Ayoub Aya, Akyea Ralph K, L'Esperance Veline, Ayis Salma, Parmar Divya, Durbaba Stevo, Fisher Mark, Patel Riyaz, Harding Seeromanie, Wierzbicki Anthony S, Qureshi Nadeem, Molokhia Mariam
Department of Population Health Sciences, King's College London, London, UK.
Department of Population Health Sciences, King's College London, London, UK; Centre for Academic Primary Care, University of Nottingham, Nottingham, UK.
Lancet. 2023 Nov;402 Suppl 1:S26. doi: 10.1016/S0140-6736(23)02150-5.
Primary dyslipidaemias, including familial hypercholesterolaemia, are underdiagnosed genetic disorders that substantially increase risk for premature coronary artery disease in adults. Early identification of primary dyslipidaemias via lipid clinic referral optimises patient management and enables cascade screening of relatives. Improving the identification of primary dyslipidaemias, and understanding disparities in ascertainment and management, is an NHS priority. We aimed to assess determinants of lipid clinic referral or attendance (LCR) in ethnically diverse adults.
We did a retrospective cross-sectional study using the Lambeth DataNet containing anonymised data from 41 general practitioner (GP) practices in south London. We looked at referral data for adult patients aged 18 years and older from Jan 1, 1995, until May 14, 2018. LCR was the main outcome. We used sequential multilevel logistic regression models adjusted for practice effects to estimate the odds of LCR assessed across six ethnic groups (reference group White) and patient-level factors (demographic, socioeconomic, lifestyle, comorbidities, total cholesterol [TC] >7·5mmol/L, statin prescription, and practice factors). The study was approved by NHS South East London Clinical Commissioning Group (CCG) and NHS Lambeth CCG.
780 (0·23%) of 332 357 adult patients were coded as referred (n=538) or seen (n=252) in a lipid clinic. 164 487 (46·49%) were women (appendix). The fully adjusted model for odds of LCR showed the following significant associations for age (odds ratio [OR] 0·96, 95% CI 0·96-0·97, p<0·001); Black, African, Caribbean, or Black-British ethnicity (0·67, 0·53-0·84, p=0·001); ex-smoker status (1·29, 1·05-1·57, p=0·014); TC higher than 7·5 mmol/L (12·18, 9·60-15·45, p<0·001); statin prescription (14·01, 10·85-18·10, p<0·001); diabetes (0·72, 0·58-0·91, p=0·005); high-frequency GP attendance at seven or more GP consultations in the past year (1·49, 1·21-1·84, p<0·001); high GP-density (0·5-0·99 full-time equivalent GPs per 1000 patients; 2·70, 1·23-5·92, p=0·013). Sensitivity analyses for LCR restricted to familial hypercholesterolaemia-coded patients (n=581) found associations with TC higher than 7·5 mmol/L (4·26, 1·89-9·62, p<0·001), statin prescription (16·96, 2·19-131·36, p=0·007), and high GP-density (5·73, 1·27-25·93, p=0·023), with no significant associations with ethnicity. The relative contribution of GP practices to LCR was 6·32% of the total variance. There were no significant interactions between ethnicity and deprivation, age, or obesity.
While interpretation is limited by the accuracy and completeness of coded records, the study showed factors associated with a higher likelihood of LCR included individuals recorded as having TC higher than 7·5 mmol/L, statin prescription, ex-smoker status, high-frequency GP attendance, and registration at a GP practice with 0·5-0·99 GP density. Patients with increasing age; Black, African, Caribbean, or Black-British ethnicity patients; and patients with diabetes had lower odds of LCR. Finally, the difference in odds of LCR between Black and White patients highlights potential health inequalities.
NHS Race & Health Observatory.
原发性血脂异常，包括家族性高胆固醇血症，是诊断不足的遗传性疾病，会大幅增加成年人患早发性冠状动脉疾病的风险。通过脂质门诊转诊早期识别原发性血脂异常可优化患者管理，并能对亲属进行级联筛查。改善原发性血脂异常的识别，以及了解诊断和管理方面的差异，是英国国家医疗服务体系（NHS）的一项优先任务。我们旨在评估不同种族成年人脂质门诊转诊或就诊（LCR）的决定因素。
我们进行了一项回顾性横断面研究，使用了兰贝斯数据网，其中包含伦敦南部41家全科医生（GP）诊所的匿名数据。我们查看了1995年1月1日至2018年5月14日期间18岁及以上成年患者的转诊数据。LCR是主要结局。我们使用经实践效应调整的序贯多水平逻辑回归模型，来估计在六个种族群体（参照组为白人）和患者层面因素（人口统计学、社会经济、生活方式、合并症、总胆固醇[TC]＞7.5mmol/L、他汀类药物处方以及诊所因素）中评估的LCR几率。该研究获得了NHS伦敦东南部临床委托小组（CCG）和NHS兰贝斯CCG的批准。
332357名成年患者中有780名（0.23%）被编码为在脂质门诊转诊（n = 538）或就诊（n = 252）。164487名（46.49%）为女性（附录）。LCR几率的完全调整模型显示，以下因素与LCR存在显著关联：年龄（优势比[OR]0.96，95%置信区间0.96 - 0.97，p＜0.001）；黑人、非洲人、加勒比人或英籍黑人种族（0.67，0.53 - 0.84，p = 0.001）；既往吸烟者状态（1.29，1.05 - 1.57，p = 0.014）；TC高于7.5mmol/L（12.18，9.60 - 15.45，p＜0.001）；他汀类药物处方（14.01，10.85 - 18.10，p＜0.001）；糖尿病（0.72，0.58 - 0.91，p = 0.005）；过去一年中高频GP就诊（七次或更多次GP会诊）（1.49，1.21 - 1.84，p＜0.001）；高GP密度（每1000名患者中有0.5 - 0.99名全职等效GP；2.70，1.23 - 5.92，p = 0.013）。对仅纳入家族性高胆固醇血症编码患者（n = 581）的LCR进行敏感性分析，发现与TC高于7.5mmol/L（4.26，1.89 - 9.62，p＜0.001）、他汀类药物处方（16.96，2.19 - 131.36，p = 0.007）和高GP密度（5.73，1.27 - 25.93，p = 0.023）有关联，与种族无显著关联。GP诊所对LCR的相对贡献占总方差的6.32%。种族与贫困、年龄或肥胖之间无显著交互作用。
尽管解读受到编码记录的准确性和完整性的限制，但该研究表明，与LCR可能性较高相关的因素包括记录为TC高于7.5mmol/L的个体、他汀类药物处方、既往吸烟者状态、高频GP就诊以及在GP密度为0.5 - 0.99的GP诊所注册。年龄增加的患者；黑人、非洲人、加勒比人或英籍黑人种族患者；以及糖尿病患者的LCR几率较低。最后，黑人和白人患者在LCR几率上的差异突出了潜在的健康不平等。
NHS种族与健康观察站
