Tables
Table 1. Deaths Prevented or Postponed and Life-Years Gained Attributable to Cholesterol-Related Factors, 2000a
| Factor |
Deaths Prevented or Postponed |
Life-Years Gained |
| Statin treatment |
28,785 |
249,125 |
| Reduction in the prevalence of high cholesterol |
82,800 |
1,102,100 |
| Total |
111,585 |
1,351,225 |
a Source: Capewell et al (5). Data from Ford et
al (4) were used to calculate the deaths prevented or postponed and life-years
gained that were attributable to treatment with statins.
Table 2. Benefits of Life-Years Gained From the Lipid Standardization Program (LSP) and Cholesterol Reference Method Laboratory Network (CRMLN)a
| Estimates |
Benefits, $ (Millions) |
| % Attributable to the LSP and CRMLN |
Life-Years Gained |
$50,000 per Life-Year |
$113,000 per Life-Year |
$300,000 per Life-Year |
| 0.5 |
6,756 |
338 |
763 |
2,027 |
| 1 |
13,512 |
676 |
1,527 |
4,054 |
| 5 |
67,561 |
3,378 |
7,634 |
20,268 |
a Benefits calculated as the share of cholesterol-related benefits attributable to the programs
multiplied by the share of life-years gained that is attributable to cholesterol-related factors
multiplied by the value of a life-year.
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Appendix
The following is an excerpt from: Hoerger TJ, Wittenborn JS, Couper S. Lipid
standardization program: cost-benefit analysis: final report. Research Triangle
Park (NC): RTI International; 2010.
3.1
Short-Term Outcomes: Improvements in Laboratory Standardization for Cholesterol
Testing
The immediate outcome of improved lab standardization and manufacturer
certification is an increase in the accuracy of cholesterol testing. The
intention of the CDC lipid standardization programs is to improve the accuracy
and comparability of research-related testing, primarily through the Lipid
Standardization Program (LSP), and to improve the accuracy of general clinical
tests directly through the Cholesterol Reference Method Laboratory Network
(CRMLN). There is strong evidence that laboratory performance on cholesterol
testing has improved through standardization during the past 25 years, although
it is difficult to say how much of the improvement has been due to the LSP and
CRMLN.
3.1.1 Accuracy of LSP Standardized
Laboratories
The goal of the LSP is to ensure that member labs exhibit consistent accuracy
in lipid testing over time. Early lipid testing was subject to significant
levels of error and bias, so initial efforts of the LSP focused on improving the
accuracy of lipid testing through the development and establishment of reference
testing methods. As standardization was achieved, the LSP focus turned to
maintaining accuracy of lipid testing. Table 3-1 shows the percentage bias and
coefficient of variation (CV) of LSP standardized labs (based on part III
standardization maintenance surveys among newly enrolled labs that entered the
program in each year) since electronic recordkeeping began in 1999. The results
show that average bias levels have remained below 2% from 1999 through 2007 and
have decreased by 0.7% percentage points over that time period. Labs are
considered standardized if neither their percentage bias nor their CV exceeds
3%. Over that same period, less than 10% of surveys exhibited a bias of more than 3% except in 1999 and 2001, and no surveys
yielded a CV of more than 3%. Note that the low number of observations may
preclude drawing significant conclusions on the trend of "failing" labs over
time.
