2010 Survey

1. 2010 Survey

2. The National Lipid Association Non-profit organization Directed toward advocacy for the education of health care professionals involved in the diagnosis and treatment of lipoprotein disorders and related metabolic diseases Developed in 1997 as outgrowth of Southeast Lipid Association by a group of lipid researchers and clinicians from southeastern U.S. 5 regional chapters Approximately 2500 active members in 2010

3. LIPID PULSE Objectives To better understand the practice dynamics, beliefs and behaviors of HCPs who specialize in lipid management To delineate the differences between respondents according to their practice’s degree of focus on lipid management To understand the awareness and utilization of various lipid parameters & information sources To understand the value NLA members place on NLA offerings 3

4. Lipid Pulse Membership Survey: Survey Design Survey Market Promotion Methodology Respondent Groupings 4

5. Survey Design On-line, ~30-Question survey that took ~13 minutes to complete Developed, programmed, tested and launched by a team including representatives from Genzyme, NLA staff, NLA Board Leadership and Reckner/Blueberry Clinician Information Practice Information Lipid ManagementPatient Information Information Services NLA Membership

6. Survey Promotional Efforts Target List: 2,581 NLA members (2,490 w/ email) Honorarium / Incentive language: The NLA is conducting a membership survey to get to know you and your practice better. When you complete the survey, you'll receive a $25 voucher to use on NLA products, a report of the survey results, and 25 copies of the Genzyme-published patient education booklet on Familial Hypercholesterolemia. Help us achieve 100% participation!” Recruited: through email, fax, mail from May 11th to June 2nd; survey closed June 14th Key Activities: May 11th: An initial email & mail invitation was sent to all members with a valid email or mailing address Timed to coincide with the NLA Scientific Sessions in Chicago, May 13-16 2010 where kiosk was present (attendees could take survey via kiosk or smartphone) May 20th: Follow-up email, fax, and USPS mailed invitation was sent to members who did not respond to the initial email or USPS invite. Also, a reminder invitation was sent (via email or fax) to those members who started the survey but did not complete the survey June 2nd: A second follow-up email and fax invitation was sent to members who had not yet participated. Also, a reminder invitation was sent (via email or fax) to those members who started the survey but did not complete the survey 6

7. Daily Responses vs. Promotional Activity # of Respondents A star indicates a promotional activity occurred on this date (e.g., email/fax communication, USPS mailing) 7

8. Methodology 657 valid survey responses 17 respondents were removed due to industry employment Pairwise comparisons between groups were tested at the 95% and 80% confidence interval throughout report Charts, graphs and tables indicate comparisons that were significant at the 95% confidence level, using uppercase letters to denote columns against which comparisons were significant Comparisons significant at the 80% confidence interval are denoted using lowercase letters Note small base sizes of < n=30; interpret with caution 8

9. Respondent Groupings Respondents grouped according to self-reported: Profession (e.g., Physicians, NPs/PAs, Pharmacists or other) Specialty* (e.g., IM/GP, Cardiologists, Endocrinologists or other) Lipid Practice Profile Which best describes the role lipid management (plays) in your practice? My practice is a… a) Lipid Clinic (i.e. staff and time specifically dedicated to seeing patients for lipid disorders) b) Lipid Specialist Practice (i.e. not a Lipid Clinic, but receive patient referrals from other clinicians for patients specifically for lipid management) c) [neither] Lipid management is incorporated into my clinical practice, but I do not work at a Lipid Clinic, nor do I receive referrals specifically for lipid problems (i.e. neither a nor b) * Only applies to MDs & NPs/PAs 9

10. 2. Respondent & Practice Profile Geographic Distribution Profession, Specialty & Lipid Practice Profile Years in Practice Practice Setting Lipid Certification Status 10

11. Geographic Distribution - All Respondents* * n=630 (27 respondents excluded because of undetermined addresses or international)

12. Geographic Distribution – By Lipid Practice Profile* Lipid Clinic Lipid Specialist Other NLA Respondent * n=628 (29 respondents excluded because of undetermined addresses or international respondents)

13. Lipid Clinic Respondents Only* * n=137

14. Geographic Distribution: Summary Lipid specialists tend to be clustered in urban areas Highest density of lipid clinics is seen in regions where initial NLA chapters were started: southwest, midwest and northeast

