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Jones LK, Tilberry S, Gregor C, Yaeger LH, Hu Y, Sturm AC, Seaton TL, Waltz TJ, Rahm AK, Goldberg A, Brownson RC, Gidding SS, Williams MS, Gionfriddo MR. Implementation strategies to improve statin utilization in individuals with hypercholesterolemia: a systematic review and meta-analysis. Implement Sci 2021; 16:40. [PMID: 33849601 PMCID: PMC8045284 DOI: 10.1186/s13012-021-01108-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 03/29/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Numerous implementation strategies to improve utilization of statins in patients with hypercholesterolemia have been utilized, with varying degrees of success. The aim of this systematic review is to determine the state of evidence of implementation strategies on the uptake of statins. METHODS AND RESULTS This systematic review identified and categorized implementation strategies, according to the Expert Recommendations for Implementing Change (ERIC) compilation, used in studies to improve statin use. We searched Ovid MEDLINE, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov from inception to October 2018. All included studies were reported in English and had at least one strategy to promote statin uptake that could be categorized using the ERIC compilation. Data extraction was completed independently, in duplicate, and disagreements were resolved by consensus. We extracted LDL-C (concentration and target achievement), statin prescribing, and statin adherence (percentage and target achievement). A total of 258 strategies were used across 86 trials. The median number of strategies used was 3 (SD 2.2, range 1-13). Implementation strategy descriptions often did not include key defining characteristics: temporality was reported in 59%, dose in 52%, affected outcome in 9%, and justification in 6%. Thirty-one trials reported at least 1 of the 3 outcomes of interest: significantly reduced LDL-C (standardized mean difference [SMD] - 0.17, 95% CI - 0.27 to - 0.07, p = 0.0006; odds ratio [OR] 1.33, 95% CI 1.13 to 1.58, p = 0.0008), increased rates of statin prescribing (OR 2.21, 95% CI 1.60 to 3.06, p < 0.0001), and improved statin adherence (SMD 0.13, 95% CI 0.06 to 0.19; p = 0.0002; OR 1.30, 95% CI 1.04 to 1.63, p = 0.023). The number of implementation strategies used per study positively influenced the efficacy outcomes. CONCLUSION Although studies demonstrated improved statin prescribing, statin adherence, and reduced LDL-C, no single strategy or group of strategies consistently improved outcomes. TRIAL REGISTRATION PROSPERO CRD42018114952 .
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Affiliation(s)
- Laney K Jones
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA.
| | - Stephanie Tilberry
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA
| | - Christina Gregor
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, PA, USA
| | - Lauren H Yaeger
- Bernard Becker Medical Library, Washington University in St. Louis, St. Louis, MO, USA
| | - Yirui Hu
- Population Health Sciences, Geisinger, Danville, PA, USA
| | - Amy C Sturm
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA
| | - Terry L Seaton
- University of Health Sciences and Pharmacy in St. Louis, St. Louis, MO, USA
- Population Health, Mercy Clinic-East Communities, St. Louis, MO, USA
| | | | - Alanna K Rahm
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA
| | - Anne Goldberg
- Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, 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) and Alvin J. Siteman Cancer Center, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Samuel S Gidding
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA
| | - Marc S Williams
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave., Danville, PA, 17822, USA
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Birnbaum RA, Horton BH, Gidding SS, Brenman LM, Macapinlac BA, Avins AL. Closing the gap: Identification and management of familial hypercholesterolemia in an integrated healthcare delivery system. J Clin Lipidol 2021; 15:347-357. [PMID: 33583725 DOI: 10.1016/j.jacl.2021.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 01/16/2021] [Accepted: 01/22/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Familial hypercholesterolemia (FH) is an autosomal dominant genetic disorder that causes markedly elevated risk for early onset coronary artery disease. Despite availability of effective therapy, only 5-10% of affected individuals worldwide are diagnosed. OBJECTIVE To develop and evaluate a novel approach for identifying and managing patients with FH in a large integrated health system with a diverse patient population, using inexpensive methods. METHODS Using Make Early Diagnosis/Prevent Early Death (MEDPED) criteria, we created a method for identifying patients at high risk for FH within the Kaiser Permanente Northern California electronic medical record. This led to a pragmatic workflow for contacting patients, establishing a diagnosis in a dedicated FH clinic, and initiating management. We prospectively collected data on the first 100 patients to assess implementation effectiveness. RESULTS Ninety-three (93.0%, 95%CI: 86.1%-97.1%) of the first 100 evaluated patients were diagnosed with FH (median age = 38 years) of whom only 5% were previously recognized; 48% were taking no lipid-lowering therapy, and 7% had acute coronary symptoms. 82 underwent successful genetic testing of whom 55 (67.1%; 95%CI: 55.8%-77.1%) had a pathogenic mutation. Following clinic evaluation, 83 of 85 (97.6%) medication-eligible patients were prescribed combination lipid-lowering therapy. 20 family members in the healthcare system were diagnosed with FH through cascade testing. CONCLUSIONS This novel approach was effective for identifying and managing patients with undiagnosed FH. Care gaps in providing appropriate lipid-lowering therapy were successfully addressed. Further development and dissemination of integrated approaches to FH care are warranted.
