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Countries' cholesterol levels tied to economy, health care system
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New data suggest that global variation in economy, health care system and health care expenses may account for lower subsequent cholesterol rates in patients with a history of hyperlipidemia.
In a cohort of more than 53,000 patients at heightened risk for MI or stroke from 36 countries, Elizabeth A. Magnuson, ScD, and colleagues evaluated the association between elevated total cholesterol (>200 mg/dL) and several country-level indices:
- Gross national income;
- Total expenditure on health as a percentage of gross domestic product (GDP);
- Government expenditure on health as percentage of total expenditure on health;
- Out-of-pocket expenditures as percentage of private expenditure on health; and
- WHO indices of health system achievement and performance/efficiency.
Thirty-eight percent of patients had elevated total cholesterol. Rates varied widely across countries, ranging from 73% in Bulgaria to 24% in Finland. Results indicated that 9.3% of the total variability in elevated cholesterol was at the country level — a proportion that was higher for patients with vs. those without a history of hyperlipidemia (12.1% vs. 7.4%). Additionally, patients with a history of hyperlipidemia in countries in the highest tertile of gross national income or WHO health system achievement were less likely to have elevated cholesterol when compared with those in countries in the lower tertiles (P<.001, for both). Patients in countries in the highest tertile of out-of-pocket health expenditures, however, were more likely to have elevated cholesterol vs. those in the lowest tertile (P<.001).
No associations were noted among patients without a history of high cholesterol.
Elevated cholesterol rates were especially high among patients in Eastern European countries such as Bulgaria, Lithuania, Romania, Ukraine, Hungary and Russia — all of which ranked relatively low on health system and economic indicators, the researchers noted. They also found health care spending was significantly higher in the United States than in other developed countries, including Finland, the United Kingdom, Israel, Australia and Canada, yet rates of elevated cholesterol were similar to these countries.
“Optimal management of CVD is complex, and country-level variation in rates of elevated cholesterol may be due to differences in clinical guidelines as well as whether and the extent to which guidelines are followed and specific initiatives are effectively implemented,” Magnuson, who is director of the Health Economics and Technology Assessment at Saint Luke’s Mid America Heart Institute in Kansas City, Mo, said in a press release. “The association between high cholesterol and out-of-pocket health care expenses may reflect an inability or unwillingness for patients in countries with higher out-of-pocket expenses to be compliant with prescribed medications. The recent availability of generic cholesterol-lowering therapy should make out-of-pocket expense less of a barrier.”
Disclosure: Dr. Magnuson has received research grants and honoraria from Sanofi-Aventis/Bristol-Meyers Squibb partnership and research grants from Eli Lilly, AstraZeneca and Daiichi-Sankyo. See the study for a list of full disclosures.
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