Pharmacist-Led Programs to Increase Statin Prescribing: A Narrative Review of the Literature

Statins are lipid-lowing medications shown to reduce cardiovascular events and are recommended for specific patient populations at elevated risk of atherosclerotic cardiovascular disease (ASCVD). Despite the demonstrated efficacy of statins for reducing ASCVD risk, and guidance on which populations should receive statin therapy, a substantial portion of eligible patients are not prescribed statin therapy. Pharmacists have attempted to increase the number of eligible patients receiving appropriate statin therapy through a variety of interventions and across several clinical settings. In this article, we highlight multiple studies evaluating the effectiveness of pharmacist-led interventions to improve statin use. A total of seven studies were selected for this narrative review, demonstrating the effectiveness and barriers of different statin-initiation programs delivered by pharmacists to increase statin use in eligible patients. Among the interventions assessed, a combination of provider communicating and statin prescribing through collaborative drug therapy management (CDTM) appear to the be the most useful at increasing statin use. Pharmacists can significantly improve statin use rates among eligible patients through multiple intervention types and across different clinical settings. Further studies should evaluate continued statin adherence and clinical outcomes among patients served by pharmacists.

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Patients Living With HIV Are Less Likely to Receive Appropriate Statin Therapy for Cardiovascular Disease Risk Reduction

Journal of Pharmacy Practice ◽

10.1177/0897190021999790 ◽

2021 ◽

pp. 089719002199979

Author(s):

Roshni P. Emmons ◽

Nicholas V. Hastain ◽

Todd A. Miano ◽

Jason J. Schafer

Keyword(s):

Cardiovascular Disease ◽

Logistic Regression ◽

Statin Therapy ◽

Risk Reduction ◽

Blood Cholesterol ◽

Control Group ◽

Atherosclerotic Cardiovascular Disease ◽

Ascvd Risk ◽

Living With Hiv ◽

To Receive

Background: Recent studies suggest that statins are underprescribed in patients living with HIV (PLWH) at risk for atherosclerotic cardiovascular disease (ASCVD), but none have assessed if eligible patients receive the correct statin and intensity compared to uninfected controls. Objectives: The primary objective was to determine whether statin-eligible PLWH are less likely to receive appropriate statin therapy compared to patients without HIV. Methods: This retrospective study evaluated statin eligibility and prescribing among patients in both an HIV and internal medicine clinic at an urban, academic medical center from June-September 2018 using the American College of Cardiology/American Heart Association guideline on treating blood cholesterol to reduce ASCVD risk. Patients were assessed for eligibility and actual treatment with appropriate statin therapy. Characteristics of patients appropriately and not appropriately treated were compared with chi-square testing and predictors for receiving appropriate statin therapy were determined with logistic regression. Results: A total of 221/300 study subjects were statin-eligible. Fewer statin-eligible PLWH were receiving the correct statin intensity for their risk benefit group versus the uninfected control group (30.2% vs 67.0%, p < 0.001). In the multivariable logistic regression analysis, PLWH were significantly less likely to receive appropriate statin therapy, while those with polypharmacy were more likely to receive appropriate statin therapy. Conclusion: Our study reveals that PLWH may be at a disadvantage in receiving appropriate statin therapy for ASCVD risk reduction. This is important given the heightened risk for ASCVD in this population, and strategies that address this gap in care should be explored.

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Statin Use With the ATP III Guidelines Compared to the 2013 ACC/AHA Guidelines in HIV Primary Care Patients

Journal of Pharmacy Practice ◽

10.1177/0897190015611774 ◽

2016 ◽

Vol 30 (1) ◽

pp. 64-69 ◽

Cited By ~ 5

Author(s):

Pansy Elsamadisi ◽

Agnes Cha ◽

Elise Kim ◽

Safia Latif

Keyword(s):