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Affiliation(s)
- Richard A Birnbaum
- Department of Cardiology, Northern California Kaiser Permanente, San Leandro, California, USA.
| | - Brandon H Horton
- Division of Research, Northern California Kaiser Permanente, Oakland, California, USA
| | - Samuel S Gidding
- Geisinger Genomic Medicine, Geisinger Health System, Danville, PA
| | - Leslie Manace Brenman
- Department of Genetics, Northern California Kaiser Permanente, Oakland, California, USA
| | - Brian A Macapinlac
- Department of Cardiology, Northern California Kaiser Permanente, San Leandro, California, USA
| | - Andrew L Avins
- Division of Research, Northern California Kaiser Permanente, Oakland, California, USA; Departments of Medicine and Epidemiology & Biostatistics, University of California, San Francisco; San Francisco, California, USA
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Kino S, Bernabé E, Sabbah W. Social Inequalities in Use of Preventive Dental and Medical Services among Adults in European Countries. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16234642. [PMID: 31766584 PMCID: PMC6926506 DOI: 10.3390/ijerph16234642] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 11/15/2019] [Accepted: 11/20/2019] [Indexed: 01/03/2023]
Abstract
This study examined inequalities in dental check-ups and medical screenings using subjective and objective socioeconomic indicators. Data from 23,464 adults, aged 20 years old and over, who participated in a multi-national survey across Europe (Eurobarometer 72.3) were analysed. Participants’ socioeconomic position (SEP) was measured by education, difficulty in paying bills and subjective social status. Use of preventive services was measured by attendance for dental check-ups, cancer and cardiovascular screenings in the past 12 months. Socioeconomic inequalities were assessed in two-level logistic regression (adults nested within countries), adjusting for demographic factors and type of healthcare system. There were apparent social inequalities in using all three preventive services. However, only dental check-ups showed consistent and significant inequalities across all socioeconomic indicators with those in the bottom groups in education (odds ratio: 0.51; 95% confidence interval: 0.46–0.55), difficulty in paying bills (OR: 0.64; 95% CI: 0.59–0.72) and subjective social status (OR: 0.63; 95% CI: 0.57–0.69) having lower odds of reporting dental check-ups in the past 12 months than those in the top groups. Cancer screening was not associated with difficulty in paying bills whereas cardiovascular disease screening was not associated with education and subjective social status. Despite the availability of universal health coverage, there were clear social gradients in using preventive services particularly across education and subjective social status groups. The stronger and more consistent gradients observed in dental check-ups compared to cancer and cardiovascular screening could be attributed to difference in the level of coverage of dental and medical services in Europe.
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Affiliation(s)
- Shiho Kino
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, University of Boston, Boston, MA 02115, USA;
| | - Eduardo Bernabé
- Faculty of Dentistry, Oral & Craniofacial Sciences, King’s College London, London SE5 9RS, UK;
- Correspondence:
| | - Wael Sabbah
- Faculty of Dentistry, Oral & Craniofacial Sciences, King’s College London, London SE5 9RS, UK;
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Giner-Galvañ V, Esteban-Giner MJ, Pallarés-Carratalá V. Overview of guidelines for the management of dyslipidemia: EU perspectives. Vasc Health Risk Manag 2016; 12:357-369. [PMID: 27660458 PMCID: PMC5019442 DOI: 10.2147/vhrm.s89038] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Modern medicine is characterized by a continuous genesis of evidence making it very difficult to translate the latest findings into a better clinical practice. Clinical practice guidelines (CPG) emerge to provide clinicians evidence-based recommendations for their daily clinical practice. However, the high number of existing CPG as well as the usual differences in the given recommendations usually increases the clinician’s confusion and doubts. It has apparently been the case for the 2013 American College of Cardiology/American Heart Association (ACC/AHA) Guideline on the Treatment of Blood Cholesterol. These CPG proposed new and controversial concepts that have usually been considered an antagonist shift respective to European CPG. The most controversial published proposals are: 1) to consider evidence just from randomized clinical trials, 2) creation of a new cardiovascular (CV) risk calculator, 3) to consider reducing CV risk instead of reducing low-density lipoprotein cholesterol (LDLc) as the target of the treatment, and 4) consideration of statins as the only drugs for treatment. A deep analysis of the 2013 American College of Cardiology/American Heart Association CPG and comparison with the European ones show that from a practical and clinical point of view, there are more similarities than differences. To further help clinicians in their daily work, in the present globalized world, it is time to discuss and adopt a mutually agreed upon document created by both sides of the Atlantic. Probably it is not a short-term solution. Meanwhile, taking advantage of the similarities, the recommended practical attitude for the daily clinical practice should be based on 1) early detection of people with increased CV risk promoting the use of validated local scales, 2) reinforce the mainstream importance of nonpharmacological treatment, and 3) need for periodically monitoring response with analytical parameters (LDL or non-high-density lipoprotein cholesterol) and global CV risk estimation. Technological solutions such as the big data technology could help to obtain high-quality evidence in an intermediate term.
