Attitudes and Barriers to Lipoprotein(a) Testing: A Survey of Providers at the University of Pennsylvania Health System

Abstract

Background/Synopsis

Lipoprotein(a) [Lp(a)] is an independent, genetic, and causal risk factor for atherosclerotic cardiovascular disease (ASCVD). Elevated Lp(a) levels increase a person's risk for myocardial infarction, coronary artery disease, ischemic stroke, and aortic stenosis. Guidelines generally recommend testing for Lp(a) in high-risk patients, with some recent guidelines recommending testing once in all adults. It is estimated that >20% of the population carry Lp(a) levels high enough to increase risk, however due to undertesting, many of these patients have not been identified.

Objective/Purpose

To understand the attitudes and barriers to testing for Lp(a) across relevant clinical settings and specialties at the University of Pennsylvania Health Systems (UPHS).

Methods

A brief IRB-approved survey in REDCap was distributed via email to select groups of UPHS providers in Cardiology, Neurology, Primary Care, and Vascular Surgery.

Results

The survey was sent to approximately 525 providers in December 2023. Of these, 116 providers completed the survey (54% Internal Medicine/Family Practice, 31% Cardiology, 10% Neurology, 4% Vascular Surgery). Approximately 31.0% (n=36) of all providers routinely tested for Lp(a) in their practice, but this varied by specialty (44% of Cardiologists versus 22% of Internal Medicine/Family Practice providers). For these providers, the most common reasons for testing included a familial history of ASCVD, a history of ASCVD in the patient, and high cholesterol (Table 1). A total of 80 providers (69%) responded that they do not regularly test for Lp(a). The most common reasons for not testing included lack of familiarity with Lp(a), insurance/billing concerns, lack of clinical trial outcomes data, and lack of available pharmaceutical interventions (Table 2).

Conclusions

While there is likely selection bias in the providers who chose to complete the survey, a surprisingly high number of responders (69%) described not regularly testing for Lp(a) in their practice. While results from ongoing clinical trial investigations of novel Lp(a)-lowering treatments may address provider hesitation toward utility of Lp(a)-testing, there is still a large gap to fill in Lp(a) awareness. Increasing provider knowledge of Lp(a) and incorporation into broader clinical guidelines are needed.