Adherence to Blood Cholesterol Treatment Guidelines Among Physicians Managing Patients With Atherosclerotic Cardiovascular Disease

The ACC/AHA blood cholesterol treatment guidelines recommend statin therapy for all patients after experiencing an acute cardiovascular event. Previous analyses have shown that physicians have been slow to adopt guidelines, and many patients remain untreated or undertreated with statins after a cardiovascular event. However, reasons for this remain unknown. This analysis used electronic medical records and patient chart data from Reliant Medical Group (Worcester, Massachusetts) to evaluate physician adherence to the 2013 ACC/AHA blood cholesterol guidelines when treating patients with evidence of acute atherosclerotic cardiovascular disease and the reasons for the observed treatment decisions. Less than 50% of acute atherosclerotic cardiovascular disease patients were treated according to the ACC/AHA guidelines. Nearly 42% of patients not treated according to guidelines received a lower statin intensity than recommended. The most common reason cited by 41.8% of physicians for treating with a statin intensity below the recommended intensity was low-density lipoprotein cholesterol stable or at goal, despite ACC/AHA guidelines recommending specific statin intensities rather than specific low-density lipoprotein cholesterol levels. In conclusion, physician and patient education on the importance of maximizing lipid-lowering therapy in this high-risk patient population should be emphasized. The ACC/AHA blood cholesterol treatment guidelines recommend statin therapy for all patients after experiencing an acute cardiovascular event. Previous analyses have shown that physicians have been slow to adopt guidelines, and many patients remain untreated or undertreated with statins after a cardiovascular event. However, reasons for this remain unknown. This analysis used electronic medical records and patient chart data from Reliant Medical Group (Worcester, Massachusetts) to evaluate physician adherence to the 2013 ACC/AHA blood cholesterol guidelines when treating patients with evidence of acute atherosclerotic cardiovascular disease and the reasons for the observed treatment decisions. Less than 50% of acute atherosclerotic cardiovascular disease patients were treated according to the ACC/AHA guidelines. Nearly 42% of patients not treated according to guidelines received a lower statin intensity than recommended. The most common reason cited by 41.8% of physicians for treating with a statin intensity below the recommended intensity was low-density lipoprotein cholesterol stable or at goal, despite ACC/AHA guidelines recommending specific statin intensities rather than specific low-density lipoprotein cholesterol levels. In conclusion, physician and patient education on the importance of maximizing lipid-lowering therapy in this high-risk patient population should be emphasized. The 2013 ACC/AHA guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) recommends statin therapy for all adult patients with known cardiovascular disease, regardless of low-density lipoprotein cholesterol (LDL-C) level, and the more recent 2018 ACC/AHA guidelines reconfirmed these recommendations.1Stone N.J. Robinson J.G. Lichtenstein A.H. Bairey Merz C.N. Blum C.B. Eckel R.H. Goldberg A.C. Gordon D. Levy D. Lloyd-Jones D.M. McBride P. Schwartz J.S. Shero S.T. Smith Jr, S.C. Watson K. Wilson P.W. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults.J Am Coll Cardiol. 2014; 63: 2889-2934Crossref PubMed Scopus (3075) Google Scholar, 2Grundy S.M. Stone N.J. Bailey A.L. Beam C. Birtcher K.K. Blumenthal R.S. Braun L.T. de Ferranti S. Faiella-Tommasino J. Forman D.E. Goldberg R. Heidenreich P.A. Hlatky M.A. Jones D.W. Lloyd-Jones D. Lopez-Pajares N. Ndumele C.E. Orringer C.E. Peralta C.A. Saseen J.J. Smith Jr, S.C. Sperling L. Virani S.S. Yeboah J. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.J Am Coll Cardiol. 2018; (pii: S0735-1097(18)39034-X)Crossref Scopus (849) Google Scholar Various literature have explored the impact of the 2013 ACC/AHA guidelines on US cardiovascular practices, including physician prescribing patterns,3Maddox T.M. Borden W.B. Tang F. Virani S.S. Oetgen W.J. Mullen J.B. Chan P.S. Casale P.N. Douglas P.S. Masoudi F.A. Farmer S.A. Rumsfeld J.S. Implications of the 2013 ACC/AHA cholesterol guidelines for adults in contemporary cardiovascular practice: insights from the NCDR PINNACLE registry.J Am Coll Cardiol. 2014; 64: 2183-2192Crossref PubMed Scopus (77) Google Scholar, 4Olufade T. Zhou S. Anzalone D. Kern D.M. Tunceli O. Cziraky M.J. Willey V.J. Initiation patterns of statins in the 2 years after release of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) cholesterol management guideline in a large US health plan.J Am Heart Assoc. 2017; 6e005205Crossref PubMed Scopus (18) Google Scholar, 5Okerson T. Patel J. DiMario S. Burton T. Seare J. Harrison D.J. Effect of 2013 ACC/AHA blood cholesterol guidelines on statin treatment patterns and low‐density lipoprotein cholesterol in atherosclerotic cardiovascular disease patients.J Am Heart Assoc. 