Table
3-1. Accuracy of LSP-Standardized Labs, 1999–2007
| Year |
Observations |
% Absolute Bias |
% CV |
% with Bias > 3% in Absolute
Value |
% with CV > 3% |
| 1999 |
16 |
1.88 |
1.61 |
13% |
0.00% |
| 2000 |
4 |
1.42 |
1.54 |
0% |
0.00% |
| 2001 |
16 |
1.55 |
0.96 |
19% |
0.00% |
| 2002 |
36 |
1.24 |
1.07 |
6% |
0.00% |
| 2003 |
60 |
1.07 |
1.37 |
0% |
0.00% |
| 2004 |
8 |
1.24 |
1.34 |
0% |
0.00% |
| 2005 |
40 |
1.28 |
1.19 |
8% |
0.00% |
| 2006 |
24 |
1.24 |
1.21 |
4% |
0.00% |
| 2007 |
24 |
1.16 |
1.38 |
4% |
0.00% |
3.1.2 Accuracy of Labs in CRMLN
Clinical Laboratory Certification Program
Although the LSP results demonstrate that standardization is being achieved
among the limited number of research-oriented LSP standardized labs, the primary
mechanism through which the CDC laboratory standardization programs may increase
clinical testing accuracy is through the CRMLN. The CRMLN labs are intended to
replicate CDC reference methods to extend the reach of standardization, most
importantly through the manufacturer certification process. The manufacturer
certification process allows manufacturers to calibrate their equipment and
supplies against accuracy-based reference values. When used by clinical testing
labs, the calibrated supplies will presumably increase the accuracy of clinical
testing conducted by these labs. A resource for evaluating how well this program
works is to look at data from clinical laboratories that participate in the
CRMLN’s Clinical Laboratory Certification Program. Table 3-2 shows the average
percentage bias and average percentage CV among clinical laboratories
participating in this program since 2000. Panel 3.2.a shows results for all labs
applying to obtain or maintain certification, and Panel 3.2.b shows results for
the subset of labs that obtained certification. As with the LSP standardized
labs, the results show consistently low and improving bias and CV values.
Table
3-2. Accuracy of Clinical Laboratories Participating in CRMLN Certification,
2000–2009
3.2.a All Labs Applying to Obtain or Maintain Certification
| Year |
Observations |
Average % Bias (Absolute Value) |
Average % CV |
% with Bias > 3% in Absolute
Value |
% with CV > 3% |
| 2000 |
467 |
1.774 |
1.269 |
18% |
3% |
| 2001 |
431 |
1.641 |
1.197 |
15% |
2% |
| 2002 |
486 |
1.590 |
1.114 |
11% |
1% |
| 2003 |
435 |
1.411 |
1.083 |
11% |
1% |
| 2004 |
450 |
1.599 |
1.142 |
11% |
1% |
| 2005 |
443 |
1.509 |
1.224 |
12% |
4% |
| 2006 |
463 |
1.484 |
1.072 |
10% |
2% |
| 2007 |
441 |
1.512 |
1.129 |
10% |
1% |
| 2008 |
417 |
1.511 |
1.172 |
13% |
1% |
| 2009 |
408 |
1.498 |
1.151 |
12% |
1% |
3.2.b Subset of Labs that Passed Certification
| Year |
0bservations |
Average % Bias (Absolute Value) |
Average % CV |
% with Bias > 3% in Absolute
Value |
% with CV > 3% |
| 2000 |
364 |
1.197 |
1.148 |
0.5% |
1.1% |
| 2001 |
356 |
1.196 |
1.117 |
0.6% |
0.8% |
| 2002 |
422 |
1.257 |
1.029 |
0.9% |
0.0% |
| 2003 |
371 |
1.049 |
1.005 |
0.3% |
0.0% |
| 2004 |
382 |
1.101 |
1.050 |
0.0% |
0.3% |
| 2005 |
367 |
1.147 |
1.091 |
0.3% |
0.5% |
| 2006 |
406 |
1.199 |
0.999 |
0.0% |
0.2% |
| 2007 |
390 |
1.232 |
1.090 |
0.8% |
0.3% |
| 2008 |
350 |
1.130 |
1.117 |
1.1% |
0.3% |
| 2009 |
351 |
1.080 |
1.095 |
0.3% |
0.6% |
3.1.3 CAP Survey Results Show
Improvement in Clinical Labs
Although the above tables show that standardization is being achieved among
labs participating in the LSP and CRMLN, these results do not directly reflect
the accuracy of the many nonprogram labs that conduct patient clinical testing.
Table 3-3 shows the results of CAP proficiency testing surveys for total
cholesterol for major methods/instruments peer groups between 2000 and 2006.