15. Respondents by Profession Of the 657 respondents who completed the survey, 67% are physicians, 16% are NPs/PAs and 8% are pharmacists “Other” includes PhD/scientists, Nurses (4%), Registered Dieticians/nutritionists (RD) (4%), Ph.D. or science specialists (2%) and Certified Diabetes Educator (CDE) (<1%). Profession % of Respondents (n=439) (n=102) (n=53) (n=63) Base: All Respondents (n=657) Q1 Please indicate your profession (select one): (Are you a) Physician (MD/DO) Nurse Practitioner (NP), Physician’s Assistant (PA) , Dietician (RD), Exercise specialist, Pharmacist, Ph.D. or science specialty, Certified Diabetes Educator (CDE) or Other: (Please specify)? 15

16. Respondents by Specialty About half of physician respondents are self-report as IMs or FPs Nearly a third of the respondents are cardiologists (CARDS) Board Certification % of Physicians (n=218) (n=138) (n=50) (n=30) Base: Physicians (n=436) Q3b Please describe your board certification: Cardiology, Endocrinology, Internal Medicine, Family Medicine, Other [specify]. Other includes Pediatrics, Lipidology/Clinical Lipidology, Medical Biochem, and Nephrology. 16

17. Respondents by Lipid Practice Profile About 57% of the respondents either work in a lipid clinic or receive referrals specifically for lipid management Lipid Practice Profile 57% % of Respondents (n=155) (n=220) (n=282) Base: All Respondents (n=657) Q9 Which best describes the role lipid management (plays) in your practice [radio button]: (My practice is a) Lipid Clinic (i.e. staff and time specifically dedicated to seeing patients for lipid disorders), lipid specialist practice (i.e. not a Lipid Clinic, but receive patient referrals from other clinicians for patients specifically for lipid management), Lipid management is incorporated into my clinical practice, but I do not work at a Lipid Clinic, nor do I receive referrals specifically for lipid problems (i.e. neither a nor b) 17

18. Lipid Practice Profile by Specialty • Physician respondent, most lipid clinics/specialists are either IM/FPs or CARDs Lipid Practice Profile by Specialty % of Physicians C C AB A B C (n=89) (n=163) (n=184) Base: Physicians (n=436). Q9 Which best describes the role lipid management (plays) in your practice [radio button]: (My practice is a) Lipid Clinic (i.e. staff and time specifically dedicated to seeing patients for lipid disorders), lipid specialist practice (i.e. not a Lipid Clinic, but receive patient referrals from other clinicians for patients specifically for lipid management), Lipid management is incorporated into my clinical practice, but I do not work at a Lipid Clinic, nor do I receive referrals specifically for lipid problems (i.e. neither a nor b) 18

19. Years in Practice by Profession Respondent physicians appear to be significantly older than respondent NPs/PAs or pharmacists 41% of the respondent physicians had more than 26 years in practice Cardiologists skew older than other specialties A B C B C Average Years in Practiceby Profession Years in Practice Distribution b BC A A % of Respondents Average # of Years BC BC A A b A a A (n=439) (n=102) (n=53) (n=439) (n=102) (n=53) Base: Physician/NP/PA/Pharm (n=594) Q2 How long you have been in clinical practice? [open # box] years [RANGE: 0-60] 19

20. Why Do Older Physicians Choose to Practice Clinical Lipidology? Less invasive More cognitive Desire to treat pathophysiology rather than symptoms of atherosclerosis Appreciation that it is the right thing to do Remembering that financial remuneration was not the reason we entered medicine

21. Lipid Certification Status Overall awareness of the lipid certification program is high Two-thirds of respondents have either passed or are preparing for certification One-third of respondents are aware of but not pursuing an NLA certification Lipid Certification Status Passed / Preparing 68% % of Respondents (n=224) (n=147) (n=159) (n=5) (n=6) Base: Physician/NP/PA (n=541). Physicians/NPs/PAs who self-identified as “Other” in Q1 were not asked Q4. Q4 How would you characterize your status in terms of Certification for Clinical Lipidology (MD) or Clinical lipid specialist (PA/NP)? [select one] (I am/have) Passed the Certification Program, Preparing to pass the Certification Program, Aware of, but not pursuing the Certification Program , or Not aware of the Certification Program 21

22. Certification Status by Lipid Practice Profile Not surprisingly, Lipid Clinic or Lipid Specialist HCPs are more likely to be certified or plan to be certified About 40% of respondents who are non-lipid specialists/clinics are currently preparing to be certified A B C Certification Status by Lipid Practice Profile C aC AB % of Phys/NP/PA aB b (n=114) (n=191) (n=236) Base: Physician/NP/PA (n=541). Physicians/NPs/PAs that self-identified as “other” in Q1 were not asked Q4. Q4 How would you characterize your status in terms of Certification for Clinical Lipidology (MD) or Clinical lipid specialist (PA/NP)? [select one] (I am/have) Passed the Certification Program, Preparing to pass the Certification Program, Aware of, but not pursuing the Certification Program , or Not aware of the Certification Program 22

