Lipid treatment goals achieved in patients treated with statin drugs in Norwegian general practice

To what extent do patients in general practice reach guideline lipid-lowering treatment goals?

BACKGROUND

We assessed the extent to which the 1998 European guideline goals were reached among patients on statin treatment.

DESIGN

A cross-sectional study.

METHODS

A total of 683 consecutive patients on statin treatment were recruited from 48 primary healthcare centres all over Sweden. Serum lipid levels and possible goal-reaching determinants were registered.

RESULTS

The treatment goal for total cholesterol was met in 55% of patients and for low-density lipoprotein cholesterol in 60% of patients. Male sex and a history of diabetes mellitus or cardiovascular disease increased the likelihood of meeting treatment goals.

CONCLUSIONS

More than half of statin-treated Swedish primary care patients reached the treatment goals.

Impact of treatment with rosuvastatin and atorvastatin on cardiovascular outcomes: evidence from the Archimedes-simulated clinical trials

Objective

No clinical trials have been conducted to directly compare the effect of the two high-intensity statins, rosuvastatin and atorvastatin, on cardiovascular outcomes. However, three such trials have been computer-simulated using the Archimedes model, an individual-based simulation of human physiology and behaviors, treatment interventions, and health care systems. The results are reviewed here.

Methods

The first simulated trial assessed clinical outcomes in patients receiving available doses of the two drugs. The second assessed the impact of initial treatment decisions, while the third assessed the effect of switching from rosuvastatin to atorvastatin.

Results

In the first simulated trial, treatment with rosuvastatin was estimated to result in greater reductions than treatment with atorvastatin in major adverse cardiac event (MACE) rates at 5 years and 20 years at all doses examined (relative risk [RR]: 0.897, 0.888, and 0.930 at 5 years for rosuvastatin 20 mg vs atorvastatin 40 mg, rosuvastatin 40 mg vs atorvastatin 80 mg, and rosuvastatin 20 mg vs atorvastatin 80 mg, respectively; all P<0.05). In the second simulated trial, outcomes were significantly better in patients initially prescribed rosuvastatin than in those initially prescribed atorvastatin (RR of MACE at 5 years: 0.918; P<0.001). In the third simulated trial, risk of MACE was significantly greater in patients switching from rosuvastatin to atorvastatin than in those remaining on rosuvastatin (RR at 5 years: 1.109; P<0.001).

Conclusion

The results of these simulated clinical trials suggest improved outcomes among patients receiving rosuvastatin relative to patients receiving atorvastatin in various clinical settings.

Genetic and immunologic susceptibility to statin-related myopathy

Statin-related myopathy (SRM) undermines drug adherence that is critical for achieving the benefits of lipid-lowering therapy. While the exact mechanism of SRM remains largely unknown, recent evidence supports specific genetic and immunologic influence on the development of intolerance. Genes of interest include those involved in the pharmacokinetics of statin response (i.e. drug metabolism, uptake transporters, and efflux transporters), pharmacodynamics (i.e. drug toxicity and immune-mediated myopathy), and gene expression. We examine the influence of genetic and immunologic variation on the pharmacokinetics, pharmacodynamics, and gene expression of SRM.

Lipid attainment among patients newly treated with lipid-altering drugs

OBJECTIVE

Guidelines for preventing and treating patients with coronary artery disease have traditionally focused on reducing low-density lipoprotein cholesterol (LDL-C). Current treatments are effective; however, previous studies have identified a significant proportion of patients that are not achieving the recommended lipid levels. New guidelines were introduced November 2013. The objective of this study was to examine recent practice patterns and factors related to initiating treatment for hypercholesterolemia, which provides a comparative baseline to the introduction of new guidelines.

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort analysis utilizing laboratory results of lipid profiles and medical claims from January 2007 to September 2011 to identify patients with elevated LDL-C and diagnoses of hypercholesterolemia without prior pharmacotherapy. Pharmacotherapy dispensed, treatment modifications, LDL-C-goal attainment, and potential drug intolerance were evaluated.

