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Bugiardini R, Gulati M. Closing the sex gap in cardiovascular mortality by achieving both horizontal and vertical equity. Atherosclerosis 2024; 392:117500. [PMID: 38503147 DOI: 10.1016/j.atherosclerosis.2024.117500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/22/2024] [Accepted: 02/27/2024] [Indexed: 03/21/2024]
Abstract
Addressing sex differences and disparities in coronary heart disease (CHD) involves achieving both horizontal and vertical equity in healthcare. Horizontal equity in the context of CHD means that both men and women with comparable health statuses should have equal access to diagnosis, treatment, and management of CHD. To achieve this, it is crucial to promote awareness among the general public about the signs and symptoms of CHD in both sexes, so that both women and men may seek timely medical attention. Women often face inequity in the treatment of cardiovascular disease. Current guidelines do not differ based on sex, but their applications based on gender do differ. Vertical equity means tailoring healthcare to allow equitable care for all. Steps towards achieving this include developing treatment protocols and guidelines that consider the unique aspects of CHD in women. It also requires implementing guidelines equally, when there is not sex difference rather than inequities in application of guideline directed care.
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Affiliation(s)
- Raffaele Bugiardini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Martha Gulati
- Department of Cardiology, Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA.
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2
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Berteotti M, Profili F, Nreu B, Casolo G, Zuppiroli A, Mannucci E, Marcucci R, Francesconi P. LDL-cholesterol target levels achievement in high-risk patients: An (un)expected gender bias. Nutr Metab Cardiovasc Dis 2024; 34:145-152. [PMID: 37996368 DOI: 10.1016/j.numecd.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/17/2023] [Accepted: 09/24/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND AND AIMS Lowering low-density lipoprotein cholesterol (LDL-C) is the cornerstone of cardiovascular disease prevention. Collection of epidemiological data is crucial for monitoring healthcare appropriateness. This analysis aimed to evaluate the proportion of high-risk patients who achieved guidelines recommended LDL-C goal, and explore the predictors of therapeutic failure, with a focus on the role of gender. METHODS AND RESULTS Health administrative and laboratory data from seven Local Health Districts in Tuscany were collected for residents aged ≥45 years with a history of major adverse cardiac or cerebrovascular event (MACCE) and/or type 2 diabetes mellitus (T2DM) from January 1, 2019, to January 1, 2021. The study aimed to assess the number of patients with optimal levels of LDL-C (<55 mg/dl for patients with MACCE and <70 mg/dl for patients with T2DM without MACCE). A cohort of 174 200 individuals (55% males) was analyzed and it was found that 11.6% of them achieved the target LDL-C levels. Female gender was identified as an independent predictor of LDL-C target underattainment in patients with MACCE with or without T2DM, after adjusting for age, cardiovascular risk factors, comorbidities, and district area (adjusted-IRR 0.58 ± 0.01; p < 0.001). This result was consistent in subjects without lipid-lowering therapies (adjusted-IRR 0.56 ± 0.01; p < 0.001). CONCLUSION In an unselected cohort of high-risk individuals, females have a significantly lower probability of reaching LDL-C recommended targets. These results emphasize the need for action to implement education for clinicians and patients and to establish clinical care pathways for high-risk patients, with a special focus on women.
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Affiliation(s)
- Martina Berteotti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Francesco Profili
- Epidemiology Unit, Regional Health Agency (ARS) of Tuscany, Florence, Italy
| | - Besmir Nreu
- Diabetology Unit, Careggi university hospital, Florence, Italy
| | | | - Alfredo Zuppiroli
- Former Department of Cardiology, Azienda Sanitaria di Firenze, Florence, Italy
| | - Edoardo Mannucci
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Diabetology Unit, Careggi university hospital, Florence, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Paolo Francesconi
- Epidemiology Unit, Regional Health Agency (ARS) of Tuscany, Florence, Italy
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3
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Kim BG, Lee SJ, Lee YJ, You SC, Hong SJ, Yun KH, Hong BK, Heo JH, Rha SW, Hong SJ, Ahn CM, Kim BK, Ko YG, Choi D, Hong MK, Jang Y, Cho YH, Kim JS. Effect of moderate-intensity statin with ezetimibe combination vs. high-intensity statin therapy according to sex in patients with atherosclerosis. Sci Rep 2023; 13:20157. [PMID: 37978309 PMCID: PMC10656546 DOI: 10.1038/s41598-023-47505-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 11/14/2023] [Indexed: 11/19/2023] Open
Abstract
We aimed to evaluate sex differences in the effects of moderate-intensity statin with ezetimibe combination therapy (rosuvastatin 10 mg plus ezetimibe) versus high-intensity statin (rosuvastatin 20 mg) monotherapy in patients with atherosclerotic cardiovascular disease (ASCVD). This was a sex-specific subgroup analysis of the RACING trial that evaluated the interaction between sex and treatment strategies for the primary outcome (composite of cardiovascular death, major cardiovascular events, or nonfatal stroke at 3 years). Of 3780 patients in the RACING trial, 954 (25.2%) were women. Regardless of sex, the effect of moderate-intensity statin with ezetimibe combination therapy on primary outcome compared with high-intensity statin monotherapy was similar (hazard ratio [HR] 0.98 [0.63-1.52] in women; HR 0.90 [0.71-1.14] in men). The rate of discontinuation or dose reduction of study drugs due to intolerance was lower in the ezetimibe combination group than in the high-intensity statin monotherapy group in both women (4.5% vs. 8.6%, P = 0.014) and men (4.8% vs. 8.0%, P < 0.001). LDL cholesterol levels of < 70 mg/dL at 1, 2, and 3 years were more frequently achieved in the ezetimibe combination group than in the high-intensity statin monotherapy group (all P < 0.001) in both sexes. There were no significant interactions between sex and treatment groups regarding the primary outcome, discontinuation, or dose reduction of study drugs, or the proportion of achievement of LDL cholesterol levels < 70 mg/dL. The effect of ezetimibe combination therapy for the 3-year composite outcomes was not different in both men and women. The benefits of ezetimibe combination therapy on LDL cholesterol lowering and drug tolerance were similarly observed regardless of sex.Trial registration: https://clinicaltrials.gov ; Unique identifier: NCT03044665.
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Affiliation(s)
- Byung Gyu Kim
- Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Seung-Jun Lee
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, 03722, Korea
| | - Yong-Joon Lee
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, 03722, Korea
| | - Seng Chan You
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
| | | | | | - Bum-Kee Hong
- Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Ho Heo
- Kosin University College of Medicine, Busan, Korea
| | | | - Sung-Jin Hong
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, 03722, Korea
| | - Chul-Min Ahn
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, 03722, Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, 03722, Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, 03722, Korea
| | - Donghoon Choi
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, 03722, Korea
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, 03722, Korea
| | - Yangsoo Jang
- CHA Bundang Medical Center, CHA University College of Medicine, Seongnam, Korea
| | - Yun-Hyeong Cho
- Division of Cardiology, Myongji Hospital, Hwasu-ro 14-55, Deogyang-gu, Goyang, 10475, Gyeonggi-do, Korea.
| | - Jung-Sun Kim
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, 03722, Korea.
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4
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Peng AW, Dudum R, Jain SS, Maron DJ, Patel BN, Khandwala N, Eng D, Chaudhari AS, Sandhu AT, Rodriguez F. Association of Coronary Artery Calcium Detected by Routine Ungated CT Imaging With Cardiovascular Outcomes. J Am Coll Cardiol 2023; 82:1192-1202. [PMID: 37704309 PMCID: PMC11009374 DOI: 10.1016/j.jacc.2023.06.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/30/2023] [Accepted: 06/20/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Coronary artery calcium (CAC) is a strong predictor of cardiovascular events across all racial and ethnic groups. CAC can be quantified on nonelectrocardiography (ECG)-gated computed tomography (CT) performed for other reasons, allowing for opportunistic screening for subclinical atherosclerosis. OBJECTIVES The authors investigated whether incidental CAC quantified on routine non-ECG-gated CTs using a deep-learning (DL) algorithm provided cardiovascular risk stratification beyond traditional risk prediction methods. METHODS Incidental CAC was quantified using a DL algorithm (DL-CAC) on non-ECG-gated chest CTs performed for routine care in all settings at a large academic medical center from 2014 to 2019. We measured the association between DL-CAC (0, 1-99, or ≥100) with all-cause death (primary outcome), and the secondary composite outcomes of death/myocardial infarction (MI)/stroke and death/MI/stroke/revascularization using Cox regression. We adjusted for age, sex, race, ethnicity, comorbidities, systolic blood pressure, lipid levels, smoking status, and antihypertensive use. Ten-year atherosclerotic cardiovascular disease risk was calculated using the pooled cohort equations. RESULTS Of 5,678 adults without ASCVD (51% women, 18% Asian, 13% Hispanic/Latinx), 52% had DL-CAC >0. Those with DL-CAC ≥100 had an average 10-year ASCVD risk of 24%; yet, only 26% were on statins. After adjustment, patients with DL-CAC ≥100 had increased risk of death (HR: 1.51; 95% CI: 1.28-1.79), death/MI/stroke (HR: 1.57; 95% CI: 1.33-1.84), and death/MI/stroke/revascularization (HR: 1.69; 95% CI: 1.45-1.98) compared with DL-CAC = 0. CONCLUSIONS Incidental CAC ≥100 was associated with an increased risk of all-cause death and adverse cardiovascular outcomes, beyond traditional risk factors. DL-CAC from routine non-ECG-gated CTs identifies patients at increased cardiovascular risk and holds promise as a tool for opportunistic screening to facilitate earlier intervention.
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Affiliation(s)
- Allison W Peng
- Department of Medicine, Stanford University, Stanford, California, USA; Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA. https://twitter.com/AllisonWPeng
| | - Ramzi Dudum
- Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Sneha S Jain
- Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - David J Maron
- Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA; Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, California, USA
| | - Bhavik N Patel
- Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA
| | | | - David Eng
- Bunkerhill Health, Palo Alto, California, USA
| | - Akshay S Chaudhari
- Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA; Department of Radiology, Stanford University, Stanford, California, USA; Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Alexander T Sandhu
- Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA; Veteran's Affairs Palo Alto Healthcare System, Palo Alto, California, USA. https://twitter.com/ATSandhu
| | - Fatima Rodriguez
- Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA.