This period was selected because the CAP specimens were relatively free of
matrix effects and CDC performed confirmatory testing on the materials used in
the program. With the exception of 2001, we used the specimen in the year’s A
survey whose total cholesterol confirmatory value was closest to 200 mg/dL.
Because the 2001 A survey was not available to us, we used the specimen in the B
survey with a confirmatory value closest to 200 mg/dL.
Table
3-3. CDC Confirmed CAP Survey Results, 2000–2006
| Year |
Number of Labs |
Number of Methods/ instruments |
Mean |
SD |
Weighted Average Bias (%
Absolute Value) |
CV% |
Number of Methods with bias >3%
in Absolute Value |
Number of Methods with CV > 3% |
| 2000 |
4,731 |
34 |
208.1 |
5.2 |
1.18 |
2.5 |
4/34 |
6/34 |
| 2001 |
4,456 |
27 |
194.1 |
5.0 |
1.43 |
2.6 |
2/27 |
4/27 |
| 2002 |
4,330 |
26 |
188.8 |
4.6 |
0.87 |
2.5 |
2/26 |
6/26 |
| 2003 |
4,490 |
25 |
197.2 |
5.0 |
1.89 |
2.5 |
7/25 |
7/25 |
| 2004 |
4,156 |
23 |
196.8 |
4.8 |
1.35 |
2.4 |
3/23 |
4/23 |
| 2005 |
3,962 |
23 |
202.4 |
5.0 |
0.98 |
2.5 |
0/23 |
4/23 |
| 2006 |
4,080 |
21 |
201.8 |
4.8 |
0.69 |
2.4 |
1/21 |
2/21 |
Table 3-3 shows that bias and CV have remained consistently low and continue
to show improvement at the method/instrument level, with the average absolute
value of bias falling from 1.2% in 2000 to 0.7% in 2006, and the CV remaining
unchanged. Four out of 34 methods/instruments had biases > 3% in absolute value
in 2000 compared with 1 out of 21 in 2006; the corresponding figures for CV were
6 out of 34 in 2000 compared with 2 out of 21 in 2006.
Improvements in standardization have likely been much larger over a longer
period, although the available data are not ideal for making long-term
comparisons. Table 3-4 shows laboratory performance on CAP surveys in 1985 and
2009. These results show clear improvement in the bias (as measured by the percentage difference between a
method/instrument mean and the all method/all instrument mean) and CV for each
method/instrument. In 1985, about half of the method/instrument groups had
biases greater than 3% in absolute value, and all but two method/instrument
groups had CVs greater than 3%. In 2009, only one method/instrument group had a
bias greater than 3% in absolute value, and only one group had a CV greater than
3%. However, the specimens used in 1985 and 2009 did not closely resemble
patient samples and may have been subject to matrix effects (meaning that an
instrument could perform well on patient samples but produce biased results on
alterated, nonpatient samples). Nevertheless, the dramatic improvements shown in
bias and in particular CV (which may be less susceptible to matrix effects)
clearly suggest that standardization of labs occurred over this period.
Table
3-4. Laboratory Performance on CAP Proficiency Testing, 1985 and 2009
| Year |
Number of Labs |
Number of Methods/ Instruments |
Mean |
SD |
Weighted Average Bias (%
Absolute Value) |
Weighted average CV% |
Number of Methods with Bias >3%
in Absolute Value |
Number of Methods with CV > 3% |
| 1985 |
4,716 |
30 |
257.2 |
12.5 |
4.45 |
5.2 |
15/30 |
28/30 |
| 2009 |
4,770 |
20 |
203.0 |
4.4 |
1.67 |
2.2 |
1/20 |
1/20 |
Source: 1985—Laboratory Standardization Panel of the National Cholesterol
Education Program, 1988; 2009—College of American Pathologists, 2009a. The
underlying data are shown in Appendix Tables A-1 and A-2.