RESULTS

Overall, among newly treated patients, 70.9% achieved the recommended LDL-C level within the first year of treatment; however, only 19.4% of those with coronary heart disease (CHD) or CHD risk equivalents achieved the more aggressive LDL-C goal of <70 mg/dL (1.8 mmol/L). LDL-C goals were generally achieved with the use of statins; however, a majority of patients underwent treatment modification(s) (e.g., discontinuation or restart). More than half of the patients diagnosed with elevated LDL-C did not initiate pharmacotherapy.

LIMITATIONS

Data was unavailable for inpatient hospitalizations, family history of cardiovascular diseases, body weight, and height, and likely under-reporting of smoking within claims data.

CONCLUSIONS

Newly treated patients with elevated LDL-C results generally achieved the recommended and risk-specific LDL-C goal with the use of lipid-altering drugs; however, there still exists a notable population of patients with CHD or CHD risk equivalents who were not treated to goal and a significant number of patients who do not receive lipid-lowering pharmacotherapy. New therapies and prescribing practices are warranted to adequately address these two patient populations.

Achieving optimal lipid goals in patients with coronary artery disease

Guidelines for lipid-lowering therapy recommend intensive low-density lipoprotein (LDL) cholesterol lowering for patients with coronary artery disease. Previous studies have found that many high-risk patients are not achieving their LDL cholesterol goals, and many patients, despite being treated with lipid-lowering therapy, also have elevated triglycerides or low levels of high-density lipoprotein (HDL) cholesterol. To evaluate lipid goals in a "real world" clinical setting, the electronic medical records of 10,040 patients with coronary artery disease from a large cardiology subspecialty practice from September 2008 to September 2009 were reviewed. Overall, 79% of patients achieved an LDL cholesterol goal of <100 mg/dl, while only 35% achieved the more aggressive goal of <70 mg/dl. Non-HDL cholesterol goals of <130 and <100 mg/dl were achieved in 79% and 44% of patients, respectively. Only 69% achieved normal triglyceride levels, and only 63% of men and 56% of women achieved normal levels of HDL cholesterol. Women and younger men were less likely to achieve their lipid goals. In conclusion, most patients with coronary artery disease achieve the minimal LDL cholesterol goal of 100 mg/dl, but few achieve the more aggressive goals of <70 mg/dl. Many high-risk patients have elevated levels of triglycerides or low levels of HDL cholesterol despite treatment. Combination lipid-lowering therapy is used infrequently in practice. There exists a significant opportunity for physicians to more aggressively treat lipids to achieve the levels recommended by clinical guidelines.

Prevalence of dyslipidemia in statin-treated patients in Canada: results of the DYSlipidemia International Study (DYSIS)

BACKGROUND

Despite clear guideline recommendations, there is a growing body of evidence that there is suboptimal use of lipid-lowering treatment in Canadians.

OBJECTIVE

To assess the prevalence and types of persistent lipid abnormalities in Canadian patients receiving statin therapy.

METHODS

The present cross-sectional study recruited 2436 outpatients 45 years of age or older who were treated with statins by 232 physicians from 10 provinces; all underwent clinical examination and had their latest fasting lipid values while on statin therapy recorded.

RESULTS

The median patient age was 66 years (interquartile range [IQR] 58 to 74 years), 60% were men and 80% were in the high 10-year risk category. The median low-density lipoprotein cholesterol level was 2.0 mmol/L (IQR 1.6 mmol/L to 2.5 mmol/L) and the median total cholesterol/high-density lipoprotein cholesterol ratio was 3.4 mmol/L (IQR 2.8 mmol/L to 4.1 mmol/L). However, based on the 2006 Canadian Cardiovascular Society recommendations, 37% of all patients did not have a low-density lipoprotein cholesterol level at goal or intervention target level, including 45% of high-risk category patients. The majority of patients received atorvastatin (50%) or rosuvastatin (37%) but primarily at low-to-medium doses, and a minority (14%) received additional lipid-modifying therapies.

