Country-level measures of healthcare systems and economic development are associated with the control of cholesterol levels, an international registry showed.
Among patients with a history of hyperlipidemia, those living in countries with low health system performance and high out-of-pocket expenditures were more likely to have elevated total cholesterol levels, according to Elizabeth Magnuson, ScD, of Saint Luke’s Mid America Heart Institute in Kansas City, Mo., and colleagues.
The findings, the researchers reported online in Circulation: Journal of the American Heart Association, “underscore the importance for countries to maintain, improve, or establish effective surveillance of chronic disease risk factors such as cholesterol levels, while also prioritizing population-based efforts aimed at the prevention and management of chronic diseases.”
Magnuson and colleagues looked at data from the international REACH (Reduction of Atherothrombosis for Continued Health) registry. The current analysis included 53,570 outpatients ages 45 and older from 36 countries. All were at risk for atherothrombosis either because of established disease or risk factors.
Overall, 38% had elevated total cholesterol, defined as 200 mg/dL or higher. The prevalence ranged widely from 24% in Finland to 73% in Bulgaria.
The researchers estimated that 9.3% of that variability could be explained by country-level factors. That figure was higher for the 80% of patients with a history of hyperlipidemia compared with those without such a history (12.1% versus 7.4%).
Country-level factors were associated with the odds of having elevated cholesterol in the patients with a history of high cholesterol only.
In that subgroup, countries in the highest tertile of gross national income or World Health Organization-defined health system achievement had lower odds of elevated cholesterol compared with those in the lower tertiles (P<0.001 for both). In addition, countries in the lowest tertile of WHO-defined health system performance and efficiency and the highest tertile of out-of-pocket health expenditures as a percentage of private health spending had increased odds of elevated cholesterol (P<0.001 for both). The relationship with out-of-pocket spending "is noteworthy," according to the researchers, "because it may reflect an inability or unwillingness on the part of some patients in countries with higher out-of-pocket healthcare expenses to be consistently compliant with prescribed chronic lipid-lowering therapy." They noted that the country-level variation in the control of total cholesterol could be related to differences in guidelines and in the use of specific initiatives aimed at controlling cardiovascular risk factors. Some of the observed associations also could be related to differences in the cutoff for elevated cholesterol. The authors acknowledged some limitations of the analysis, including the inability to draw conclusions about causality from an observational registry, the inclusion of participants who had access to healthcare only, the use of medical records to get information on the use of lipid-lowering therapy, and the lack of information on factors that might affect the use of lipid-lowering medications, such as side effects.
Magnuson reported receiving research grants and honoraria from sanofi-aventis/Bristol-Myers Squibb partnership, and research grants from Eli Lilly, AstraZeneca, and Daiichi Sankyo. Her co-authors reported relationships with a number of companies including Boston Scientific, Abbott Vascular, Edwards Lifesciences, Merck/Schering Plough, Daiichi Sankyo, St. Jude Medical, AstraZeneca, Medtronic, Bristol-Myers Squibb, CV Therapeutics, Datascope, Eli Lilly, Marquet, and sanofi-aventis.
Primary source: Circulation: Journal of the American Heart Association
Source reference: Venkitachalam L, et al “Global variation in the prevalence of elevated cholesterol in outpatients with established vascular disease of three cardiovascular risk factors according to national indices of economic development and health system performance” Circulation 2012; DOI: 10.1161/CIRCULATIONAHA.111.064378.