Veterans are Commonly Prescribed Statins for Indications Unsupported by Guidelines for Managing High Cholesterol
BACKGROUND:
Statins are recommended for lowering cholesterol in people at risk for – or who have – atherosclerotic cardiovascular disease (ASCVD). Several professional organizations issue guidelines for clinicians regarding the treatment of high cholesterol, including the Adult Treatment Panel III (ATP III), the American College of Cardiology (ACC), and the American Heart Association (AHA). This national retrospective study of new statin prescriptions in the VA healthcare system examined concordance with ATP-III guidelines (in force in 2102) and ACC-AHA guidelines (updated in 2013). Using VA data, investigators identified Veterans who received new statin prescriptions in 2012 and met study criteria. [For example, Veterans were excluded if they had received a statin outside VA.] Investigators also used patient demographics, systolic blood pressure (SBP), presence of diabetes, use of blood pressure medication, cholesterol, and smoking status to calculate the patient's 10-year ASCVD risk at the time of statin initiation.
FINDINGS:
- Veterans were commonly prescribed statins for indications not supported by either the ATP-III or the ACC-AHA 2013 guidelines. Of Veterans receiving new statins for primary prevention, 48% did not meet ATP III guidelines; 20% did not fulfill the new ACC-AHA guidelines.
- Of the Veterans included in the study (n=121,081), 68% (n=82,600) of new statins were prescribed for primary prevention and 32% (n=38,481) were for secondary prevention of ASCVD.
- Twenty-eight percent of Veterans met ACC-AHA guideline recommendations but not the ATP III guidelines; only 0.3% of patients met the ATP III guidelines and not the ACC-AHA guidelines; and 19% did not meet either set of guidelines.
- Approximately 20% of Veterans with an LDL <70 mg/dl or who were current smokers were prescribed statins despite not meeting either guideline recommendation.
IMPLICATIONS:
- The identification of the use of statins outside of established guidelines represents an opportunity to improve the quality and value of VA healthcare delivery.
LIMITATIONS:
- Investigators began the study in 2013 using 2012 data, and planned to use existing guidelines. The issuance of new AHA guidelines in 2013 complicated the study, but also provided an opportunity to use both guidelines in assessing care.
- This study is based on VA data, and there may have been some under-recognition of risk factors, including family history used to calculate risk in the ATP III guidelines, as well as race used to determine risk in the ACC-AHA guidelines, as patients of unknown race were assumed to be White.
AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (RRP 13-420). Dr. Bravata is part of HSR&D's Center for Health Information and Communication (CHIC), Indianapolis, IN.
Cascino T, Vali M, Redberg R, Bravata D, Boscardin J, Eilkhani E, and Keyhani S. Guideline Concordance of New Statin Prescriptions: Who Got a Statin?). The American Journal of Managed Care. September 2017;23(9):528-533.