CONCLUSIONS

The present observational study highlights the need for more intensive treatment of lipid abnormalities, particularly among high-risk patients. Recognizing several important limitations related to the observational nature of the study, the findings suggest the possibility that, in addition to optimizing adherence, there remains an important need to titrate current statin therapy to higher doses and potentially use a combination of lipid-modifying treatments (once the statin dose has been truly maximized) to further bridge the gap between evidence-based medicine and current Canadian practice.

Lipid lowering treatment patterns and goal attainment in Nordic patients with hyperlipidemia

OBJECTIVES

Observational studies and surveys have shown that lipid-lowering treatment is not optimal neither with regard to number of patients treated nor with number of patients achieving recommended goals. To address this issue in the Nordic countries, we evaluated the published literature on lipid-lowering therapies in preventive cardiology in this region.

DESIGN

Nordic papers published from 2000 throughout 2006 dealing with lipid-lowering management in coronary heart disease prevention were identified. In total, 19 studies were analyzed.

RESULTS

Approximately half of the patients are inadequately treated and have not achieved recommended treatment goals of total cholesterol <5.0 and LDL-cholesterol <3.0 mmol/L. Statins were prescribed most often in low or medium doses. The predictive factors for treatment were cholesterol level, risk of cardiovascular disease, previous cardiovascular disease, age, and gender.

CONCLUSIONS

There is a considerable need to improve standards of preventive cardiology. Statins have to be given evidence based to achieve treatment goals according to lipid levels, and higher doses of statins or combination therapy with a statin and a cholesterol absorption inhibitor or niacin is often needed.

Trends in total cholesterol screening and in prescribing lipid-lowering drugs in general practice in the period 1994-2003

BACKGROUND

General Practitioners (GPs) play a central role in controlling an important risk factor for cardiovascular diseases, i.e. cholesterol levels in serum. In the past few decades different studies have been published on the effect of treating hyperlipidemia with statins. Guidelines for treatment have been adopted. We investigated the consequences on the practice of GPs screening cholesterol levels and on the timing of starting statin prescription.

METHODS

For this descriptive study, data from the Intego database were used, composed with data from the electronic medical records (EMR) of 47 general practices in Flanders. GPs had not received special instructions for testing specific patients. For each patient the mean cholesterol level per year was calculated. A patient belonged to the group with lipid-lowering drugs if there was at least one prescription of the drug in a year in his EMR. Mixed model linear regression models were used to quantify the effect of covariates on total cholesterol values.

RESULTS

In the period 1994-2003 total cholesterol was tested in 47,254 out of 139,148 different patients. Twelve percent of those tested took lipid-lowering medication. The proportion of patients with at least one cholesterol test a year, increased over a period of ten years in all age groups, but primarily for those over the age of 65. The mean cholesterol level decreased in the treated as well as in the non-treated group. Of the patients with a cardiovascular antecedent who were on lipid-lowering drugs in 2003, 56% had a cholesterol level

CONCLUSION

The indications for testing and treating cholesterol levels broadened considerably in the period examined. In 2003 cholesterol was tested in many more patients and patients were already treated at lower cholesterol values than in previous years. Comparisons of cholesterol levels over different years should therefore be interpreted with caution as they are a reflection of changes in medical care, and not necessarily of efficacy of treatment.

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MESH Headings

• Belgium
• Cholesterol/blood
• Drug Utilization Review
• Family Practice/statistics & numerical data
• Guideline Adherence
• Humans
• Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use
• Hypolipidemic Agents/therapeutic use
• Mass Screening/trends
• Practice Patterns, Physicians'/trends

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Affiliation(s)

Stefaan Bartholomeeusen Department of General Practice, Katholieke Universiteit Leuven, Kapucijnenvoer 33, Leuven, Belgium
Jan P Vandenbroucke Clinical Epidemiology, Rijksuniversiteit Leiden, Leiden University Medical Centre, Leiden, The Netherlands
Carla Truyers Department of General Practice, Katholieke Universiteit Leuven, Kapucijnenvoer 33, Leuven, Belgium
Frank Buntinx Department of General Practice, Katholieke Universiteit Leuven, Kapucijnenvoer 33, Leuven, Belgium Research Institute Caphri, Universiteit Maastricht, The Netherlands

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Contemporary management of dyslipidemia in high-risk patients: targets still not met

PURPOSE

Our objective was to evaluate treatment patterns and the attainment of current National Cholesterol Education Program (NCEP)-recommended lipid targets in unselected high-risk ambulatory patients.

