Physicians’ misperceived cardiovascular risk and therapeutic inertia as determinants of low LDL-cholesterol targets achievement in diabetes
Authors: Morieri Mario Luca , Lamacchia Olga , Manzato Enzo , Giaccari Andrea , Avogaro Angelo ,   Lipid-Lowering-Relevance Study Group, Amoresano Lucio , Angotti Stefania , Bartone Laura , Caraffa Francesco , Carboni Antonello , Carro Stefano , Cervone Silvestre , Clerico Alessandra , Console Ida , Conti Danilo Mario , D’Addato Sergio , de Bellis Alessandra , de Meo Francesco , di Carlo Alberto , di Cianni Graziano , di Giovanni Giuseppe , di Lembo Sergio , Diacono Fabrizio , Dolcino Mara , Elia Giovanni , Elli Paolo , Fatone Cristina , Galli Angelica , Galluzzo Giovanni , Garzaniti Adriana , Ghelardi Renata , Giacchini Anna , Giunta Loretta , Golia Francesco , Gregorio Franco , Ierna Dario , Lampitella Antonio , Luciano Antonio , Maffettone Ada , Mancini Raffaele , Mangone Ida , Mantovani Linneo Enzo , Marangoni Alberto , Marelli Giuseppe , Marin Narciso , Marino Gennaro , Mastromatteo Eugenio , Mazziotti Gaetano , Me Elisa , Memoli Giuseppe , Menicatti Laura Silvia Maria , Moffa Simona , Moise’ Manuela , Monaco Fabrizio , Morgante Sara Nazzarena , Pellicano Francesca , Petraroli Ettore , Piersanti Deamaria , Pipitone Antonino , Puglisi Susanna , Rinaldi Maura , Rizzo Mario , Rosco Maura , Scollo Giampaolo , Simioni Natalino , Squadrone Mariarosaria , Sturniolo Giacomo , Tedeschi Anna , Tizio Biagio , Ugolotti Diletta , Valente Livio , Vinci Carmela , Zenoni Luca , Zenti Maria Grazia 
Published: April 2022

Abstract
Background
Greater efforts are needed to overcome the worldwide reported low achievement of LDL-c targets. This survey aimed to dissect whether and how the physician-based evaluation of patients with diabetes is associated with the achievement of LDL-c targets.

Methods
This cross-sectional self-reported survey interviewed physicians working in 67 outpatient services in Italy, collecting records on 2844 patients with diabetes. Each physician reported a median of 47 records (IQR 42–49) and, for each of them, the physician specified its perceived cardiovascular risk, LDL-c targets, and the suggested refinement in lipid-lowering-treatment (LLT). These physician-based evaluations were then compared to recommendations from EAS/EASD guidelines.

Results
Collected records were mostly from patients with type 2 diabetes (94%), at very-high (72%) or high-cardiovascular risk (27%). Physician-based assessments of cardiovascular risk and of LDL-c targets, as compared to guidelines recommendation, were misclassified in 34.7% of the records. The misperceived assessment was significantly higher among females and those on primary prevention and was associated with 67% lower odds of achieving guidelines-recommended LDL-c targets (OR 0.33, p < 0.0001). Peripheral artery disease, target organ damage and LLT-initiated by primary-care-physicians were all factors associated with therapeutic-inertia (i.e., lower than expected probability of receiving high-intensity LLT). Physician-suggested LLT refinement was inadequate in 24% of overall records and increased to 38% among subjects on primary prevention and with misclassified cardiovascular risk.

Conclusions
This survey highlights the need to improve the physicians’ misperceived cardiovascular risk and therapeutic inertia in patients with diabetes to successfully implement guidelines recommendations into everyday clinical practice.