Readjudication

Assessing Utilization and Perceptions of Advanced Lipid Testing and Coronary Artery Calcium Scanning Among Primary Care and Cardiology Providers

Introduction

The major orientation of Western medicine is focused on the mitigation of cardiovascular disease (CVD) which remains a leading cause of morbidity and mortality. Despite this herculean effort, age-standardized cardiovascular disease has been stagnant since 2010^[1]. Advanced lipid testing, including measurements of apolipoprotein B (ApoB),    Lipoprotein Fractionation, and lipoprotein(a) [Lp(a)], provides a more detailed insight into cardiovascular risk beyond the myopic standard lipid panel. Additionally, the coronary artery calcium (CAC) scan is an inexpensive, non-invasive imaging tool that predicts mortality ^[2]. Despite their potential, the adoption and perceived utility of these tests in clinical practice is significantly heterogeneous among primary care physicians (PCPs), advanced practice providers (APPs), and cardiology specialists. This study aims to evaluate the utilization of these tests and their influence on prescribing decisions among these provider groups.

Research Objectives

1. To assess the frequency of use of advanced lipid testing (ApoB, Lipoprotein fractionation, and Lp(a)) and CAC scanning among PCPs, primary care APPs, cardiologists, and cardiology APPs.
2. To explore differences in test utilization between primary care and cardiology providers.
3. To evaluate providers’ perceptions of the clinical utility of these tests in guiding prescribing decisions for lipid-lowering therapies or other interventions.
4. To identify barriers to the adoption of advanced lipid testing and CAC scanning in clinical practice.

Research Questions

1. How familiar are clinicians with ApoB, Lp(a), lipoprotein fractionation, and CAC scanning?

• What are clinicians’ perceptions of the clinical utility of these tests in risk stratification and management of patients at risk for ASCVD?

• What are the major barriers (e.g., cost, interpretation complexity, perceived guideline ambiguity) to ordering these tests?

• How does utilization vary between cardiologists vs. primary care clinicians, and between MDs/DOs vs. APPs?

Hypotheses

1. Cardiology providers (physicians and APPs) utilize advanced lipid testing and CAC scanning more frequently than primary care providers.
2. Providers who regularly use these tests have different prescribing patterns and decisions compared to those who use them infrequently.
3. Barriers such as cost, access, and lack of familiarity limit the use of advanced lipid testing and CAC scanning, particularly among primary care providers.

Methods

Study Design

A cross-sectional survey study will be conducted using a structured questionnaire distributed to PCPs, primary care APPs, cardiologists, and cardiology APPs in the Indian River Hospital outpatient clinics and relevant surrounding offices.

Population and Sampling

Population:

• Inclusion: Board-certified or board-eligible MDs, DOs, NPs, and PAs practicing in outpatient primary care or cardiology in the United States.

• Exclusion: Clinicians not involved in lipid management or CVD risk assessment.

Survey Instrument:

• A structured, anonymous online questionnaire developed with input from lipidology and cardiology experts.
• Sections will include demographics, practice characteristics, familiarity with tests, perceived utility, ordering behavior, and barriers to use.

Data Collection

• Questionnaire Development: A question survey will be developed, including:
  • Demographic information (age, years in practice, specialty, practice setting).
  • Frequency of ordering advanced lipid tests (ApoB, lipoprotein fractionation, Lp(a)) and CAC scans (never, rarely, sometimes, often, always).
  • Clinical scenarios where these tests are ordered (e.g., high-risk patients, equivocal lipid profiles).
  • Perceived utility of each test in guiding prescribing decisions (e.g., statins, PCSK9 inhibitors, lifestyle interventions) using a 5-point Likert scale.
  • Barriers to test utilization (e.g., cost, insurance coverage, availability, lack of guidelines).
  • Open-ended questions to capture qualitative insights on test utility and barriers.
• Validation: The questionnaire will be pilot-tested with a small group to ensure clarity and reliability.
• Distribution: The survey will be administered electronically via a secure platform with a 4-week response period. Follow-up reminders will be sent at 1 and 3 weeks.
• Ethical Considerations: The study will obtain Institutional Review Board (IRB) approval if deemed necessary. Participation will be voluntary, anonymous, and confidential. Informed consent will be obtained electronically before survey completion.

Data Analysis

• Quantitative Analysis:
  • Descriptive statistics (frequencies, means, standard deviations) to summarize test utilization and demographic data.
  • Chi-square tests or Fisher’s exact tests to compare test utilization frequencies between provider groups.
  • Logistic regression to identify factors (e.g., years in practice, practice setting) associated with test utilization.
  • Analysis of variance (ANOVA) or Kruskal-Wallis tests to compare perceived utility scores across provider groups.

Expected Outcomes

1. Identification of gaps in knowledge and application of advanced lipid testing and CAC scanning.
2. Insights into specialty-specific attitudes that may inform targeted educational interventions or policy changes.
3. Recommendations for improving adoption and integration into routine practice.

Timeline

• Month 1–2: IRB approval, questionnaire development, and pilot testing.
• Month 3–4: Survey distribution and data collection.
• Month 5–6: Data analysis and interpretation.
• Month 7–8: Manuscript preparation and submission to a peer-reviewed journal (e.g., Journal of the American College of Cardiology or American Family Physician).

Possible Costs

• Expected to be minimal, but possible costs could include:
• Survey Platform: $500–$1,000 (e.g., Qualtrics subscription).
• Participant Incentives: If necessary (e.g., $5 gift cards for participants to improve response rates).
• Statistical Software: $500 (e.g., SPSS license or open-source R).

Significance

Understanding how clinicians perceive and utilize advanced lipid testing and imaging tools will help address implementation gaps and align clinical practice with evolving evidence. This research could guide educational efforts, policy development, and guideline dissemination aimed at reducing CVD risk through more precise, personalized care.

References

1. Leah Abrams, Nora Brower, Mikko Myrskylä, Neil Mehta, Pervasive stagnation: flat and increasing cardiovascular disease mortality rates after 2010 across US states and counties, American Journal of Epidemiology, 2024;, kwae414, https://doi.org/10.1093/aje/kwae414
2. Budoff MJ, Hokanson JE, Nasir K, Shaw LJ, Kinney GL, Chow D, Demoss D, Nuguri V, Nabavi V, Ratakonda R, Berman DS, Raggi P. Progression of coronary artery calcium predicts all-cause mortality. JACC Cardiovasc Imaging. 2010 Dec;3(12):1229-36. doi: 10.1016/j.jcmg.2010.08.018. PMID: 21163451.
3. Grundy SM, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. Circulation. 2019;139(25):e1082-e1143.
4. Greenland P, et al. Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals. JAMA. 2004;291(2):210-215.

Survey Tool: