LIPID DISORDERS (Screening, Counseling and Treatment)

Evidence Statement Benefit Plan Language Other Information and Resources Author(s)

References


Updated 8/17/2011

Evidence Statement

Clinical Preventive Service Recommendations

U.S. Preventive Services Task Force Recommendation
The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening women aged 45 years and older for lipid disorders if they are at increased risk for coronary heart disease (CHD) and all men aged 35 years and older.

Risk for coronary heart disease is defined by the presence of any one of the following risk factors: diabetes, previous personal history of CHD or non-coronary atherosclerosis, a family history of cardiovascular disease before age 50 in male relatives or age 60 in female relatives, tobacco use, hypertension, and obesity.1

Evidence Rating: A (Strongly Recommended)
The USPSTF strongly recommends that clinicians provide lipid screening to eligible patients. The USPSTF found good evidence that lipid screening improves important health outcomes and concludes that benefits substantially outweigh harms.1

U.S. Preventive Services Task Force Recommendation
The USPSTF recommends screening men aged 20 to 35 years and women aged 20 to 45 years for lipid disorders if they are at increased risk for coronary heart disease.1

Evidence Rating: B (Recommended)
The USPSTF recommends that clinicians provide lipid screening to eligible patients. The USPSTF found at least fair evidence that lipid screening improves important health outcomes and concludes that benefits outweigh harms.1

U.S. Preventive Services Task Force Assessment
The USPSTF concludes that the benefits of screening for and treating lipid disorders in all men aged 35 years and older and women aged 45 years and older at increased risk for coronary heart disease substantially outweigh the potential harms. The USPSTF concludes that the benefits of screening for and treating lipid disorders in young adults at increased risk for coronary heart disease moderately outweigh the potential harms.

Note: We are including the National Cholesterol Education Program's (NCEP) Adult Treatment Expert Panel-III (ATP III) recommendation which includes frequency of testing. The NCEP-ATP III, sponsored by the National Institutes of Health and endorsed by the American Heart Association, recommends lipid screening for total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides with fasting blood samples in all adults older than the age of 20 once every 5 years.2

Centers for Disease Control and Prevention (CDC) Guidance
The Centers for Disease Control and Prevention (CDC) supports the National Cholesterol Education Program's Adult Treatment Expert Panel-III recommendations. More information is available on the CDC Web site at www.cdc.gov/dhdsp/library/fs_cholesterol.htm.

NOTE:
The USPSTF makes no recommendation for or against routine screening for lipid disorders in low-risk adults (men aged 20 to 35 years, or women aged 20 years and older who are not at increased risk for coronary heart disease).

Evidence Rating: C

The USPSTF found at least fair evidence that lipid screening can improve health outcomes but concludes that the balance of benefits and harms is too small to justify a general recommendation.

The USPSTF also concluded that the evidence is insufficient to recommend for or against routine screening for lipid disorders in infants, children, adolescents, or young adults (up to age 20).

Evidence Rating: I




The Value of Prevention

Economic Burden of Condition/Disease
The economic burden of lipid disorders is substantial because of the impact of lipid levels on the risk of cardiovascular disease and coronary heart disease events. The direct and indirect costs of all types of cardiovascular disease in 2010 were estimated to be $503.2 billion.6 The cost of cardiovascular disease exceeds that of any other high-cost medical conditions. For example, in 2008, the estimated total cost of all cancers was $228 billion and in 2007, the cost attributable to diabetes mellitus was $174 billion.6

Workplace Burden of Condition/Disease
Heart disease and stroke are not only a major cause of premature death in persons younger than 65 years but also are major causes of serious disability in the United States.6 The indirect costs of cardiovascular disease, including those related to lost productivity, are enormous. It is estimated that the indirect cost of cardiovascular disease will total more than $179.1 billion in 2010.6

Interventions at the work site are effective for helping employees control their burden of cholesterol. A systematic review of selected interventions for worksite health promotion found strong and sufficient evidence that assessing health risk factors with feedback to employees combined with health education counseling with or without other worksite interventions is effective for controlling elevated cholesterol.8

Economic Benefit of Preventive Intervention
Cost-effectiveness analyses show that reducing low-density lipoprotein cholesterol levels can reduce costs in the following three ways:2:
  1. Direct economic savings from decreased hospital and ambulatory services from angina, myocardial infarction, revascularization procedures, stroke, and heart failure.
  2. Prevention of coronary heart disease mortality, which increases rates of gainful employment and productivity.
  3. Prevention of the disability, distress, and pain associated with coronary heart disease, which increases quality-adjusted life expectancy as well as rates of gainful employment and productivity.
Estimated Cost of Preventive Intervention
The cost of implementing a lipid screening program varies by location, provider base, method of screening, which cholesterol measurements are taken, and other factors. The average cost of a single cholesterol or lipid profile test is relatively low but the cumulative costs of screening can be substantial, especially if all recommended screening and follow-up procedures are followed.9 In 2008, the private-sector cost of annual visits to lower LDL cholesterol averaged $74 per session.4

Estimated Cost of Counseling and Treatment
The total cost of reducing low-density lipoprotein includes the costs of physician services, lifestyle counseling, screening, case finding and monitoring, dietary and exercise modifications, medications, and treating side effects. The annual cost of statin drugs to reduce low-density lipoprotein cholesterol levels can range from $1,082 to $1,543 per year.4 The cost of follow-up or treatment-related appointments varies by type of provider, location, and practice setting. Although the cost of reducing low-density lipoprotein cholesterol levels can be high, it is much lower than the direct and indirect costs of cardiovascular disease.

Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive Intervention
In 2002, the National Cholesterol Education Program (NCEP) panel found that, on the basis of current retail prices for lipid-lowering drugs, low-density lipoprotein-lowering drug therapy is highly cost-effective for persons with established coronary heart disease (including a prior coronary heart disease event); cost-effective for the primary prevention of coronary heart disease in persons with a coronary heart disease risk equivalent (the person does not have coronary heart disease but does have an absolute 10-year risk of developing major coronary events, such as myocardial infarction and coronary death, equal to that of persons with coronary heart disease), and those at high risk for coronary heart disease; and acceptable for the primary prevention of coronary heart disease in persons whose 10-year risk of "hard coronary heart disease" (heart attack and death from coronary heart disease) is between 10% and 20%.2,10

The National Cholesterol Education Program recommends using dietary therapy, which is more cost-effective than low-density lipoprotein-lowering drugs, as the first-line therapy in persons with a 10-year risk of coronary heart disease that is less than 10% per year. (Information about dietary therapy is found in the Other Important Information section of this document).



Condition / Disease Specific Information

Explanation of Condition
Lipid disorders, which result from abnormal levels of cholesterol in the blood, increase the risk of cardiovascular diseases, including coronary heart disease. Some amount of cholesterol in the blood is normal and, in fact, necessary. However, high levels of low-density lipoprotein cholesterol increase the risk of — and can even cause — coronary heart disease. In contrast, low levels of high-density lipoprotein cholesterol are strongly associated with increased risks of coronary heart disease and high levels of high-density lipoprotein are associated with a reduced risk for coronary heart disease. Elevated serum triglycerides are associated with increased risk of coronary heart disease.2

Table 1: Classification of Low-Density Lipoprotein Cholesterol, High-Density Lipoprotein
Cholesterol, Total Cholesterol, and Triglyceride Levels

Low-Density Lipoprotein (bad) Cholesterol Levels (mg/dL) Classification by Association with Cardiovascular Disease Risk
Less than 100 Optimal
100-129 Near or above optimal
130-159 Borderline high
160-189 High
190 and above Very high
High-Density Lipoprotein (good) Cholesterol Levels (mg/dL) Classification by Association with Cardiovascular Disease Risk
Less than 40 Low (major risk factor for coronary heart disease)
60 and above High (protective against heart disease)
Total cholesterol levels (mg/dL)
Less than 200 Desirable
200-239 Borderline high
240 and above High
Triglyceride levels (mg/dL)
Less than 150 Normal/desirable
150-199 Borderline high
200-499 High
500 and above Very high

Adapted from: National Heart, Lung, and Blood Institute's Third Report of the National Cholesterol Education Program (NCEP) on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III); May 2001, p. 3.

Reducing low-density lipoprotein cholesterol levels to normal reduces the risk of coronary heart disease and cardiovascular events such as heart attacks and strokes. Because low-density lipoprotein cholesterol levels are so strongly correlated with coronary heart disease and controlling low-density lipoprotein cholesterol would reduce coronary heart disease risk, goals and thresholds for low-density lipoprotein cholesterol have been established.2 Please refer to Table 2 for information about recommended target low-density lipoprotein cholesterol levels.

Epidemiology of Condition/Disease
Between 2005 and 2006, about 21% of adults aged 20 years and older in the United States had high levels of low-density lipoprotein cholesterol (defined as levels above the specific target for each risk category outlined in the National Cholesterol Education Program Adult Treatment Panel III, see Table 2).3

Clinical studies have repeatedly shown a strong and graded relationship between increasing levels of low-density lipoprotein cholesterol ("bad" cholesterol) and increasing risk of coronary heart disease events.2,3,5 Low levels of high-density lipoprotein cholesterol levels are strongly associated with increased risks of coronary heart disease.2,5 Evidence from clinical trials suggests that increasing high-density lipoprotein cholesterol ("good" cholesterol) levels reduces the risk of coronary heart disease.2

Abnormal lipid levels contribute to the development of cardiovascular diseases, including coronary heart disease, stroke, and coronary atherosclerosis. Coronary heart disease, which kills more Americans than any other single disease, can lead to angina pectoris (heart pain), heart attack, or both.1 One American has a coronary attack about every 25 seconds, and about 34% of people who experience a coronary attack will die from it in any given year.6 At age 40, a man in the United States has a 49% chance and a woman has a 32% chance of having a coronary heart disease event (such as a heart attack) in his or her lifetime.7

Condition/Disease Risk Factors
Risk factors that are associated with high cholesterol levels include a family history of cardiovascular disease (including familial hypercholesterolemia, an inherited genetic condition), older age, male, a diet high in fats, overweight, and lack of exercise. Many of these risk factors including diet, overweight, and lack of exercise are modifiable:2:
  • Diets high in saturated fat increases low-density lipoprotein (low-density lipoprotein) cholesterol levels more than any other factor in the human diet. Trans-fatty acids, formed when vegetable oil is hydrogenated to harden it, also increase cholesterol levels. These fatty acids are found in such foods as stick margarine, crackers, and French fries. Cholesterol is found in foods from animal sources, such as egg yolks, meat, and cheese.
  • Being overweight tends to increase low-density lipoprotein levels, decrease high-density lipoprotein levels, and increase total cholesterol levels.
  • Lack of regular exercise can lead to weight gain, which can increase low-density lipoprotein cholesterol levels. Poor physical fitness appears to be associated with cardiovascular disease, even if it has not produced overweight or obesity.


Preventive Intervention Information

Preventive Intervention:
Purpose of Screening, Counseling, and Treatment
Screening for lipid disorders allows patients and clinicians to begin lipid-lowering treatment before cardiovascular disease develops or progresses. Most patients agree to be screened for lipid disorders, even when the screening involves fasting.11

Benefits and Risks of Intervention
Clinical trials have shown that reducing low-density lipoprotein levels reduces coronary heart disease risk, but the benefits of increasing high-density lipoprotein levels have not yet been fully demonstrated. In short-term clinical trials, a 1% reduction in low-density lipoprotein cholesterol levels, on average, reduced the risk of hard coronary heart disease events by about 1%. Persons who take low-density lipoprotein cholesterol-lowering drugs for about 5 years reduce their low-density lipoprotein levels by approximately 30% and decrease their risk of cardiovascular disease, including heart attacks, by about 30%.2 However, only about half of those who would benefit from lipid treatment receive it.2

In persons with established coronary heart disease, low-density lipoprotein-lowering therapy reduces risk of stroke by about 30%.7 Statin therapy for the primary and secondary prevention of cardiovascular disease can reduce adverse cardiovascular events (including heart attacks and strokes) by 32% among patients aged 65 and older.12 Primary prevention trials using statins have shown a significant reduction in coronary heart disease mortality, no increase in non-coronary heart disease mortality, and a strong trend toward lower overall mortality.

Initiation, Cessation, and Interval
Screening
All adults aged 20 and older should be screened for abnormal lipid and elevated blood cholesterol levels every 5 years. Evidence is insufficient to determine the age at which screening is no longer necessary; therefore, decisions regarding when to stop screening are left to the discretion of the clinician.2

Counseling and Treatment
The USPSTF recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease.13 Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians. Beginning at the initial visit with a patient who has a high level of cholesterol, the clinician should counsel and encourage the patient to make therapeutic lifestyle changes—such as dietary changes, increased physical activity, and weight control—and monitor the patient's progress.2 The clinician should evaluate the patient's low-density lipoprotein cholesterol level at the 6-week, 12-week, and 4- to 6-month follow-up visits, or more often if necessary.2

Intervention Process
Risk Assessment
Low-density lipoprotein cholesterol levels should be the primary target of cholesterol-lowering therapy.2 The first step in selecting a low-density lipoprotein-lowering therapy is assessing the patient's coronary heart disease risk status, which requires measuring low-density lipoprotein cholesterol levels as part of lipoprotein analysis; identifying risk factors, such as family history; and determining whether the patient has coronary heart disease, other clinical forms of atherosclerotic disease, or the major risk factors for coronary heart disease other than low-density lipoprotein cholesterol.2

Patients are considered to be at high risk of coronary heart disease if they have coronary heart disease or coronary heart disease risk equivalents (the person does not have coronary heart disease, but does have an absolute 10-year risk of developing major coronary events, such as myocardial infarction and coronary death, equal to that of persons with coronary heart disease), including the following:
  • Other clinical forms of atherosclerotic disease (such as peripheral arterial disease, abdominal aortic aneurysm, or symptomatic carotid artery disease)
  • Diabetes.
  • • Multiple risk factors that confer a 10-year risk of coronary heart disease of at least 20%.
Risk status in persons without coronary heart disease or other forms of atherosclerotic disease is determined by a two-step procedure. First, the clinician counts the number of risk factors for coronary heart disease, including the following:

  • Cigarette smoking.
  • Hypertension (blood pressure of 140/90 mmHg or higher, or the patient is taking antihypertensive medication)
  • Diminished high-density lipoprotein cholesterol level (less than 40 mg/dL)
  • Family history of premature coronary heart disease (in male first degree relative younger than 55 or a female first degree relative younger than 65)
  • Age (men aged 45 years or older, women aged 55 years or older)
If the clinician determines that the patient has at least 2 of these risk factors, the Framingham scoring is used to determine the patient's 10-year risk of coronary heart disease.2 Risk factors used in Framingham scoring include age, total or low-density lipoprotein cholesterol level, high-density lipoprotein cholesterol level, smoking status, systolic blood pressure, and whether the individual is taking antihypertensive therapy.

Persons with several of these risk factors are assigned to 1 of 3 categories of 10-year risk of coronary heart disease — higher than 20%, 10% to 20%, or less than 10%. A person with 10-year risk that is higher than 20% is categorized as "coronary heart disease risk equivalent," meaning that the person does not have coronary heart disease but does have an absolute 10-year risk of developing major coronary events, such as myocardial infarction and coronary death, equal to that of persons with coronary heart disease, or the person has diabetes. Framingham scoring is the most reliable method available for identifying high-risk persons to determine the appropriate low-density lipoprotein level goal and treatment intensity.2

A Framingham-based risk assessment tool is available at http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof.

Screening
The preferred screening tests for dyslipidemia are total cholesterol and HDL-C on non-fasting or fasting samples in addition to assessing other risk factors such as family history, smoking status, weight, blood pressure, and age.11 Abnormal screening test results should be confirmed by a repeated sample on a separate occasion, and the average of both results should be used for risk assessment. In conjunction with HDL-C, the addition of either LDL-C or total cholesterol would provide comparable information, but measuring LDL-C requires a fasting sample and is more expensive.11

Counseling and Treatment
Beginning at the initial visit with a patient who has a high level of cholesterol, the clinician should counsel and encourage the patient to make therapeutic lifestyle changes — such as dietary changes, increased physical activity, and weight control — and monitor the patient's progress.2 The clinician should evaluate the patient's low-density lipoprotein cholesterol level at the 6-week, 12-week, and 4- to 6-month follow-up visits, or more often if necessary.2

Target goals for low-density lipoprotein levels and treatment are based on the person's risk category of coronary heart disease, as described in the "Risk Assessment" section.

The first line of therapy for elevated low-density lipoprotein cholesterol levels is therapeutic lifestyle changes. Drug therapy can be combined with therapeutic lifestyle changes if additional low-density lipoprotein reduction is required.

Therapeutic Lifestyle Interventions (Initial Treatment/"First-Line" Therapy):
On the therapeutic lifestyle change diet, saturated fat should account for no more than 7% of calories, no more than 200 mg of cholesterol should be consumed per day, and total fat intake may range from 25% to 35% of all calories.2,9 Trans-fat intake should be as low as possible. The person's diet should also include 2–3 g/day of plant stanol esters (sitostanol and sitostanol esters, found in soft margarine), 10–25 g/day of soluble fiber (fruits, vegetables, and whole grains), and 400 mg/day of folate consumed largely from dietary sources. Carbohydrates should be limited to 60% of total calories.

Therapeutic lifestyle interventions also include smoking cessation, weight management, regular physical exercise, and moderation of alcohol intake — no more than 2 drinks per day for men and 1 drink per day for women (1 alcoholic drink is defined as 5 ounces of wine, 12 ounces of beer, or 1.5 ounces of hard liquor). If, after 3 months, therapeutic lifestyle interventions in a patient who is not at high risk have not reduced low-density lipoprotein cholesterol levels sufficiently, the addition of drug therapy to the treatment plan should be considered. In high-risk patients, drug therapy should be considered together with therapeutic lifestyle changes at the initiation of treatment if the low-density lipoprotein level is at least 100 mg/dL. The intensity of risk-reduction therapy should be adjusted to an individual's absolute 10-year risk of coronary heart disease, which is based on age, lipoprotein profile, previous history of coronary heart disease events, and other risk factors.

A combination of sustained changes in diet, weight loss, and exercise can lower low-density lipoprotein cholesterol levels by as much as 20% to 30%.2

If the patient's target low-density lipoprotein cholesterol level has not been achieved by the 6-week visit, the clinician should intensify the low-density lipoprotein-lowering therapy by adding plant stanol/sterol esters and viscous (soluble) fiber to the diet (refer to "Treatment Information and Therapeutic Lifestyle Interventions" for more information). If the low-density lipoprotein goal is not achieved by the 12-week follow-up visit, the therapeutic lifestyle changes should be intensified by increasing the emphasis on physical activity and weight control. Drug treatment, such as statins, should also be considered. After the 12-week visit, adherence to therapeutic lifestyle changes and drug treatment should be monitored every 4 to 6 months, or more often if necessary.2

TThe recommended first-line therapy for elevated serum triglycerides is therapeutic lifestyle changes, including reduced fat intake, avoidance of very high carbohydrate intake (no more than 60% of calories), increased physical activity, weight control, and restriction of alcohol intake.

Therapeutic lifestyle changes and drug therapy by risk category are summarized in Table 2.