2017; 6e004909Crossref PubMed Scopus (34) Google Scholar changes in patient's adherence to and initiation of statin therapy,6Bellows B.K. Olsen C.J. Voelker J. Wander C. Antihyperlipidemic medication treatment patterns and statin adherence among patients with ASCVD in a managed care plan after release of the 2013 ACC/AHA guideline on the treatment of blood cholesterol.J Manag Care Spec Pharm. 2016; 22: 892-900Crossref PubMed Scopus (26) Google Scholar, 7Huang Q. Grabner M. Sanchez R.J. Willey V.J. Cziraky M.J. Palli S.R. Power T.P. Clinical characteristics and unmet need among patients with atherosclerotic cardiovascular disease stratified by statin use.Am Health Drug Benefits. 2016; 9: 434-444PubMed Google Scholar and implications for defining treatment targets.8Gunasekaran P. Jeevanantham V. Sharma S. Thapa R. Gupta K. Implications of the 2013 ACC/AHA cholesterol guidelines on contemporary clinical practice for patients with atherosclerotic coronary and peripheral arterial disease.Indian Heart J. 2017; 69: 464-468Crossref PubMed Scopus (5) Google Scholar The majority of these analyses have concluded that a large proportion of statin-eligible patients are not receiving guideline-recommended lipid-lowering therapy after an acute cardiovascular event; however, the reasons for this deficit largely remain unknown. This study used detailed electronic medical records (EMR) and chart review data to establish a more comprehensive understanding of blood cholesterol management practices in a broad sample of patients with acute ASCVD and the reasons for high-risk patients not being treated in accordance with recent guidelines, as documented by the prescribing physician. Understanding the reasons for treatment decisions supplements findings from previous analyses on physician adherence to 2013 ACC/AHA blood cholesterol guidelines and provides a more detailed framework for promoting physician education and improving patient management. This analysis was conducted using EMR (Epic Systems, Verona, Wisconsin), administrative claims, and patient chart data from Reliant Medical Group (Worcester, Massachusetts), a multispecialty group practice with a predominantly managed care population of about 300,000 patients. Reliant Medical Group has implemented the 2013 ACC/AHA guidelines across its provider network and therefore provides a rich data source for evaluating physician adherence to the most recent blood cholesterol treatment guidelines. The retrospective analysis included data from January 1, 2013 to June 30, 2016. This study received approval from the Reliant Medical Institutional Review Board before initiation. All data were de-identified and compliant with the provisions of the Health Insurance Portability and Accountability Act of 1996. The analysis was implemented in 2 distinct phases, each with the following objectives: (1) to evaluate physician adherence to 2013 ACC/AHA blood cholesterol guidelines when treating patients with evidence of acute ASCVD in an Integrated Delivery Network; (2) to conduct a systematic chart review in patients who are not managed according to the 2013 ACC/AHA guidelines to determine the details surrounding their treatment experience. For the first study objective, patients were required to have at least 1 EMR-based encounter with a diagnosis code for an acute ASCVD event between January 1, 2014 and June 30, 2015. Acute ASCVD events included codes for acute coronary syndrome (i.e., myocardial infarction and unstable angina), stroke, or transient ischemic attack, and the first observed acute ASCVD event was flagged as the index date. Patients with coronary/peripheral revascularization or peripheral arterial disease without acute ASCVD as defined above were not included in this analysis. All patients were ≥18 years at the index date, were not pregnant anytime during the study period, and had at least 1 EMR-based encounter identified in the year before index and 1 EMR-based encounter in the year following index to ensure enrollment in the integrated delivery network pre- and postindex event (Figure 1). Patient characteristics including age, gender, select co-morbidities, and prior statin use were evaluated during the 1-year baseline period. Physician adherence to the prescribing guidelines was assessed over a 1-year time period, starting on the day after the index date. The first statin prescribed after the index event was evaluated against the 2013 ACC/AHA guidelines for secondary prevention after a clinical ASCVD event. Specifically, patients ≤75 years of age that initiated or continued therapy with a high-intensity statin after their index event and patients >75 years of age that initiated or continued treatment with a moderate- or high-intensity statin after their index event were flagged as being treated according to guideline recommendations. Given that the exact definition for low, moderate, and high intensity therapy varies by statin type, the dosage of each index treatment was evaluated in order to determine its level of intensity consistent with ACC/AHA statin intensity definitions (Table 1). Adherence to treatment