CAP launched its Accuracy Based Lipid (ABL) Survey in 2008 to eliminate or
minimize matrix effects and provide better measures of the accuracy and
harmonization of cholesterol testing. Results from the 2009 ABL (Table 3-5)
suggest that almost all participating laboratories meet current NCEP standards
for total cholesterol (total error within 9% of the target level). Most
participating laboratories meet National Cholesterol Education Program (NCEP)
standards for HDL cholesterol (total error within 13% of the target level),
although the performance is not as strong as on total cholesterol. The ABL
should be useful for identifying trends in laboratory accuracy as more years of
data become available.
Table 3-5. Percentage of
Laboratories Meeting NCEP Targets
| |
Total Cholesterol (within 10%
of target) |
| ABL-01 |
ABL-02 |
ABL-03 |
| Target |
152.6 mg/dl |
180.0 mg/dl |
244.2 mg/dl |
| Labs |
98.6% |
100% |
99.3% |
| |
HDL Cholesterol (within 13% of
target) |
| ABL-01 |
ABL-02 |
ABL-03 |
| Target |
33.9 mg/dl |
56.8 mg/dl |
49.3 mg/dl |
| Labs |
77.4% |
96.6% |
91.8% |
Source: College of American Pathologists, 2009b.
3.2
Medium-Term Outcomes
Increasing the accuracy of research and clinical testing will result in
several medium-term outcomes, including improving clinical diagnosis rates and
improving cholesterol-related research. Standardization of research testing has
facilitated several important events, from the early research linking elevated
total and LDL cholesterol to higher mortality, to more focused, clinical
research on the efficacy of treatment and prevention interventions, including
drugs and diet and exercise changes. Together, these findings have allowed for
the creation of the ATP practice guidelines and provided the impetus for
numerous public health campaigns targeted toward increasing physician and public
awareness of the risks of high cholesterol and its modifiable risk factors.
3.2.1 Improved Clinical Diagnosis
Rates
Better laboratory accuracy facilitates better diagnosis of persons with high
cholesterol. If a laboratory produces biased cholesterol readings, some patients
who truly need cholesterol reduction may not receive treatment, whereas other
patients who do not need treatment may receive it. We used the data on bias from
the method/instrument observations underlying Table 3-3 to estimate the
percentage of patients whose total cholesterol would be misclassified in 2000
and 2006. We examined the ATP III cutoffs of 200 and 240 mg/dl to distinguish
between desirable, borderline, and high total cholesterol. We used cholesterol
information for U.S. adults from the 1988–1994 National Health and Nutrition
Examination Survey (NHANES III), as reported in the ATP III report (ATP III,
2002), to calculate separate total cholesterol population distributions for men
and women. For men, the data are roughly consistent with a normal distribution
with mean 202 and variance 40.5. For women, the data are roughly consistent with
a normal distribution with mean 206 and variance 43.5. Using the percentage bias
for each individual laboratory method in 2000 and 2006 from the data underlying
Table 3-3, we calculated the percentage of people misclassified relative to the
"true" ATP-III distributions. For example, if the true distribution for males
was distributed normally with a mean of 200 and variance of 10, then we would
expect to find 50% of men classified as having desirable cholesterol (<200
mg/dl); however, if an individual laboratory method had 5% bias so that its
distribution of cholesterol values was distributed normally with a mean of 210
and variance of 10, then too few men would be classified as having desirable
cholesterol level and too many would be put into the borderline or high
cholesterol categories.
Tables 3-6 and 3-7 show the percentage of adults whose total cholesterol
would be correctly reported (so that a patient’s reported value is the same as
the true value, as highlighted in green) and the percentage that would be
misclassified (so that the patient’s reported value is not the same as the true
value, as highlighted in red) in 2000 and 2006. The reduced bias in 2006 leads
to fewer misclassifications. In 2000, a total of 3.9% of the male population
would have been misclassified, including 0.5% of the population with true high
cholesterol who would have been reported as having borderline cholesterol. In
2006, misclassifications reduced to 2.3% of the male population, including 0.2%
of the population with true high cholesterol who would have been reported as
having borderline cholesterol. Values for the female population exhibit the same
trend toward fewer misclassifications.