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Sarraju A, Zammit A, Ngo S, Witting C, Hernandez‐Boussard T, Rodriguez F. Identifying Reasons for Statin Nonuse in Patients With Diabetes Using Deep Learning of Electronic Health Records. J Am Heart Assoc 2023; 12:e028120. [PMID: 36974740 PMCID: PMC10122887 DOI: 10.1161/jaha.122.028120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 02/07/2023] [Indexed: 03/29/2023]
Abstract
Background Statins are guideline-recommended medications that reduce cardiovascular events in patients with diabetes. Yet, statin use is concerningly low in this high-risk population. Identifying reasons for statin nonuse, which are typically described in unstructured electronic health record data, can inform targeted system interventions to improve statin use. We aimed to leverage a deep learning approach to identify reasons for statin nonuse in patients with diabetes. Methods and Results Adults with diabetes and no statin prescriptions were identified from a multiethnic, multisite Northern California electronic health record cohort from 2014 to 2020. We used a benchmark deep learning natural language processing approach (Clinical Bidirectional Encoder Representations from Transformers) to identify statin nonuse and reasons for statin nonuse from unstructured electronic health record data. Performance was evaluated against expert clinician review from manual annotation of clinical notes and compared with other natural language processing approaches. Of 33 461 patients with diabetes (mean age 59±15 years, 49% women, 36% White patients, 24% Asian patients, and 15% Hispanic patients), 47% (15 580) had no statin prescriptions. From unstructured data, Clinical Bidirectional Encoder Representations from Transformers accurately identified statin nonuse (area under receiver operating characteristic curve [AUC] 0.99 [0.98-1.0]) and key patient (eg, side effects/contraindications), clinician (eg, guideline-discordant practice), and system reasons (eg, clinical inertia) for statin nonuse (AUC 0.90 [0.86-0.93]) and outperformed other natural language processing approaches. Reasons for nonuse varied by clinical and demographic characteristics, including race and ethnicity. Conclusions A deep learning algorithm identified statin nonuse and actionable reasons for statin nonuse in patients with diabetes. Findings may enable targeted interventions to improve guideline-directed statin use and be scaled to other evidence-based therapies.
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Affiliation(s)
- Ashish Sarraju
- Division of Cardiovascular Medicine and Cardiovascular InstituteStanford UniversityStanfordCA
- Department of Cardiovascular MedicineCleveland Clinic FoundationClevelandOH
| | - Alban Zammit
- Department of MedicineStanford UniversityStanfordCA
- Department of Biomedical Data ScienceStanford UniversityStanfordCA
| | - Summer Ngo
- Division of Cardiovascular Medicine and Cardiovascular InstituteStanford UniversityStanfordCA
| | - Celeste Witting
- Division of Cardiovascular Medicine and Cardiovascular InstituteStanford UniversityStanfordCA
| | - Tina Hernandez‐Boussard
- Department of MedicineStanford UniversityStanfordCA
- Department of Biomedical Data ScienceStanford UniversityStanfordCA
- Department of SurgeryStanford University School of MedicineStanfordCA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and Cardiovascular InstituteStanford UniversityStanfordCA
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Jaam M, Al-Naimi HN, Haddad MM, Abushanab D, Al-Badriyeh D. Comparative efficacy and safety among high-intensity statins. Systematic Review and Meta-Analysis. J Comp Eff Res 2023; 12:e220163. [PMID: 36847307 PMCID: PMC10288954 DOI: 10.57264/cer-2022-0163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/05/2022] [Indexed: 03/01/2023] Open
Abstract
Aim: To summarize the evidence in terms of efficacy and safety of head-to-head studies of high-intensity statins regardless of the underlying population. Materials & methods: A systematic review and meta-analysis was conducted to summarize the effect sizes in randomized controlled trials and cohort studies that compared high-intensity statins. Results: Based on 44 articles, similar effectiveness was observed across the statins in reducing LDL levels from baseline. All statins were observed to have similar adverse drug reactions (ADRs), although higher dosages were associated with more ADRs. Based on a pooled quantitative analysis of atorvastatin 80 mg versus rosuvastatin 40 mg, rosuvastatin was statistically more effective in reducing LDL. Conclusion: This review further confirms that high-intensity statins reduce LDL by ≥50%, favoring rosuvastatin over atorvastatin. Additional data are needed to confirm the clinical significance on cardiovascular outcomes using real-world studies.
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Affiliation(s)
- Myriam Jaam
- College of Pharmacy, QU Health, Qatar University, Doha, 2713, Qatar
| | | | | | - Dina Abushanab
- Drug Information Department, Hamad Medical Corporation, Doha, 3050, Qatar
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, 3052, Australia
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7
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Sarraju A, Coquet J, Zammit A, Chan A, Ngo S, Hernandez-Boussard T, Rodriguez F. Using deep learning-based natural language processing to identify reasons for statin nonuse in patients with atherosclerotic cardiovascular disease. COMMUNICATIONS MEDICINE 2022; 2:88. [PMID: 35856080 PMCID: PMC9287295 DOI: 10.1038/s43856-022-00157-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 06/29/2022] [Indexed: 11/09/2022] Open
Abstract
Abstract
Background
Statins conclusively decrease mortality in atherosclerotic cardiovascular disease (ASCVD), the leading cause of death worldwide, and are strongly recommended by guidelines. However, real-world statin utilization and persistence are low, resulting in excess mortality. Identifying reasons for statin nonuse at scale across health systems is crucial to developing targeted interventions to improve statin use.
Methods
We developed and validated deep learning-based natural language processing (NLP) approaches (Clinical Bidirectional Encoder Representations from Transformers [BERT]) to classify statin nonuse and reasons for statin nonuse using unstructured electronic health records (EHRs) from a diverse healthcare system.
Results
We present data from a cohort of 56,530 ASCVD patients, among whom 21,508 (38%) lack guideline-directed statin prescriptions and statins listed as allergies in structured EHR portions. Of these 21,508 patients without prescriptions, only 3,929 (18%) have any discussion of statin use or nonuse in EHR documentation. The NLP classifiers identify statin nonuse with an area under the curve (AUC) of 0.94 (95% CI 0.93–0.96) and reasons for nonuse with a weighted-average AUC of 0.88 (95% CI 0.86–0.91) when evaluated against manual expert chart review in a held-out test set. Clinical BERT identifies key patient-level reasons (side-effects, patient preference) and clinician-level reasons (guideline-discordant practices) for statin nonuse, including differences by type of ASCVD and patient race/ethnicity.
Conclusions
Our deep learning NLP classifiers can identify crucial gaps in statin nonuse and reasons for nonuse in high-risk populations to support education, clinical decision support, and potential pathways for health systems to address ASCVD treatment gaps.
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Underberg J, Toth PP, Rodriguez F. LDL-C target attainment in secondary prevention of ASCVD in the United States: barriers, consequences of nonachievement, and strategies to reach goals. Postgrad Med 2022; 134:752-762. [PMID: 36004573 DOI: 10.1080/00325481.2022.2117498] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in the United States. Elevated low-density lipoprotein cholesterol (LDL-C) is a major causal risk factor for ASCVD. Current evidence overwhelmingly demonstrates that lowering LDL-C reduces the risk of secondary cardiovascular events in patients with previous myocardial infarction or stroke. There is no lower limit for LDL-C: large, randomized studies and meta-analyses have found continuous benefit and no safety concerns in patients achieving LDL-C levels <25 mg/dL. As 'Time is plaque' in patients with ASCVD, early, sustained reductions in LDL-C are critical to slow or halt disease progression. However, despite use of lipid-lowering medications, <30% of patients with ASCVD achieve guideline-recommended reductions in LDL-C, resulting in a substantial societal burden of preventable cardiovascular events and early mortality. LDL-C goals are not met due to several factors: lipid-lowering therapy is not initiated and intensified as directed by clinical guidelines (clinical inertia); most patients do not adhere to prescribed medications; and high-risk patients are frequently denied access to add-on therapies by their insurance providers. Promoting patient and clinician education, multidisciplinary collaboration, and other interventions may help to overcome these barriers. Ultimately, achieving population-level guideline-recommended reductions in LDL-C will require a collaborative effort from patients, clinicians, relevant professional societies, drug manufacturers, and payers.
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Affiliation(s)
| | - Peter P Toth
- Cicarrone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
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9
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Yu J, Wang AA, Zimmerman LP, Deng Y, Vu THT, Tedla YG, Soulakis ND, Ahmad FS, Kho AN. A Cohort Analysis of Statin Treatment Patterns Among Small-Sized Primary Care Practices. J Gen Intern Med 2022; 37:1845-1852. [PMID: 34997391 PMCID: PMC9198125 DOI: 10.1007/s11606-021-07191-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 10/01/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Small-sized primary care practices, defined as practices with fewer than 10 clinicians, delivered the majority of outpatient visits in the USA. Statin therapy in high-risk individuals reduces atherosclerotic cardiovascular disease (ASCVD) events, but prescribing patterns in small primary care practices are not well known. This study describes statin treatment patterns in small-sized primary care practices and examines patient- and practice-level factors associated with lack of statin treatment. METHODS We conducted a retrospective cohort analysis of statin-eligible patients from practices that participated in Healthy Hearts in the Heartland (H3), a quality improvement initiative aimed at improving cardiovascular care measures in small primary care practices. All statin-eligible adults who received care in one of 53 H3 practices from 2013 to 2016. Statin-eligible adults include those aged at least 21 with (1) clinical ASCVD, (2) low-density lipoprotein cholesterol (LDL-C) ≥ 190 mg/dL, or (3) diabetes aged 40-75 and with LDL-C 70-189 mg/dL. Eligible patients with no record of moderate- to high-intensity statin prescription are defined by ACC/AHA guidelines. RESULTS Among the 13,330 statin-eligible adults, the mean age was 58 years and 52% were women. Overall, there was no record of moderate- to high-intensity statin prescription among 5,780 (43%) patients. Younger age, female sex, and lower LDL-C were independently associated with a lack of appropriate intensity statin therapy. Higher proportions of patients insured by Medicaid and having only family medicine trained physicians (versus having at least one internal medicine trained physician) at the practice were also associated with lower appropriate intensity statin use. Lack of appropriate intensity statin therapy was higher in independent practices than in Federally Qualified Health Centers (FQHCs) (50% vs. 40%, p value < 0.01). CONCLUSIONS There is an opportunity for improved ASCVD risk reduction in small primary care practices. Statin treatment patterns and factors influencing lack of treatment vary by practice setting, highlighting the importance of tailored approaches to each setting.
