Julia M. Akeroyd

Is High-Intensity Statin Therapy Associated With Lower Statin Adherence Compared With Low- to Moderate-Intensity Statin Therapy? Implications of the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guidelines

The recent cholesterol guideline recommends high‐intensity statins in cardiovascular disease (CVD) patients. High‐intensity statins are associated with more frequent side effects. Therefore, it may be of concern that these recommendations might reduce statin adherence.

Provider Type and Quality of Outpatient Cardiovascular Disease Care : Insights From the NCDR PINNACLE Registry

BACKGROUND The current number of physicians will not be sufficient to accommodate 30 to 40 million Americans expected to secure health coverage with Affordable Care Act implementation. One proposed solution is to use advanced practice providers (APPs) (nurse practitioners and physician assistants). OBJECTIVES This study sought to determine whether there were clinically meaningful differences in the quality of care delivered by APPs versus physicians in a national sample of cardiology practices. METHODS Within the American College of Cardiologys PINNACLE Registry, we compared quality of coronary artery disease (CAD), heart failure, and atrial fibrillation care delivered by physicians and APPs for outpatient visits between January 1, 2012, and December 31, 2012. We performed hierarchical regression adjusting for provider sex; panel size; duration of participation in registry; and patients age, sex, insurance, number of outpatient visits, history of hypertension, diabetes, myocardial infarction, and percutaneous coronary intervention or coronary artery bypass grafting in the preceding 12 months. RESULTS We included 883 providers (716 physicians and 167 APPs) in 41 practices who cared for 459,669 patients. Mean number of patients seen by APPs (260.7) was lower compared with that seen by physicians (581.2). Compliance with most CAD, heart failure, and atrial fibrillation measures was comparable, except for a higher rate of smoking cessation screening and intervention (adjusted rate ratio: 1.14; 95% confidence interval: 1.03 to 1.26) and cardiac rehabilitation referral (rate ratio: 1.40; 95% confidence interval: 1.16 to 1.70) among CAD patients receiving care from APPs. Compliance with all eligible CAD measures was low for both (12.1% and 12.2% for APPs and physicians, respectively) with no significant difference. Results were consistent when comparing practices with both physicians and APPs (n = 41) and physician-only practices (n = 49). CONCLUSIONS Apart from minor differences, a collaborative care delivery model, using both physicians and APPs, may deliver an overall comparable quality of outpatient cardiovascular care compared with a physician-only model.

Estimation of Eligibility for Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors and Associated Costs Based on the FOURIER Trial (Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk): Insights from the Department of Veterans Affairs

In the Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) trial,1 treatment with evolocumab resulted in a 15% relative (1.5% absolute) risk reduction of major cardiovascular events in patients with atherosclerotic cardiovascular disease (ASCVD) at a median follow-up of 2.2 years. This trial included patients with LDL-C≥70mg/dL or non-HDL-C ≥100mg/dL on at least moderate-intensity statins. It is not known what proportion of ASCVD patients would qualify for evolocumab based on FOURIER entry criteria and how eligibility would change if maximal doses of evidence-based lipid lowering therapies were required. We assessed the number and proportion of U.S. Veterans with ASCVD who would qualify for evolocumab based on FOURIER trial entry criteria and how these figures would change if high-intensity statins, ezetimibe or the combination of both agents was used.In the FOURIER trial (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk),1 treatment with evolocumab resulted in a 15% relative (1.5% absolute) risk reduction of major cardiovascular events in patients with atherosclerotic cardiovascular disease (ASCVD) at a median follow-up of 2.2 years. This trial included patients with low-density lipoprotein cholesterol (LDL-C) ≥70 mg/dL or non–high-density lipoprotein cholesterol ≥100 mg/dL on at least moderate-intensity statins. It is not known what proportion of patients with ASCVD would qualify for evolocumab on the basis of FOURIER entry criteria and how eligibility would change if maximal doses of evidence-based lipid-lowering therapies were required. We assessed the number and proportion of US veterans with ASCVD who would qualify for evolocumab on the basis of FOURIER trial entry criteria and how these figures would change if high-intensity statins, ezetimibe, or the combination of both agents were used. Using a cohort of veterans with ASCVD (myocardial infarction, ischemic stroke, or peripheral arterial disease) receiving care in the Veterans Affairs (VA) system between October 2013 and September 2014, we identified all patients with ASCVD 40 to 85 years of age (n=631 855) using previously described algorithms with a positive predictive value of 88% in correctly identifying patients with ASCVD.2 We identified patients meeting 1 major or 2 minor FOURIER protocol criteria and excluded patients with LDL-C 400 mg/dL, and those meeting other FOURIER exclusions.1 Among patients meeting FOURIER inclusion and exclusion criteria, we determined proportions receiving moderate-intensity statins (30%–<50% LDL-C reduction), high-intensity statins (≥50% LDL-C reduction),3 or a …

