Study identifies substantial over- and underuse of lipid testing

Cholesterol levels have long been associated with heart disease. And cholesterol tests (known in the medical world as lipid tests) are a routine part of preventive care to determine whether a person’s levels are too high. But are patients actually being tested appropriately?

Guidelines from the U.S. Preventive Services Task Force (USPSTF) recommend that clinicians order routine cholesterol tests for these groups:

• Men, beginning at age 35; and
• Men age 20–34, and women age 20 and older, only if they are at increased risk: diabetes, hypertension, tobacco use, obesity, previous personal history of cardiovascular (heart or blood vessel) disease, or a family history of early cardiovascular disease.

In this era of increasing health care costs, much attention has been paid to the risks and costs of unnecessary testing—such as for breast, colon, and prostate cancers—but no one has looked at possible overuse of routine cholesterol tests in people who are at low risk for cardiovascular disease.

Too much testing, and too little

Group Health researchers set out to bridge this gap.  They examined the records of adult Group Health patients without a prior history of cardiovascular disease to see how often they were prescribed cholesterol tests, given their risk factors for cardiovascular disease.

In most cases, providers are ordering the cholesterol testing that the guidelines say the patients should receive. But the research team found room to improve care:

• Among those who did not meet USPSTF criteria for testing, around 36 percent of men and 62 percent of women received at least one lipid test in the prior five years; and approximately 8 percent of the men and 24 percent of the women had two or more tests.
• On the flip side, among individuals at moderate and high risk (not already treated with cholesterol-lowering drugs), and for whom screening is recommended, between 21.4 percent and 25.1 percent had not received a screening test in the past five years.

“Other health systems are likely to have similar issues,” said Beverly Green, MD, MPH, a Group Health Physician and GHRI associate investigator. “These findings can lead the way to improve care for Group Health members—and people everywhere.”

The researchers point out that providers may be ordering tests because some patients ask for them, or perhaps because some patients make frequent visits and are entering old age. Risk calculators are available to determine who should be tested, but physicians may find these tools difficult to use. It is time-consuming for providers to retrieve the results manually in the middle of office visits. And the results can be challenging for patients to understand.

“While lipid testing is relatively inexpensive, there may be downstream consequences, particularly for those at low risk, such as potential distress over an abnormal value, or the time clinicians use to explain results,” the researchers conclude.

With Robert Reid, MD, PhD; Melissa Anderson, MS; Paul Fishman, PhD; Jennifer McClure, PhD; Ron Johnson, MA; and Sheryl Catz, PhD, Dr. Green published Relationship between cardiovascular risk and lipid testing in one health care system: a retrospective cohort study in BMC Health Services Research.

by Casey Luce, MSPH
Casey Luce is a project manager at Group Health Research Institute.