guidelines was evaluated for the overall cohort, as well as by index ASCVD type.Table 1Statin intensity categoriesStatin treatment categoriesGeneric nameLow intensity statinSimvastatin 10 mgPravastatin 10–20 mgLovastatin 20 mgFluvastatin 20–40 mgPitavastatin 1 mgModerate intensity statinAtorvastatin 10–20 mgRosuvastatin 5–10 mgSimvastatin 20–40 mgPravastatin 40–80 mgLovastatin 40 mgFluvastatin XL 80 mgFluvastatin 80 mgPitavastatin 2–4 mgHigh intensity statinAtorvastatin 40–80 mgRosuvastatin 20–40 mg Open table in a new tab For the second study objective, a chart review was conducted in a random subsample of 500 patients that were not prescribed a statin after index or were prescribed a statin that did not meet the criteria detailed in the guidelines. The chart review included all available medical history and physician notes from the Reliant provider network during the 4-year study period, adding significant detail beyond what was available through the initial EMR/claims analysis. Adherence to guidelines for the index treatment, as captured by the EMR and administrative claims data, was confirmed by chart review for the random sample of patients. A team of trained medical professionals from the Reliant provider network conducted the chart review on the randomized, de-identified set of patient IDs and abstracted data on a structured chart review form. Reviewers were provided the date and type of acute ASCVD index event identified through the EMR analysis, and recorded the following information for each patient ID: clinical characteristics, including blood pressure, body mass index, smoking status, and ASCVD events before the index; family medical history; LDL-C laboratory values closet to and before the ASCVD index date; presence of a lipid lowering therapy before the ASCVD index date; confirmation of statin medication type and intensity on or within 12 months after the ASCVD index event; reason for observed statin prescription (if patient received statin) or reason for not receiving statin; and modifications to statin treatment prescription at any point after the index event. Less than half of the 4,106 ASCVD patients that met cohort selection criteria (Table 2) were treated according to the 2013 ACC/AHA guidelines. Approximately 30% of patients did not receive any statin, and approximately 30% of patients ≤75 years not treated according to guidelines were receiving a moderate intensity statin (Table 3). Physicians were most likely to adhere to guidelines when treating patients with myocardial infarction (MI) versus other forms of ASCVD (Figure 2).Table 2Baseline demographic and clinical characteristics for electronic medical records analysis (n = 4,016)VariableAverage age (standard deviation) (years)71.5 (13.8) ≤752,233 (55.6%) >751,783 (44.4%)Women1,831 (45.6%)Diabetes mellitus1,208 (30.1%)Hypertension2,731 (68.0%)Arrhythmias1,103 (27.5%)Peripheral artery disease667 (16.6%)Myocardial infarction339 (8.4%)Unstable angina pectoris55 (1.4%)Stroke679 (16.9%)Transient ischemic attack350 (8.7%)Baseline medications Antihypertensives1,993 (49.6%) Antidiabetics837 (20.8%) Antihyperlipidemics2,645 (65.9%) Statin2,563 (63.8%) Ezetimibe78 (1.9%)Source: electronic medical records data from Reliant Medical Group (Worcester, Massachusetts), January 1, 2013 to June 30, 2016. Open table in a new tab Table 3Statin therapy treatment characteristics after an acute atherosclerotic cardiovascular disease event (n = 4,016).Patient population as percentage of overall populationAdherent (as per algorithm)1,941 (48.3%) Aged ≤75 years, on high-intensity statins21.3% Aged >75 years, on high-intensity statins10.6% Aged >75 years, on moderate-intensity statins16.5%Nonadherent (as per algorithm)2,075 (51.7%) Aged ≤75 years, on moderate-intensity statins15.9% Aged ≤75 years, on low-intensity statins2.4% Aged ≤75 years, NO statins16.0% Aged >75 years, on low-intensity statins3.6% Aged >75 years, NO statins13.8%Source: electronic medical records data from Reliant Medical Group (Worcester, Massachusetts), January 1, 2013 to June 30, 2016.Adherence algorithm: patients ≤75 years of age that initiated or continued therapy with a high-intensity statin after their index event and patients >75 years of age that initiated or continued treatment with a moderate- or high-intensity statin after their index event. Open table in a new tab Source: electronic medical records data from Reliant Medical Group (Worcester, Massachusetts), January 1, 2013 to June 30, 2016. Source: electronic medical records data from Reliant Medical Group (Worcester, Massachusetts), January 1, 2013 to June 30, 2016. Adherence algorithm: patients ≤75 years of age that initiated or continued therapy with a high-intensity statin after their index event and patients >75 years of age that initiated or continued treatment with a moderate- or high-intensity statin after their index event. Of the 2,075 patients not treated according to guidelines, 500 were randomly identified for further analysis. In this sample, 72 (14.4%) patients were excluded from the analysis because they were found to be prescribed statins in accordance with