23. Board Certification: Limitation of Lipid Pulse Survey 41% of respondents stated that they are board certified by the ABCL or ACCL As of November 2010, 691 or the active 2,461 active members (28%) were board certified Thus, respondents likely represent a more engaged group than the general membership

24. Type of Practice Nearly four-fifths of Physicians/NP/PA/Pharms work in either a single-specialty or a multi-specialty group practice; the remainder are in solo practice. Practice Type Group - 78% % of Respondents A B C (n=129) (n=249) (n=216) Base: Physician/NP/PA/Pharm (n=594) Q5 Please describe your clinical practice (select one): Is it a Solo, a Group – Single Specialty, or a Group – Multi-Specialty practice? 24

25. Practice Setting A majority (60%) of respondents are office-based More than one-fourth work in a hospital (outpatient clinics included) “Academic” indicates both hospital and clinic affiliation with an academic institution Practice Setting(check all that apply) % of Respondents Base: Physician/NP/PA/Pharm (n=594). Respondent may report more than on practice setting. Q6 Which best describes your practice setting (select all that apply): a) Private practice (office-based), Academic/research, Hospital-based , Pharmacy-based, Community clinic or Other setting ? [free text] *Includes Community, HMO and Other 25

26. 3. Staffing & Patient Volume FTEs Total Patient Volume Hours Per Week Seeing Patients

27. Total Clinician Staffing in Practice (FTEs) • Reflecting presence in group practices, Lipid Clinics and Lipid Specialists describe working with more staff Average # of FTEs Staffing in FTEs Distribution (n=134) A B (n=205) C c c (n=255) % of Respondents Average # of FTEs A a BC A B C (n=134) (n=205) (n=255) # of FTEs Base: Physician/NP/PA/Pharm (n=594) Q12 In terms of full-time equivalents (FTEs), including yourself, how many clinicians are in your practice?

28. Total Patient Volume • Respondent clinicians who work in lipid clinics see a lower overall volume of patients • Possible reasons include academic research, clinical trial activities and other responsibilities Average # of Patients Patient Distribution Ac a % of Respondents Average # of Patients Ac C a BC aB B b A B C A B C (n=134) (n=205) (n=255) (n=134) (n=205) (n=255) Base: Physician/NP/PA/Pharm (n=594) Q8 How many patients are under your care in your personal practice? If NA enter zero. [# box – 5 digits (0-99999)]

29. Hours Per Week Seeing Patients • Respondent clinicians who work more in lipid-focused settings spend less of their time actually seeing patients for all types of medical issues Average Hours Per Week Seeing Patients Hours Per Week Distribution A A Average Hours Per Week % of Respondents BC C C A A ab A B C A B C (n=134) (n=205) (n=255) (n=134) (n=205) (n=255) Base: Physician/NP/PA/Pharm (n=594) Q10 Please indicate the number of hours per week you spend seeing patients. If NA enter zero: [# - 2 digits (0-99)]

30. 4. Lipid Practice Characteristics Practice Services Lipid Management Staffing Lipid Management Patient Volume Time Respondents Spend Seeing Lipid Management Patients Anticipated Changes in Lipid Practice Characteristics Loss / Profitability

31. Frequency of Practice Services More than half of practices provide diabetes management, nutrition/exercise programs, and weight management services. % of Respondents *Includes: Lipid management, Hypertension/Anticoagulation Management, CIMT, HTN management, Advanced lipid/lipoprotein testing **Other miscellaneous mentions, Internal medicine, Lab, Sports medicine ***Non-Invasive Cardiology Diagnostics, General  (e.g. Stress testing/(nuclear/echo), Cardiology services (general cardiology/non specific), Preventive Cardiology Services & Risk Assessment ((non-specific)), Interventional Cardiology ****Smoking cessation, Diabetes education, Teaching/education (non-specific), Med management/education (non-specific) Base: Physician/NP/PA/Pharm (n=594). Total is greater than 100% due to multiple responses. Q15 Please indicate which of the following services your practice provides: [check boxes], Clinical trial participation, Cardiac rehab, Diabetes management, Nutrition/exercise programs, Weight management, LDL apheresis, Other – please specify [fill in blank] 31

