Strategies for implementing lipid-lowering therapy: pharmacy-based approach

A Mistake Not to Be Repeated: What Can We Learn from the Underutilization of Statin Therapy for Efficient Dissemination of Cardioprotective Glucose Lowering Agents?

PURPOSE OF REVIEW

To review the factors contributing to underutilization of guideline-directed therapies, identify strategies to alleviate these factors, and apply these strategies for effective and timely dissemination of novel cardioprotective glucose-lowering agents.

RECENT FINDINGS

Recent analyses demonstrate underutilization of cardioprotective glucose lowering agents despite guideline recommendations for their use. Major contributors to underutilization of guideline-directed therapies include therapeutic inertia, perceptions about side effects, and factors found at the level of the clinicians, patients, and the healthcare system. The recent emergence of several novel therapies, such as sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, for use in cardiovascular disease provides a unique avenue to improve patient outcomes. To effectively utilize novel cardioprotective glucose lowering agents to improve cardiovascular outcomes, clinicians must recognize and learn from prior barriers to application of guideline-directed therapies. Further endeavors are prudent to ensure uptake of novel agents.

Implementation strategies to improve statin utilization in individuals with hypercholesterolemia: a systematic review and meta-analysis

BACKGROUND

Numerous implementation strategies to improve utilization of statins in patients with hypercholesterolemia have been utilized, with varying degrees of success. The aim of this systematic review is to determine the state of evidence of implementation strategies on the uptake of statins.

METHODS AND RESULTS

This systematic review identified and categorized implementation strategies, according to the Expert Recommendations for Implementing Change (ERIC) compilation, used in studies to improve statin use. We searched Ovid MEDLINE, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov from inception to October 2018. All included studies were reported in English and had at least one strategy to promote statin uptake that could be categorized using the ERIC compilation. Data extraction was completed independently, in duplicate, and disagreements were resolved by consensus. We extracted LDL-C (concentration and target achievement), statin prescribing, and statin adherence (percentage and target achievement). A total of 258 strategies were used across 86 trials. The median number of strategies used was 3 (SD 2.2, range 1-13). Implementation strategy descriptions often did not include key defining characteristics: temporality was reported in 59%, dose in 52%, affected outcome in 9%, and justification in 6%. Thirty-one trials reported at least 1 of the 3 outcomes of interest: significantly reduced LDL-C (standardized mean difference [SMD] - 0.17, 95% CI - 0.27 to - 0.07, p = 0.0006; odds ratio [OR] 1.33, 95% CI 1.13 to 1.58, p = 0.0008), increased rates of statin prescribing (OR 2.21, 95% CI 1.60 to 3.06, p < 0.0001), and improved statin adherence (SMD 0.13, 95% CI 0.06 to 0.19; p = 0.0002; OR 1.30, 95% CI 1.04 to 1.63, p = 0.023). The number of implementation strategies used per study positively influenced the efficacy outcomes.

CONCLUSION

Although studies demonstrated improved statin prescribing, statin adherence, and reduced LDL-C, no single strategy or group of strategies consistently improved outcomes.

TRIAL REGISTRATION

PROSPERO CRD42018114952 .

Evaluation of a multidisciplinary lipid clinic to improve the care of individuals with severe lipid conditions: a RE-AIM framework analysis

BACKGROUND

Individuals with complex dyslipidemia, or those with medication intolerance, are often difficult to manage in primary care. They require the additional attention, expertise, and adherence counseling that occurs in multidisciplinary lipid clinics (MDLCs). We conducted a program evaluation of the first year of a newly implemented MDLC utilizing the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to provide empirical data not only on program effectiveness, but also on components important to local sustainability and future generalizability.

METHODS

The purpose of the MDLC is to increase the uptake of guideline-based care for lipid conditions. Established in 2019, the MDLC provides care via a centralized clinic location within the healthcare system. Primary care providers and cardiologists were invited to refer individuals with lipid conditions. Using a pre/post-study design, we evaluated the implementation outcomes from the MDLC using the RE-AIM framework.

