Objectives: The 2013 ACC/AHA guidelines recommend statin therapy for all diabetic patients between the ages of 40 to 75. The intensity of statin therapy is guided by the 10-year atherosclerosis cardiovascular disease (ASCVD) risk for a given patient. A quality-improvement project was carried out in the Jacobi Medical Center (JMC) Primary Care Medicine clinic to help clinicians improve statin therapy appropriateness. Interventions included: Intense education to house staff and clinic faculty members beginning in November 2015; Establishment of a pre-visit planning system beginning in August 2016 whereby nursing staff would preview the lipid panel of diabetic patients and alert providers when the LDL was above 100 mg/dl. A retrospective study was carried out to evaluate statin therapy appropriateness before and after this quality improvement project.
Methods: Type 2 Diabetes Mellitus (T2DM) patients (age between 40-75) were selected from the JMC Medicine Clinic visits in September 2015 (baseline), May 2016 (after intense education), and September 2016 (after launching the pre-visit planning system). Exclusion criteria included: heart failure, ESRD on hemodialysis, active malignancy, and missing information for ASCVD risk calculation. In patients with LDL > 70 and with no history of CVD, the 10-year ASCVD risk was calculated and statin appropriateness was determined by comparing the actual statin prescription with the statin intensity suggested by the 2013 ACC/AHA guidelines. For patients who had an established diagnosis of CVD, statin therapy appropriateness was evaluated by whether the patients were on high-intensity statin therapy. Comparisons among groups were performed using chi-square analysis.
Results: The numbers of patients in each of the three months after the exclusions were 371, 346 and 358; among which, 68, 70 and 77 patients had existing CVD respectively. Overall, 38.8% of the patients seen in September 2015 were prescribed an appropriate statin dose; the number rose to 42.2% in May 2016, and further to 50.0% in September 2016 (p = 0.0086).
For primary prevention of CVD, 35.3% of patients received an appropriate statin dose in September 2015; this number improved to 38.5% in May 2016, after intense education; and to 44.2% in September 2016. (p = 0.089)
For secondary prevention of CVD events in patients with clinical CVD, 54.4% of the patients in September 2015 were given high-intensity statins. The high-intensity statin prescription rate was 57.1% in May 2016, and subsequently increased to 70.1% in September 2016. (p = 0.11)
Conclusions: Significant improvement in compliance with the 2013 ACC/AHA guideline-based statin dose for lipid management in the JMC Primary Care Medicine Clinic was found to be associated with the implementation of a quality-improvement project consisting of intense physician education and a pre-visit planning system.