Study Finds Inconsistencies in Management of Cardiovascular Disease in Pediatric Diabetes Patients

Zijing Guo, MPH

Childhood risk factors for cardiovascular disease and associated high cholesterol and high blood pressure are significantly increased in pediatric patients with type 1 diabetes mellitus (T1D).

A new survey lead by Michelle Katz, MD, MPH, a Joslin Diabetes Center pediatric endocrinologist, has determined that in many cases clinicians are not prescribing antihypertensive and LDL lowering medications according to clinical guidelines set forth by the American Diabetes Association (ADA), American Heart Association (AHA), and other professional organizations such as the National Heart, Lung, and Blood Institute (NHLBI). The inconsistencies in treatment, Katz and colleagues state, suggest more efforts are needed to "align clinical practice with clinical guidelines."

To gauge adherence to clinical treatment guidelines, Katz and colleagues, including Zijing Guo, MPH, distributed a 33-item anonymous electronic survey using a 3-point Likert scale (rarely/sometimes/often) and additional open response option. The survey, Katz writes, was developed by "pediatric endocrinologists with input from a multidisciplinary team, including physicians, nurse practitioners, nutritionists, and mental health professionals, all with pediatric type 1 diabetes expertise."

The survey's goal was to determine how current management of high cholesterol and high blood pressure (BP) in pediatric T1D patients compares with commonly referenced guidelines.

The survey was distributed to 1361 members of the ADA Diabetes in Youth interest group, 1368 members of the Pediatric Endocrine Society, and 754 pediatric providers from the T1D Exchange. Of the 207 respondents, demographic data showed that 95% were centered in the US, 86% were physicians, and 2/3 of respondents were involved in practices treating over 500 pediatric (0-25 years) T1D patients.

Data showed that evaluation of hypertension in pediatric patients with T1D varied among surveyed providers. Katz noted that "many did not perform an extensive workup" during evaluation, with low numbers of respondents reporting use of renal ultrasound scans (13%), 4-extremity BPs (9%), or cardiac ultrasound scans (7%).

Data also showed that respondents "overwhelmingly endorsed lifestyle modification as their initial recommendation for confirmed primary hypertension or hyperlipidemia" for pediatric T1D patients in their care, and that 80% of respondents recommended "counseling on healthy eating, increasing physical activity, and losing weight (if patient was overweight/obese)."

Katz and colleagues report that ≥95% of surveyed respondents also recommended improvements to glycemic control. Data showed that respondents were mixed on their tendency to refer patients to specialists for hypertension (57%) or to a lipid specialist (8%).

Endorsement of medications to treat hypertension or hyperlipidemia was likewise mixed among respondents. Katz and colleagues report that 21% of all respondents endorsed never prescribing medication for BP, 73 % endorsed prescribing medication only when lifestyle changes were not effective, and 64% endorsed prescribing medication only when other CVD risk factors were present.

Katz and colleagues reported that survey respondents also indicated "a number of perceived barriers to effective hypertension or hyperlipidemia management" that included patient-centered barriers to adopting recommended lifestyle changes (lack of patient motivation, insufficient patient support, lack of patient confidence). Ultimately, despite the fact that 80% of the respondents surveyed said lifestyle changes were the primary recommendation for patients, those respondents judged that lifestyle changes were effective for patients less than 10% of the time.

Data collected on provider familiarity with practice guidelines and medication guidelines revealed that age of provider and recentness of training were factors. Katz reported that providers who completed training <10 years ago vs ≥10 years ago more commonly endorsed lack of familiarity with practice guidelines (22% vs 7%), lack of expertise prescribing medication (35% vs 13%), and concerns about patient adherence (44% vs 24%) as barriers to managing HTN or hyperlipidemia. Data on providers ≤45 years old vs >45 years old showed a similar pattern: lack of familiarity with practice guidelines (21% vs 7%,) and lack of expertise prescribing medication (30% vs 16%) as barriers to managing HTN or hyperlipidemia.

Katz and colleagues believe that the survey data revealed some concerning information, among which are a lack of guideline-recommended diagnostic evaluations, a lack of adherence to guidelines on treatment for hypertension and hyperlipidemia, and a general discomfort among providers to prescribe medications based on ADA, AHA, and NHLBI guidelines.

Katz writes that "our findings suggest providers inconsistently follow practice guidelines, especially with regard to medication initiation and titration," adding that some of that inconsistency may be the result of a lack of "harmony" among some of the guidelines put forth by various groups. The researchers recommend that more education on treatment guidelines should be offered at professional conferences and through "virtual education efforts" to create greater consistency in diagnosis and treatment for pediatric T1D patients with hypertension and hyperlipidemia.

The study, "Management of Hypertension and High Low-Density Lipoprotein in Pediatric Type 1 Diabetes," appeared in The Journal of Pediatrics in February.