Background: Statins are recommended for the treatment of cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD). The 2013 ACC-AHA guidelines for the management of cholesterol was the first major update in the management of cholesterol since the 2004 guideline (ATP III). The new guidelines expand the number of patients recommended to receive statin therapy compared to ATP III with the greatest increase among patients taking statins for primary prevention. Despite the prevalence of statin use, little has been published about the indications for new prescriptions and the concordance of statin prescriptions to guidelines.
Objective: To assess the concordance of new statin prescriptions in the Veterans Health Administration (VA) compared with the ATP-III (the guidelines in force in 2012) and the ACC-AHA guidelines.
Methods: Using national data, we identified every patient who had received a new statin prescription (no statin use in the prior year) in the VA in 2012. Patients were excluded if they had less than 2 primary care visits or if they had incomplete data. Data on age, risk factors, and clinical conditions were extracted. Framingham and ACC-AHA 2013 cardiovascular risk calculator scores were calculated to determine estimates of 10-year risk for ASCVD for all patients. Statin use was compared with the recommendations of ATP III and the ACC-AHA guidelines. We considered all age ranges to be concordant with the guideline.
Results: We identified 266,008 new statin prescriptions in 2012 in the VA, of which, 156,756 patients had complete data. Among statin prescriptions, 85% (133,434 of 156,756) were prescribed for primary prevention and 15% (23,322 of 156,756) were prescribed for secondary prevention. Mean age was 62 and 68 among patients receiving statins for primary and secondary prevention, respectively. The respective median Framingham risk score and ACC-AHA scores were 16 (IQR 10 to 20), and 19.26 (IQR 11to 32) among patients receiving statins for primary prevention. Among patients receiving statins for primary prevention, 23% (31,085 of 133,434) did not have an indication supported by the ATP III guidelines and 20% (26,413 of 133,434) did not have an indication supported by the ACC/AHA guideline. Within patients who received a statin for primary prevention, 9% (11,716 of 133,434) were less than 45 years old, 14% (18,210 of 133,434) were greater than 75 years old, 0.28% (373 of 133,434) were receiving dialysis, 2% (2,702 of 133,434) had evidence of terminal cancer or were receiving end of life care, and 0.06% (83 of 133,434) had evidence of severe congestive heart failure or severe chronic obstructive pulmonary disease.
Conclusions: Among veterans, the majority of statins are prescribed for primary prevention. One in 5 veterans received a statin for an indication not supported by either guideline. These findings present an opportunity to reduce inefficient care.