32. Frequency of Practice Services Lipid Clinics (to a lesser extent Lipid Specialists) are more likely to offer nutrition/exercise programs, weight management and clinical trial participation Services Provided by Lipid Practice Profile A B C (n=134) (n=205) (n=255) BC A A BC C BC c C % of Respondents C C bC C Ab a b Base: Physician/NP/PA/Pharm (n=594). Total is greater than 100% due to multiple responses. Q15 Please indicate which of the following services your practice provides: [check boxes], Clinical trial participation, Cardiac rehab, Diabetes management, Nutrition/exercise programs, Weight management, LDL apheresis, Other – please specify [fill in blank] 32

33. Frequency of Practice Services Offered:Study Limitation • Note that 10% of respondents reported that LDL apheresis is offered in their practice • This response is clearly not reflective of the general membership of clinical lipidologists

34. Past Year and Anticipated Changes: Patient Volume Not asked Increase No Change Decrease Over the past year my patient volume has… Over the next 3 years, I expect patient volume to… A % of Physicians b A B A B (n=114) (n=191) (n=114) (n=191) Base: Physician/NP/PA who works in a Lipid Clinic or Lipid Specialist practice (Q9) (n=305) Q20 Please describe the changes in your lipid management practice (in terms of Decrease(d) No(t) Change(d) Increase(d)) Over the past year my patient volume has… // Over the next 3 yrs, I expect patient volume to… // Over the next 3 years, I expect staffing needs to… // Over the next 3 years, I expect equipment needs to… // Over the next 3 years, I expect payer (insurance/Medicare/Medicaid) reimbursement pressures to… 34 About 60% of LC/LSs respondents indicate that their patient volume has increased in the past year Lipid clinic respondents are slightly more likely than lipid specialists to expect increased patient volume in the next 3 years

35. Loss/profitability At a loss At break-even or better by Lipid Practice Profile by Specialty by Profession c c % of Physicians ab A B C B A C D (n=134) (n=90) (n=24)* (n=20)* (n=35) (n=32) (n=10)* (n=12)* Base: Physician/NP/PA/Pharm (for Profession and Lipid Practice Profile) who works in a Lipid Clinic (Q9) (n=134) Base: Physician (Speciality) who works in a Lipid Clinic (Q9) (n=89) Q21 From a financial standpoint, do you consider your lipid clinic to be operating (select one): [radio button] At break-even or better , At a loss. *Note: Small base size. Interpret with caution 35 • Respondents who work in lipid clinics (only) were asked about the profitability of their practices • Approximately two-thirds of these respondents say they operate at break-even or better

36. Loss/Profitability:Limitations of Lipid Pulse Survey • Survey only employed financial appraisal by clinician • No verification by administrator of CFO • Likely result is an overestimation of profitability of many of these programs • Are endocrinologists really different?

37. 5. Lipid Management Referral Patterns Referral Patterns Referral Reasons 37

38. Other ENDO CARD IM/FP Lipid Management Referral Patterns • Amongst LC/LSs referral sources are fairly similar across all specialty types • Respondent IM/FPs do receive about 20% of their referrals from cardiologists Lipid Management Referral Patterns by Specialty d D aD Mean % Referred From Specialist aB B bD A B C D (n=85) (n=99) (n=34) (n=17)* (n=269) Base: Respondent is a Physician, NP or PA at Q1, Lipid clinic/specialist at Q9 and has patients referred for lipid management specifically at Q17 Q18 Of referrals you receive for lipid management, please describe the type of referring clinicians: [enter the % of referred patients] GP/FP or Internist, Cardiologist, Endocrinologist, Other, please specify______ , Other, please specify______ [sum to 100%] *Note: Small base size. Interpret with caution

39. Elevated LDL-C Hypertri-glyceridemia Isolated low HDL Combined dyslipidemia Statin-intolerance Presence of CVD or evidence of risk with normal lipid profile Other Lipid Management Referral Reasons • Respondent Lipid Clinics/Specialists receive patient referrals for similar reasons • About half are due to elevated LDL-C, combined dyslipedmia • Statin intolerance accounts for ~ 20% • High TGs makes up just under 20% of referrals Reasons for Lipid Management Referral by Lipid Practice Profile Mean % Referred From Specialist A B (n=269) Base: Respondent is a Physician, NP or PA at Q1, Lipid clinic/specialist at Q9 and has patients referred for lipid management specifically at Q17 Q19 Of those patients referred to you for lipid management, please indicate the reason for referral: Enter the % Patients seen for Elevated LDL-C, Hypertriglyceridemia, Isolated low HDL, Combined dyslipidemia, Statin-intolerance, Presence of CVD or evidence of risk with normal lipid profile, Other, please specify______ , Other, please specify______ [sum to 100%] (n=97) (n=172)