Statin Therapy ◽

Retrospective Chart Review ◽

Population Based ◽

Risk Scores ◽

Atherosclerotic Cardiovascular Disease ◽

Laboratory Test Results ◽

Hiv Primary Care ◽

Cholesterol Guidelines ◽

Level Of Agreement ◽

Statin Use

Background: The 2013 Cholesterol Guidelines include a new atherosclerotic cardiovascular disease (ASCVD) risk calculator that determines the 10-year risk of coronary heart disease and/or stroke. The applicability of this calculator and its predecessor, the Framingham risk score (FRS) in Adult Treatment Panel (ATP) III, has been limited in patients with HIV. The objective of this study was to compare the risk scores of ASCVD and FRS in the initiation of statin therapy in patients with HIV. Methods: We conducted a retrospective chart review of patients with HIV on statin therapy from October 1, 2013, to April 1, 2014. Data collection included patient demographics, pertinent laboratory test results, and medication list. The primary end point evaluated the level of agreement between the guidelines. Results: Of 155 patients who met the inclusion criteria, 116 were treated similarly with both guidelines. This showed a moderate level of agreement ( P < .001). Forty-eight of 86 patients requiring statins were placed on the correct intensity statin using the 2013 guidelines. Regardless of which guideline, a majority of patients required statin therapy. Conclusion: A moderate agreement was found between both guidelines in terms of statin use when applied to an HIV patient population. Based on the 2013 guidelines and taking into account drug interactions with antiretrovirals, 44.2% of the patients were treated with an incorrect statin intensity.

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Low statin use in nondialysis-dependent chronic kidney disease in the absence of clinical atherosclerotic cardiovascular disease or diabetes

Clinical Kidney Journal ◽

10.1093/ckj/sfy131 ◽

2019 ◽

Vol 12 (4) ◽

pp. 530-537

Author(s):

Talar W Markossian ◽

Holly J Kramer ◽

Nicholas J Burge ◽

Ivan V Pacold ◽

David J Leehey ◽

...

Keyword(s):

Cardiovascular Disease ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Atherosclerotic Cardiovascular Disease ◽

Risk Equation ◽

Diabetes Status ◽

Increased Risk ◽

Ascvd Risk ◽

Risk Equivalent ◽

Statin Use

Abstract Background Both reduced glomerular filtration rate and increased urine albumin excretion, markers of chronic kidney disease (CKD), are associated with increased risk of atherosclerotic cardiovascular disease (ASCVD). However, CKD is not recognized as an ASCVD risk equivalent by most lipid guidelines. Statin medications, especially when combined with ezetimibe, significantly reduce ASCVD risk in patients with nondialysis-dependent CKD. Unless physicians recognize the heightened ASCVD risk in this population, statins may not be prescribed in the absence of clinical cardiovascular disease or diabetes, a recognized ASCVD risk equivalent. We examined statin use in adults with nondialysis-dependent CKD and examined whether the use differed in the presence of clinical ASCVD and diabetes. Methods This study ascertained statin use from pharmacy dispensing records during fiscal years 2012 and 2013 from the US Department of Veterans Affairs Healthcare System. The study included 581 344 veterans aged ≥50 years with nondialysis-dependent CKD Stages 3–5 with no history of kidney transplantation or dialysis. The 10-year predicted ASCVD risk was calculated with the pooled risk equation. Results Of veterans with CKD, 62.1% used statins in 2012 and 55.4% used statins continuously over 2 years (2012–13). Statin use in 2012 was 76.2 and 75.5% among veterans with CKD and ASCVD or diabetes, respectively, but in the absence of ASCVD, diabetes or a diagnosis of hyperlipidemia, statin use was 21.8% (P < 0.001). The 10-year predicted ASCVD risk was ≥7.5% in 95.1% of veterans with CKD, regardless of diabetes status. Conclusions Statin use is low in veterans with nondialysis-dependent CKD in the absence of ASCVD or diabetes despite high-predicted ASCVD risk. Future studies should examine other populations.

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New Approaches for the Prevention and Treatment of Cardiovascular Disease: Focus on Lipoproteins and Inflammation

Annual Review of Medicine ◽

10.1146/annurev-med-100119-013612 ◽

2020 ◽

Vol 72 (1) ◽

Author(s):

Aliza Hussain ◽

Christie M. Ballantyne

Keyword(s):

Cardiovascular Disease ◽

Statin Therapy ◽

Low Density Lipoprotein ◽

Density Lipoprotein ◽

Annual Review ◽

Publication Date ◽

Atherosclerotic Cardiovascular Disease ◽

Substantial Progress ◽

Ascvd Risk ◽

Made In

Although numerous trials have convincingly shown benefits of statin therapy in both primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD), most showed relative risk reductions of 25–40%, and thus many individuals continue to have ASCVD events despite statin therapy. Substantial progress has been made in developing therapies that address the residual risk for ASCVD despite statin therapy. In this review, we summarize progress of currently available therapies along with therapies under development that further reduce low-density lipoprotein cholesterol and apolipoprotein B–containing lipoproteins, reduce lipoprotein(a), reduce ASCVD events in patients with high triglycerides, and directly target inflammation to reduce ASCVD risk. Expected final online publication date for the Annual Review of Medicine, Volume 72 is January 27, 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

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Atherosclerotic Cardiovascular Disease Risk Profile of Tenofovir Alafenamide Versus Tenofovir Disoproxil Fumarate

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz472 ◽

2019 ◽

Vol 7 (1) ◽

Author(s):

Gregory D Huhn ◽

David J Shamblaw ◽

Jean-Guy Baril ◽

Priscilla Y Hsue ◽

Brittany L Mills ◽

...

Keyword(s):

Cardiovascular Disease ◽

Total Cholesterol ◽

Statin Therapy ◽

Tenofovir Disoproxil Fumarate ◽

Density Lipoprotein ◽

Hiv Care ◽

Atherosclerotic Cardiovascular Disease ◽

Ascvd Risk ◽

Tenofovir Alafenamide ◽

The Impact

Abstract Background In human immunodeficiency virus (HIV) treatment, tenofovir alafenamide (TAF) is associated with greater increases in all fasting cholesterol subgroups compared with tenofovir disoproxil fumarate (TDF). Because lipid abnormalities may contribute to cardiovascular morbidity and mortality, cardiovascular risk assessment is integral to routine HIV care. This post hoc study evaluates the impact of lipid changes on predicted atherosclerotic cardiovascular disease (ASCVD) risk and statin eligibility in treatment-naive adults living with HIV treated with TAF or TDF. Methods Participants (N = 1744) were randomized (1:1) to initiate TAF or TDF, each coformulated with elvitegravir/cobicistat/emtricitabine (studies GS-US-292-0104 and GS-US-292-0111). Eligibility for statin therapy and estimated 10-year ASCVD risk among adults aged 40–79 years treated with TAF or TDF for 96 weeks (W96) were analyzed based on American College of Cardiology/American Heart Association Pooled Cohort Equations. Categorical shifts in 10-year ASCVD risk from <7.5% to ≥7.5% by W96 on TAF versus TDF were calculated. Results Participants initiating TAF versus TDF in the overall study population showed small but significant increases in median fasting lipid parameters at W96, including total cholesterol (191 vs 177 mg/dL; P < .001), low-density lipoprotein ([LDL] 119 vs 112 mg/dL; P < .001), and high-density lipoprotein ([HDL] 51 vs 48 mg/dL; P < .001), respectively. At baseline, 18% and 23% on TAF versus TDF had a 10-year ASCVD risk score ≥7.5%, with mean risk scores low overall for TAF versus TDF at baseline (4.9% vs 5.4%; P = .35) and W96 (6.1% vs 6.2%; P = .04). Increases in ASCVD risk from baseline to W96 were driven by both increasing age and changes in total cholesterol (TC) and HDL cholesterol. At W96, TC/HDL ratios (median) were 3.7 for both groups (P = .69). There was no difference between shifts in categorical risk for TAF versus TDF (9% vs 5%; P = .19). Eligibility for high-intensity statin therapy were similar for TAF versus TDF groups (19% vs 21%; P = .47). Conclusions Lipid changes with TAF as part of coformulated regimens do not substantively affect CVD risk profiles compared with TDF.