RESULTS

In 2019, 420 referrals were made to the MDLC (reach). Referrals were made by 19% (148) of the 796 active cardiology and primary care providers, with an average of 35 patient referrals per month in 2019 (SD 12) (adoption). The MDLC saw 83 patients in 2019 (reach). Additionally, 50% (41/82) had at least one follow-up MDLC visit, and 12% (10/82) had two or more follow-up visits in 2019 (implementation). In patients seen by the MDLC, we found an improved diagnosis of specific lipid conditions (FH (familial hypercholesterolemia), hypertriglyceridemia, and dyslipidemia), increased prescribing of evidence-based therapies, high rates of medication prior authorization approvals, and significant reductions in lipid levels by lipid condition subgroup (effectiveness). Over time, the operations team decided to transition from in-person follow-up to telehealth appointments to increase capacity and sustain the clinic (maintenance).

CONCLUSIONS

Despite limited reach and adoption of the MDLC, we found a large intervention effect that included improved diagnosis, increased prescribing of guideline-recommended treatments, and clinically significant reduction of lipid levels. Attention to factors including solutions to decrease the large burden of unseen referrals, discussion of the appropriate number and duration of visits, and sustainability of the clinic model could aid in enhancing the success of the MDLC and improving outcomes for more patients throughout the system.

Previous myocardial infarction as a risk factor for in-hospital cardiovascular outcomes (from the National Registry of Myocardial Infarction 4 and 5)

Patients with acute coronary syndromes have a substantial disease burden and are at continued risk of future cardiovascular events. In this setting, the relation between previous myocardial infarction (MI) and the risk of subsequent in-hospital adverse cardiovascular outcomes has not been definitively established. The data were analyzed from 427,778 hospitalized patients presenting with acute MI from July 2002 to December 2006, who were enrolled in the National Registry of Myocardial Infarction 4-5 study. Multivariate logistic regression models were developed to examine the association between a history of MI and in-hospital all-cause mortality, recurrent MI, and congestive heart failure/pulmonary edema. Covariate adjustments were made for demographic characteristics, co-morbidities, prearrival medications, and health status at presentation. Similarly, multivariate linear regression models were used to evaluate the length of stay. Of the 232,927 patients with acute MI included in the present study after exclusions, 24.7% reported a history of MI. In-hospital mortality was not significantly different between the patients with and without a history of MI (adjusted odds ratio 0.99, 95% confidence interval 0.95 to 1.04, p = 0.75). However, patients with a previous MI had a small increased risk of in-hospital recurrent MI (adjusted odds ratio 1.18, 95% confidence interval 1.08 to 1.29, p <0.001) and congestive heart failure/pulmonary edema (adjusted odds ratio 1.23, 95% confidence interval1.19 to 1.28, p <0.001) compared with patients with no history of MI. In conclusion, a history of MI did not significantly affect in-hospital mortality after admission for an acute MI.

Transdisciplinary approach to the follow-up of patients after myocardial infarction

OBJECTIVES

To compare conventional and transdisciplinary care in a tertiary outpatient clinic for patients after their first acute myocardial infarction.

METHODS

One hundred fifty-three patients with acute myocardial infarction were randomized at hospital discharge and followed-up to compare conventional (n=75) and transdisciplinary care (n=78). They were submitted to a clinical evaluation, received a dietary plan, and were re-evaluated twice in 60-180 days by a nurse, dietitian and physician, when new clinical and laboratory data were collected. The primary outcome was clinical improvement, as evaluated by an index including reduction of body weight, lowering of blood pressure, smoking cessation, increase in physical activity and compliance with medication.