Table 2: Target Low-Density Lipoprotein Cholesterol Levels and Treatment Recommendations

Risk Category Target Low-Density Lipoprotein Level (mg/dL) Low-Density Lipoprotein Levels (mg/dL) at Which to Initiate Therapeutic Lifestyle Changes Low-Density Lipoprotein Levels (mg/dL) at Which to Consider Drug Therapy
High Risk: Coronary heart disease or a 10-year coronary heart disease risk equivalent (including diabetes or two or more risk factors and a 10-year risk of at least 20%) <100 (<70 optional goal for patients with coronary heart disease) ≥100 ≥100 (if lipoprotein levels are <100, a lipid-lowering drug is a therapeutic option, based on clinical trials)
Moderately High Risk: Two or more risk factors (10-year risk 10% to 20%) <130 ≥130 ≥130 (after 3 months of therapeutic lifestyle changes)
Moderate Risk: Two or more risk factors (10-year risk <10%) <130 ≥130 ≥160 (after 3 months of therapeutic lifestyle changes)
Low Risk: No risk factors or one risk factor <160 ≥160 ≥190 (after 3 months of therapeutic lifestyle changes (at 160-189 mg/dL, low-density lipoprotein-lowering drugs are optional)

Table adapted from: Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT, Hunninghake DB, Implications of recent clinical trials for the National Cholesterol Education Adult Treatment Panel III (ATP III) guidelines. Circulation. 2004; 110:227-39.



Other Important Information

Physicians should have primary responsibility for implementing the Adult Treatment Expert Panel-III treatment guidelines. In addition, a multidisciplinary team, potentially including nurses, dieticians, nurse practitioners, pharmacists, and health educators, should be involved in and reimbursed whenever possible for these services. The model of a multidisciplinary case management approach for patients with lipid disorders encompasses primary and secondary prevention across the lifespan and nutritional and exercise management, defines the indications for pharmacological therapy, and emphasizes the importance of treatment adherence.14 Using this collaborative approach for treating lipid disorders will ultimately reduce cardiovascular and cerebrovascular (stroke) morbidity and mortality. More information on adherence methods that payers can use to improve beneficiary adherence to lipid-lowering treatments is available in Part VI of the Purchaser's Guide, Leveraging Benefits.

More information on the therapeutic lifestyle intervention diet is available in the National Heart, Lung, and Blood Institute tipsheets at www.nhlbi.nih.gov/chd/Tipsheets/daily.htm.

Information on ways to reduce low-density lipoprotein cholesterol levels is available in Your Guide to Lowering your Cholesterol Level with Therapeutic Lifestyle Changes (www.nhlbi.nih.gov/health/public/heart/chol/_tlc.pdf).



Strength of Evidence

The level of evidence supporting the recommendations contained in this chapter is described below.
Evidence-Based Research:
The U.S. Preventive Services Task (USPSTF)
Strength of Evidence: A (Strongly Recommended / Good Evidence)
  • The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men aged 35 years and older and women aged 45 years and older for lipid disorders if they are at increased risk for coronary heart disease.1

    The USPSTF concludes that the benefits of screening for and treating lipid disorders in all men aged 35 years and older and women aged 45 years and older at increased risk for coronary heart disease substantially outweigh the potential harms.



Summary Plan Description Language: Lipid Disorders (Screening)

Covered Screening
Nine- to 12-hour fasting lipoprotein profile of total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides.

Initiation, Cessation, and Interval
Screening is a covered benefit for all adults aged 20 years and older and may be conducted once every 5 years, or as medically indicated.

Summary Plan Description Language: Lipids Disorders (Counseling and Treatment)

Covered Counseling and Treatments
Covered treatment for a lipid disorder includes:
  • Counseling to promote therapeutic lifestyle changes
  • Office visits to monitor lipid disorders and treatment efforts
  • Medications used to treat lipid disorders
Initiation, Cessation, and Interval
Six counseling, treatment, and monitoring sessions are covered per calendar year. Additional counseling sessions are covered, as medically indicated.

Beneficiaries undergoing treatment with lipid-lowering medications qualify for additional medication management visits, as medically indicated.