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Optimisation of lipids for prevention of cardiovascular disease in a primary care

BMJ Open Quality ◽

10.1136/bmjoq-2017-000071 ◽

2018 ◽

Vol 7 (3) ◽

pp. e000071

Author(s):

Smita Bakhai ◽

Aishwarya Bhardwaj ◽

Parteet Sandhu ◽

Jessica L. Reynolds

Keyword(s):

Cardiovascular Disease ◽

Electronic Health Records ◽

Lipid Profile ◽

Statin Therapy ◽

Risk Score ◽

Completion Rate ◽

Atherosclerotic Cardiovascular Disease ◽

Health Records ◽

Ascvd Risk ◽

Electronic Health

The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines focus on atherosclerotic cardiovascular disease (ASCVD) risk reduction, using a Pooled Cohort Equation to calculate a patient’s 10-year risk score, which is used to guide initiation of statin therapy. We identified a gap of evidence-based treatment for hyperlipidaemia in the Internal Medicine Clinic. Therefore, the aim of this study was to increase calculation of ASCVD risk scores in patients between the ages of 40 and 75 years from a baseline rate of less than 1% to 10%, within 12 months, for primary prevention of ASCVD. Root cause analysis was performed to identify materials/methods, provider and patient-related barriers. Plan-Do-Study-Act cycles included: (1) creation of customised workflow in electronic health records for documentation of calculated ASCVD risk score; (2) physician education regarding guidelines and electronic health record workflow; (3) refresher training for residents and a chart alert and (4) patient education and physician reminders. The outcome measures were ASCVD risk score completion rate and percentage of new prescriptions for statin therapy. Process measures included lipid profile order and completion rates. Increase in patient wait time, and blood test and medications costs were the balanced measures. We used weekly statistical process control charts for data analysis. The average ASCVD risk completion rate was 14.2%. The mean ASCVD risk completion rate was 4.0%. In eligible patients, the average lipid profile completion rate was 18%. ASCVD risk score completion rate was 33% 1-year postproject period. A team-based approach led to a sustainable increase in ASCVD risk score completion rate. Lack of automation in ASCVD risk score calculation and physician prompts in electronic health records were identified as major barriers. Furthermore, the team identified multiple barriers to lipid blood tests and treatment of increased ASCVD risk based on ACC/AHA guidelines.

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Factors Associated with Disparities in Appropriate Statin Therapy in an Outpatient Inner City Population

10.1101/2020.08.14.20174185 ◽

2020 ◽

Author(s):

Giselle Alexandra Suero Abreu ◽

Aris Karatasakis ◽

Sana Rashid ◽

Maciej Tysarowski ◽

Analise Y Douglas ◽

...

Keyword(s):

Statin Therapy ◽

Statin Treatment ◽

Blood Cholesterol ◽

Lipid Lowering ◽

Atherosclerotic Cardiovascular Disease ◽

Care Clinic ◽

Black Race ◽

Black Patients ◽

Hispanic Patients ◽

Ascvd Risk

Introduction: Appropriate lipid-lowering therapies are essential for the primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). The aim of this study is to identify discrepancies between cholesterol management guidelines and current practice in an underserved population, with a focus on statin treatment. Methods: We reviewed the records of 1,042 consecutive patients seen between August 2018 and August 2019 in an outpatient academic primary care clinic. Eligibility for statin and other lipid-lowering therapies was determined based on the 2018 American Heart Association and American College of Cardiology (AHA/ACC) guideline on the management of blood cholesterol. Results: Among 464 statin-eligible patients, age was 61.1 +/- 10.4 years and 53.9% were female. Most patients were Black (47.2%), followed by Hispanic (45.7%), and White (5.0%). Overall, 82.1% of patients were prescribed a statin. Statin-eligible patients who qualified based only on a 10-year ASCVD risk > 7.5% were less likely to be prescribed a statin (32.8%, p<0.001). After adjustment for gender and health insurance status, appropriate statin treatment was independently associated with age > 55 years (OR = 4.59 [95% CI 1.09 - 16.66], p = 0.026), hypertension (OR = 2.38 [95% CI 1.29 - 4.38], p = 0.005) and chronic kidney disease (OR = 3.95 [95% CI 1.42 - 14.30], p = 0.017). Factors independently associated with statin undertreatment were Black race (OR = 0.42 [95% CI 0.23 - 0.77], p = 0.005), and statin-eligibility based solely on an elevated 10-year ASCVD risk (OR = 0.14 [95% CI 0.07 - 0.25], p < 0.001). Hispanic patients were more likely to be on appropriate statin therapy when compared to Black patients (86.8% vs 77.2%). Conclusion: Statin underprescription is seen in approximately one out of five eligible patients, and is independently associated with Black race, younger age, fewer comorbidities, and eligibility via 10-year ASCVD risk only. Hispanic patients are more likely to be on appropriate statin therapy compared to Black patients.