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Affiliation(s)
- Jingzhi Yu
- Center for Health Information Partnerships (CHiP), Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Ann A Wang
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lindsay P Zimmerman
- Center for Health Information Partnerships (CHiP), Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Yu Deng
- Center for Health Information Partnerships (CHiP), Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Thanh-Huyen T Vu
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Yacob G Tedla
- Center for Health Information Partnerships (CHiP), Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nicholas D Soulakis
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Faraz S Ahmad
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Abel N Kho
- Center for Health Information Partnerships (CHiP), Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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10
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Gobbel GT, Matheny ME, Reeves RR, Akeroyd JM, Turchin A, Ballantyne CM, Petersen LA, Virani SS. Leveraging structured and unstructured electronic health record data to detect reasons for suboptimal statin therapy use in patients with atherosclerotic cardiovascular disease. Am J Prev Cardiol 2022; 9:100300. [PMID: 34950914 PMCID: PMC8671496 DOI: 10.1016/j.ajpc.2021.100300] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/19/2021] [Accepted: 11/27/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To determine whether natural language processing (NLP) of unstructured medical text can improve identification of ASCVD patients not using high-intensity statin therapy (HIST) due to statin-associated side effects (SASEs) and other reasons. METHODS Reviewers annotated reasons for not prescribing HIST in notes of 1152 randomly selected patients from across the VA healthcare system treated for ASCVD but not receiving HIST. Developers used reviewer annotations to train the Canary NLP tool to detect and extract notes containing one or more of these reasons. Negative predictive value (NPV), sensitivity, specificity and Area Under the Curve (AUC) were used to assess accuracy at detecting documents containing reasons when using structured data, NLP-extracted unstructured data, or both data sources combined. RESULTS At least one documented reason for not prescribing HIST occurred in 47% of notes. The most frequent reasons were SASEs (41%) and general intolerance (20%). When identifying notes containing any documented reason for not using HIST, adding NLP-extracted, unstructured data significantly (p<0.05) increased sensitivity (0.69 (95% confidence interval [CI] 0.60-0.76) to 0.89 (95% CI 0.81-0.93)), NPV (0.90 (95% CI 0.87 to 0.93) to 0.96 (95% CI 0.93-0.98)), and AUC (0.84 (95% confidence interval [CI] 0.81-0.88) to 0.91 (95% CI 0.90-0.93)) compared to structured data alone. CONCLUSIONS NLP extraction of data from unstructured text can improve identification of reasons for patients not being on HIST over structured data alone. The additional information provided through NLP of unstructured free text should help in tailoring and implementing system-level interventions to improve HIST use in patients with ASCVD.
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Affiliation(s)
- Glenn T. Gobbel
- Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Department of Veterans Affairs, Nashville, TN, USA
- Department of Biomedical Informatics, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Michael E. Matheny
- Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Department of Veterans Affairs, Nashville, TN, USA
- Department of Biomedical Informatics, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Ruth R. Reeves
- Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Department of Veterans Affairs, Nashville, TN, USA
- Department of Biomedical Informatics, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Julia M. Akeroyd
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, Texas; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Alexander Turchin
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Brigham and Women's Hospital, Boston, MA, USA
| | - Christie M. Ballantyne
- Section of Cardiology and Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Laura A. Petersen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, Texas; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Salim S. Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, Texas; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Section of Cardiology and Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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11
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The Magnitude and Potential Causes of Sex Disparities in Statin Therapy in Veterans with Type 2 Diabetes: A 10-year Nationwide Longitudinal Cohort Study. Womens Health Issues 2021; 32:274-283. [PMID: 34949527 DOI: 10.1016/j.whi.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/01/2021] [Accepted: 10/15/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Past research has shown that women eligible for statin therapy are less likely than their male counterparts to receive any statin therapy or be prescribed a statin at the guideline-recommended intensity. We compared statin treatment in men and women veterans from a national cohort of older veterans with type 2 diabetes. METHODS The Veterans Health Administration Corporate Data Warehouse and Centers for Medicare and Medicaid Services data were used to create a unique dataset and perform a longitudinal study of veterans with type 2 diabetes from 2007 to 2016. Mixed-effects logistic regression was used to model the association between the primary exposure (sex) and statin use. RESULTS The study included 714,212 veterans with diabetes, including 9,608 women, with an overall mean age of 75.9 years. In the unadjusted model for any statin use, women veterans had a 14% significantly lower odds of having any statin use compared with men. After adjusting for all covariates, including markers of Veterans Administration care use (service-connected disability rating, Veterans Administration use, and primary care visits) that serve as proxies for access and mental health comorbidities (depression and psychiatric disorder), this disparity narrowed from 14% to 3% and was no longer statistically significant. In the model for high-intensity statin therapy (high-intensity vs. low or none), women were 10% less likely than men to use high-intensity statins in the base model that included only time and sex. After adjusting for all measured covariates, the direction of the association changed and women had 16% higher odds of high-intensity statin use compared with men (odds ratio, 1.16; 95% confidence interval, 1.03-1.31). CONCLUSIONS Consistent with prior research, in the unadjusted analysis a significant sex disparity was observed in statin use, with lower rates observed in women. For the outcome of any statin use, after adjustment for covariates that included variables that are proxies for access as well as psychiatric and depression comorbidities, this disparity lost statistical significance and narrowed. In the high-intensity statin versus low or none model, the direction of the association changed after controlling for measured covariates and women had a 16% higher odds of high-intensity statin use compared with men. This study highlights a persistent health disparity in lipid-lowering therapy for women veterans. Additional research is needed to further elucidate the reasons for and develop interventions to mitigate this persistent sex disparity in cholesterol management for veterans with diabetes.
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Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) guidelines for management of dyslipidemia and cardiovascular disease risk reduction: Putting evidence in context. Prog Cardiovasc Dis 2021; 68:2-6. [PMID: 34371083 DOI: 10.1016/j.pcad.2021.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 01/21/2023]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality in the United States (U.S.) and incurs significant cost to the healthcare system. Management of cholesterol remains central for ASCVD prevention and has been the focus of multiple national guidelines. In this review, we compare the American Heart Association (AHA)/American College of Cardiology (ACC) and the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) Cholesterol guidelines. We review the evidence base that was used to generate recommendations focusing on 4 distinct themes: 1) the threshold of absolute 10-year ASCVD risk to start a clinician-patient discussion for the initiation of statin therapy in primary prevention patients; 2) the utility of coronary artery calcium score to guide clinician-patient risk discussion pertaining to the initiation of statin therapy for primary ASCVD prevention; 3) the use of moderate versus high-intensity statin therapy in patients with established ASCVD; and 4) the utility of ordering lipid panels after initiation or intensification of lipid lowering therapy to document efficacy and monitor adherence to lipid lowering therapy. We discuss why the VA/DoD and AHA/ACC may have reached different conclusions on these key issues.
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Dayoub EJ, Eberly LA, Nathan AS, Khatana SAM, Adusumalli S, Navar AM, Giri J, Groeneveld PW. Adoption of PCSK9 Inhibitors Among Patients With Atherosclerotic Disease. J Am Heart Assoc 2021; 10:e019331. [PMID: 33904340 PMCID: PMC8200752 DOI: 10.1161/jaha.120.019331] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors represent a promising class of lipid‐lowering therapy, although their use has been limited by cost concerns. Methods and Results A retrospective cohort study was conducted using a nationwide commercial claims database comprising patients with atherosclerotic cardiovascular disease (ASCVD), aged 18 to 64 years. We identified the number of patients with ASCVD started on a PCSK9 inhibitor from the dates of US Food and Drug Administration approval in quarter 3 2015 through quarter 2 2019. Secondary objectives identified the proportions of patients started on a PCSK9 inhibitor in various ASCVD risk groups based on statin use and baseline low‐density lipoprotein cholesterol. We identified 126 419 patients with ASCVD on either PCSK9 inhibitor or statin therapy. Among these patients, 1168 (0.9%) filled a prescription for a PCSK9 inhibitor. The number of patients initiating a PCSK9 inhibitor increased from 2 patients in quarter 3 2015 to 119 patients in quarter 2 2019, corresponding to an increase from 0.05% to 2.5% of patients with ASCVD already on statins who started PCSK9 inhibitor therapy. Of patients with ASCVD with high adherence to a high‐intensity statin, 13 643 had low‐density lipoprotein cholesterol ≥70 mg/dL, and in this subgroup, 119 (0.9%) patients initiated a PCSK9 inhibitor. Conclusions Few patients started PCSK9 inhibitors from 2015 through mid‐2019, despite increasing trial evidence of efficacy, guidelines recommending PCSK9 inhibitors in high‐risk patients with ASCVD, and price reductions during this period. The magnitude of price reductions may not yet be sufficient to influence use management strategies aimed to limit PCSK9 inhibitor use.
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Affiliation(s)
- Elias J Dayoub
- Division of Cardiovascular Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA
| | - Lauren A Eberly
- Division of Cardiovascular Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA
| | - Ashwin S Nathan
- Division of Cardiovascular Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA
| | - Sameed Ahmed M Khatana
- Division of Cardiovascular Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA.,Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
| | - Srinath Adusumalli
- Division of Cardiovascular Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA
| | - Ann Marie Navar
- Duke Clinical Research InstituteDuke University School of Medicine Durham NC
| | - Jay Giri
- Division of Cardiovascular Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA.,Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
| | - Peter W Groeneveld
- Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health Economics at the University of Pennsylvania Philadelphia PA.,Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA
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14
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Spencer-Bonilla G, Chung S, Sarraju A, Heidenreich P, Palaniappan L, Rodriguez F. Statin Use in Older Adults with Stable Atherosclerotic Cardiovascular Disease. J Am Geriatr Soc 2021; 69:979-985. [PMID: 33410499 PMCID: PMC8049971 DOI: 10.1111/jgs.16975] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/14/2020] [Accepted: 11/14/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND/OBJECTIVES Older adults (>75 years of age) represent two-thirds of atherosclerotic cardiovascular disease (ASCVD) deaths. The 2013 and 2018 American multi-society cholesterol guidelines recommend using at least moderate intensity statins for older adults with ASCVD. We examined annual trends and statin prescribing patterns in a multiethnic population of older adults with ASCVD. DESIGN Retrospective longitudinal study using electronic health record (EHR) data from 2007 to 2018. SETTING A large multi-specialty health system in Northern California. PARTICIPANTS A total of 24,651 adults older than 75 years with ASCVD. MEASUREMENTS Statin prescriptions for older adults with known ASCVD were trended over time. Multivariable regression models were used to identify predictors of statin prescription (logistic) after controlling for relevant demographic and clinical factors. RESULTS The study cohort included 24,651 patients older than 75 years; 48% were women. Although prescriptions for moderate/high intensity statins increased over time for adults over 75, fewer than half of the patients (45%) received moderate/high intensity statins in 2018. Women (odds ratio (OR) = 0.77; 95% confidence interval (CI) = 0.74, 0.80), patients who had heart failure (OR = 0.69; 95% CI = 0.65, 0.74), those with dementia (OR = 0.88; 95% CI = 0.82, 0.95) and patients who were underweight (OR = 0.64; 95% CI = 0.57, 0.73) were less likely to receive moderate/high intensity statins. CONCLUSIONS Despite increasing prescription rates between 2007 and 2018, guideline-recommended statins remained underused in older adults with ASCVD, with more pronounced disparities among women and those with certain comorbidities. Future studies are warranted to examine reasons for statin underuse in older adults with ASCVD.