RESULTS

The groups were similar at baseline: 63.4% were men, 89.9% had an acute myocardial infarction with ST-segment-elevation, 32.7% were diabetic, and 72.2% were hypertensive. The clinical improvement index was similar between the studied groups: in 33.3 % (transdisciplinary care) vs. 30.4 % (conventional care) of patients, the improvement was very good (P=1.000). Rates of re-hospitalization and death (p=0.127) were similar between transdisciplinary and conventional care. Compliance with diet was higher for transdisciplinary care (50.0%) vs. conventional care (26.1%) (p=0.007), as was compliance with visits (73.3 vs. 40.3%, respectively, p<0.001).

CONCLUSIONS

Compliance with diet and visits was higher for transdisciplinary care vs. conventional care; however, the transdisciplinary approach did not provide more clinical benefits than the conventional approach after patients' first acute myocardial infarction in this setting.

Lowering LDL cholesterol in adults: a prospective, community-based practice initiative

PURPOSE

The purpose of our study was to see if a clinic-wide initiative, with low-density lipoprotein cholesterol (LDL)-lowering interventions, could be an effective health maintenance strategy to decrease LDL levels to <100 mg/dL in a community-based, internal medicine outpatient setting.

METHODS

There were 1375 patients screened with an initial/baseline LDL (LDL(1)) measurement. Patients whose LDL(1) levels were >100 mg/dL were put on a lipid-lowering action plan and re-evaluated with a follow-up LDL (LDL(2)) in 3-4 months. An additional action plan was given to patients whose LDL(2) values were still too high, and their values retested in 3-4 months for a third LDL (LDL(3)). LDL(1) levels versus postintervention LDL measurement (LDL(2) or LDL(3)) levels were the primary endpoints, with secondary endpoints of total cholesterol, total triglyceride, and high-density lipoprotein cholesterol (HDL) levels over the 3 measurement periods.

RESULTS

Of 514 patients who were given action plans, 443 returned for their follow-up lipid assessment. LDL levels in this group fell from 140.7 +/- 29.2 (mean+/-1 SD) mg/dL (LDL(1)) to 110.9 (29.6) mg/dL (LDL(2)) (P <.05). Of these 443 patients, 167 individuals had LDL(2) levels that now met National Cholesterol Education Program/Third Adult Treatment Panel III guidelines (<100 mg/dL) and 87 were now considered by their primary care provider as controlled (LDL 100-130 mg/dL). However, 158 individuals had LDL(2) levels that were either not controlled or not meeting National Cholesterol Education Program/Third Adult Treatment Panel guidelines. These 158 patients were provided with a second action plan, and of these, 50 (32%) returned to the clinic for a third lipid panel. Their LDLs, as a group, subsequently fell from an LDL(2) of 139.9 (24.4) mg/dL to 112.5 (28.2) mg/dL (LDL(3)) (P <.05). Sixteen of 50 now had LDLs <100 mg/dL, and 26 of 50 were considered controlled. Initial HDL (HDL(1)) levels rose from 55.4 (17.2) mg/dL to 57.3 (14.6) mg/dL (HDL(2)) (n=443). Blood levels of triglycerides and cholesterol also decreased in our returning patients over this time period (P <.05).

CONCLUSIONS

Community-based physicians can help their patients realize significant reductions in low-density lipoprotein cholesterol levels by implementing and closely monitoring lipid-lowering initiatives for their patients, resulting in potentially large positive impacts on the long-term health and well-being of their patients.

Statin initiation following coronary artery bypass grafting: outcome of a hospital discharge protocol

STUDY OBJECTIVES

To evaluate the outcome of a hospital discharge statin drug therapy initiation protocol following coronary artery bypass graft (CABG) surgery. Our goal was to measure the percentage of patients receiving statin drugs at hospital discharge and at a post-hospital discharge assessment following the implementation of the statin drug therapy initiation protocol. We also evaluated low-density lipoprotein cholesterol (LDL-C) goal attainment (ie, < 100 mg/dL), safety monitoring, and tolerability of the statin drug.

DESIGN

Single-center, observational study with a historical control group.

SETTING

University-affiliated health system with a comprehensive heart care program that included a 14-bed cardiac surgery ICU. Approximately 400 CABG procedures are performed annually.

