Naumberg EH, Franks P, Bell B, Gold M, Engerman J.
Racial differences in the identification of hypercholesterolemia.
J Fam Pract 1993;36(4):425-30.

Given the importance of “identifying cardiovascular risk factors in populations known to be at high risk,” this study sought to “examine the factors affecting screening for and diagnosis of hypercholesterolemia in a family practice setting.” The Family Medicine Center, located in Rochester, NY, is an outpatient training site for a family medicine residency program. The staff is composed of 30 residents, 9 faculty and fellows, and 8 nurse practitioners. The data for this study was collected prospectively on all adult patients over 18 years of age who visited the center during the period from December 15, 1988 to April 15, 1990. Race was recorded for 77.8% of the sample, of which 22.9 % were minorities (80.0% were African American, 4.2% were Hispanic, and 15.9% were other racial minority). The patients were designated as “hypercholesteromic” if the “diagnosis had been coded on the encounter form and there was any cholesterol value included in the database.”

The demographic analysis of the sample revealed that “a higher percentage of identified minorities were likely to be women, have Medicaid, be younger, have more cardiovascular risk factors, and have made slightly more visits” to the center. Despite having more cardiovascular risk factors, “minorities were less likely to have had their cholesterol checked, with an adjusted odds ratio (AOR) of 0.84 (95% CI = 0.98 to 0.72).” Furthermore, “multivariate analysis restricted to those with serum cholesterol values greater than 240mg/dL” revealed that “minorities were less likely to have the diagnosis of hypercholesterolemia (AOR = 0.47, 95% CI = 0.28 to 0.78).”

The evidence suggests “that cholesterol screening is given lower priority in minorities, persons with Medicaid, or persons with no insurance.” In conclusion, the findings of this study indicate that “despite the heightened attention applied to cholesterol,” the “specific health needs of African Americans are unmet for reasons other than structural barriers to health care and sociodemographic factors.”

The authors state that “the lower rate of screening and diagnosis in the group of patients with higher cardiovascular risk may be partly explained by visits focused on other acute health care needs.” However, “it remains the physician’s responsibility…to insure that the patient receives optimal preventive care.” Although “patient, physician, and institutional factors may influence whether screening occurs…once the necessary data are obtained, diagnosis of the disease is the physician’s responsibility.” The authors conclude that “the underdiagnosis of hypercholesterolemia in minority patients suggests a difference in the behavior of health care providers toward white patients compared with African American patients.”

A limitation of the study is that data was collected from encounter forms completed by the staff. An approach that “does not provide a uniform measure of physician behavior.”

Given that (1) “hypercholesterolemia has gained acceptance as an appropriate risk factor to screen for and treat,” (2) “studies show that physician diagnosis and treatment of elevated cholesterol levels has grown,” and (3) “African-Americans have an increased risk for cardiovascular disease;” it is a disturbing finding that this high-risk group is less likely to be tested for this risk factor and, upon screening, will less likely be given an appropriate diagnosis. This “underdiagnosis of hypercholesterolemia” in the African-American population, which is “at increased cardiovascular risk” will “contribute to ongoing increased mortality.” Furthermore, as the authors note, this “reverse targeting” (i.e. “patients who are at increased risk are less likely to be screened”) demonstrates “pervasive biases in the provision of health care for socioeconomically disadvantaged groups.”