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Affiliation(s)
| | - Sukyung Chung
- Palo Alto Medical Foundation Research Institute, Palo Alto, California
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Ashish Sarraju
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California
| | - Paul Heidenreich
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California
- Division of Cardiovascular Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Latha Palaniappan
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California
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15
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Facility-Level Variation in Reported Statin-Associated Side Effects Among Patients with Atherosclerotic Cardiovascular Disease-Perspective from the Veterans Affair Healthcare System. Cardiovasc Drugs Ther 2021; 36:295-300. [PMID: 33523335 DOI: 10.1007/s10557-021-07148-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 01/14/2023]
Abstract
PURPOSE Statin-associated side effects (SASEs) can limit statin adherence and present a potential barrier to optimal statin utilization. How standardized reporting of SASEs varies across medical facilities has not been well characterized. METHODS We assessed facility-level variation in SASE reporting among patients with atherosclerotic cardiovascular disease receiving care across the Veterans Affairs (VA) healthcare system from October 1, 2014, to September 30, 2015. The facility rates for SASE reporting were expressed as cases per 1000 patients with ASCVD. Facility-level variation was determined using hierarchical regression analysis to calculate median rate ratios (MRR [95% confidence interval]) by first using an unadjusted model and then adjusting for patient, provider, and facility characteristics. RESULTS Of the 1,248,158 patients with ASCVD included in our study across 130 facilities, 13.7% had at least one SASE reported. Individuals with a history of SASE were less likely to be on a statin at follow-up compared with those without SASE (72.0% vs 80.8%, p < 0.01). The median (interquartile range) facility rate of SASE reported was 140.5 (109.4-167.7) cases per 1000 patients with ASCVD. Significant facility-level variation in the rate of SASE reported was observed: MRR 1.38 (1.33-1.44) in the unadjusted model and MRR 1.56 (1.47-1.65) in the adjusted model. CONCLUSION Significant facility-level variation in SASE reporting was found within the VA healthcare system suggesting room for improvement in standardized documentation of SASEs among medical facilities. This has the potential to lead to improvement in statin utilization.
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16
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Liang Y, Ketchum NS, Turner BJ, Flores J, Bullock D, Villarreal R, Noël PH, Yin MT, Taylor BS. Cardiovascular Risk Assessment Varies Widely by Calculator and Race/Ethnicity in a Majority Latinx Cohort Living with HIV. J Immigr Minor Health 2021; 22:323-335. [PMID: 31004259 DOI: 10.1007/s10903-019-00890-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Comparison of cardiovascular disease (CVD) risk calculators in Latinx majority populations living with HIV can assist clinicians in selecting a calculator and interpreting results. 10-year CVD risks were estimated for 652 patients seen ≥ 2 times over 12 months in a public clinic using three risk calculators: Atherosclerotic CVD risk Calculator (ASCVD), Framingham Risk Calculator (FRC), and Data Collection on Adverse Effects of Anti-HIV Drugs Study (D:A:D) Calculator. Median estimated 10-year CVD risk in this population was highest using FRC (11%), followed by D:A:D (10%), and lowest with ASCVD (5%; p < 0.001). However, D:A:D classified 44.3% in a high/very high risk category compared to FRC (20.7%) and ASCVD (33.4%) (all p < 0.001). ASCVD risk estimates differed significantly by race/ethnicity (p < 0.001). Risk varied widely across three risk calculators and by race/ethnicity, and providers should be aware of these differences when choosing a calculator for use in majority minority populations.
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Affiliation(s)
- Yuanyuan Liang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Norma S Ketchum
- Department of Epidemiology and Biostatistics, UT Health San Antonio, San Antonio, TX, USA
| | - Barbara J Turner
- Research to Advance Community Health (ReACH) Center, UT Health San Antonio, San Antonio, TX, USA.,Department of Medicine, UT Health San Antonio, 7703 Floyd Curl Dr., San Antonio, TX, 78229, USA
| | - John Flores
- Joint Residency Program in Medicine and Pediatrics, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Delia Bullock
- Department of Medicine, UT Health San Antonio, 7703 Floyd Curl Dr., San Antonio, TX, 78229, USA
| | - Roberto Villarreal
- Research and Information Management, University Health System, San Antonio, TX, USA
| | - Polly H Noël
- Department of Family & Community Medicine, UT Health San Antonio, 7703 Floyd Curl Dr., San Antonio, TX, 78229, USA
| | - Michael T Yin
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Barbara S Taylor
- Research to Advance Community Health (ReACH) Center, UT Health San Antonio, San Antonio, TX, USA. .,Department of Medicine, UT Health San Antonio, 7703 Floyd Curl Dr., San Antonio, TX, 78229, USA.
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Uptake of Statin Guidelines to Prevent and Treat Cardiovascular Disease. J Am Board Fam Med 2021; 34:113-122. [PMID: 33452089 PMCID: PMC7847084 DOI: 10.3122/jabfm.2021.01.200292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/03/2020] [Accepted: 09/08/2020] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION In December 2013, cholesterol treatment guidelines changed the approach to statin therapy by recommending fixed doses of low-, medium-, or high-intensity statins based on cardiovascular risk. We sought to evaluate the guideline's adoption in a diverse group of practices. METHODS Using a mixed-methods approach, we analyzed electronic health record data the year before and 2 years following guideline publication in 45 practices across 8 states. We examined associations based on patient, clinician, and practice characteristics and interviewed 24 clinicians and practice leaders to inform findings. RESULTS The proportion of patients adherent with all recommendations 2 years after the guideline only increased from 18.5% to 20.3% (P < .01). There were clinically insignificant increases in statin use across risk strata (1.7% to 3.5%) and small increases in high-intensity statin use (2.6% to 4.6%). Only half of patients with cardiovascular disease (52.9%) were on any statin, not much different from patients at moderate (49.6% to 50.9%) or low (41.6% to 48.7%) risk. Multiple patient (risk, use of health care), clinician (age), and practice (type, rurality) factors were associated with statin use. Clinicians reported patient resistance to statins but liked having a risk calculator to guide discussions. CONCLUSION Despite general agreement with statin benefit, the guideline was poorly implemented. Marginal differences in statin use between the highest and lower risk strata of patients is concerning. Rather than intensifying statin potency and recommending more patients take statins, guidelines may want to focus on ensuring that those who will benefit most get treatment.
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18
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Utilization of High-Intensity Statins in Patients at Risk for Cardiovascular Events: A National Cross-Sectional Study. Am J Ther 2020; 29:e1-e17. [PMID: 33021546 DOI: 10.1097/mjt.0000000000001274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The 2013 American College of Cardiology/American Heart Association cholesterol guidelines, which identified four groups of patients at risk for atherosclerotic cardiovascular disease events, departed from the target-based approach to managing cholesterol. The impact of these guidelines on high-intensity statin use across the United States is unclear. STUDY QUESTION The primary objective was to evaluate the rate of high-intensity potential (HIP) statin use before and after the 2013 guidelines. The secondary objective was to identify predictors of HIP statin use within the study population. STUDY DESIGN A national cross-sectional study was conducted using data from the National Ambulatory Medical Care Survey. Office visits involving patients aged 21-75 years where criteria for HIP statin therapy were met were included. Visits involving pregnant patients were excluded. MEASURES AND OUTCOMES Prescribing trends of HIP statins were measured from National Ambulatory Medical Care Survey data before and after the 2013 guidelines. Multivariate logistic regression identified variables associated with prescribing HIP statins. RESULTS A total of 48,884 visits were included, representing more than 940 million office visits nationally. HIP statins were listed in 9.5% and 16.5% of visits before and after 2013, respectively (odds ratio [OR] 1.88; 95% confidence interval [CI] 1.62-2.20). The strongest predictors of HIP statin use were antihypertensive use (OR 5.38, 95% CI 4.67-6.20), comorbid hyperlipidemia (OR 2.93, 95% CI 2.62-3.29), Black race (OR 0.63, 95% CI 0.49-0.81), and Hispanic ethnicity (OR 0.65, 95% CI 0.52-0.80). CONCLUSIONS Prescribing rates for HIP statins increased after the release of the 2013 guidelines. The prescribing rates were lower than expected, especially in Black and Hispanic patients. These observations signify opportunities to improve the quality of care for patients who are at risk for atherosclerotic cardiovascular disease events in the United States.
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Cardiovascular Risk and Statin Therapy Considerations in Women. Diagnostics (Basel) 2020; 10:diagnostics10070483. [PMID: 32708558 PMCID: PMC7400394 DOI: 10.3390/diagnostics10070483] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/10/2020] [Accepted: 07/12/2020] [Indexed: 12/23/2022] Open
Abstract
Despite major progress in the prevention and treatment of cardiovascular diseases, women remain an underdiagnosed and insufficiently treated group, with higher hospitalization and death rates compared to men. Obesity, more frequently encountered in women, raises the risk of metabolic syndrome and cardiovascular diseases as women age. There are some differences based on sex regarding the screening, diagnosis, and treatment of dyslipidemia, as it has been observed that women are less frequently prescribed statins and, when they are, they receive lower doses, even after myocardial infarction or coronary revascularization. Real-life data show that, compared to men, women are at higher risk of non-adherence to statin treatment and are more predisposed to discontinue treatment because of side effects. Statin metabolism has some particularities in women, due to a lower glomerular filtration rate, higher body fat percentage, and overall faster statin metabolism. In women of fertile age, before initiating statin treatment, contraception methods should be discussed because statins may have teratogenic effects. Older women have a higher likelihood of polypharmacy, with greater potential for drug interactions when prescribing a statin.