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338. Patients Living with HIV Infection Are Less Likely to Receive the Correct Intensity of Statin Therapy for Cardiovascular Disease Risk Reduction

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.411 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S179-S180

Author(s):

Jason J Schafer ◽

Roshni Patel ◽

Nicholas V Hastain ◽

Todd Miano

Keyword(s):

Cardiovascular Disease ◽

Statin Therapy ◽

Risk Reduction ◽

Univariate Analysis ◽

Blood Cholesterol ◽

Atherosclerotic Cardiovascular Disease ◽

Lipid Panel ◽

Ascvd Risk ◽

Living With Hiv ◽

To Receive

Abstract Background Patients living with HIV (PLWH) at risk for atherosclerotic cardiovascular disease (ASCVD) should receive risk reduction interventions recommended in current guidelines. This includes routine ASCVD risk assessments and when eligible, statins selected and dosed to achieve appropriate low-density lipoprotein cholesterol (LDL-C) reduction. Recent studies suggest that statins are underprescribed in PLWH, but none have assessed if eligible patients receive the correct statin intensity compared with uninfected controls. Methods This retrospective study evaluated statin eligibility and prescribing among consecutive patients in an HIV clinic and an internal medicine clinic at an urban, academic medical center from June-September 2018. To determine statin eligibility, the 2013 American College of Cardiology/American Heart Association guideline on treating blood cholesterol to reduce ASCVD risk was used. Patients aged 40–75 that had a lipid panel obtained within the last year were included. All patients were assessed to determine eligibility for and actual treatment with appropriate statin therapy. Characteristics of patients correctly and incorrectly treated with statins were compared with chi-square testing and predictors for receiving correct statin therapy were determined with logistic multivariable regression. Results A total of 221/300 study subjects were statin eligible (Table 1). While many eligible PLWH were receiving a statin (54/106), considerably fewer were on the correct statin intensity for their benefit group (33/106). In the univariate analysis (Table 2), correctly treated patients were less likely to be PLWH or female, and were more likely to have polypharmacy and hypertension. In the multivariable logistic regression analysis (Table 3), PLWH (OR 0.26, CI95 0.12–0.57)) were significantly less likely to receive correct statin therapy, while those with concomitant polypharmacy were significantly more likely to receive correct statin therapy (OR 5.52, CI95 1.94, 15.69). Conclusion This study reveals that PLWH may be at a substantial disadvantage in terms of receiving correct statin therapy for ASCVD risk reduction. This finding may be particularly important given the heightened risk for ASCVD in this patient population. Disclosures All authors: No reported disclosures.

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Abstract 17321: Guideline Recommended Statin Therapy Implementation and Cardiovascular Outcomes: Insights From a Multi-Site Healthcare Primary Prevention Cohort

Circulation ◽

10.1161/circ.142.suppl_3.17321 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Anum Saeed ◽

Jianhui Zhu ◽

Floyd W Thoma ◽

Oscar C MARROQUIN ◽

Aryan Aiyer ◽

...