METHODS

Between December 2001 and December 2004, the prospective Vascular Protection and Guidelines Oriented Approach to Lipid Lowering Registries recruited 8056 outpatients with diabetes, established cardiovascular disease (CVD), or both, who had a complete lipid profile measured within 6 months before enrollment. The primary outcome measure was treatment success, defined as the achievement of LDL-cholesterol<2.6 mmol/L (100 mg/dL) according to NCEP guidelines. We examined patient characteristics and use of lipid-modifying therapy in relation to treatment outcome, which included the recently proposed optional LDL-cholesterol target (<1.8 mmol/L [70 mg/dL]) for very high-risk patients.

RESULTS

Overall, 78.2% of patients were treated with a statin and 51.2% had achieved the recommended LDL-cholesterol target. Treatment success rate was highest in diabetic patients with CVD (59.6%), followed by nondiabetic patients with CVD (51.8%), and lowest (44.8%) in diabetic patients without CVD (P<.0001). Compared with untreated patients, those on statins were more likely to achieve target (34.4% vs 55.9%, P<.0001). Of the patients who failed to meet target, only 9.9% were taking high-dose statin, while 29.3% were not prescribed any statin therapy. Among very high-risk patients, 20.8% attained the optional LDL-cholesterol goal. In multivariable analysis, advanced age, male sex, diabetes, coronary artery disease, coronary revascularization, and use of statin were associated with treatment success (all P<.0001).

CONCLUSION

Despite the well-established benefits of available lipid-modifying drugs, current management of dyslipidemia continues to be suboptimal, with a substantial proportion of patients failing to achieve guideline-recommended lipid targets. There remains an important opportunity to improve the quality of care for these high-risk patients.

Rational prescribing in primary care (RaPP): a cluster randomized trial of a tailored intervention

BACKGROUND

A gap exists between evidence and practice regarding the management of cardiovascular risk factors. This gap could be narrowed if systematically developed clinical practice guidelines were effectively implemented in clinical practice. We evaluated the effects of a tailored intervention to support the implementation of systematically developed guidelines for the use of antihypertensive and cholesterol-lowering drugs for the primary prevention of cardiovascular disease.

METHODS AND FINDINGS

We conducted a cluster-randomized trial comparing a tailored intervention to passive dissemination of guidelines in 146 general practices in two geographical areas in Norway. Each practice was randomized to either the tailored intervention (70 practices; 257 physicians) or control group (69 practices; 244 physicians). Patients started on medication for hypertension or hypercholesterolemia during the study period and all patients already on treatment that consulted their physician during the trial were included. A multifaceted intervention was tailored to address identified barriers to change. Key components were an educational outreach visit with audit and feedback, and computerized reminders linked to the medical record system. Pharmacists conducted the visits. Outcomes were measured for all eligible patients seen in the participating practices during 1 y before and after the intervention. The main outcomes were the proportions of (1) first-time prescriptions for hypertension where thiazides were prescribed, (2) patients assessed for cardiovascular risk before prescribing antihypertensive or cholesterol-lowering drugs, and (3) patients treated for hypertension or hypercholesterolemia for 3 mo or more who had achieved recommended treatment goals. The intervention led to an increase in adherence to guideline recommendations on choice of antihypertensive drug. Thiazides were prescribed to 17% of patients in the intervention group versus 11% in the control group (relative risk 1.94; 95% confidence interval 1.49-2.49, adjusted for baseline differences and clustering effect). Little or no differences were found for risk assessment prior to prescribing and for achievement of treatment goals.

CONCLUSIONS

Our tailored intervention had a significant impact on prescribing of antihypertensive drugs, but was ineffective in improving the quality of other aspects of managing hypertension and hypercholesterolemia in primary care.