If we conduct this same exercise using the 1985 and 2009 CAP proficiency
testing survey data, the share of the population that would be misclassified is
much larger (Tables 3-8 and 3-9) in 1985 with misclassifications falling
dramatically by 2009. These results should be interpreted cautiously, however,
because these specimens may have included matrix effects that distorted the true
bias in patient samples.
Table 3-6. Percentage of Patients Misclassified in 2000 and 2006, Based on Total
Cholesterol, Men
| |
True Desirable
<200 mg/dl |
True Borderline
200–239 mg/dL |
True High
>240 mg/dl |
|
Reported as Desirable |
Reported as Borderline |
Reported as Desirable |
Reported as Borderline |
Reported as High |
Reported as Borderline |
Reported as High |
| True values |
48.0% |
— |
— |
34.6% |
— |
— |
17.4% |
| 2000 |
46.4% |
1.6% |
0.7% |
32.7% |
1.1% |
0.5% |
16.9% |
| 2006 |
46.9% |
1.1% |
0.3% |
33.5% |
0.7% |
0.2% |
17.2% |
Table 3-7. Percentage of Patients Misclassified in 2000 and 2006, Based on
Total Cholesterol, Women
| |
True Desirable
<200 mg/DL |
True Borderline
200 – 239 mg/dL |
True High
>240 mg/dl |
|
Reported as Desirable |
Reported as Borderline |
Reported as Desirable |
Reported as Borderline |
Reported as High |
Reported as Borderline |
Reported as High |
| True values |
44.5% |
— |
— |
33.8% |
— |
— |
21.7% |
| 2000 |
43.0% |
1.5% |
0.7% |
31.9% |
1.2% |
0.5% |
21.2% |
| 2006 |
43.5% |
1.0% |
0.3% |
32.7% |
0.8% |
0.2% |
21.5% |
Table 3-8. Percentage of Patients Misclassified in 1985 and 2009, Based on Total
Cholesterol, Men
| |
True Desirable
<200 mg/dl |
True Borderline
200–239 mg/dL |
True High
>240 mg/dl |
|
Reported as Desirable |
Reported as Borderline |
Reported as Desirable |
Reported as Borderline |
Reported as High |
Reported as Borderline |
Reported as High |
| True values |
48.0% |
— |
— |
34.6% |
— |
— |
17.4% |
| 1985 |
43.4% |
4.6% |
3.5% |
27.5% |
3.6% |
2.1% |
15.3% |
| 2009 |
46.4% |
1.6% |
1.7% |
31.8% |
1.1% |
1.0% |
16.4% |
Table 3-9. Percentage of Patients Misclassified in 1985 and 2009, Based on Total
Cholesterol, Women
| |
True Desirable
<200 mg/DL |
True Borderline
200 – 239 mg/dL |
True High
>240 mg/dl |
|
Reported as Desirable |
Reported as Borderline |
Reported as Desirable |
Reported as Borderline |
Reported as High |
Reported as Borderline |
Reported as High |
| True values |
44.5% |
— |
— |
33.8% |
— |
— |
21.7% |
| 1985 |
40.2% |
4.3% |
3.3% |
26.8% |
3.7% |
2.3% |
19.4% |
| 2009 |
43.0% |
1.5% |
1.6% |
31.0% |
1.2% |
1.1% |
20.6% |
3.2.2 Practice Patterns
High levels of cholesterol, including LDL cholesterol, were not definitively
linked to increased risk of heart disease until the publication of the results
of the Lipid Research Clinics Coronary Primary Prevention Trial in 1984 (Lipid
Research Clinics Program, 1984). In 1985, NHLBI formed NCEP to organize public
health efforts to reduce cholesterol-attributable heart disease. At the heart of
these efforts are the clinical practice guidelines, the latest of which is the
Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults
(ATP III, 2002).
