Article Figures & Data
Tables
- Table 1.
Key Recommendations from the 2013 American College of Cardiology/American Heart Association Guideline on Cholesterol Treatment
Risk Strata Clinical Characteristics Recommended Statin Intensity Highest risk CVD with age ≤ 75 years High CVD with age > 75 years Moderate Moderate risk LDL ≥ 190 High Diabetes mellitus, age 40-75 years and estimated 10-year CVD risk ≥ 7.5% High Estimated 10-year CVD risk ≥ 10% and age 40 to 75 years Moderate or high Lower risk Diabetes mellitus, age 40 to 75 years and estimated 10-year CVD risk < 7.5% Moderate Estimated 10-year CVD risk 7.5% to 10% and age 40 to 75 years Moderate or high CVD, cardiovascular disease; LDL, low-density lipoprotein.
- Table 2.
Characteristics of Patients Included in Study to Examine Uptake of AHA/ACC Cholesterol Treatment Guidelines (n = 223,289)
Characteristics n (%) Gender Male 9,9569 (44.6%) Female 12,3707 (55.4%) Ethnicity Hispanic 1,1354 (5.8%) Non-Hispanic 18,4724 (94.2%) Race Asian 1,6613 (8.2%) Black 2,9500 (14.5%) Other 1,4842 (7.3%) White 14,2230 (70.0%) Insurance Type Commercial 16,8692 (75.7%) Medicaid 1,2361 (5.5%) Medicare 2,8217 (12.7%) Uninsured 1,3655 (6.1%) Average age in years (SD) 53.3 (9.9) Age, years 18 to 30 473 (0.2%) 31 to 39 2580 (1.1%) 40 to 49 8,6519 (38.8%) 50 to 59 7,4710 (33.5%) 60 to 69 4,3678 (19.6%) 70 to 79 1,3475 (6.0%) ≥80 1854 (0.8%) AHA, American Heart Association; ACC, American College of Cardiology; SD, standard deviation.
- Table 3.
Uptake of Statin Use for Prevention of Cardiovascular Disease Guideline Using Electronic Health Record Patient Data from 2013-2016
Category Baseline 1 Year After 2 Years After P-Value Overall guideline uptake Overall uptake of 2013 ACC/AHA guideline 18,690 (18.5%) 20,408 (19.0%) 21,719 (20.3%) < .01 Highest-risk patients—CVD Age 40 to 75 years with CVD on high-dose statin 1435 (16.4%) 1764 (18.1%) 2227 (20.5%) < .01 Age 40 to 75 years with CVD on any statin 4592 (52.5%) 5101 (52.4%) 5757 (52.9%) .73 Moderate-risk patients—heredity hyperlipidemia or diabetes (risk ≥7.5%) or primary prevention (risk ≥ 10%) Age 40 to 75 years with LDL ≥ 190 on high-dose statin 124 (10.8%) 160 (12.7%) 158 (12.8%) .26 Age 40 to 75 years with LDL ≥ 190 on any statin 592 (51.8%) 638 (50.6%) 626 (50.9%) .85 Age 40 to 75 years with DM and ≥ 7.5% risk on high-dose statin 904 (12.2%) 1124 (13.8%) 1353 (15.1%) < .01 Age 40 to 75 years with DM and ≥ 7.5% risk on any statin 4044 (54.7%) 4513 (55.3%) 5067 (56.6%) .05 Age 40 to 75 years with > 10% risk on moderate- or high-dose statin 6046 (43.0%) 6704 (43.6%) 7541 (45.6%) < .01 Age 40 to 75 years with > 10% risk on any statin 6733 (47.9%) 7413 (48.2%) 8216 (49.6%) < .01 Lower-risk patients—diabetes or primary prevention and risk <7.5% Age 40 to 75 years with DM and < 7.5% risk on moderate- or high-dose statin 2879 (40.8%) 3323 (43.3%) 3647 (44.9%) < .01 Age 40 to 75 years with DM and < 7.5% risk on any statin 3192 (45.2%) 3664 (47.7%) 3957 (48.7%) < .01 Age 40 to 75 years with 7.5 to 10% risk on moderate- or high-dose statin 1211 (37.9%) 1315 (37.9%) 1363 (37.7%) .99 Age 40 to 75 years with 7.5 to 10% CVD risk on any statin 1325 (41.5%) 1441 (41.5%) 1504 (41.6%) .99 Patients receiving non-recommended care or potential overuse Age 40 to 75 years on non-statin medication 10,454 (10.7%) 11,282 (10.9%) 11,642 (11.3%) < .01 Age 40 to 75 years on 80-mg simvastatin* 541 (0.6%) 460 (0.4%) 455 (0.4%) < .01 Any age on a statin without an indication 1867 (7.0%) 1919 (6.6%) 1890 (6.2%) < .01 Age 40 to 75 years with lipid measurement in past 15 months 61,350 (62.8%) 66,468 (64.2%) 67,974 (65.9%) < .01 ACC, American College of Cardiology; AHA, American Heart Association; CVD, cardiovascular disease; DM, diabetes mellitus; LDL, low-density lipoprotein.
