE)
ratings after an orientation and tutorial on the evidence grading
process. Each reference was appraised for scientific merit, clinical
relevance, and applicability to the populations served by the
Federal health care system. The QE rating is based on experimental
design and overall quality. Randomized controlled trials (RCT)
received the highest ratings (QE=I), while other well-designed
studies received a lower score (QE=II-1, II-2, or II-3). The QE
ratings are based on the quality, consistency, reproducibility,
and relevance of the studies.
Table 1. Quality of Evidence
Rating Scheme (U.S. PSTF, 1996)
| I |
Evidence is obtained from at
least one properly randomized controlled trial. |
| II-1 |
Evidence is obtained from well-designed
controlled trials without randomization. |
| II-2 |
Evidence is obtained from well-designed
cohort or case-control analytic studies, preferably from more
than one center or research group. |
| II-3 |
Evidence is obtained from multiple
time series with or without the intervention. Dramatic results
in uncontrolled experiments could also be regarded as this type
of evidence. |
| III |
Opinions of respected authorities
are based on clinical experience, descriptive studies in case
reports, or reports of expert committees. |
The U.S. PSTF grading process suggests assigning
a second grade that reflects the strength of the recommendation
(SR) for each appraised study, and this grading system was also
used by the dyslipidemia experts to develop recommendations.
The SR (displayed in Table 2) is influenced
primarily by the significance of the scientific evidence. Other
factors that were taken into consideration when making the SR determination
are standards of care, policy concerns, and cost of care.
Table 2: Strength of Recommendation
(SR)
| A |
There is good evidence to support
the recommendation that the condition be specifically considered. |
| B |
There is fair evidence to support
the recommendation that the condition be specifically considered
|
| C |
There is insufficient evidence
to recommend for or against the inclusion of the condition,
but a recommendation may be based on other grounds. |
| D |
There is fair evidence to support
the recommendation that the condition be excluded from consideration
|
| E |
There is good evidence
to support the recommendation that the condition be excluded
from consideration |
|
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