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20
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Have the Government's prescription algorithm and the 2013 American College of Cardiology/American Heart Association guidelines for managing dyslipidemia influenced the management of dyslipidemia? The MEJORALO-CV Project. Rev Clin Esp 2020. [DOI: 10.1016/j.rceng.2019.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Romanelli RJ, Ito MK, Karalis DG, Huang HC, Iorga ŞR, Kam IW, Thompson S, Azar KMJ. Statin utilization and low-density lipoprotein cholesterol in statin-treated patients with atherosclerotic cardiovascular disease: Trends from a community-based health care delivery system, 2002-2016. J Clin Lipidol 2020; 14:305-314. [PMID: 32362513 DOI: 10.1016/j.jacl.2020.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/20/2020] [Accepted: 03/24/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND A better understanding of patterns in statin utilization and low-density lipoprotein cholesterol (LDL-C) among patients with atherosclerotic cardiovascular disease (ASCVD) in a clinical practice setting is needed. OBJECTIVES The objective of this study was to examine statin utilization and LDL-C among new statin users with ASCVD. METHODS This retrospective study used an electronic health record database from a community-based health care system. We identified ASCVD patients ≥21 years of age with a new statin prescription during the study period (2002-2016). Outcomes included high-intensity statin therapy (HIST) prescribing at treatment initiation, medication adherence (defined as proportion of days covered ≥0.80), statin therapy titrations rates, and changes in LDL-C during follow-up. RESULTS Among 6199 eligible patients, mean follow-up was 16.8 months. At treatment initiation, 16.6% of patients received HIST. Approximately 53% of patients were adherent to statin regimens. Mean percent reduction in LDL-c was 25% during follow-up; 18% of patients, overall, and 30% of those initiating on HIST attained LDL-C reductions >50%. Rates of statin intensity-level increases were 8.4 per 100 person-years. HIST prescribing increased over time, beginning after generic atorvastatin availability and preceded treatment guidelines by two years. Initiation on HIST, higher adherence, and treatment intensification during follow-up were independent predictors of attaining LDL-C goals of <70 mg/dL or <100 mg/dL. CONCLUSIONS In a community-based health care system, modest LDL-C lowering for secondary ASCVD prevention is likely driven by suboptimal adherence and low HIST prescribing and treatment intensification rates. Clinician and patient education are needed to reduce clinical inertia and improve medication adherence to better manage ASCVD.
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Affiliation(s)
- Robert J Romanelli
- Sutter Health, Center for Health Systems Research, Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA.
| | | | - Dean G Karalis
- Thomas Jefferson University Hospital, Sidney Kimmel College of Medicine, Philadelphia, PA, USA
| | - Hsiao-Ching Huang
- Sutter Health, Center for Health Systems Research, Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | | | - Ivy W Kam
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | | | - Kristen M J Azar
- Sutter Health, Center for Health Systems Research, Division of Research, Development and Dissemination, Walnut Creek, CA, USA
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Comparison of High-Dose Rosuvastatin Versus Low-Dose Rosuvastatin Plus Ezetimibe on Carotid Atherosclerotic Plaque Inflammation in Patients with Acute Coronary Syndrome. J Cardiovasc Transl Res 2020; 13:900-907. [DOI: 10.1007/s12265-020-10009-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/17/2020] [Indexed: 02/03/2023]
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Buckley K, Fairman KA. Beneficial Agents for Patients With Type 2 Diabetes and Cardiovascular Disease or Obesity: Utilization in an Era of Accumulating Evidence. Clin Diabetes 2020; 38:176-180. [PMID: 32327890 PMCID: PMC7164997 DOI: 10.2337/cd19-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study was an analysis of a national sample of U.S. medical office visits from 2014 to 2016, a period when evidence of effectiveness was emerging for a variety of beneficial type 2 diabetes agents with regard to potential reduction in diabetes comorbidities. Ideal therapy was defined as an American Diabetes Association-identified beneficial agent plus metformin. The associations between atherosclerotic cardiovascular disease or obesity and use of these agents were explored.
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Affiliation(s)
- Kelsey Buckley
- Midwestern University College of Pharmacy - Glendale, Glendale AZ
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Gao J, Ren H, Feng Z, Chen S, Liang Y, Liu W, Zhou Q, Wang M. Effects of multidose simvastatin co-administration on pharmacokinetic profile of apatinib in rats by UPLC-MS/MS. Xenobiotica 2020; 50:1115-1120. [PMID: 32150479 DOI: 10.1080/00498254.2020.1740952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Apatinib, a small molecule anti-angiogenic tyrosine kinase inhibitor is used extensively to treat advanced gastric cancer and simvastatin (SV) is often co-prescribed to treat cardiovascular disease in cancer patients. As both apatinib and SV are metabolized primarily by cytochrome P450 variant CYP3A4, they are likely to interact. Therefore, the potential effect of SV co-administration on pharmacokinetics of apatinib in Sprague-Dawley male rats is demonstrated for the first time.Sixteen rats were randomly divided into two groups (n = 8), 2 mg/kg SV orally co-administrated for seven days (group B) and the corresponding control group (group A). Apatinib concentrations of rat plasma samples were detected by ultra-performance liquid chromatography tandem mass spectrometry. Pharmacokinetic parameters were calculated using non compartmental methods.Co-administration of SV for seven days significantly increased area under curve (AUC(0-t)), AUC(0-∞) and maximum plasma concentration of apatinib by 2.4-, 2.4-, and 2.7-fold, respectively while decreasing apparent volume of distribution and clearance by 81.7 and 73.9%, respectively.These findings suggest that concomitant administration of SV with 7 days may have inhibited the metabolism of apatinib in rats.
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Affiliation(s)
- Jinglin Gao
- Department of Clinical Pharmacology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Huan Ren
- Department of Clinical Pharmacology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhangying Feng
- Department of Clinical Pharmacology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Shanshan Chen
- Department of Clinical Pharmacology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yu Liang
- Department of Clinical Pharmacology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wanqiu Liu
- Department of Clinical Pharmacology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Qian Zhou
- Department of Clinical Pharmacology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Mingxia Wang
- Department of Clinical Pharmacology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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Jones LK, Gidding SS, Seaton TL, Goldberg A, Gregor C, Sturm AC, Brownson RC, Rahm AK, Williams MS. Developing implementation strategies to improve uptake of guideline-recommended treatments for individuals with familial hypercholesterolemia: A protocol. Res Social Adm Pharm 2020; 16:390-395. [PMID: 31229402 PMCID: PMC6911646 DOI: 10.1016/j.sapharm.2019.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/13/2019] [Accepted: 06/14/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Familial hypercholesterolemia (FH) affects more than one million Americans, and most individuals have not been formally diagnosed with the condition. Individuals with FH have markedly elevated serum low-density lipoprotein cholesterol (LDL-C) levels from birth that substantially increase their risk for early-onset cardiovascular (CV) events. Guideline-recommended treatments exist to lower LDL-C and reduce the risk of CV events in individuals with FH and hypercholesterolemia. This study seeks to address a significant gap in the care of individuals with FH by systematically developing an effective approach to increase the adoption of guideline-recommended treatments for FH. METHODS This developmental study will consist of three aims: 1) determine the barriers to and facilitators of treatment of FH; 2) develop a list of potential implementation strategies to promote the adoption of guideline-recommended treatment of individuals with FH, and 3) pilot one implementation strategy from Aim 2 in one health care system to evaluate implementation outcomes of the strategy. The Practical, Robust Implementation and Sustainability Model will guide this project, including the development of interview questions, implementation strategies, and evaluation of the implementation strategy. The implementation outcomes include: of individuals targeted by the implementation strategy, how many are impacted by it (reach), measure the change in knowledge, attitude, and behavior that is impacted by the implementation strategy (effectiveness), in settings targeted by the implementation strategy, how many adopt it (adoption), and fidelity and cost of the implementation strategy (implementation). Data sources will include electronic health records, administrative databases, surveys, and semi-structured interviews. DISCUSSION The inclusion of patient and organizational stakeholder experiences is a critically important step in developing efficient and effective implementation strategies. Additionally, perspectives from a variety of geographic areas and cultural perspectives should increase feasibility and fidelity of the interventional approach to improve adoption of guideline-recommended practices for FH care.
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Affiliation(s)
- Laney K Jones
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA, USA.
| | | | - Terry L Seaton
- St. Louis College of Pharmacy, St. Louis, MO, USA; Mercy Clinic-East Communities, St. Louis, MO, USA
| | - Anne Goldberg
- Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Christina Gregor
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA, USA
| | - Amy C Sturm
- Genomic Medicine Institute, Geisinger, Danville, PA, USA
| | - Ross C Brownson
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, MO, USA; Department of Surgery (Division of Public Health Sciences), Alvin J. Siteman Cancer Center, Washington University School of Medicine; Washington University in St. Louis, St. Louis, MO, USA
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Have the Government's prescription algorithm and the 2013 American College of Cardiology/American Heart Association guidelines for managing dyslipidaemia influenced the management of dyslipidaemia? The MEJORALO-CV Project. Rev Clin Esp 2019; 220:282-289. [PMID: 31744620 DOI: 10.1016/j.rce.2019.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/14/2019] [Accepted: 08/13/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the management of dyslipidaemia in primary care after the publication of the American College of Cardiology/American Heart Association (ACC/AHA) 2013 guidelines and Valencian government's algorithm. METHOD We conducted a cross-sectional descriptive study that employed a survey of primary care physicians of the Community of Valencia between January and October 2016. RESULTS A total of 199 physicians (mean age, 48.9±11.0 years; experience, 21.3±11.1 years) participated in the survey. The most followed guidelines were those of the European Society of Cardiology (37.5% of respondents) and Valencian government (23.4% of respondents). Some 6.3% of the respondents followed the 2013 ACC/AHA guidelines, and 88.0% established objectives based on LDL cholesterol and cardiovascular risk. The choice of lipid-lowering drug was based on its LDL cholesterol lowering capacity (28.6% of respondents), on the Valencian government's algorithm (23.4%) and on the drug's safety (20.4%). Statins, ezetimibe and fibrates were the preferred hypolipemiant agents, and their combination (51% of respondents) and dosage increases (35%) were the strategies employed for poor control. Lipid profile and transaminase and creatine kinase levels were measured every 6 (59.5%, 52.3% and 54.3% of respondents, respectively) or 12 months (25.1%, 29.2% and 30.3%, respectively). Forty-one percent of the respondents were aware of the controversy surrounding the 2013 ACC/AHA guidelines. Although 60% of the respondents acknowledged its relevance, only 21% changed their daily practices accordingly. CONCLUSIONS The Valencian government's algorithm had a greater impact than the 2013 ACC/AHA guidelines in primary care in Valencia. Areas for improvement included the low use of validated guidelines and risk tables and the streamlining of laboratory test periodicity.
