Trends in prevalence of guideline‐based use of lipid‐lowering therapy in a large health system

Abstract

BackgroundThe 2013 ACC/AHA (American College of Cardiology/American Heart Association) cholesterol guidelines provided an evidence‐based rationale for the allocation of lipid‐lowering therapy based on risk for atherosclerotic cardiovascular disease (ASCVD). Adoption of these guidelines was initially suboptimal but whether this has improved over time remains unclear.HypothesisPrevalence of guideline‐based statin therapy will increase over time.MethodsElectronic health record data were used to create two cross‐sectional data sets of patients (age 40‐75) served in 2013 and 2017 by a large health system. Data sets included demographics, clinical risk factors, lipid values, diagnostic codes, and active medication orders during each period. Prevalence of indications for statin therapy according to the ACC/AHA guidelines and statin prescriptions were compared between each time period.ResultsIn 2013, of the 219 376 adults, 57.7% of patients met statin eligibility criteria, of which 61.3% were prescribed any statin and 19.0% a high intensity statin. Among those eligible, statin use was highest in those with established ASCVD (83.9%) and lowest in those with elevated ASCVD risk >7.5% (39.3%). In 2017, of the 256 074 adults, 62.3% were statin eligible, of which 62.3% were prescribed a statin and 24.3% a high intensity statin. In 2017, 66.4% of statin eligible men were prescribed a statin compared to 57.4% of statin eligible women (P < 0.001). The use of ezetimibe (3.6% in 2013, 2.4% in 2017) and protein convertase subtilisin/kexin type 9 inhibitors (<0.1% and 0.1%) was infrequent.ConclusionIn a large health system, guideline‐based statin use has remained suboptimal. Improved strategies are needed to increase statin utilization in appropriate patients.

Statin Use in Older Adults with Stable Atherosclerotic Cardiovascular Disease

“…Identifying gaps in contemporary prescribing patterns is key to formulating strategies to bridge prevalent gaps and optimize ASCVD outcomes in this high‐risk population. Our findings are consistent with and complementary to prior studies that have identified low high intensity statin prescription rates 14,15 . Of note, the rates of statin prescription in this study population of patients who had regular access to medical care may be higher than those in the general population.…”

“…Ezetimibe and PCSK9 inhibitor prescriptions were low as in prior studies 15 . We note, however, that PSCK9 inhibitors were not FDA approved until 2015 (9 years into the 12‐year study period) and were not present in the 2013 multi‐society guidelines.…”

Cardiology clinic visit increases likelihood of evidence‐based cholesterol prescribing in severe hypercholesterolemia

“…This is slightly better than a previous study of a German diabetes registry which showed that of 51 640 SH patients with type 2 diabetes, 25.5% were prescribed a statin 14 . A recent study at another large health system found that in 2017, 59.4% of patients with an LDL > 190 were on a statin and a percentage similar to our cohort were on ezetimibe (2.5%) and PCSK9 inhibitors (0.7%) 20 …”

“…Another limitation includes not excluding patients with the common secondary causes of hyperlipidemia, such as thyroid‐related disease, certain medications, and nephrotic syndrome. Prior studies suggest that this is likely only 1–2% of this population 20 …”

Statin Therapy and Intensity: Prognosis in Patients with Myocardial Injury

“…In contrast to our observations, other studies investigating statin use and treatment intensity after myocardial infarction around the study period showed higher proportions of patients who were taking high-intensity statins. 21,22 However, a substantial proportion of patients was excluded from these studies (eg, all patients with missing data on low-density lipoprotein cholesterol and patients aged older than 75 years). We included all patients regardless of age, and the mean age in our study population was 71 years.…”