CPT Codes

Lipid Disorders (Screening)
82465 Cholesterol, serum or whole blood, total
83721 Lipoprotein, direct measurement, LDL cholesterol
83719 Lipoprotein, direct measurement, VLDL cholesterol
83718 Lipoprotein, direct measurement, high density cholesterol
84478 Triglycerides
Lipid Disorders (Counseling and Treatment)
99401 Preventive medicine counseling/risk factor reduction, 15 minutes
99402 Preventive medicine counseling/risk factor reduction, 30 minutes
99403 Preventive medicine counseling/risk factor reduction, 45 minutes
99404 Preventive medicine counseling/risk factor reduction, 60 minutes
99385 Comprehensive preventive services, 18 to 39 years, new patient
99386 Comprehensive preventive services, 40 to 64 years, new patient
99387 Comprehensive preventive services, 65 years and older, new patient
99395 Comprehensive preventive services, 18 to 39 years, established patient
99396 Comprehensive preventive services, 40 to 64 years, established patient
99397 Comprehensive preventive services, 65 years and older, established patient



Other Information and Resources

Business Group Resource(s)

CDC Resource



Author(s)

Matson-Koffman DM, Dai S, Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion. Update 201015



References

1 U.S. Preventive Services Task Force. Lipid disorder screening. Summary of Recommendations. Rockville, MD: Agency for Healthcare Research and Quality; 2008. Available at: http://www.ahrq.gov/clinic/uspstf/uspschol.htm. Accessed July 24, 2011.
2 National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. 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. Circulation. 2002;106:3143-3421.
3 Kulkina EV, Yoon PW, Keenan NL. Trends in high levels of low-density lipoprotein cholesterol in the United States, 1999-2006. JAMA. 2009;302(19):2104-2110.
4 Kahn R, Robertson RM, Smith R, Eddy D. The impact of prevention on reducing the burden of cardiovascular disease. Circulation. 2010; 2008;118:576-585.
5 Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT, Hunninghake DB, Pasternak RC, Smith SC Jr, Stone NJ. Implications of recent clinical trial for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110(6):763.br> 6 Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, et al; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010;121:e46-e215. Available at: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.109.192667. Accessed July 9, 2010.
7 Pignone MP, Phillips CJ, Atkins DA, Teutsch SM, Mulrow CD, KN. L. Screening and treating adults for lipid disorders: a summary of the evidence. Am J Prev Med. 2001;20(3 Suppl):77-89.
8 Soler RE, Leeks KD, Razi S, Hopkins DP, et al., and Community Guide Task Force. A Systematic Review of Selected Interventions for Worksite Health Promotion: The Assessment of Health Risks with Feedback. Am J Prev Med. 2010;38(2S):S237–S262.
9 Prosser LA, Stinnett AA, Goldman PA, et al. Cost-effectiveness of cholesterol-lowering therapies according to selected patient characteristics. Ann Intern Med. 2000;132:769-779.
10 National Guidelines Clearinghouse. Screening and management of lipids. Available at: http://www.guideline.gov/content.aspx?id=14421&search=lipids. Accessed May 27, 2009.
11Helfand M, Carson S. Screening for Lipid Disorders in Adults: Selective Update of 2001 U.S. Preventive Services Task Force Review. Evidence Synthesis No. 49. Rockville, MD: Agency for Healthcare Research and Quality, April 2008. AHRQ Publication no. 08-05114-EF-1. Available at http://www.ncbi.nlm.nih.gov/books/NBK33494/.
12 Morgan JM, Capuzzi DM. Hypercholesterolemia: the NCEP Adult Treatment Panel III Guidelines. Geriatrics. 2003;58:33-38.
13 Pignone MP, Ammerman A, Fernandez L, Orleans T, Pender N, Woolf S, Lohr KN, Sutton S. U.S. Preventive Services Task Force. Counseling to Promote a Healthy Diet in Adults. Summary of the Evidence. Rockville, MD: Agency for Healthcare Research and Quality;2003. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspsdiet.htm.
14 Cohen JD. A population-based approach to cholesterol control. Am J Med. 1997;102:23-25.
15 Matson Koffman D. Lipid disorders evidence-statement: screening, counseling, and treatment. In: Campbell KP, Lanza A, Dixon R, Chattopadhyay S, Molinari N, Finch RA, editors. A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage. Washington, DC: National Business Group on Health; 2006.