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Affiliation(s)
- Vicente Giner-Galvañ
- Department of General Internal Medicine, Unit of Hypertension and Cardiometabolic Risk, Hospital Mare de Déu dels Lliris, Alcoy, Alicante
| | - María José Esteban-Giner
- Department of General Internal Medicine, Unit of Hypertension and Cardiometabolic Risk, Hospital Mare de Déu dels Lliris, Alcoy, Alicante
| | - Vicente Pallarés-Carratalá
- Department of Health Surveillance, Unión de Mutuas, Castellón de la Plana; Department of Medicine, Universitat Jaume I, Castellón, Spain
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Savolainen J, Kautiainen H, Niskanen L, Mäntyselkä P. Decreasing cholesterol levels in the community--lifestyle change with statin? BMC FAMILY PRACTICE 2015; 16:29. [PMID: 25879518 PMCID: PMC4356061 DOI: 10.1186/s12875-015-0240-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 02/13/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND The Lapinlahti 2005-2010 study was carried out to explore cardiovascular disease risk factors and changes in lifestyle in Lapinlahti residents in eastern Finland. Our aim was to analyse factors influencing the level of cholesterol in the community. METHODS In 2005, 480 subjects aged 30-65 years underwent a complete health survey (baseline study) that consisted of a structured questionnaire and a health examination. The follow-up was carried out five years later in 2010. The present study population included 326 individuals who did not use lipid-lowering medication at the baseline. A trained research nurse measured weight, height, waist circumference and blood pressure at the baseline and follow-up. Respectively, lifestyle factors (nutrition, exercise, smoking and alcohol use) were examined with a structured questionnaire. Each lifestyle item was valued as -1, 0 or 1, depending on how closely it fitted to the recommendations. Cholesterol level analyses at the baseline and follow-up were performed according to the protocol of the Kuopio University Hospital's medical laboratory. Based on their baseline cholesterol levels, the participants were divided into tertiles. The age- and sex-adjusted linear trend between the tertiles was tested. RESULTS The change in cholesterol level was associated with lipid-lowering medication (P < 0.001). Lifestyle improvement was associated with the cholesterol level change but did not reach statistical significance (P = 0.061), although the interaction of lipid-lowering medication and lifestyle change was associated with the change in cholesterol level (P = 0.018). In multivariate analysis, a favourable change in fat consumption (P = 0.007) and lipid-lowering medication (P < 0.001) were associated with decreasing cholesterol levels. CONCLUSIONS At the population level, dyslipidaemia is one of the most easily modifiable risk factors of CHD. Lipid-lowering medication may have the most significant impact on cholesterol level in communities with primary health care with good coverage. On the other hand, the potential of health-promoting and population-based prevention strategies may be underused.
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Affiliation(s)
- Jorma Savolainen
- Institute of Public Health and Clinical Nutrition, Primary Health Care, School of Medicine, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland.
- Primary Health Care Unit, Kuopio University Hospital, P.O. Box 100, FI-72009 KYS, Kuopio, Finland.
| | - Hannu Kautiainen
- Department of General Practice, Helsinki University Central Hospital, Unit of Primary Health Care and University of Helsinki, P.O. Box 20, FI-00014, Helsinki, Finland.
| | - Leo Niskanen
- Endocrinology, Abdominal Center, Helsinki University Central Hospital, P.O. Box 55, FI- 00014, Helsinki, Finland.
| | - Pekka Mäntyselkä
- Institute of Public Health and Clinical Nutrition, Primary Health Care, School of Medicine, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland.
- Primary Health Care Unit, Kuopio University Hospital, P.O. Box 100, FI-72009 KYS, Kuopio, Finland.