Keyword(s):

Primary Prevention ◽

High Risk ◽

Statin Therapy ◽

Healthcare System ◽

Risk Groups ◽

Prescription Practices ◽

Ascvd Risk ◽

Mean Time ◽

Risk Categories ◽

Statin Use

Background: The 2013 and 2018 ACC/AHA cholesterol guidelines recommend using the 10-year ASCVD risk to guide statin therapy for primary prevention. Evidence of real-world consequences of non-adherence to these guidelines in primary prevention cohorts is limited. We investigated outcomes based on statin use in a large healthcare system, stratified by 10y ASCVD risk. Methods: Statin prescription practices in patients without CAD or ischemic stroke were evaluated ( 2013-2019). Patient categories constructed per the ASCVD risk were; Borderline (5%-7.4%), Intermediate (7.5%-19.9%) or High (≥20%). Guideline-directed statin intensity (GDSI) , at time of first event, was defined as; “none or any intensity” for borderline , “at least moderate” for Intermediate and high -risk groups. Mean (±SD) time to start/change to GD therapy from first interaction in healthcare, ASCVD incident rates [IR] and mortality were calculated across risk categories stratified by statin utilization. Results: Among 282,298 patients (mean age ~50y), 29,134 (10.3%), 63,299 (22.4%) and 26,687 (9.5%) were borderline, intermediate and high risk, respectively. Within intermediate-risk, 27,358 (43%) and 8,300 (31%) of high-risk never received any statin. Only 17,519 (65.6%) high-risk subjects who were prescribed statin, received GDSI [mean time ~1.8y]. A graded increase in ASCVD and mortality IRs was seen in all risk categories comparing statin versus no statin use (Table). Conclusions: In a multi-site healthcare network, over one-third of statin-eligible patients were not prescribed statin therapy. In eligible patients, who ultimately received statins, mean time to GDSI was ~2yrs. The consequences of non-adherence to guidelines is illustrated with greater incident ASCVD events and mortality among those patients not treated with statin therapy. Further research can define identify barriers and develop healthcare system strategies to optimize preventive therapies.

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Abstract 16936: Implications of the 2013 ACC/AHA Cholesterol Guidelines for Adults in Contemporary Cardiovascular Practice: Insights from the NCDR® PINNACLE Registry®

Circulation ◽

10.1161/circ.130.suppl_2.16936 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Thomas Maddox ◽

William Borden ◽

Fengming Tang ◽

Salim Virani ◽

William Oetgen ◽

...

Keyword(s):

Statin Therapy ◽

Current Practice ◽

Risk Group ◽

National Registry ◽

Lipid Lowering ◽

Fixed Dose ◽

Atherosclerotic Cardiovascular Disease ◽

Ascvd Risk ◽

Cholesterol Guidelines ◽

Testing Patterns

Background: In a significant update, the 2013 ACC/AHA cholesterol guidelines recommend fixed-dose statin therapy for those at risk and do not recommend non-statin therapies or treatment to target LDL-C levels, limiting the need for repeated LDL-C testing. We examined the implications of these updated guidelines on current lipid treatment and testing patterns in a national registry of cardiology practices. Methods: Using NCDR® PINNACLE Registry® data from 2008 to 2012, we assessed current practice patterns as a function of the 2013 cholesterol guidelines. Lipid-lowering therapies and LDL-C testing patterns by patient risk group (atherosclerotic cardiovascular disease (ASCVD), diabetes, off-treatment LDL-C ≥190mg/dL, or an estimated 10-year ASCVD risk ≥7.5%) were described. Results: Among a cohort of 1,174,545 patients, 1,129,205 (96.1%) were statin-eligible (91.2% ASCVD, 6.6% diabetes, 0.3% off-treatment LDL-C ≥190mg/dL, 1.9% estimated 10-year ASCVD risk ≥7.5%). 377,311 (32.4%) patients were not receiving statin therapy and 259,143 (22.6%) were receiving non-statin therapies. 20.8% patients had 2 or more LDL-C assessments during the study period, and 7.0% had more than 4 assessments. Conclusions: In U.S. cardiovascular practices, 32.4% of statin-eligible patients, as defined by the 2013 ACC/AHA cholesterol guidelines, were not currently receiving them. In addition, 22.6% were receiving non-statin lipid-lowering therapies and 20.8% had repeated LDL-C testing. Achieving concordance with the new cholesterol guidelines would result in significant increases in statin use, as well as significant reductions in non-statin therapies and laboratory testing.

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