PATIENTS

Patients who underwent CABG surgery were eligible for inclusion in the study. The exclusion criteria were as follows: contraindications to statin therapy; refusal to take a statin drug; refusal to give informed consent; and age < 18 years.

INTERVENTION

A protocol was implemented to recommend treatment with a statin drug at hospital discharge in all post-CABG surgery patients if the presurgical LDL-C level was > 100 mg/dL or the patient was receiving a statin prior to hospital admission. The protocol also included a presurgical assessment of lipoprotein levels and hepatic function. All cardiac surgery staff were educated regarding the specifics of the protocol.

RESULTS

A total of 403 patients were included in the study. The historical control group (202 subjects) and the intervention group (201 subjects) were similar with respect to gender, age, and baseline lipoprotein levels. The follow-up assessment interval was approximately 6 months in both groups. Overall, patients were more likely to receive a statin at hospital discharge in the intervention group compared to the control group (relative risk [RR], 1.6; 95% confidence interval [CI], 1.3 to 2.0). Attainment of the goal for LDL-C level was similar between the intervention and control groups in the overall sample. Patients who were not at their LDL-C goal at baseline were more likely to have a follow-up LDL-C level of < 100 mg/dL in the intervention group (RR, 1.9; 95% CI, 1.0 to 3.5). The rate of liver function assessment was similar in the control and intervention groups. No patients in either group experienced elevations of alanine aminotransferase levels that were more than three times the upper limit of normal, and no cases of muscle toxicity were noted.

CONCLUSION

The initiation of therapy with a statin drug at hospital discharge following CABG surgery was associated with increased utilization rates. The LDL-C goal attainment improved in patients who were not at their goal prior to surgery. However, the persistence of medication use declined within 6 months. Statin therapy initiation was well-tolerated in this cohort of patients.

Impact of a cardiac risk reduction program in vulnerable patients hospitalized with coronary artery disease

STUDY OBJECTIVE

To increase the use of guideline-based pharmacotherapy in vulnerable patients (ethnic minorities and the poor) with coronary artery disease (CAD) through a nurse-based quality-improvement program.

DESIGN

Retrospective program evaluation.

SETTING

Inner-city hospital in Denver, Colorado.

PATIENTS

One hundred fifty-one consecutive patients hospitalized with a CAD-related diagnosis.

INTERVENTION

A nurse-management program was initiated for patients with angiographically documented CAD, and rates of guideline-based care were compared with rates for historic controls. The intervention consisted of two key elements: patient counseling with language-appropriate education materials and direct physician education regarding the importance of cardioprotective drugs. The 151 patients in the intervention group were compared with 125 historic control patients hospitalized before the program was begun. Multivariable logistic regression analysis was used to assess differences in care with regard to ethnicity, education level, and insurance status, and to adjust for different baseline characteristics.

MEASUREMENTS AND MAIN RESULTS

At hospital discharge, patients in the intervention group were more likely to receive statins (71% vs 52%, p=0.001) and angiotensin-converting enzyme inhibitors (79% vs 51%, p<0.001) compared with controls. These differences remained after adjusting for ethnicity, education level, insurance status, and baseline clinical characteristics. Also, a trend was noted toward greater use of aspirin (92% vs 86%, p=0.13) and beta-blockers (79% vs 73%, p=0.24) in the intervention group compared with controls. Patients in the intervention group were more likely to receive counseling for smoking cessation.

CONCLUSION

An inpatient nurse-management program improved the quality of care for patients with CAD regardless of sociodemographic status. Properly designed disease-management initiatives can be effective for disadvantaged patients, who often obtain health care through emergency and inpatient services.

Level of Awareness of on-Treatment Patients About Prescribed Statins

BACKGROUND

Statins are frequently prescribed drugs for patients with coronary heart disease according to evidence-based medicine. However, compliance with these agents has still been far from ideal, since they require long term, probably life long therapy. We conducted a survey on patients who were already on statin treatment and evaluated their level of awareness of prescribed statins.