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Wiklund O, Pirazzi C, Romeo S. Monitoring of lipids, enzymes, and creatine kinase in patients on lipid-lowering drug therapy. Curr Cardiol Rep 2014; 15:397. [PMID: 23888382 PMCID: PMC3751280 DOI: 10.1007/s11886-013-0397-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
A number of plasma lipid parameters have been used to estimate cardiovascular risk and to be targets for treatment to reduce risk. Most risk algorithms are based on total cholesterol (T-C) or low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C), and most intervention trials have targeted the LDL-C levels. Emerging measures, which in some cases may be better for risk calculation and as alternative treatment targets, are apolipoprotein B and non-HDL-C. Other lipid measures that may contribute in risk analysis are triglycerides (TG), lipoprotein(a), and lipoprotein-associated phospholipase A2. The primary treatment target in cardiovascular prevention is LDL-C, and potential alternative targets are apoB and non-HDL-C. In selected individuals at high cardiovascular (CV) risk, TG should be targeted, but HDL-C, Lp(a), and ratios such as LDL-C/HDL-C or apoB/apoAI are not recommended as treatment targets. Lipids should be monitored during titration to targets. Thereafter, lipids should be checked at least once a year or more frequently to improve treatment adherence if indicated. Monitoring of muscle and liver enzymes should be done before the start of treatment. In stable conditions during treatment, the focus should be on clinical symptoms that may alert muscle or liver complications. Routine measurement of CK or ALT is not necessary during treatment with statins.
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Affiliation(s)
- Olov Wiklund
- Wallenberg Laboratory, Department of Experimental and Clinical Medicine, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, 413 45, Göteborg, Sweden.
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Waiting for the National Cholesterol Education Program Adult Treatment Panel IV Guidelines, and in the meantime, some challenges and recommendations. Am J Cardiol 2012; 110:307-13. [PMID: 22497674 DOI: 10.1016/j.amjcard.2012.03.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Revised: 03/09/2012] [Accepted: 03/09/2012] [Indexed: 11/24/2022]
Abstract
The National Cholesterol Education Program Adult Treatment Panel (ATP) has provided education and guidance for decades on the management of hypercholesterolemia. Its third report (ATP III) was published 10 years ago, with a white paper update in 2004. There is a need for translation of more recent evidence into a revised guideline. To help address the significant challenges facing the ATP IV writing group, this statement aims to provide balanced recommendations that build on ATP III. The authors aim for simplicity to increase the likelihood of implementation in clinical practice. To move from ATP III to ATP IV, the authors recommend the following: (1) assess risk more accurately, (2) simplify the starting algorithm, (3) prioritize statin therapy, (4) relax the follow-up interval for repeat lipid testing, (5) designate <70 mg/dl as an "ideal" low-density lipoprotein cholesterol target, (6) endorse targets beyond low-density lipoprotein cholesterol, (7) refine therapeutic target levels to the equivalent population percentile, (8) remove misleading descriptors such as "borderline high," and (9) make lifestyle messages simpler. In conclusion, the solutions offered in this statement represent ways to translate the totality of published reports into enhanced hyperlipidemia guidelines to better combat the devastating impact of hyperlipidemia on cardiovascular health.
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Catapano AL, Reiner Z, De Backer G, Graham I, Taskinen MR, Wiklund O, Agewall S, Alegria E, Chapman MJ, Durrington P, Erdine S, Halcox J, Hobbs R, Kjekshus J, Filardi PP, Riccardi G, Storey RF, Wood D. ESC/EAS Guidelines for the management of dyslipidaemias The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Atherosclerosis 2012; 217:3-46. [PMID: 21882396 DOI: 10.1016/j.atherosclerosis.2011.06.028] [Citation(s) in RCA: 441] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Reiner Ž, Catapano AL, De Backer G, Graham I, Taskinen MR, Wiklund O, Agewall S, Alegría E, Chapman MJ, Durrington P, Erdine S, Halcox J, Hobbs RH, Kjekshus JK, Perrone Filardi P, Riccardi G, Storey RF, David W. [ESC/EAS Guidelines for the management of dyslipidaemias]. Rev Esp Cardiol 2011; 64:1168.e1-1168.e60. [PMID: 22115524 DOI: 10.1016/j.recesp.2011.09.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Accepted: 09/16/2011] [Indexed: 01/15/2023]
Affiliation(s)
- Željko Reiner
- University Hospital Center Zagreb, School of Medicine, University of Zagreb, Salata 2, 10 000 Zagreb, Croacia.
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Reiner Z, Catapano AL, De Backer G, Graham I, Taskinen MR, Wiklund O, Agewall S, Alegria E, Chapman MJ, Durrington P, Erdine S, Halcox J, Hobbs R, Kjekshus J, Filardi PP, Riccardi G, Storey RF, Wood D. ESC/EAS Guidelines for the management of dyslipidaemias: The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Eur Heart J 2011; 32:1769-818. [PMID: 21712404 DOI: 10.1093/eurheartj/ehr158] [Citation(s) in RCA: 1942] [Impact Index Per Article: 149.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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