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Guideline-based statin use, adherence higher with cardiologist care
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Patients with atherosclerotic cardiovascular disease who receive care by a cardiologist had higher rates of guideline-based statin use and adherence in an outpatient setting, according to data published in the American Journal of Cardiology.
Analysis of 1,249,061 Veterans Affairs patients with clinical ASCVD showed while 19.9% of patients overall were not prescribed statins for ASCVD, patients who visited a cardiologist had a 25% higher chance of a statin prescription, 21% higher chance of a high-intensity statin prescription and 9% higher odds of adherence to guideline-based statin therapy.
Cardiology Today spoke with Salim S. Virani, MD, PhD, staff cardiologist at the Michael E. DeBakey Veterans Affairs Medical Center and professor of medicine at Baylor College of Medicine, regarding the potential impact of these findings on clinical practice.
“Even after going to cardiology providers, there's a lot of room for improvement both in terms of prescription of high-intensity statin therapy in these patients, which is a class I recommendation, as well as improving statin adherence in these patients,” Virani said. “That's where I think a lot of time needs to be spent on a clinician-patient discussion: trying to explain to patients why they need to be on these medications.”
In the new retrospective study, the researchers identified more than 1.2 million VA patients (mean age, 72 years; 98% men) with ASCVD who received care in 130 facilities and community-based outpatient clinics from October 2013 to September 2014. The cohort was divided into two groups: patients with at least one outpatient cardiology visit and patients with no outpatient cardiology visits in the year prior to the index primary care visit.
Patients who visited a cardiology provider were more likely to be prescribed a statin (87.4% vs. 78.4%; OR = 1.25; 95% CI, 1.24-1.26)and higher statin adherence (62% vs. 57.3%; OR = 1.09; 95% CI, 1.09-1.11) compared with than those with no outpatient cardiology visits.
Additionally, the researchers found a dose-response relationship between higher number of cardiology visits and subsequent statin use and adherence.”
Patients with ASCVD who had outpatient cardiology visits also were more likely to receive a prescription for high-intensity statin therapy compared with those who received only primary outpatient care.
Virani told Cardiology Today the results of this study “do not mean that primary care providers are not doing their job.” Rather, he said, “primary care providers have a lot on their plate; they are the quarterbacks here, and they have multiple things that they’re trying to take care of [at once] while seeing an ASCVD patient with multiple comorbidities. It is quite possible that similar dose-response relationship exists for primary care, which we are currently looking at.”
The goal — for any physician treating patients with ASCVD — is to increase statin use and adherence, he said.
“Utilizing services of support staff such as pharmacists to review medications and educate patients about the importance of statins in clinic as well as pharmacy settings may [result] in better prescription and adherence rates in primary care,” the authors wrote. “[Further] research is needed to fully understand whether other novel communication methods such as tele-consultation with a cardiology provider are associated with similar increases in evidence-based statin use and statin adherence as those novel methods are less resource intensive and could be more scalable as opposed to increasing in-person visits with a cardiology provider.” – by Scott Buzby
Disclosures: Virani reports no relevant financial disclosures. Se the full study for the other authors’ disclosures.
Perspective
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L. Samuel Wann, MD
I agree with the authors that not every patient qualifying for guideline-directed statin use needs to see a cardiologist. Rather, we need to remove barriers between primary and specialty care and leverage modern telecommunications to emphasize team-based care, not just write a prescription and forget about it.
Perspective
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Robert S. Rosenson, MD
This work from the Veterans Administration confirms our previously published work using claims data from Medicare and MarketScan beneficiaries.
In Medicare beneficiaries hospitalized for an acute MI, adherence to high-intensity statins was improved by more interactions with health care providers, including more frequent visits to the cardiologist (Colantonio LD, et al. JAMA Cardiol. 2017;doi:10.1001/jamacardio.2017.0911 and Booth JN 3rd, et al. Circ Cardiovasc Qual Outcomes. 2017;doi:10.1161/CIRCOUTCOMES.117.003626). Similarly, in the MarketScan, a commercial insurance database, that included patients aged younger than 65 years, more frequent visits to the cardiologist improved treatment adherence to high-intensity statins and other evidence-based therapies. Further, interactions with the cardiologists resulted in higher rates of re-challenge to statin therapy in high-risk patients (Booth JN 3rd, et al. J Am Heart Assoc. 2018;doi:10.1161/JAHA.117.008462). The authors state that the "financial costs" of low rates of adherence to high-intensity statins are not known, but we published these data in 2018 (Colantonio LD, et al. Cardiovasc Drugs Ther. 2017;doi:10.1007/s10557-016-6680-3). In Medicare beneficiaries hospitalized for acute MI, health care expenditures in the year after the event were about $14,000 higher than for patients who were at least 80% adherent to high-intensity statins. Our data suggested that focused interventions to improve treatment adherence, particularly in the highest-risk patients, has the potential to reduce medical costs. In conclusion, the report from Rehman et al supports previous work in patients hospitalized for MI.
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