METHODS

236 participants (117 male, 119 female), who had been on treatment with statins for at least three months, were enrolled in our study after giving informed consent. Patients were asked close-ended survey questions.

RESULTS

Only 5.5% of participants were on statin treatment for primary prevention, and 16.1% of them had a CHD equivalent, defined as those with clinical manifestations of noncoronary forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, carotid artery disease) and diabetes mellitus. Most participants (70%) stated that they had been using statins to decrease cholesterol, whereas 16.5% stated that they had no idea. More than half of the participants (58%) stated that they did not know how long they would have to keep using their statins, whereas 21% replied that they would use them continuously. One fifth of participants had some idea about side effects. Participants in whom statin therapy was started during hospitalisation for coronary angiography and/or PCI more frequently answered that statins should be used continuously (49% vs. 12% not hospitalised, p < 0.01). Also, therapy adjustment by the physician led to a better understanding of the need for continuous use (55% vs. 31% without medication change, p < 0.001), as was the case for patients with < 2 co-medications (36% vs. 17% with > 2 co-medications, p 0.002). Presence of other risk factors did not have any impact on level of awareness.

CONCLUSION

Comprehensive information at initial prescription, initiation of statins during hospitalization, dose adjustment during follow up, and as little co-medication as possible seem to increase the level of awareness of the benefits of long-term statin treatment. This might result in better compliance rates.

Effective strategies for long-term statin use

Long-term statin use achieves a significant reduction in mortality (24% to 42%) for patients with coronary artery disease (CAD) that is equal to or greater than that seen with other secondary prevention medications, including aspirin, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors. In patients with diabetes, the reduction in mortality exceeds that seen with tight glycemic control or any other treatment for diabetes. Several studies have found that almost all patients with atherosclerosis are considered candidates for statin treatment. The scientific evidence needed to revise the national guidelines has been provided by showing that initiation of statins before hospital discharge results in (1). a marked increase in long-term treatment rates, (2). improved long-term patient compliance, (3). more patients reaching levels of low-density lipoprotein (LDL) cholesterol <100 mg/dL, and (4). improved clinical outcome. Nonetheless, many studies in a variety of clinical settings have demonstrated that, regardless of the health care delivery system, an unacceptable number of patients with atherosclerosis are left untreated or undertreated with statin therapy. Applying hospital-based systems has been demonstrated to address the problems of underuse. The national guidelines now recommend that, in addition to diet and exercise counseling, lipid-lowering medications be initiated before hospital discharge for patients diagnosed with cardiovascular disease. Optimal use of statins and other cardioprotective medications in high-risk patients could save >83000 lives per year in the United States.

Provision of drug information to patients by pharmacists: the impact of the Omnibus Budget Reconciliation Act of 1990 a decade later

Drug-related illness in the United States factors substantially in health care costs, although often these illnesses and their attendant costs are preventable. One strategy for minimizing adverse drug reactions is to provide drug information to consumers in the form of prescription counseling at pharmacies. The Omnibus Budget Reconciliation Act of 1990 (OBRA 1990) contained provisions for mandating such counseling to Medicaid patients. OBRA 1990 was implemented in 1993, but most states acted quickly to extend counseling services to all patients receiving prescription drugs. We looked at the extent and quality of prescription counseling available in community pharmacies 1 decade after OBRA 1990 was written. We evaluated the counseling services afforded at large chain pharmacies, independent community pharmacies, and on-line pharmacies for a hydrochlorothiazide prescription. We found that most (69%) pharmacies offered to provide prescription counseling service, and that average counseling index scores, a measure of the quality or extent of information provided as determined by a Rasch analysis, were generally satisfactory. Our observations based on a single prescription for hydrochlorothiazide, along with other studies, suggest that there is a positive upward trend in the number of pharmacies providing prescription drug information, and that the extent of information provided suggests that the objectives of OBRA 1990 and related legislation to reduce ADRs are being fundamentally satisfied.