guidelines after chart review. Reasons for this discrepancy primarily included instances where the receipt of statin therapy was not captured in the administrative claims data because the patient paid for the prescription using cash or obtained the prescription through a different medical system, such as the veterans affairs (VA) system. For the remaining 428 patients, the conclusion of nonadherence determined from the EMR and administrative claims data was confirmed by the chart review. Patients analyzed in the chart review were demographically similar to the nonadherent EMR sample. Full clinical and demographic data for the random chart review subsample are presented in Table 4.Table 4Baseline demographic and clinical characteristics among a subset of patients not adherent to the 2013 ACC/AHA statin treatment guidelines*Based on analysis of electronic medical record data showing patients to be non-adherent to 2013 ACC/AHA treatment guidelines. Source: Reliant Medical Group, January 1, 2013 - June 30, 2016, electronic medical record chart review among patients non-adherent to 2013 ACC/AHA treatment guidelines (n = 428)VariableAverage age (standard deviation) (years)73.95 atherosclerotic cardiovascular history prior to index event - patient have myocardial unstable angina coronary artery ischemic transient ischemic peripheral artery peripheral artery body mass index blood pressure, blood pressure, of (if Patient history prior to index event - patient have on analysis of electronic medical record data showing patients to be non-adherent to 2013 ACC/AHA treatment Reliant Medical Group, January 1, 2013 - June 30, 2016, electronic medical record chart review among patients non-adherent to 2013 ACC/AHA treatment guidelines Open table in a new tab The majority of the chart review subset were prescribed a statin within 12 months of ASCVD index; however, the treatment did not meet intensity half of patients prescribed a statin that did not meet guidelines for intensity were prescribed a moderate intensity statin, 42% were prescribed a intensity The of the chart review subset were not prescribed a statin therapy within 12 months of ASCVD index ASCVD type, the majority of patients prescribed a statin below the recommended intensity were ≤75 years of In the majority of patients that were not prescribed a statin were >75 years of age at the time of the patients who were not prescribed a statin after index, the chart review for provided specific reasons for this (Table The reasons included events before the ASCVD index date, patient LDL-C and LDL-C the exact criteria for LDL-C are defined by and across as primarily that LDL-C were and well on the prescribed level was not on most and therefore to be provider For the remaining patients prescribed a statin with a lower intensity than the chart review for provided a reason for the prescribing (Table to patients not receiving any statin the most common reasons for prescribing a lower intensity statin included LDL-C LDL-C and events before the ASCVD index date. The majority of patients prescribed a statin that did not meet intensity guidelines received the initial prescription from a care physician. A of the reasons for nonadherence in for nonadherence to 2013 ACC/AHA guidelines among a subset of on analysis of electronic medical record data showing patients to be non-adherent to 2013 ACC/AHA treatment guidelines. Source: Reliant Medical Group, January 1, 2013 to June 30, 2016, electronic medical record chart review in patients nonadherent to 2013 ACC/AHA treatment guidelines. LDL-C = low-density lipoprotein not prescribed a statin after atherosclerotic cardiovascular disease index (n = before index event patients who were not prescribed a statin following the ASCVD index date, reasons for not therapy events to events or to LDL-C cholesterol LDL-C was LDL-C at Patient Clinical reasons to cardiovascular on analysis of electronic medical record data showing patients to be non-adherent to 2013 ACC/AHA treatment Reliant Medical Group, January 1, 2013 to June 30, 2016, electronic medical record chart review in patients nonadherent to 2013 ACC/AHA treatment guidelines. LDL-C = low-density lipoprotein Open table in a new tab Table for to 2013 ACC/AHA guidelines among a subset of patients prescribed a statin of intensity than recommended by guidelines*Based on analysis of electronic medical record Source: Reliant Medical Group, January 1, 2013 to June 30, 2016, electronic medical record chart review in patients nonadherent to 2013 ACC/AHA treatment guidelines. LDL-C = low-density lipoprotein (n = before index event for not prescribing statin therapy according to 2013 ACC/AHA treatment guidelines, among patients prescribed a statin events to events or to LDL-C cholesterol LDL-C was LDL-C at Patient Patient had treatment on their Patient Clinical reasons over with other Patient care on analysis of electronic medical record Reliant Medical Group, January 1, 2013 to June 30, 2016, electronic medical record chart review in patients nonadherent to 2013 ACC/AHA treatment guidelines. LDL-C = low-density lipoprotein Open table in a new tab