Lipid Screening in Pediatrics

Audubon Clinic QI Project

2008-2009

How can we prevent this?

Why screen for high cholesterol?

Cardiovascular disease is the leading cause of death and morbidity in the US

Causes are both genetic and environmental Risk factors in adults have been well studied

– High concentration of low-density lipoprotein (LDL)– Low concentration of high-density lipoprotein (HDL)– Obesity– Elevated blood pressure– Diabetes (Type 1 or Type 2)– Cigarette smoking

But why screen in kids?

National Health and Nutrition Examination Study (NHANES)– collected lipid values in children ages 4-19 from

1988-1994– mean total cholesterol concentration 165 mg/dL– females vs. males:

• higher total cholesterol and LDL• higher HDL (after puberty)

10% of adolescents had total cholesterol > 200!

Johnson et al., Arch Pediatr Adolesc Med, 2009; 163(4): 371-7.

Atherosclerosis in Children

Bogalusa Heart Study

– Autopsies on young people with accidental cause of death– Found prevalence of fatty streaks and/or fibrous plaques by young

adulthood of ~ 70%– Degree of atherosclerosis correlates directly with elevated total

cholesterol, LDL, and TG– Negative correlation with HDL level

PDAY Study (Pathological Determinants of Atherosclerosis in Youth)

– Evaluated 3,000 children age 15-34 who died of accidental causes– demonstrated the presence of early signs of atherosclerosis– showed an association between elevated cholesterol and degree of

pathology (fatty streaks and fibrous plaques)

McGill et al. Circulation. 2001; 103 (11): 1546-1550.Newman et al. N Eng J Med. 1986; 314 (3): 138-144.

AAP Recommendations 2008

Who should we screen?– Children ages 2-10yo– Personal history of hypertension, obesity, smoking, or

diabetes– Family history of dyslipidemia OR premature CVD– Those in whom family history is unknown– Screening should take place at WCCs and if results are

normal, children should be rescreened in 3-5 years

AAP Recommendations 2008 How should we screen?

– Fasting lipid panel recommended

What’s abnormal?– 1992 NCEP Guidelines for total and LDL

cholesterol cut offs in children and adolescents

Category Percentile Total Cholesterol (mg/dL)

LDL (mg/dL)

Acceptable <75th <170 <110

Borderline 75th-95th 170-199 110-129

Elevated >95th >200 >130

Daniels, S. et al. Lipid Screening and Cardiovascular Health in Childhood. Pediatrics 2008: 122; 198-208

AAP Recommendations 2008 What do we do with an elevated lipid level?

– Counseling on nutrition and physical activity– Consider pharmacologic intervention if above age 8

and:• LDL ≥ 190• LDL ≥ 160 with positive family history of early CVD• LDL ≥ 130 with diabetes mellitus

What is the goal of treatment?– Lower LDL to below 160, or even lower (<110 or

<130) in the presence of family history, obesity, diabetes, or other risk factors

Our project

A chart review was completed on 50 patients with at least 3 visits to the Audubon practice to determine the percentage of children screened by 10 years of age– 72% had been screened for cholesterol by their

10th birthday

AIM Statement: By the end of the academic year 2008-2009 we aim to increase cholesterol screening in children, 2-10 years of age, within the Audubon Practice from 72 to 95%

Questions and Concerns

What criteria would we use for screening?

Would providers remember the criteria for ordering bloodwork?

Would it be easier to associate the 4yo visit with lipid screening instead of starting at 2yo?

How would we screen? Would using a non-fasting total cholesterol be easier than using a fasting lipid panel?

However, how accurate is random total cholesterol as a screening test?

Based on our results, what follow up bloodwork would we do, what treatment would we implement and to whom would we refer?

Conversations with Dr. Starc

Non-fasting total cholesterol would be the preferred method of screening in a child without significant risk factors

Both a non-fasting total cholesterol and a non-fasting HDL could be obtained for those children with risk factors

Fasting total cholesterol and HDL with subsequent LDL calculation would be a better screening method in children with risk factors

Referrals to nutrition for dietary counseling would be appropriate after obtaining an abnormal screen

Revised Methods AIM Statement: By the end of the academic year

2008-2009 we aim to increase cholesterol screening in children, 4–10yo, within the Audubon Practice from 72 to 95%

– Screening criteria for all 4-10 year olds:

• BMI >85%ile • Blood Pressure > 95%ile• Family History of CVD in men <55yo or women < 65yo or dyslipidemia

OR unknown FHx

– Non-fasting total cholesterol (HDL for those with risk factors)– Those with total cholesterol >170 +/- HDL <40 will return for fasting lipid

panel and should receive dietary counseling through nutrition referral– Those with TC <170, but normal HDL will also receive dietary counseling– All normal screens would get re-screened in 3-5 years

New AAP Policy Statement published!

Fasting lipid panel is the preferred method of screening

PDSA #1 P:P: Screen all 4-10yo who fit the criteria

using fasting lipid profiles D:D: Fasting lipid profiles pre-ordered in

Eclipsys, families asked to return for bloodwork, and patient info recorded for data collection

S:S: 41% (9/22) returned for bloodwork A:A: How could we improve?

– Appointment forms for families– Stickers on all computers as reminders to

providers of criteria for screening– Involvement of nutrition for follow up

QuickTime™ and a decompressor

are needed to see this picture.