Why do sales of lipid-lowering drugs vary between counties in Norway? Evidence from the OPPHED Health Study 2000-2001

OBJECTIVE

To study and compare plausible factors that might explain varying sales of lipid-lowering drugs (LLDs) in the two neighbouring counties of Hedmark and Oppland in Norway, with a similar age distribution, socioeconomic structure, and access to healthcare services.

DESIGN, SETTING, SUBJECTS

Cross-sectional population study comprising 10 598 attendants aged 40, 45, 60, and 75 years in the OPPHED Health Study, 2000-2001 (attendance rate 61%).

MAIN OUTCOME MEASURE

Treatment eligibility (cardiovascular morbidity and risk score), treatment frequency in treatment-eligible subgroups and treatment intensity in terms of achievement of total cholesterol (TC) goal.

RESULTS

Proportions eligible for LLD treatment in Hedmark and Oppland were similar. There was no difference in prevalence of LLD use among participants with cardiovascular disease or diabetes (secondary prevention subgroup). However, LLD use among men in the primary prevention subgroup was higher in Hedmark compared with Oppland, 6.3% and 4.1%, respectively (p < 0.05). The same tendency was seen among women. In both sexes, more LLD users in the primary prevention subgroup achieved the TC goal in Hedmark compared with Oppland (p < 0.05).

CONCLUSION AND IMPLICATIONS

The proportion of the population eligible for LLD treatment in the two counties should imply similar treatment rates in both. Higher LLD treatment frequency and intensity in the primary prevention subgroup in Hedmark are probably both contributing factors that explain the higher sales of LLDs in Hedmark compared with Oppland. Feasible intervention thresholds for primary prevention with concurrent reimbursement rules should be defined in guidelines to avoid unintentional variation in LLD use in the future.

Adherence to statin therapy and LDL cholesterol goal attainment by patients with diabetes and dyslipidemia

OBJECTIVE

The purpose of this study was to assess the relationship between adherence to statin therapy and LDL cholesterol goal achievement in patients with diabetes and dyslipidemia.

RESEARCH DESIGN AND METHODS

The records of patients being medically treated for dyslipidemia in a managed care diabetes program from January 2001 to December 2002 were used to assess LDL cholesterol goal attainment (<100 mg/dl) and to compute a 9-month medication possession ratio (percentage of days when medication was available [MPR], beginning with the first prescription in the database).

RESULTS

A total of 653 patient records was analyzed. The average MPR was significantly higher for men than for women (0.75 vs. 0.66, P < 0.05). Overall, 44% (n = 290) of the patients achieved an LDL cholesterol level <100 mg/dl (52% of men and 37% of women, P < 0.05). A significant correlation emerged between MPR and plasma LDL cholesterol (P < 0.001), and MPR was significantly higher in patients who achieved the LDL cholesterol target than in those who did not (0.82 vs. 0.61, P < 0.05).

CONCLUSIONS

Although statins are highly effective for decreasing LDL cholesterol levels in patients with dyslipidemia, including those with diabetes, failure to reach LDL cholesterol targets remains common. Adherence to statin therapy, as reflected by MPR, is closely related to LDL cholesterol goal attainment in patients with diabetes and dyslipidemia. The probability of goal achievement appears to increase substantially when the MPR is >0.80. Pharmacy records can be used to identify patients who are poorly compliant with statin therapy and at high risk for failure to attain LDL cholesterol goals. Because outcomes are directly related to patients' medication-taking behavior, when clinical goals (such as serum cholesterol levels) are not being reached, adherence should be the first item assessed by the clinician.

Achieving lipid goals in Europe: how large is the treatment gap?

Despite the established benefits of decreasing low-density lipoprotein cholesterol levels in reducing morbidity and mortality from coronary heart disease, not all patients who would benefit from lipid-lowering therapy are being managed appropriately. An in-depth review of the literature (2000-2003) demonstrates that the 'treatment gap' varies across different clinical settings. Although the use of lipid-lowering agents has increased in recent years, there continues to be a widespread failure in the achievement of recommended lipid levels. A combination of the use of the most efficacious statins, together with intervention strategies to ensure that all eligible individuals receive appropriate treatment to achieve lipid goals, are important considerations in minimizing the burden of dyslipidemia in Europe.

