Underuse of Statins among Veterans with Hypercholesterolemia
BACKGROUND:
Severe hypercholesterolemia – defined as low-density lipoprotein cholesterol (LDL-C) >190 mg/dL – affects approximately 5% of the U.S. population. The 2013 American College of Cardiology/American Heart Association (ACC/AHA) cholesterol guideline recommends early initiation of high-intensity statin therapy for the primary prevention of atherosclerotic cardiovascular disease events among patients with this condition. This study sought to examine the prevalence and treatment of Veterans with uncontrolled severe hypercholesterolemia who received VA healthcare. Using VA data, investigators identified 63,576 VA outpatients with severe hypercholesterolemia, including 8,553 (14%) women and 26,879 (29%) non-white men; all who received VA care between April 2011 and March 2014. Statin intensity was classified according to ACC/AHA cholesterol guidelines. Statin intensification was determined for those patients who were on no statin or a low or moderate-intensity statin 6 months prior to the index date compared to statin intensity 6 months after the index date.
FINDINGS:
- Investigators found a marked underuse of statins in Veterans with uncontrolled severe hypercholesterolemia. Within six months of this abnormal lab value, only 52% were being treated with statins, and less than 10% were on high-intensity statin therapy as recommended by the 2013 ACC/AHA guidelines.
- Older (over age 75) and younger (under age 35) Veterans were less likely to be treated. Women also were less likely to be treated with statins, whereas minority groups and those with a diagnosis of hypertension were more likely to be treated.
- Black Veterans were significantly more likely to be on high-intensity statin therapy as compared with Whites (12 vs. 9%), as were those with hypertension (11 vs. 8%) and renal disease (12 vs. 9%).
- Veterans treated at VA facilities in the West were least likely to have a statin prescription or, particularly, high-intensity statin therapy, as compared with Veterans in other geographic regions.
IMPLICATIONS:
- Significant improvement is needed in order to meet guideline-recommended care for Veterans with uncontrolled severe hypercholesterolemia.
LIMITATIONS:
- Investigators were unable to determine if Veterans had received statin treatment outside VA, although most of these patients would have been excluded from their analysis, which required at least one medication filled in VA during the six-month window.
- Investigators were unable to determine if lack of treatment was due to patient preferences, i.e., statin intolerance.
AUTHOR/FUNDING INFORMATION:
Dr. Heidenreich leads HSR&D's MedSafe QUERI national program located in Palo Alto, CA. Dr. Virani is part of HSR&D's Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Houston, TX.
Rodriguez F, Knowles J, Maron D, Virani S, and Heidenreich P. Frequency of Statin Use in Patients with Low-Density Lipoprotein Cholesterol > 190 mg/dl Severe Hypercholesterolemia: Findings from the Veteran’s Affairs Health System. American Journal of Cardiology. September 1, 2018;122(5):756-61
