Aligning Cholesterol Guidelines, Quality Measures, and Laboratory Testing

Based on data from the Family Heart Foundation , less than 30% of high-risk Americans are reaching their LDL-cholesterol (LDL-C) goals.? This despite the fact that we are in a golden age of lipid lowering with many tools in the LDL-C lowering toolbox to help patients reach their LDL Safe Zone.

In previous LinkedIn articles, I’ve written about the disconnect between current guidelines and performance-based quality measures.? Briefly, the 2018 AHA Cholesterol guidelines are based on LDL-C and measurement of LDL-C as part of a lipid profile in all adults 20 years of age and older is a Class I recommendation:

Additionally, decisions on intensification of therapy for high-risk patients are based on LDL-C and so clearly, measurement of LDL-C should be prioritized.

However, current performance quality measures from NCQA and CMS for patients with ASCVD are not based on LDL-C but rather on statin initiation and persistence.? This reflects alignment with the 2013 AHA cholesterol guidelines which overturned 25 years of precedent and removed LDL-C treatment goals in favor of 4 statin benefit groups.? However, the 2018 AHA cholesterol guidelines introduced the concept of LDL-C “thresholds” for treatment intensification, but this concept of thresholds has never been reflected in the national quality measures.? Hence a fundamental disconnect between guidelines and quality measures.

What about laboratory assessments of lipids?? Do they prioritize LDL-C in a manner consistent with AHA guidelines?? To better determine this, I checked my own lipid profile with four of the major testing companies ( Quest Diagnostics , Labcorp , LetsGetChecked , and Everly Health ) and what I found was concerning.? On the positive side, all 4 companies (2 finger stick and 2 venipuncture) returned results which were very similar.? This consistency between tests is reassuring.? However, none of the companies give any special weight to the reporting of LDL-C in the results:?

1)????? Labcorp

The Labcorp lipid panel includes total cholesterol (TC), triglycerides (TG), HDL-cholesterol, VLDL cholesterol, and LDL-cholesterol.? LDL-C is reported last and with equal prominence to all of the other lipid parameters:

?2)????? Let’s Get Checked

Let’s Get Checked reports TC, triglycerides, HDL, LDL, and the HDL% of total cholesterol, which is a parameter that appears in no guidelines.? LDL-C is reported 4th with no special emphasis:

3)????? Everlywell, part of Everly Heath

Everlywell reports LDL-C, TC, HDL-C, and triglycerides.? While nothing highlights LDL-C as the most important lipid parameter, at least it is listed first – well done.? And kudos to Amgen for partnering with Everlywell to offer free LDL-C screening through “What Is My LDL ”!? Their efforts to raise awareness are appreciated!

4)??????? Quest Diagnostics

Quest lists TC, HDL-C, triglycerides, LDL-C, TC/HDL ratio, and non-HDL cholesterol.? It is concerning that LDL-C is reported 4th with no special emphasis and the inclusion of the TC/HDL ratio is also problematic.? While the concept of ratios was popular in the 1980s and early 1990’s, it is clearly an outdated concept and none of the current cholesterol guidelines are based on ratios.? In our community at the Family Heart Foundation, we have heard from numerous people who were told not to worry about their LDL-C because their ratio was fine….until they had their first heart attack.? The time is long past to retire the concept of ratios.

At the Family Heart Foundation, we seek to be solution-oriented and so when we launched our free screening initiative on Lp(a) Awareness Day, we included LDL-C along with Lp(a) and highlighted it at the top of the report.? For us, this is mission centric.? Our testing partners at Endless Health worked with us to create the custom report below, with LDL-C featured prominently at the top:

Final Thoughts:

More than 200 studies involving over 2 million participants have firmly established the causal role of LDL-C in the atherosclerotic process.? With few high-risk Americans achieving and maintaining adequate LDL-C control, we need to urgently reexamine our approach or we risk realizing Einstein’s definition of insanity.?

Millions of Americans get their lipids tested every year and have their results returned to them directly through apps or from their HCPs.? Depending on the laboratory company, people currently receive a report which includes 4-6 different numbers, with no prioritization or indication that they should be focused on LDL-C.? Some even receive false reassurance that their “ratio” is good and are at low risk despite a high LDL-C.? Could we make things any more confusing?

Aligning treatment guidelines, financial incentives for payers and HCPs (via quality measures), and laboratory testing to prioritize LDL-C control would be a significant step forward.? The current disconnects send mixed signals to all stakeholders in the healthcare ecosystem and limit our ability to save lives and reduce the burden of cardiovascular disease through better LDL-C control.