PDSA #2 P:P: All pts 4-10yo who fit the criteria referred to

nutritionist regardless of whether they return for bloodwork

D:D: Appointment forms given to all families instructing them why and when to return for fasting bloodwork and referrals to nutrition made

S:S: 30% (6/20) returned for bloodwork and 1 pt followed up with nutrition

A:A: How could we improve?– New red reminder sheets in all rooms stating specific

criteria for screening and what to do after ordering labs

– Eliminate need to return for fasting bloodwork by obtaining random total cholesterol and HDL at WCC

– Increase efficiency of getting children to see nutrition– Provide a list of neighborhood activities

PDSA#3 P:P: 1) Obtain non-fasting TC & HDL;

call families to return for fasting lipid panel if results are abnormal

2) If BMI > 85%ile, refer to nutrition and give list of neighborhood activities

3) Nutritionist to see patient immediately after encounter

4) BMI percentile charts and blood pressure charts posted in conference room to facilitate screening process

D:D: Above screening and referrals performed and red forms distributed during a Friday clinic session

S:S: 50% (6/12) of patients were screened and seen by nutrition the same day

The number of activity lists provided could not be assessed

Final Results180 EMRs reviewed

34 patients fit screening criteria (61%)

Bloodwork ordered on 23/34 patients (68%)

Only 13/56 (23%) had FH documentation in the EMR

follow up notes

1 pt with HTN (referred to cards)

All with BMI > 85%ile

13 pts with FH risk factors or unknown FH

All had EMR documentation of dietary

counseling

11 fasting lipid panels

12 TC and HDL

6/23 returned for bloodwork

(26%)

4 with TC > 170

4 with HDL < 40

1 with LDL > 110

11 pts referred to nutrition

11/23 pts followed up with nutrition

56 patients ages 4-10yo

Challenges

Providers need constant reminders of the criteria for screening

Providers forget to screen altogether

No dedicated section in EMR follow up notes for family history, so even though providers may be asking about FH, they are not documenting it at every visit

Difficulty in screening using BMI percentiles when these values do not appear in Eclypsis flowsheet (only on growth charts)

Families often do not return for fasting bloodwork or nutrition appointments

List of affordable neighborhood activities needs to be made available in both English and Spanish

Future Directions Establish universal screening criteria among all ACN clinics

Changes to the EMR– Provider is prompted to order bloodwork when any of the screening criteria is

entered via check box or flowsheet– BMI percentiles to accompany BMI in flowsheet data set– Creation of a dyslipidemia screening section like the asthma section, but only

for 2-10yo– Dedicated section for updating family history in each follow up note– Trial of age based order prompts for lipid screening

Providing affordable and available resources for treatment– Nutrition appointments on the same day as fasting bloodwork drawn– List of neighborhood activities translated into Spanish to be made available to

all populations at risk (currently in progress with Martha Bolivar and Oscar Pena)

The Audubon Team

Attendings: Larry Williams, Val Niketakis, Christine Krause, Amy Lief, Connie Kostacos, Nikki Timko, Betsy Wedemeyer, Daryl Wisler, Omolara Thomas, Karen Soren, Betsy Pfeffer

Residents: Emily, Tania, Yaffa, Alexa, Bram, Amie, Jason, Alanna, Josh, Zoe, Tal, Mithila, Melissa, Aarti, Janienne, Michele, Annika, Daniel, Lauren, Aki, Matt, Neha

Nurses: Vicki, Tina, Estella, Diana, Jasmine, Adora, Theresa, Kim

MAs: Theresa, Hassie, Jean, Yvette, Jessie, Stacey, Doreen PFAs: Marie, Yahaira, Alfred, Kecia, Xavier, Jennifer, Roxanne,

Vivian

Thanks to Dr. Starc, Mariellen Lane and all the other ACN Clinics

References1) McGill et al. Circulation. 2001; 103 (11): 1546-15502) Newman et al. N Eng J Med. 1986; 314 (3): 138-1443) Daniels, S. et al. Lipid Screening and Cardiovascular Health in Childhood. Pediatrics 2008: 122; 198-

2084) Haney EM, Huffman LH, Bougatsos C, et al. Screening for lipid disorders in children and

adolescents: systematic evidence review for the U.S. Preventive Services Task Force. Evidence Synthesis Number 47. Prepared for the Agency for Healthcare Research and Quality (AHRQ) by the Oregon Evidence-based Practice Center, Portland, Oregon, under Contract Number 290-02- 0024. AHRQ Publication No. 07-0598-EF-1. July 2007

5) Freedman DS, Shear CL, Srinivasan SR, Webber LS, Berenson GS. Tracking of serum lipids and lipoproteins in children over an 8-year period: the Bogalusa Heart Study. Prev Med. 1985;14(2):203-216.

6) National Cholesterol Education Program. Highlights of the report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Pediatr. 1992;89(3):495-501.

7) Kavey RE, Daniels SR, Lauer RM, et al. American Heart Association guidelines for primary prevention of atherosclerotic cardiovascular disease beginning in childhood. Circulation. 2003 Mar 25;107(11):1562-6.

8) McCrindle BW, Urbina EM, Dennison BA, et al. Drug therapy of high-risk lipid abnormalities in children and adolescents: a scientific statement from the American heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee, Council of Cardiovascular Disease in the Young, with the Council on Cardiovascular Nursing. Circulation. 2007;115:1948- 1967. Epub 2007 Mar 21.

9) Johnson et al., Arch Pediatr Adolesc Med, 2009; 163(4): 371-7.