To produce the practice guidelines, NCEP and its partners had to synthesize
data from a number of sources to produce a comprehensive cholesterol control
strategy. For example, epidemiological and clinical trials have demonstrated the
harms of high cholesterol in the overall population and the degree of elevated
risk among subpopulations. Other trials have assessed the efficacy of treatment
to reduce high cholesterol. Finally, epidemiological surveys such as NHANES are
necessary to identify actual cholesterol levels in the population. Combining the
outcomes of such disparate studies is only possible when the cholesterol values
of each study are directly comparable. To achieve comparability, the major
cholesterol studies used to produce the practice guidelines have depended on LSP
standardized labs to ensure accuracy and allow comparability.
3.2.3 Cholesterol Awareness
An important goal of public health programs focused on cholesterol is to
increase awareness of the risks of high cholesterol among physicians and the
general public. NCEP has focused efforts in two key areas: (1) improving
clinical practice to increase the detection of high cholesterol and improve
cholesterol treatment, and (2) increasing public awareness of the risks of high
cholesterol to promote cholesterol-reducing lifestyle choices. By working with
physician associations, continuing to refine the ATP guidelines, and conducting
national conferences on cholesterol, NCEP continues to focus on physician
education and training. NCEP has also focused on public health information
campaigns, including the Know Your Number campaign to highlight the risks of
high cholesterol among the general public and the Healthy People 2000 and
Healthy People 2010 campaigns, which set defined targets for population
cholesterol control.
NCEP efforts to improve physicians’ understanding of the risks of cholesterol
on CHD appear to have been largely successful. The NHLBI Cholesterol Awareness
Surveys found that the number of patients who had ever had their cholesterol
levels checked increased from 35% to 75% between 1993 and 1995 (NHLBI
Cholesterol Awareness Surveys press release, December 1995). This survey also
found that physicians had lowered the threshold for initiating cholesterol
reduction treatment and were generally in compliance with the ATP guidelines. A
CDC study using Behavioral Risk Factor Surveillance System data found that the
proportion of people who reported having their blood cholesterol screened in the
preceding 5 years increased from 67.6% in 1991 to 73.1% in 2003 (Saddlemire et
al., 2005). However, recent evidence finds that lower rates of dietary and
pharmacologic therapy initiation remain among certain physician groups,
indicating that education efforts need to continue (Yarzebski, Bujor, &
Goldberg, 2002).
As with the development of the clinical guidelines, public health information
campaigns are ultimately the product of multiple and disparate sources of data
on the risks of high cholesterol and the effectiveness of different treatment
and prevention strategies; as with the formation of the practice guidelines,
this is possible only when the data used are directly comparable due to the
underlying accuracy of the cholesterol measurements. Thus, the CDC lipid
standardization programs have played an important role in facilitating the
research necessary to inform, guide, and bolster public health information
efforts.
3.2.4 Cholesterol-Lowering Drugs
There have been clear improvements in drug therapies to reduce LDL
cholesterol levels and/or increase HDL cholesterol levels in recent years (the
LSP does not standardize LDL testing, although the CRMLN does; to estimate LDL
levels, most U.S. laboratories use the Friedewald equation, which depends on
total cholesterol, HDL cholesterol, and triglyceride measures that are
standardized by both programs). In particular, the introduction and widespread
adoption of statins has revolutionized cholesterol management. Currently, six
statins (atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, and
simvastatin) are approved for use in the United States. These statins have been
shown to reduce LDL cholesterol by 34% to 55%, with the most recently approved
statins producing the largest reductions (Senior Journal, 2005). Other
cholesterol-lowering drugs include ezetimide, nictonic acid, fenofibrate, and
gemfibrozil.
The standardization of cholesterol measurement has played an important but
difficult-to-quantify role in the development of cholesterol-lowering drugs.
Cholesterol-lowering drugs are approved based primarily on their safety and
their efficacy in lowering LDL cholesterol levels. To assess efficacy, it is
necessary to accurately and reliably measure cholesterol levels. Standardization
of cholesterol testing allows a large number of patients to be tested in large,
multicenter clinical trials. Standardization also facilitates comparisons across
trials and allows improvements in cholesterol to be assessed in the context of
previous epidemiological studies showing the relationship between standardized
cholesterol levels and clinical outcomes.