Treating to goal: new strategies for initiating and optimizing lipid-lowering therapy in patients with atherosclerosis

Abstract: The National Cholesterol Education Program (NCEP) guidelines prepared by the Adult Treatment Panel (ATP) provide clinicians with recommendations for the clinical management of abnormal blood cholesterol to reduce the risk of cardiovascular events. The recently updated NCEP guidelines have included a number of key amendments such as the recognition of low high-density lipoprotein cholesterol (HDL-C) as a risk factor for cardiovascular disease, while maintaining the focus of treatment on lowering low-density lipoprotein cholesterol (LDL-C) levels. Several agents can be used to modify the lipid profile in-line with the NCEP ATP-III recommendations, but hydroxymethyl glutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) remain the most effective and best-tolerated drugs for lowering LDL-C. The optimal time to initiate drug therapy had been in question, although recent studies suggest in-hospital initiation following admission with cardiovascular disease reduces the risk of recurrent events and improves long-term patient compliance. Inpatient physicians and nurses therefore play a pivotal role in influencing not only short-term management needs, but also the long-term recovery of their patients. This role should not be underestimated, as recent surveys have highlighted a significant problem of undertreatment in patients with documented atherosclerosis with regards to lipid-lowering and other cardioprotective therapy. Although reversing patient undertreatment will require clinicians to address a variety of issues, systematic in-hospital initiation of currently available lipid-lowering therapies in patients with atherosclerotic vascular disease is likely to have major benefits, reducing the occurrence of cardiovascular events and saving lives. Several statins, cholesterol absorption inhibitors, novel metabolic inhibitors, and combinations of agents are currently in clinical development and it is hoped that these will also assist clinicians in the important task of getting patients to recommended LDL-C and HDL-C levels.

Statin therapy after acute myocardial infarction: are we adequately treating high-risk patients?

After acute myocardial infarction, patients remain at high risk for recurrent cardiovascular events and mortality. Despite the compelling scientific and clinical trial evidence that lipid-lowering medications reduce mortality in patients after acute myocardial infarction, this life-saving therapy continues to be underutilized. A number of studies in a variety of clinical settings have documented that a significant proportion of patients after myocardial infarction are not receiving treatment with lipid-lowering medications when guided by conventional care. It has recently been demonstrated that implementation of a hospital-based system for initiation of statins prior to hospital discharge results in a marked increase in treatment rates, improved long-term patient compliance, more patients reaching low-density lipoprotein levels of less than 100 mg/dL, and improved clinical outcomes. Adopting in-hospital initiation of lipid-lowering medications as the standard of care for patients hospitalized with acute myocardial infarction could dramatically improve treatment rates and thus substantially reduce the risk of future coronary events and prolong life in the large number of patients hospitalized each year.

Economic impact of community pharmacist intervention in cholesterol risk management: an evaluation of the study of cardiovascular risk intervention by pharmacists

The Study of Cardiovascular Risk Intervention by Pharmacists, a randomized, controlled trial in over 50 community pharmacies in Alberta and Saskatchewan, Canada, demonstrated that a pharmacist intervention program improved cholesterol risk management in patients at high risk for cardiovascular disease. In a substudy, costs and consequences were analyzed to describe the economic impact of the program. Two perspectives were taken: a government-funded health care system and a pharmacy manager. Costs were reported in 1999 Canadian dollars. Incremental costs to a government payor and community pharmacy manager were $6.40/patient and $21.76/patient, respectively, during the 4-month follow-up period. The community pharmacy manager had an initial investment of $683.50. The change in Framingham risk function for the intervention group from baseline also was reported. The 10-year risk of cardiovascular disease decreased from 17.3% to 16.4% (p<0.0001) during the 4 months. The intervention program in this study led to a significant reduction in cardiovascular risk in the intervention group during the 4-month follow-up period. The incremental cost to provide the program appeared minimal from both government and pharmacy manager perspectives. It is hoped that these results could support negotiations for reimbursement of clinical pharmacy services with payors.