40. 6. Beliefs & Information Sources Tests Routinely Ordered Parameters Most Predictive of Cardiovascular Risk Education Needs Information Mediums / Sources New Product Awareness 40

41. Tests Routinely Ordered Base: All Respondents (n=657) Q22-1. Of the lipid parameters and related topics listed below: What tests do you order routinely (more than once a month in your overall practice)? (check all that apply) 41

42. I IIa IIb III B Recommendations for General Approaches to Risk Stratification Global risk scores (such as the Framingham Risk Score [FRS]) that use multiple traditional cardiovascular risk factors should be obtained for risk assessment in all asymptomatic adults without a clinical history of CHD. These scores are useful for combining individual risk factor measurements into a single quantitative estimate of risk that can be used to target preventive interventions. Benefit>>>Risk Should be performed Limited populations >90% order lipid profile Lipid profile enables global risk scoring 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults

43. I IIa IIb III B Recommendations for Measurement of C-Reactive Protein (CRP) In men 50 years of age or older or women 60 years of age or older with LDL cholesterol less than 130 mg/dL; not on lipid-lowering, hormone replacement, or immunosuppressant therapy; without clinical CHD, diabetes, chronic kidney disease, severe inflammatory conditions, or contraindications to statins, measurement of CRP can be useful in the selection of patients for statin therapy. Benefit>>Risk Is reasonable Limited populations >60% order hs-CRP 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults

44. I IIa IIb III B Recommendation for Lipoprotein-associated Phospholipase A2 Lipoprotein-associated phospholipase A2 (Lp-PLA2) might be reasonable for cardiovascular risk assessment in intermediate-risk asymptomatic adults. 18-30% order Lp-PLA2 Benefit ≥ risk May/might be considered Limited populations 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults

45. I IIa IIb III Recommendation for Lipoprotein and Apolipoprotein Assessments Measurement of lipid parameters, including lipoproteins, apolipoproteins, particle size, and density, beyond a standard fasting lipid profile is not recommended for cardiovascular risk assessment in asymptomatic adults. 56-61% order apo B 38-61% order LDL-P 18-28% order particle size 29-35% order Lp(a) Not recommended 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults

46. Parameters Most Predictive of CV Risk Base: All Respondents (n=657) Q22-2. Of those listed, which 5 parameters you believe to be most predictive for assessing CV risk? (select 5) 46

47. Greatest Need for Education/Awareness Base: All Respondents (n=657) Q22-3. Of those listed, the 5 topics where you believe there is greatest need for increased awareness and/or education? (select 5) 47

48. Sources Used to Learn About Lipid Management Journal of Clinical Lipidology/Journal of Lipidology 45% NEJM 23% Lipid Spin 20% JACC 20% Circulation 16% JAMA 10% NLA 23% NEJM 13% Heart.org 12% Medscape 12% Heart.org 17% Medscape 13% NLA 12% UpToDate 11% NLA 63% AHA 21% ACC 19% NLA 27% ReachMD 12% Heart.org 10% NLA 42% Heart.org 9% • Respondents cite JCL, NEJM and JACC as most often used sources for LM information • ~60% describe reading journals online; 45% use other (non-journal) online source % of Respondents Base: All respondents (n=657). Total is greater than 100% due to multiple responses. Top mentions noted in text boxes. Q23. Which sources do you use to learn about lipid management? Which ones? 48

49. Awareness of Technologies/Therapies in Development Base: All Respondents (n=657) Q26. What - if any - new therapies or technologies in development for lipid management are you aware of? Open-end - Top mentions shown. 49

50. Summary of Tests Ordered and Information Sources/ Needs Lipid Tests Routinely Ordered Over 90% routinely order the standard lipid panel (e.g., HDL, LDL, TG) About half of the MD respondents reported regularly (>once/month) ordering particle #, Lp(a), Apo B (Two-thirds said CRP) in addition to the standard lipid panel Lp(a) and Apo B were found to be more common in more lipid-centric physicians Lipid Parameters Most Predictive of CV Risk Non-HDL/Apo B believed to be the same in terms of being most predictive of risk However, Apo B is ordered less often, this is likely because clinicians can obtain non-HDL for free of cost w/ standard panel Followed by HDL, then lipoprotein particle # Interestingly, lipid clinic physicians frequently indicated that genetic testing for FH was one of the top five parameters to measure CV Risk Greatest Need for Education/Awareness Statin intolerance / patient compliance were frequently mentioned These are related and appear more frequently in lipid clinic responses compared to other clinicians Lipoprotein particle # is also a top interest