3.2.5 Diet and Exercise
In addition to pharmacological cholesterol reduction treatment, diet and
exercise are important for ensuring reductions in cholesterol levels. On the
basis of observational study findings, ATP III lists physical inactivity and an
atherogenic diet (which generally includes high cholesterol) as major modifiable
risk factors for high levels of LDL cholesterol and low levels of HDL
cholesterol. The consumption of saturated fats and cholesterol has been falling
since the early 1970s. In 1972, the average American consumed 355mg of
cholesterol and 13.2g of saturated fat with a total energy intake of 1,983
kilocalories per day. By 1990, the cholesterol and fat intake measures had
improved to 291mg of cholesterol and 12.6g of saturated fat with 2,199
kilocalories consumed per day (Ernst, Sempos, & Briefel, 1997). So while total
caloric intake has markedly increased, cholesterol and saturated fat have
decreased both in proportional and absolute levels. In the following decade, the
proportion of calories from saturated fat continued to fall, although total
cholesterol intake decreased only in men and actually increased by 11g per day
in women (Carroll, Lacher, & Sorlie, 2005). However, the consumption of LDL
cholesterol has decreased (Carroll, Lacher, & Sorlie, 2005). As with cholesterol
medications, the evidence for the efficacy of lifestyle interventions to
mitigate these risk factors came from clinical and epidemiological research,
which, in most cases, benefited from increased accuracy due to the LSP.
References
Adult Treatment Panel III (ATP III). (2002). The third report of the
National Cholesterol Education Program (NCEP) expert panel on detection,
evaluation, and treatment of high blood cholesterol in adults (Adult Treatment
Panel III). Final Report. National Cholesterol Education Program, National
Heart, Lung, and Blood Institute, National Institutes of Health. NIH Publication
No. 02-5215.
Carroll, M. D., Lacher, D. A., & Sorlie, P. D. (2005). Trends in serum lipids
and lipoproteins of adults, 1960–2002. Journal of the American Medical
Association, 294(14), 1773–1781.
College of American Pathologists. (2009a). Survey 2009: C-B
chemistry/therapeutic drug monitoring, participant summary. College of
American Pathologists.
College of American Pathologists. (2009b). ABL-A: Accuracy based lipid:
Participant summary. College of American Pathologists.
Ernst, N. D., Sempos, C. T., & Briefel, R. R. (1997). Consistency between
U.S. dietary fat intake and serum total cholesterol concentrations: The national
health and nutrition surveys. American Journal of Clinical Nutrition, 66(Suppl),
965S–9672S.
Laboratory Standardization Panel of the National Cholesterol Education
Program. (1988). Current status of blood cholesterol measurement in the United
States. Clinical Chemistry, 34(1), 193–201.
Lipid Research Clinics Program. (1984). The lipid research clinics coronary
primary prevention trial results, I. Reduction in incidence of coronary heart
disease. Journal of the American Medical Association, 251(3),
351–364.
National Heart, Lung, and Blood Institute Cholesterol Awareness Surveys
[press release]. Bethesda, Md: National Heart, Lung, and Blood Institute;
December 4, 1995.
Saddlemire, A. E., Denny, C. H., Greenlund, K. J., Coolidge, J. N., Fan, A.
Z., & Croft, J. B. (2005). Trends in cholesterol screening and awareness of high
blood cholesterol: United States, 1991–2003. MMWR, 54(35), 865–870
Senior Journal. (2005). Latest statistics show 30 percent of seniors
using statins in 2002. Retrieved October 15, 2009, from
http://seniorjournal.com/NEWS/Health/5-10-11StatinUse2002.htm.
Yarzebski, J., Bujor, C. F., & Goldberg, R. J. (2002). A community-wide
survey of physician practices and attitudes toward cholesterol management in
patients with recent acute myocardial infarction. Archives of Internal
Medicine, 162, 797–804.
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