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Virani SS, Akeroyd JM, Ahmed ST, Krittanawong C, Martin LA, Slagle J, Gobbel GT, Matheny ME, Ballantyne CM, Petersen LA. The use of structured data elements to identify ASCVD patients with statin-associated side effects: Insights from the Department of Veterans Affairs. J Clin Lipidol 2019; 13:797-803.e1. [PMID: 31501043 PMCID: PMC8393880 DOI: 10.1016/j.jacl.2019.08.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 07/29/2019] [Accepted: 08/04/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Accurate identification of patients with statin-associated side effects (SASEs) is critical for health care systems to institute strategies to improve guideline-concordant statin use. OBJECTIVE The objective of this study was to determine whether adverse drug reaction (ADR) entry by clinicians in the electronic medical record can accurately identify SASEs. METHODS We identified 1,248,214 atherosclerotic cardiovascular disease (ASCVD) patients seeking care in the Department of Veterans Affairs. Using an ADR data repository, we identified SASEs in 15 major symptom categories. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were assessed using a chart review of 256 ASCVD patients with identified SASEs, who were not on high-intensity statin therapy. RESULTS We identified 171,189 patients (13.71%) with documented SASEs over a 15-year period (9.9%, 2.7%, and 1.1% to 1, 2, or >2 statins, respectively). Statin use, high-intensity statin use, low-density lipoprotein cholesterol, and non-high-density lipoprotein cholesterol levels were 72%, 28.1%, 99 mg/dL, and 129 mg/dL among those with vs 81%, 31.1%, 84 mg/dL, and 111 mg/dL among those without SASEs. Progressively lower statin and high-intensity statin use, and higher low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol levels were noted among those with SASEs to 1, 2, or >2 statins. Two-thirds of SASEs were related to muscle symptoms. Sensitivity, specificity, PPV, NPV compared with manual chart review were 63.4%, 100%, 100%, and 85.3%, respectively. CONCLUSION A strategy of using ADR entry in the electronic medical record is feasible to identify SASEs with modest sensitivity and NPV but high specificity and PPV. Health care systems can use this strategy to identify ASCVD patients with SASEs and operationalize efforts to improve guideline-concordant lipid-lowering therapy use in such patients. The sensitivity of this approach can be further enhanced by the use of unstructured text data.
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Affiliation(s)
- Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Health Services Research & Development Center for Innovations, Houston, TX, USA; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Julia M Akeroyd
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Health Services Research & Development Center for Innovations, Houston, TX, USA; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Sarah T Ahmed
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Health Services Research & Development Center for Innovations, Houston, TX, USA; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Chayakrit Krittanawong
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai St. Luke's and Mount Sinai West, NY, New York, USA
| | - Lindsey A Martin
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Health Services Research & Development Center for Innovations, Houston, TX, USA; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jason Slagle
- Department of Anesthesiology, Center for Research and Innovation in Systems Safety, Vanderbilt University School of Medicine, Nashville, TN, USA; Department of Veterans Affairs, Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Glenn T Gobbel
- Department of Veterans Affairs, Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA; Department of Biomedical Informatics, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Michael E Matheny
- Department of Veterans Affairs, Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA; Department of Biomedical Informatics, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Christie M Ballantyne
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Laura A Petersen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Health Services Research & Development Center for Innovations, Houston, TX, USA; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, Faiella-Tommasino J, Forman DE, Goldberg R, Heidenreich PA, Hlatky MA, Jones DW, Lloyd-Jones D, Lopez-Pajares N, Ndumele CE, Orringer CE, Peralta CA, Saseen JJ, Smith SC, Sperling L, Virani SS, Yeboah J. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 139:e1082-e1143. [PMID: 30586774 PMCID: PMC7403606 DOI: 10.1161/cir.0000000000000625] [Citation(s) in RCA: 1166] [Impact Index Per Article: 233.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Scott M Grundy
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Neil J Stone
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Alison L Bailey
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Craig Beam
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Kim K Birtcher
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Roger S Blumenthal
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Lynne T Braun
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Sarah de Ferranti
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Joseph Faiella-Tommasino
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Daniel E Forman
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Ronald Goldberg
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Paul A Heidenreich
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Mark A Hlatky
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Daniel W Jones
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Donald Lloyd-Jones
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Nuria Lopez-Pajares
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Chiadi E Ndumele
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Carl E Orringer
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Carmen A Peralta
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Joseph J Saseen
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Sidney C Smith
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Laurence Sperling
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Salim S Virani
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Joseph Yeboah
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
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Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, Faiella-Tommasino J, Forman DE, Goldberg R, Heidenreich PA, Hlatky MA, Jones DW, Lloyd-Jones D, Lopez-Pajares N, Ndumele CE, Orringer CE, Peralta CA, Saseen JJ, Smith SC, Sperling L, Virani SS, Yeboah J. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. J Am Coll Cardiol 2019; 73:e285-e350. [DOI: 10.1016/j.jacc.2018.11.003] [Citation(s) in RCA: 1113] [Impact Index Per Article: 222.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Pokharel Y, Tang F, Jones PG, Nambi V, Bittner VA, Hira RS, Nasir K, Chan PS, Maddox TM, Oetgen WJ, Heidenreich PA, Borden WB, Spertus JA, Petersen LA, Ballantyne CM, Virani SS. Adoption of the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guideline in Cardiology Practices Nationwide. JAMA Cardiol 2019; 2:361-369. [PMID: 28249067 DOI: 10.1001/jamacardio.2016.5922] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance The 2013 American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Management Guideline recommends moderate-intensity to high-intensity statin therapy in eligible patients. Objective To examine adoption of the 2013 ACC/AHA guideline in US cardiology practices. Design, Setting, and Participants Among 161 cardiology practices, trends in the use of moderate-intensity to high-intensity statin and nonstatin lipid-lowering therapy (LLT) were analyzed before (September 1, 2012, to November 1, 2013) and after (February 1, 2014, to April 1, 2015) publication of the 2013 ACC/AHA guideline among 4 mutually exclusive risk groups within the ACC Practice Innovation and Clinical Excellence Registry. Interrupted time series analysis was used to evaluate for differences in trend in use of moderate-intensity to high-intensity statin and nonstatin LLT use in hierarchical logistic regression models. Participants were a population-based sample of 1 105 356 preguideline patients (2 431 192 patient encounters) and 1 116 472 postguideline patients (2 377 219 patient encounters). Approximately 97% of patients had atherosclerotic cardiovascular disease (ASCVD). Exposures Moderate-intensity to high-intensity statin and nonstatin LLT use before and after publication of the 2013 ACC/AHA guideline. Main Outcomes and Measures Time trend in the use of moderate-intensity to high-intensity statin and nonstatin LLT. Results In the study cohort, the mean (SD) age was 69.6 (12.1) years among 1 105 356 patients (40.2% female) before publication of the guideline and 70.0 (11.9) years among 1 116 472 patients (39.8% female) after publication of the guideline. Although there was a trend toward increasing use of moderate-intensity to high-intensity statins overall and in the ASCVD cohort, such a trend was already present before publication of the guideline. No significant difference in trend in the use of moderate-intensity to high-intensity statins was observed in other groups. The use of moderate-intensity to high-intensity statin therapy was 62.1% (before publication of the guideline) and 66.6% (after publication of the guideline) in the overall cohort, 62.7% (before publication) and 67.0% (after publication) in the ASCVD cohort, 50.6% (before publication) and 52.3% (after publication) in the cohort with elevated low-density lipoprotein cholesterol levels (ie, ≥190 mg/dL), 52.4% (before publication) and 55.2% (after publication) in the diabetes cohort, and 41.9% (before publication) and 46.9% (after publication) in the remaining group with 10-year ASCVD risk of 7.5% or higher. In hierarchical logistic regression models, there was a significant increase in the use of moderate-intensity to high-intensity statins in the overall cohort (4.8%) and in the ASCVD cohort (4.3%) (P < .01 for slope for both). There was no significant change for other risk cohorts. Nonstatin LLT use remained unchanged in the preguideline and postguideline periods in the hierarchical logistic regression models for all of the risk groups. Conclusions and Relevance Adoption of the 2013 ACC/AHA Cholesterol Management Guideline in cardiology practices was modest. Timely interventions are needed to improve guideline-concordant practice to reduce the burden of ASCVD.
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Affiliation(s)
- Yashashwi Pokharel
- Department of Cardiovascular Research, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri2Department of Medicine, University of Missouri-Kansas City
| | - Fengming Tang
- Department of Cardiovascular Research, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri
| | - Philip G Jones
- Department of Cardiovascular Research, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri
| | - Vijay Nambi
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas4Department of Medicine, Baylor College of Medicine, Houston, Texas5Center of Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Vera A Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham
| | - Ravi S Hira
- Division of Cardiology, University of Washington, Seattle
| | - Khurram Nasir
- Center for Prevention and Wellness Research, Miami Beach, Florida
| | - Paul S Chan
- Department of Cardiovascular Research, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri2Department of Medicine, University of Missouri-Kansas City
| | - Thomas M Maddox
- Department of Medicine, Veterans Affairs Colorado Health Care System and University of Colorado School of Medicine, Denver
| | | | | | - William B Borden
- Department of Medicine, George Washington University, Washington, DC
| | - John A Spertus
- Department of Cardiovascular Research, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri2Department of Medicine, University of Missouri-Kansas City
| | - Laura A Petersen
- Department of Medicine, Baylor College of Medicine, Houston, Texas13Health Policy, Quality and Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center of Innovation, Houston, Texas
| | - Christie M Ballantyne
- Department of Medicine, Baylor College of Medicine, Houston, Texas5Center of Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Salim S Virani
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas4Department of Medicine, Baylor College of Medicine, Houston, Texas5Center of Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas13Health Policy, Quality and Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center of Innovation, Houston, Texas
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Rodriguez F, Maron DJ, Knowles JW, Virani SS, Lin S, Heidenreich PA. Association of Statin Adherence With Mortality in Patients With Atherosclerotic Cardiovascular Disease. JAMA Cardiol 2019; 4:206-213. [PMID: 30758506 PMCID: PMC6439552 DOI: 10.1001/jamacardio.2018.4936] [Citation(s) in RCA: 195] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 12/17/2018] [Indexed: 01/07/2023]
Abstract
Importance Statins decrease mortality in those with atherosclerotic cardiovascular disease (ASCVD), but statin adherence remains suboptimal. Objective To determine the association between statin adherence and mortality in patients with ASCVD who have stable statin prescriptions. Design, Setting, and Participants This retrospective cohort analysis included patients who were between ages 21 and 85 years and had 1 or more International Classification of Diseases, Ninth Revision, Clinical Modification codes for ASCVD on 2 or more dates in the previous 2 years without intensity changes to their statin prescription who were treated within the Veterans Affairs Health System between January 1, 2013, and April 2014. Exposures Statin adherence was defined by the medication possession ratio (MPR). Adherence levels were categorized as an MPR of less than 50%, 50% to 69%, 70% to 89%, and 90% or greater. For dichotomous analyses, adherence was defined as an MPR of 80% or greater. Main Outcomes and Measures The primary outcome was death of all causes adjusted for demographic and clinical characteristics, as well as adherence to other cardiac medications. Results Of 347 104 eligible adults with ASCVD who had stable statin prescriptions, 5472 (1.6%) were women, 284 150 (81.9%) were white, 36 208 (10.4%) were African American, 16 323 (4.7%) were Hispanic, 4093 (1.2%) were Pacific Islander, 1293 (0.4%) were Native American, 1145 (0.3%) were Asian, and 1794 (0.5%) were other races. Patients taking moderate-intensity statin therapy were more adherent than patients taking high-intensity statin therapy (odds ratio [OR], 1.18; 95% CI, 1.16-1.20). Women were less adherent (OR, 0.89; 95% CI, 0.84-0.94), as were minority groups. Younger and older patients were less likely to be adherent compared with adults aged 65 to 74 years. During a mean (SD) of 2.9 (0.8) years of follow-up, there were 85 930 deaths (24.8%). Compared with the most adherent patients (MPR ≥ 90%), patients with an MPR of less than 50% had a hazard ratio (HR; adjusted for clinical characteristics and adherence to other cardiac medications) of 1.30 (95% CI, 1.27-1.34), those with an MPR of 50% to 69% had an HR of 1.21 (95% CI, 1.18-1.24), and those with an MPR of 70% to 89% had an HR of 1.08 (95% CI, 1.06-1.09). Conclusions and Relevance Using a national sample of Veterans Affairs patients with ASCVD, we found that a low adherence to statin therapy was associated with a greater risk of dying. Women, minorities, younger adults, and older adults were less likely to adhere to statins. Our findings underscore the importance of finding methods to improve adherence.