Whom are we treating with lipid-lowering drugs? Are we following the guidelines? Evidence from a population-based study: the Troms� study 2001

OBJECTIVE

The beneficial effect of lipid-lowering drugs (LLDs) is well documented. Despite increasing sales of LLDs, little is known about what characterizes LLD users. Our objective was to describe LLD users in a general population according to socio-demographic factors, cardiovascular risk factors and coronary heart disease (CHD), and to study the achievement of cholesterol treatment goals according to national guidelines.

METHODS

The Tromso study is a population-based study of chronic diseases, risk factors and drug use in the municipality Tromso, in north Norway. The fifth survey was conducted in 2001 and included 7,973 men and women (attendance rate 78.1%). Self-reported use of LLDs and/or proprietary LLDs was included as LLD use in the analysis.

RESULTS

LLD use was reported in 9.6% of all women and 14.0% of all men, of whom 36.5% achieved the nationally recommended lipid goal. Among individuals with CHD, 49.9% of all women and 55.4% of all men were LLD users. The individuals with a risk condition (hypertension and/or diabetes) and total cholesterol level above the target of 5.0 mmol/l and the healthy individuals with total cholesterol level >/=8.0 mmol/l constituted 47.2% of the study population without CHD. In this group, which was eligible for primary prevention, 8.0% of the women and 7.4% of the men reported LLD use.

CONCLUSIONS

Only half of all subjects with CHD were taking a LLD. The large discrepancy between national recommendations and actual LLD use in primary prevention should be addressed in future revisions of the guidelines.

Improving prescribing of antihypertensive and cholesterol-lowering drugs: a method for identifying and addressing barriers to change

BACKGROUND

We describe a simple approach we used to identify barriers and tailor an intervention to improve pharmacological management of hypertension and hypercholesterolaemia. We also report the results of a post hoc exercise and survey we carried out to evaluate our approach for identifying barriers and tailoring interventions.

METHODS

We used structured reflection, searched for other relevant trials, surveyed general practitioners and talked with physicians during pilot testing of the intervention. The post hoc exercise was carried out as focus groups of international researchers in the field of quality improvement in health care. The post hoc survey was done by telephone interviews with physicians allocated to the experimental group of a randomised trial of our multifaceted intervention.

RESULTS

A wide range of barriers was identified and several interventions were suggested through structured reflection. The survey led to some adjustments. Studying other trials and pilot testing did not lead to changes in the design of the intervention. Neither the post hoc focus groups nor the post hoc survey revealed important barriers or interventions that we had not considered or included in our tailored intervention.

CONCLUSIONS

A simple approach to identifying barriers to change appears to have been adequate and efficient. However, we do not know for certain what we would have gained by using more comprehensive methods and we do not know whether the resulting intervention would have been more effective if we had used other methods. The effectiveness of our multifaceted intervention is under evaluation in a randomised controlled trial.

Undertreatment of hypercholesterolaemia: a population-based study

AIMS

To assess the level of undertreatment of hypercholesterolaemia in the general population, taking intra-person variability in serum cholesterol concentrations into account, and to identify determinants of undertreatment of hypercholesterolaemia.

METHODS

In this cross-sectional study, data from two population-based surveys on cardiovascular disease risk factors conducted between 1987 and 1997 in the Netherlands were used. For all 64 757 respondents aged 20-59 years, treatment eligibility for lipid-lowering drug use was established according to the Dutch Cholesterol Consensus. Multivariate logistic models were used to identify determinants of undertreatment.

RESULTS

During the study period, 56.8% of the study population had undesirable cholesterol concentrations (serum total cholesterol> 5 mmol l(-1)) and 5.5% of those were eligible for pharmacological treatment based on their absolute risk of coronary heart disease. Of those eligible for pharmacological treatment, 16.3% were treated, and 19.6% of those treated had their serum total cholesterol concentration controlled. Only 3.2% of those eligible for pharmacological treatment were both treated and controlled. We identified several determinants for undertreatment, e.g. male gender and younger age for primary prevention and female gender and older age for secondary prevention. Treatment has improved slightly in more recent years.

