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Although the benefits of treatment guidelines established by the National Cholesterol Education Program (NCEP) are undisputed, achieving compliance is difficult in a typical primary care practice, according to research presented at the Scientific Assembly and Exposition of the American Academy of Family Physicians (AAFP), held September 28–October 1 in San Francisco.
A retrospective review of records from one family practice based in Fort Wayne, Ind., revealed that the Adult Treatment Panel III (ATP III) guidelines, the most recent put forth by the NCEP, are much more difficult to achieve than earlier standards, according to family physician Thomas A. Kintanar, MD.
Kintanar's group includes eight primary care doctors affiliated with Indiana University who practice at three locations.
The guidelines promulgated by ATP II in 1994 call for treatment of LDL
cholesterol when levels are 
130
mg/dl.1 Kintanar's
practice was able to achieve about 90% compliance with ATP II guidelines. But
the more stringent ATP III guidelines are another story.
ATP III guidelines designate low HDL cholesterol as a cardiovascular risk
factor, include a definition of metabolic syndrome—a constellation of
symptoms including insulin resistance, large waist size, high blood pressure,
and dyslipidemia—and encourage aggressive treatment of patients with
risk factors such as diabetes, symptomatic carotid artery disease, or
peripheral vascular
disease.2 Under the
terms of ATP III, patients with type 2 diabetes should be treated for high LDL
cholesterol if levels are 100 mg/dl.
Meeting the tougher clinical standard, Kintanar and colleagues learned, is a tougher nut to crack, with compliance falling to 50–60%.
"It's very frustrating to tally our ATP II and ATP III rates," Kintanar says. "Our compliance rate [with ATP III] was not as satisfactory as we would like it to be. The results were quite disappointing."
In terms of therapies, the review showed that the practice used all lipid-lowering agents on the market, without favoring one over another, Kintanar says.
Further analysis showed that compliance with ATP III guidelines was higher in more recent years, he notes, which suggests "there is a learning curve between ATP II and III guidelines... not only contingent on the attention of the family medicine group, but also being compliant on the part of the patient."
Kintanar says he would like to see compliance rates continue to rise over
time. "Our compliance with ATP III will be revisited," he says.
"I hope we improve, but we still have a ways to go in the
trenches." 
Footnotes
NCEP has tools and resources to help providers improve compliance with high cholesterol treatment goals, including full copies of the ATP III report, quick-reference guides, a risk calculator, and information for patients.
Visit www.nhlbi.nih.gov/guidelines/cholesterol.
References
2. Expert Panel on the Detection, Evaluation, and Treatment of High
Blood Cholesterol in Adults: 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). JAMA 285:2486–2497, 2001.
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