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Affiliation(s)
- Fatima Rodriguez
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California
| | - David J. Maron
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California
| | - Joshua W. Knowles
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California
| | - Salim S. Virani
- Michael E. DeBakey Veterans Affairs Medical Center, Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Shoutzu Lin
- Veterans Affairs Health System, Palo Alto, California
| | - Paul A. Heidenreich
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University, Stanford, California
- Veterans Affairs Health System, Palo Alto, California
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Affiliation(s)
- Janet K. Han
- Division of Cardiology, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, CA (J.K.H., R.E.)
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles (J.K.H., K.E.W., R.E.)
| | - Elizabeth M. Yano
- Veterans Affairs Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, CA (E.M.Y.)
- Department of Health Policy and Management, University of California Los Angeles Fielding School of Public Health (E.M.Y.)
| | - Karol E. Watson
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles (J.K.H., K.E.W., R.E.)
| | - Ramin Ebrahimi
- Division of Cardiology, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, CA (J.K.H., R.E.)
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles (J.K.H., K.E.W., R.E.)
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Clough JD, Martin SS, Navar AM, Lin L, Hardy NC, Rogers U, Curtis LH. Association of Primary Care Providers' Beliefs of Statins for Primary Prevention and Statin Prescription. J Am Heart Assoc 2019; 8:e010241. [PMID: 30681391 PMCID: PMC6405576 DOI: 10.1161/jaha.118.010241] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 12/20/2018] [Indexed: 12/17/2022]
Abstract
Background The 2013 American College of Cardiology/American Heart Association Cholesterol Treatment Guideline increased the number of primary prevention patients eligible for statin therapy, yet uptake of these guidelines has been modest. Little is known of how primary care provider ( PCP ) beliefs influence statin prescription. Methods and Results We surveyed 164 PCP s from a community-based North Carolina network in 2017 about statin therapy. We evaluated statin initiation among the PCP s' statin-eligible patients between 2014 and 2015 without a previous prescription. Seventy-two PCP s (43.9%) completed the survey. The median estimate of the relative risk reduction for high-intensity statins was 45% (interquartile range, 25%-50%). A minority of providers (27.8%) believed statins caused diabetes mellitus, and only 16.7% reported always/very often discussing this with patients. Most PCPs (97.2%) believed that statins cause myopathy, and 72.3% reported always/very often discussing this with patients. Most (77.7%) reported always/very often using the 10-year atherosclerotic cardiovascular disease risk calculator, although many reported that in most cases other risk factors or patient preferences influenced prescribing (59.8% and 43.1%, respectively). Of 6172 statin-eligible patients, 22.3% received a prescription for a moderate- or high-intensity statin at follow-up. Providers reporting greater reliance on risk factors beyond atherosclerotic cardiovascular disease risk were less likely to prescribe statins. Conclusions Although beliefs and approaches to statin discussions vary among community PCP s, new prescription rates are low and minimally associated with those beliefs. These results highlight the complexity of increasing statin prescriptions for primary prevention and suggest that strategies to facilitate standardized discussions and to address external influences on patient beliefs warrant future study.
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Affiliation(s)
- Jeffrey D. Clough
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
- Department of MedicineDuke University School of MedicineDurhamNC
| | - Seth S. Martin
- Ciccarone Center for the Prevention of Heart DiseaseDivision of CardiologyJohns Hopkins University School of MedicineBaltimoreMD
| | - Ann Marie Navar
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
- Department of MedicineDuke University School of MedicineDurhamNC
| | - Li Lin
- Department of Population Health SciencesDuke University School of MedicineDurhamNC
| | - N. Chantelle Hardy
- Department of Population Health SciencesDuke University School of MedicineDurhamNC
| | - Ursula Rogers
- Department of Duke ForgeDuke University School of MedicineDurhamNC
| | - Lesley H. Curtis
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
- Department of Population Health SciencesDuke University School of MedicineDurhamNC
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Guedeney P, Baber U, Claessen B, Aquino M, Camaj A, Sorrentino S, Vogel B, Farhan S, Faggioni M, Chandrasekhar J, Kalkman DN, Kovacic JC, Sweeny J, Barman N, Moreno P, Vijay P, Shah S, Dangas G, Kini A, Sharma S, Mehran R. Temporal trends, determinants, and impact of high-intensity statin prescriptions after percutaneous coronary intervention: Results from a large single-center prospective registry. Am Heart J 2019; 207:10-18. [PMID: 30404046 DOI: 10.1016/j.ahj.2018.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/04/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND High-intensity statins (HIS) are recommended for secondary prevention following percutaneous coronary intervention (PCI). We aimed to describe temporal trends and determinants of HIS prescriptions after PCI in a usual-care setting. METHODS All patients with age ≤75 years undergoing PCI between January 2011 and May 2016 at an urban, tertiary care center and discharged with available statin dosage data were included. HIS were defined as atorvastatin 40 or 80 mg, rosuvastatin 20 or 40 mg, and simvastatin 80 mg. RESULTS A total of 10,495 consecutive patients were included. Prevalence of HIS prescriptions nearly doubled from 36.6% in 2011 to 60.9% in 2016 (P < .001), with a stepwise increase each year after 2013. Predictors of HIS prescriptions included ST-segment elevation myocardial infarction/non-ST-segment elevation myocardial infarction (odds ratio [OR] 4.60, 95% CI 3.98-5.32, P < .001) and unstable angina (OR 1.31, 95% CI 1.19-1.45, P < .001) as index event, prior myocardial infarction (OR 1.48, 95% CI 1.34-1.65, P < .001), and co-prescription of β-blocker (OR 1.26, 95% CI 1.12-1.43, P < .001). Conversely, statin treatment at baseline (OR 0.86, 95% CI 0.77-0.96, P = .006), Asian races (OR 0.73, 95% CI 0.65-0.83, P < .001), and older age (OR 0.90, 95% CI 0.88-0.92, P < .001) were associated with reduced HIS prescriptions. There was no significant association between HIS prescriptions and 1-year rates of death, myocardial infarction, or target-vessel revascularization (adjusted hazard ratio 0.98, 95% CI 0.84-1.15, P = .84), although there was a trend toward reduced mortality (adjusted hazard ratio 0.71, 95% CI 0.50-1.00, P = .05). CONCLUSION Although the rate of HIS prescriptions after PCI has increased in recent years, important heterogeneity remains and should be addressed to improve practices in patients undergoing PCI.
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Affiliation(s)
- Paul Guedeney
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY; ACTION study group, Sorbonne université, INSERM UMRS 1166, Institut de Cardiologie (AP-HP), Hospital Pitié Salpêtrière, Paris, France
| | - Usman Baber
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Bimmer Claessen
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Melissa Aquino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Anton Camaj
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sabato Sorrentino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Serdar Farhan
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michela Faggioni
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jaya Chandrasekhar
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Deborah N Kalkman
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jason C Kovacic
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | | | | | | | | | | | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
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Superko HR, Williams PT, Dansinger M, Schaefer E. Trends in low-density lipoprotein-cholesterol blood values between 2012 and 2017 suggest sluggish adoption of the recent 2013 treatment guidelines. Clin Cardiol 2018; 42:101-110. [PMID: 30444024 DOI: 10.1002/clc.23115] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/07/2018] [Accepted: 11/13/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Over a 14-year period, age-adjusted high total cholesterol (≥240 mg/dL) in the United States declined from 18.3% in 1999 to 2000 to 11.0% in 2013 to 2014, coinciding with the 2001 National Cholesterol Education Program Adult Treatment Panel (ATP)-III guidelines that endorsed low-density lipoprotein (LDL)-cholesterol blood value goals. Statin treatment recommendations were revised by the American College of Cardiology and the American Heart Association (ACC/AHA) in November 2013 to a "risk-based prescription" approach that did not utilize blood cholesterol values. This increased dosage and expanded the statin-eligible population by an estimated 12.8 million US adults. These changes should further lower total and LDL cholesterol concentrations nationally. METHODS We examined data from 507 752 patients nationally aged ≥16 years whose fasting bloods were sent to Boston Heart Diagnostics for direct LDL-cholesterol measurements. Between 2012 and 2017, age-adjusted concentrations were examined by analysis of covariance and LDL-cholesterol ≥160 mg/dL by logistic regression. RESULTS Contrary to expectations, age-adjusted mean LDL-cholesterol concentrations (±SE, mg/dL) increased significantly (P < 10-16 ) in men (2012:113.8 ± 0.3; 2013:115.3 ± 0.2; 2014:114.7 ± 0.2; 2015:116.0 ± 0.2; 2016:117.6 ± 0.2; and 2017:117.1 ± 0.2 mg/dL) and women (2012:119.5 ± 0.3; 2013:120.7 ± 0.2; 2014:119.8 ± 0.02; 2015:120.8 ± 0.2; 2016:122.7 ± 0.1; and 2017:123.8 ± 0.2 mg/dL). The percentage with LDL-cholesterol ≥160 mg/dL also increased significantly (P < 10-9 ) in men and women. Similar results were obtained for ages 40 to 75 years olds (corresponding to ACC/AHA guidelines). CONCLUSION These results provide additional evidence that declining blood LDL-cholesterol levels observed following the ATP-III recommendations, did not further decline (actually increased) following the 2013 ACC/AHA recommendations.