CONCLUSIONS

Over 95% of the population eligible for the pharmacological treatment of hypercholesterolaemia was either untreated or was uncontrolled. To decrease undertreatment, identification of high-risk patients should be increased. Those who are treated with lipid-lowering medication could further benefit from more aggressive treatment, especially with statins.

Rational Prescribing in Primary Care (RaPP-trial). A randomised trial of a tailored intervention to improve prescribing of antihypertensive and cholesterol-lowering drugs in general practice [ISRCTN48751230]

BACKGROUND

The underlying reasons for differences between clinical practice and systematically developed guidelines vary from one clinical problem to another. It is therefore logical to tailor strategies to support the implementation of guidelines to address identified barriers to change. The objective of this trial is to evaluate the effects of a tailored intervention to support the implementation of systematically developed guidelines for the use of antihypertensive and cholesterol-lowering drugs for the primary prevention of cardiovascular disease.

METHODS/DESIGN

Unblinded, cluster-randomised trial. 150 general practices will be recruited from two geographical areas in Norway, and randomised to the intervention or control group (passive dissemination of guidelines). Outcomes will be measured for all eligible patients seen in the participating practices during one year after the intervention. A multifaceted intervention has been tailored to address identified barriers to change. Key components are an educational outreach visit with audit and feedback, and computerised reminders. Pharmacists will conduct the visits. During the outreach visit the main recommendations will be presented and software will be installed that links to the electronic medical record systems used in the participating practices. The software will perform an audit that will be fed back during the visit, present pop-up reminders for patients with high blood pressure or cholesterol, and provide a cardiovascular risk calculator and patient education material. The main outcomes are the proportions of 1) first time prescriptions for hypertension where thiazides are not prescribed, 2) patients not assessed for cardiovascular risk before prescribing antihypertensive or cholesterol-lowering drugs, and 3) patients treated for hypertension or high cholesterol for three months or more who have not achieved recommended treatment goals.

Time trends in lipid lowering drug use in The Netherlands. Has the backlog of candidates for treatment been eliminated?

AIMS

To assess time trends in lipid lowering drug use in The Netherlands.

METHODS

Data were obtained from the PHARMO-database, comprising pharmacy records of approximately 300 000 people in The Netherlands. In the period from 1991-98, we estimated prevalence of lipid lowering drug use on the first Wednesday of October. A patient was defined as incident user if (s)he filled a prescription for lipid lowering medication after a 360 days lipid lowering drug free interval. Both prevalence and incidence estimates were weighted for the sex and age distribution of the general Dutch population.

RESULTS

From 1991 to 1998, the prevalence of lipid lowering drug use increased from 0.5% (95% confidence interval (CI): 0.5, 0.6) to 2.3% (95% CI: 2.2, 2.4) in women and from 0.6% (95% CI: 0.6, 0.6) to 2.9% (95% CI: 2.8, 3.0) in men. Prevalence increased with increasing age and was highest in the age category 60-69 years (in 1998: 9.9% (95% CI: 9.4, 10.4) in women and 11.6% (95% CI: 11.0, 12.1) in men). In 1992, the estimated incidence of lipid lowering drug use was 251(95% CI: 226, 277)/100,000 person years in women and 251(95% CI: 225, 276)/100,000 person years in men. The largest incidence estimates were observed in 1996 (685(95% CI: 644, 726)/100,000 person years in women and 881(95% CI: 834, 928)/100,000 person years in men). After 1996, incidence stabilized in 1997 and decreased in 1998 to 599(561, 637)/100,000 person years in women and 731(688, 773)/100,000 person years in men. Most of the patients (approximately 95%) were treated with one lipid lowering agent. Statins were used by over 90% of patients from 1996 onwards. In 1998, 35% of the patients started with a statin that was not a first choice drug (mainly atorvastatin).

CONCLUSIONS

In the period from 1991-98, prevalence of lipid lowering drug use significantly increased in The Netherlands. However, incidence stabilized and decreased after 1996 which may be explained by the fact that the number of patients eligible for treatment was reached. The question remains whether lipid lowering medication was targeted to the appropriate patients.