Italic value denotes statistically significant increase in guideline uptake compared with baseline and adjusted for clinician and practice (included as random effects).
Bold italic value denotes statistically significant decrease in guidelines uptake compared with baseline and adjusted for clinician and practice (included as random effects).
↵* Current FDA black box warning recommends against using simvastatin at 80-mg dosing.
- Table 4.
Associations between Patient, Clinician and Practice Characteristics, and Uptake of ACC/AHA Cholesterol Guideline [(Odds Ratio, (95% CI)] Using Electronic Health Record Patient Data from 2013 to 2016
Highest RiskAge 40 to 75 years with CVD Moderate Risk–DMAge 40 to 75 years with DM and ≥ 7.5% Risk Moderate Risk–Primary PreventionAge 40-75 years with > 10% Risk High-Dose Statin Any Statin High-Dose Statin Any Statin High-Dose Statin Any Statin Patient Factors Patient age 5-year difference 1.08 (1.04, 1.11) 1.25 (1.21, 1.28) 0.99 (0.94, 1.03) 1.10 (1.06, 1.14) 1.04 (1.00, 1.07) 1.07 (1.03, 1.10) Comorbidity index 1-unit difference 1.16 (1.13, 1.20) 1.13 (1.10, 1.16) 1.21 (1.16, 1.26) 1.08 (1.04, 1.12) 1.19 (1.15, 1.22) 1.19 (1.16, 1.23) No. of visits 1-visit difference 1.01 (0.99, 1.02) 1.03 (1.02, 1.05) 1.00 (0.98, 1.03) 1.01 (0.99, 1.02) 1.02 (1.01, 1.03) 1.02 (1.00, 1.03) Gender Female versus male 0.56 (0.50, 0.63) 0.52 (0.47, 0.58) 0.81 (0.70, 0.94) 0.94 (0.84, 1.05) 0.87 (0.81, 0.95) 0.88 (0.81, 0.96) Race Asian versus white 1.12 (0.84, 1.49) 1.36 (1.01, 1.82) 0.71 (0.53, 0.97) 0.98 (0.74, 1.30) 1.02 (0.86, 1.22) 1.12 (0.94, 1.34) Black versus white 0.97 (0.85, 1.11) 1.15 (1.02, 1.30) 0.81 (0.68, 0.96) 0.98 (0.74, 1.30) 0.91 (0.82, 1.01) 0.95 (0.86, 1.06) Other versus white 1.23 (0.92, 1.63) 0.98 (0.75, 1.29) 1.03 (0.75, 1.43) 0.91 (0.78, 1.04) 0.90 (0.75, 1.08) 0.90 (0.74, 1.08) Ethnicity Hispanic versus non-Hispanic 0.70 (0.46, 1.07) 1.17 (0.83, 1.64) 0.51 (0.30, 0.85) 1.00 (0.70, 1.43) 1.36 (1.05, 1.76) 1.41 (1.09. 1.84) Insurance type Medicaid versus commercial 0.68 (0.53, 0.88) 0.87 (0.71, 1.05) 0.67 (0.47, 0.95) 0.88 (0.70, 1.10) 0.84 (0.70, 1.01) 0.88 (0.73, 1.05) Medicare versus commercial 0.93 (0.79, 1.09) 0.95 (0.83, 1.09) 1.15 (0.94, 1.41) 0.91 (0.78, 1.06) 0.96 (0.86, 1.07) 0.98 (0.88, 1.09) Wellness visit during year No versus Yes 1.18 (1.03, 1.36) 1.20 (1.06, 1.36) 1.07 (0.89, 1.27) 1.13 (0.97, 1.31) 1.20 (1.09, 1.32) 1.21 (1.10, 1.33) Clinician factors Clinician age, years > 50 versus < 50 0.46 (0.40, 0.52) 1.18 (1.05, 1.34) 0.43 (0.36, 0.51) 0.67 (0.61, 0.74) 1.22 (1.09, 1.36) 1.16 (1.04, 1.29) Attending versus resident Attending versus resident 3.55 (1.32, 9.58) 2.51 (1.33, 3.48) 1.71 (0.70, 4.17) 2.38 (1.42, 3.99) 2.44 (1.63, 3.65) 2.45 (1.67, 3.59) Practice factors Practice type Community health centers versus univ. affiliate <0.10 (<0.10, <0.10) 0.15 (0.13, 0.17) <0.10 (<0.10, <0.10) 0.28 (0.25, 0.31) 0.25 (0.22, 0.27) 0.26 (0.24, 0.28) Private versus univ. affiliate 0.29 (0.26, 0.32) 0.32 (0.29, 0.34) 0.24 (0.21, 0.28) 0.34 (0.31, 0.36) 0.44 (0.41, 0.46) 0.42 (0.39, 0.44) Practice location Rural versus urban 0.20 (0.15, 0.26) 0.45 (0.40, 0.51) 0.15 (0.10, 0.22) 0.55 (0.49, 0.63) 0.61 (0.55, 0.68) 0.63 (0.57, 0.70) Suburban versus urban 0.41 (0.37, 0.46) 0.43 (0.40, 0.46) 0.34 (0.30, 0.39) 0.42 (0.39, 0.45) 0.60 (0.56, 0.64) 0.58 (0.54, 0.61) Year obtained EHR 1-year difference 1.15 (1.13, 1.17) 1.16 (1.15, 1.17) 1.17 (1.14, 1.19) 1.14 (1.1, 1.15) 1.08 (1.07, 1.09) 1.09 (1.08, 1.10) Year obtained patient portal 1-year difference 1.22 (1.20, 1.25) 1.23 (1.22, 1.25) 1.25 (1.22, 1.28) 1.22 (1.20, 1.23) 1.13 (1.12, 1.14) 1.14 (1.13, 1.16) Standing orders No versus Yes 5.20 (4.69, 5.77) 4.70 (4.40, 5.01) 5.68 (4.98, 6.48) 3.57 (3.33, 3.83) 2.67 (2.51, 2.83) 2.74 (2.59, 2.90) EHR, electronic health record; ACC, American College of Cardiology; AHA, American Heart Association; CVD, cardiovascular disease; DM, diabetes mellitus; CI, confidence interval.