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Affiliation(s)
- H Robert Superko
- Cholesterol, Genetics, and Heart Disease Institute, Carmel, California
| | | | - Michael Dansinger
- Boston Heart Diagnostics, Framingham, Massachusetts.,Department of Internal Medicine, Tuft's University, Medford, Massachusetts
| | - Ernst Schaefer
- Boston Heart Diagnostics, Framingham, Massachusetts.,Department of Internal Medicine, Tuft's University, Medford, Massachusetts
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36
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The effect of statin use and intensity on stroke and myocardial infarction after carotid endarterectomy. J Vasc Surg 2018; 68:1398-1405. [DOI: 10.1016/j.jvs.2018.02.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 02/20/2018] [Indexed: 12/23/2022]
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37
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Schiele F. Quality of data in observational studies: separating the wheat from the chaff. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2018; 3:99-100. [PMID: 28927179 DOI: 10.1093/ehjqcco/qcx003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Walther CP, Richardson PA, Virani SS, Winkelmayer WC, Navaneethan SD. Association between intensity of statin therapy and mortality in persons with chronic kidney disease. Nephrol Dial Transplant 2018; 35:312-319. [DOI: 10.1093/ndt/gfy237] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/14/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Carl P Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Peter A Richardson
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Salim S Virani
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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Musich S, Wang SS, Schwebke K, Slindee L, Waters E, Yeh CS. Underutilization of Statin Therapy for Secondary Prevention of Cardiovascular Disease Among Older Adults. Popul Health Manag 2018; 22:74-82. [PMID: 29893617 PMCID: PMC6386076 DOI: 10.1089/pop.2018.0051] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Secondary cardiovascular disease (CVD) clinical trials have demonstrated that higher intensity levels of statin therapy are more effective than lower levels in reducing mortality rates. Despite updated treatment guidelines, statin therapy may be underutilized, with evidence that females are treated less aggressively than males. The primary objective of this study was to determine the prevalence of statin utilization by varying therapy intensity by sex. The secondary objective was to document the benefits of statin therapy intensity levels on all-cause mortality for males and females. A 25% random sample of adults ≥65 years was utilized to identify those with established CVD. Inclusion criteria included: (1) 12-month pre period and (2) up to 30 months post period. Five categories of statin utilization were established: adherent to high-, moderate-, or low-intensity statin therapy, nonadherent, and no statins. Among eligible insureds (N = 49,530 males; N = 44,710 females), 20% of males and 12% of females were identified as high-intensity statin users. Mortality rates significantly increased similarly for males and females as statin therapy intensity decreased. Likewise, mortality hazard ratios indicated the most benefit from high-intensity statin therapy compared to all other categories. Statin therapy for secondary prevention of CVD is beneficial in reducing mortality for males and females but is underutilized, especially among females. Education programs among patients to increase heart health awareness and among physicians to promote the benefits of updated statin guidelines should be encouraged.
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Affiliation(s)
- Shirley Musich
- 1 Research for Aging Populations , Optum, Ann Arbor, Michigan
| | - Shaohung S Wang
- 1 Research for Aging Populations , Optum, Ann Arbor, Michigan
| | - Kay Schwebke
- 2 Informatics & Data Science , Optum, Ann Arbor, Michigan
| | - Luke Slindee
- 2 Informatics & Data Science , Optum, Ann Arbor, Michigan
| | - Evonne Waters
- 3 Medicare & Retirement, UnitedHealthcare Alliances , Minneapolis, Minnesota
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40
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Lamprecht DG, Shaw PB, King JB, Hogan KN, Olson KL. Trends in high-intensity statin use and low-density lipoprotein cholesterol control among patients enrolled in a clinical pharmacy cardiac risk service. J Clin Lipidol 2018; 12:999-1007. [PMID: 29803357 DOI: 10.1016/j.jacl.2018.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 04/02/2018] [Accepted: 04/17/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Although high-intensity statin therapy (HIST) is recommended for most patients between 21 and 75 years of age with atherosclerotic cardiovascular disease (ASCVD), several recent analyses examining contemporary statin use trends have identified a clinical care gap in the utilization of HIST. OBJECTIVE The objective of this study was to assess secular trends in lipid management for patients with ASCVD enrolled in a clinical pharmacy program within an integrated health care delivery system. METHODS We performed serial cross-sectional studies over time, comprising 18,006 adults with both acute and chronic ASCVD, to assess trends in statin use and low-density lipoprotein cholesterol (LDL-C) levels from 2007 to 2016. RESULTS Although the use of statin therapy (any intensity) remained relatively consistent throughout the 10-year study period (89% in 2007, 87% in 2016), the proportion of patients receiving HIST increased over time (44% in 2007, 67% in 2016; P < .001 for trend). Population mean LDL-C levels ranged from 73 to 83 mg/dL with a downward trend over the 10-year study period (P < .001 for trend). By 2016, the proportion of patients attaining an LDL-C <100 mg/dL and <70 mg/dL was 85% and 54%, respectively. Nonstatin lipid-lowering therapy use decreased over the study period, which was primarily driven by decreased use of ezetimibe (24% in 2007, 2% in 2016; P < .001 for trend). CONCLUSIONS Among adults with ASCVD enrolled in a clinical pharmacy cardiac risk reduction service, guideline-directed use of HIST significantly increased over the past 10 years and coincided with decreased population LDL-C levels.
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Affiliation(s)
- Donald G Lamprecht
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO, USA; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.
| | - Paul B Shaw
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO, USA; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA; Regis University School of Pharmacy, Denver, CO, USA
| | - Jordan B King
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Keri N Hogan
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO, USA; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Kari L Olson
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO, USA; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Peters SA, Colantonio LD, Zhao H, Bittner V, Dai Y, Farkouh ME, Monda KL, Safford MM, Muntner P, Woodward M. Sex Differences in High-Intensity Statin Use Following Myocardial Infarction in the United States. J Am Coll Cardiol 2018; 71:1729-1737. [DOI: 10.1016/j.jacc.2018.02.032] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/16/2018] [Accepted: 02/07/2018] [Indexed: 12/15/2022]
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Bin Abdulhak AA, Vaughan-Sarrzin M, Kaboli P, Horwitz PA, Mosher H, Sigurdsson G, Walker NE, Wallace R, Robinson JG. Temporal Trends of High-Intensity Statin Therapy Among Veterans Treated With Percutaneous Coronary Intervention. J Am Heart Assoc 2018; 7:JAHA.117.007370. [PMID: 29503265 PMCID: PMC5866316 DOI: 10.1161/jaha.117.007370] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The 2013 American College of Cardiology/American Heart Association blood cholesterol guideline recommends high-intensity statin therapy among certain groups of patients, but full implementation of the guideline has not yet been satisfactory. We aimed to investigate the temporal trends and predictors of high-intensity statin therapy among veterans who had been treated with percutaneous coronary intervention (PCI) and followed up by cardiologists within the Veterans Health Administrative system. METHODS AND RESULTS A retrospective cohort study was conducted at the Veterans Health Administrative system including all patients >18 years old who had their PCI procedure between October 2010 and September 2016. National Veterans Health Administrative databases were used to retrieve study participant's demographics, comorbid conditions, statin type and dose within 90 days before and after the PCI procedure. There were 48 862 patients who underwent a PCI procedure during the study period. High-intensity statin use at 90 days post-PCI rose from 23% in 2010 to 37% before release of the 2013 American College of Cardiology/American Heart Association cholesterol guideline, then rose sharply to 80% by 2016. The projected 10-year risk of arteriosclerotic cardiovascular disease events among our study population was projected to be ≈1841 fewer if the cohort had received high-intensity statin therapy versus moderate-intensity statin. CONCLUSIONS By 2016, the 2013 American College of Cardiology/American Heart Association blood cholesterol guideline was well implemented among veterans who had a PCI procedure in the Veterans Health Administrative system, suggesting systems of care can be improved to increase rates of high-intensity statin initiation.
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Affiliation(s)
- Aref A Bin Abdulhak
- Center for Access Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA.,Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.,College of Public Health, University of Iowa, Iowa City, IA
| | - Mary Vaughan-Sarrzin
- Center for Access Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Peter Kaboli
- Center for Access Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Phillip A Horwitz
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Hilary Mosher
- Center for Access Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Gardar Sigurdsson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Nicholas E Walker
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Robert Wallace
- College of Public Health, University of Iowa, Iowa City, IA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Jennifer G Robinson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA .,College of Public Health, University of Iowa, Iowa City, IA
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Markovitz AA, Holleman RG, Hofer TP, Kerr EA, Klamerus ML, Sussman JB. Effects of Guideline and Formulary Changes on Statin Prescribing in the Veterans Affairs. Health Serv Res 2017; 52:1996-2017. [PMID: 29130272 PMCID: PMC5682154 DOI: 10.1111/1475-6773.12788] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE To compare the effects of two sequential policy changes-the addition of a high-potency statin to the Department of Veterans Affairs (VA) formulary and the release of the American College of Cardiology/American Heart Association (ACC/AHA) cholesterol guidelines-on VA provider prescribing. DATA SOURCES/STUDY SETTING Retrospective analysis of 1,100,682 VA patients, 2011-2016. STUDY DESIGN Interrupted time-series analysis of changes in prescribing of moderate-to-high-intensity statins among high-risk patients and across high-risk subgroups. We also assessed changes in prescribing of atorvastatin and other statin drugs. We estimated marginal effects (ME) of formulary and guideline changes by comparing predicted and observed statin use. DATA COLLECTION/EXTRACTION METHODS Data from VA Corporate Data Warehouse. PRINCIPAL FINDINGS The use of moderate-to-high-intensity statins increased by 2 percentage points following the formulary change (ME, 2.4, 95% confidence interval [CI], 2.2 to 2.6) and less than 1 percentage point following the guideline change (ME, 0.8, 95% CI, 0.6 to 0.9). The formulary change led to approximately a 12 percentage-point increase in the use of moderate-to-high-intensity atorvastatin (ME, 11.5, 95% CI, 11.3 to 11.6). The relatively greater provider response to the formulary change occurred across all patient subgroups. CONCLUSIONS Addition of a high-potency statin to formulary affected provider prescribing more than the ACC/AHA guidelines.
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Affiliation(s)
- Adam A. Markovitz
- VA Center for Clinical Management and ResearchAnn ArborMI
- University of Michigan Medical SchoolAnn ArborMI
- University of Michigan School of Public HealthAnn ArborMI
| | | | - Timothy P. Hofer
- VA Center for Clinical Management and ResearchAnn ArborMI
- University of Michigan Medical SchoolAnn ArborMI
- Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMI
| | - Eve A. Kerr
- VA Center for Clinical Management and ResearchAnn ArborMI
- University of Michigan Medical SchoolAnn ArborMI
- Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMI
| | | | - Jeremy B. Sussman
- VA Center for Clinical Management and ResearchAnn ArborMI
- University of Michigan Medical SchoolAnn ArborMI
- Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMI
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