The majority of patients who were not prescribed statin therapy did not receive any lipid-lowering therapy during the study For that received an lipid-lowering therapy after index, most were treated with of patients received and received Of the received received and received In patients who were prescribed a statin with a lower statin intensity than recommended by treatment guidelines, had any type of treatment to their index statin prescription time to the time of this analysis, the 2018 ACC/AHA guidelines had not been as the 2013 ACC/AHA guidelines were used to evaluate prescribing the 2018 and 2013 ACC/AHA guidelines on the treatment of blood cholesterol for secondary ASCVD prevention recommends high-intensity statin therapy for patients ≤75 years of age and statin therapy for patients >75 years of age not the of this analysis are to guidelines. new for the 2018 ACC/AHA guidelines and not evaluated in this analysis the of a high-risk ASCVD cohort for of are recommended LDL-C with high or statin The from analysis findings from previous that many patients for statin therapy the ACC/AHA guidelines not receive Approximately of patients with acute ASCVD in initial sample received a statin; however, in receiving a statin, of patients ≤75 years of age and of patients >75 years of age received treatment with the guideline-recommended This of adherence to guidelines or above of statin use in managed care T. Patel J. DiMario S. Burton T. Seare J. Harrison D.J. Effect of 2013 ACC/AHA blood cholesterol guidelines on statin treatment patterns and low‐density lipoprotein cholesterol in atherosclerotic cardiovascular disease patients.J Am Heart Assoc. 2017; 6e004909Crossref PubMed Scopus (34) Google Scholar, T. B.K. Chan P.S. of the 2013 cholesterol guideline on patterns of lipid-lowering treatment in patients with atherosclerotic cardiovascular disease or after 1 Manag Care Spec Pharm. 2016; 22: PubMed Scopus (26) Google Scholar chart review analysis on previous that on physician to observed statin treatment C.J. M.J. provider with the 2013 ACC/AHA for high-intensity statins for patients with coronary artery 2017; Full Full PubMed Scopus Google Scholar, S.S. L. Chan S.A. V. Jones V. understanding of the 2013 ACC/AHA cholesterol 2016; 10 Full Full PubMed Scopus Google Scholar evaluating the reasons decisions documented in the notes of the prescribing not available through study provides information to statin prescribing findings understanding of from guidelines for statin therapy in a high-risk population and to a more detailed for practice For the high presence of reasons patient or previous patient that adherence to treatment guidelines should be more for these high-risk patients, and the need for more patient In patients prescribed a therapy that was not adherent to ACC/AHA treatment guidelines, a high proportion of physicians report stable or LDL-C as the reason for the treatment despite ACC/AHA guidelines from a set definition for recommended cholesterol levels. Patients that were as stable or did have lower LDL-C before their index event than patients with other cited reasons to however, were many with above what be for secondary prevention according to the set by previous guidelines (i.e., set by adult treatment Specifically, of patients with cited or stable cholesterol had LDL-C the time of statin impact treatment patterns for secondary ASCVD For a large proportion of patients with previous event did not receive any statin therapy after the index event. this treatment the known event that a proportion of patients from this received an lipid lowering therapy were prescribed The chart review was conducted in a random subsample of patients who were found to be nonadherent to treatment the from this analysis are not to a ASCVD In not all provided reasons for the treatment decisions observed in the EMR analysis. to that about of the patients that were flagged as a nonadherent treatment in the administrative claims data were adherent after the more data during the chart review. were to this to the EMR sample, the percentage of patients that received a therapy adherent to ACC/AHA be approximately In conclusion, this analysis found that approximately of patients with acute ASCVD in a large integrated delivery network were not prescribed a statin recommended by the 2013 ACC/AHA blood cholesterol guidelines, with of all ASCVD patients not receiving any statin A chart review conducted in a subset of patients that statin to patient LDL-C and patient was the most common reason for the observed treatment decisions. Physician and patient education on the importance of adherence to guideline-recommended lipid-lowering in this high-risk patient population should be emphasized. All have in the and have and with the of the of the are for in any other or have been in any of the has been from other in the literature in with that the to for any or from any previous and to any This was by Health and Reliant Medical Group, and was by from being of Health or Reliant Medical Group receiving from the study and have to and Harrison are of the study received from the study and in Health