Italic value denotes statistically significant increase in guideline uptake compared to baseline.
Bold italic value denotes statistically significant decrease in guideline uptake compared to baseline.
- Table 5.
Perspectives from Clinicians and Practice Leaders on Factors Affecting Guideline Implementation from Qualitative Interviews
Themes/Findings Quotations Patient factors Factors external to the clinic (ex. TV ads and experiences of friends and family) can affect patient attitudes. “Quite a few folks are leery about statins. They’ve seen ads on TV saying there are potential side effects. ‘I know my Aunt Suzi had problems and I’m not going to do that to myself.” Some patients may be initially resistant to change and need multiple visits and promptings to adjust to new guidelines. “Some people, despite all of the evidence I show them, still don’t want to do something; like starting a statin. I respect their decision. I say that’s fine. I’ll bring it up with you again in a year.” Patient education with concrete numbers and measurements helps with guideline implementation “I think having the risk calculators… having some numbers to discuss with people about what we think their risk is and how much the risk might be reduced if they took medicine, I think that’s helpful.” Clinician factors Primary care clinicians need more time to engage patients to help with reducing frequency of or ceasing testing when they are recommended. “I spent 10 minutes telling a lady who had her cholesterol checked twice this year that she didn’t need to check it a third time. You know how much more time it takes to tell somebody they don’t need a test than to tell them, oh sure, I’ll order another test. That would have taken me 5 seconds; and 10 minutes later I’m like, no you don’t need to do it a third time.” Although clinicians are frustrated with the frequency with which guidelines change, they are committed to making changes that are based on new evidence. “There seems to be no end in sight to how you can flip these numbers and come up with another guideline about stuff. It’s nice to be up to date on that kind of thing, although I find sometimes that we do end up flipping pretty quickly on things. But that’s okay. If the original thing was founded on not enough data and they got more data, then great.” Clinicians want to engage patients in shared decisions. “I’m a big believer in kind of the mutual decision; not just me telling them what to do, and realistically if they don’t believe what I’m saying they won’t do it anyway.” Practice/health system factors EHR templates are not always up to date with current guideline recommendations. “The other thing we’ll do sometimes is look at existing templates in the EMR and see if the templates are consistent with guidelines.” EHR can help facilitate care by automatically calculating CVD risks. “For me to be able to type in CVD risk and have it calculate out then 10-year risk is amazingly helpful rather than having to go on the calculator every time and enter stuff in.” Quality metrics that clinicians are held accountable to are not always up to date with current guideline recommendations. “I mean we have these quality guidelines now that kind of drive me insane. They’re helpful to a point. They kind of make me crazy too because I don’t feel like those are as up to date as we are maybe.” EHR, electronic health record; CVD, cardiovascular disease.