Statin Use and Its Facility-Level Variation in Patients With Diabetes: Insight From the Veterans Affairs National Database

We sought to determine use of any and at least moderate‐intensity statin therapy in a national sample of patients with diabetes mellitus (DM), with the hypothesis that nationwide frequency and facility‐level variation in statin therapy are suboptimal. We sampled patients with DM age 40 to 75 years receiving primary care between October 1, 2012, and September 30, 2013, at 130 parent facilities and associated community‐based outpatient clinics in the Veterans Affairs Health Care System. We examined frequency and facility‐level variation in use of any or at least moderate‐intensity statin therapy (mean daily dose associated with ≥30% low‐density lipoprotein cholesterol lowering). In 911 444 patients with DM, 68.3% and 58.4% were receiving any and moderate‐ to high‐intensity statin therapy, respectively. Patients receiving statin had higher burden of cardiovascular disease, were more likely to be on nonstatin lipid‐lowering therapy and to receive care at a teaching facility, and had more frequent primary‐care visits. Median facility‐level uses of any and at least moderate‐intensity statin therapy were 68.7% (interquartile range, 65.9%–70.8%) and 58.6% (interquartile range, 55.8%–61.4%), respectively. After adjusting for several patient‐related and some facility‐related characteristics, the median rate ratios for any and moderate‐ to high‐intensity statin therapy were 1.20 (95% confidence interval: 1.18‐1.22) and 1.29 (95% confidence interval: 1.24‐1.33) respectively, indicating 20% to 29% variation in statin use between 2 identical patients receiving care at 2 random facilities. Statin use was suboptimal in a national sample of patients with DM with modest facility‐level variation, likely indicating differences in statin‐prescribing patterns.

Comparative effectiveness of outpatient cardiovascular disease and diabetes care delivery between advanced practice providers and physician providers in primary care: Implications for care under the Affordable Care Act.

BACKGROUND The objective was to compare quality of diabetes and cardiovascular disease (CVD) care between advanced practice providers (APPs) and physicians in a primary care setting. METHODS We identified diabetes (n=1,022,588) and CVD (n=1,187,035) patients receiving primary care between October 2013 and September 2014 in 130 Veterans Affairs facilities. We compared glycemic control (hemoglobin A1c <7%) in diabetic patients, blood pressure (BP) <140/90 mmHg in diabetic or CVD patients, cholesterol control (low-density lipoprotein cholesterol<100 mg/dL, receiving a statin) in diabetic or CVD patients, and those receiving a β-blocker (with history of myocardial infarction in the last 2 years) among patients receiving care from physicians and APPs. We also compared the proportion meeting composite measure (glycemic, BP, and cholesterol control in diabetic patients; BP, cholesterol control, and receipt of β-blocker among eligible CVD patients). RESULTS Diabetic patients receiving care from APPs were statistically more likely to have glycemic (50% vs 51.4%, odds ratio [OR] 1.06 [1.05-1.08]) and BP control (77.5% vs 78.4%, OR 1.04 [1.03-1.06]), whereas patients receiving care from physicians were more likely to have cholesterol control (receipt of statin 68% vs 66.5%, OR 0.94 [0.93-0.95]) in adjusted models, although these differences are not clinically significant. Similar results were seen in CVD patients. Few patients met the composite measure (27.1% and 27.6% of diabetic and 54.0% and 54.8% of CVD patients receiving care from physicians and APPs, respectively). CONCLUSIONS Diabetes and CVD care quality was comparable between physicians and APPs with clinically insignificant differences. Regardless of provider type, there is a need to improve performance on eligible measures in diabetes or CVD patients.

Adherence to cardiovascular medications in the South Asian population: A systematic review of current evidence and future directions

AIM To review methods of assessing adherence and strategies to improve adherence to cardiovascular disease (CVD) medications, among South Asian CVD patients. METHODS We conducted a systematic review of English language studies that examined CVD medication adherence in South Asian populations from 1966 to April 1, 2015 in SCOPUS and PubMed. Working in duplicate, we identified 61 studies. After exclusions, 26 studies were selected for full text review. Of these, 17 studies were included in the final review. We abstracted data on several factors including study design, study population, method of assessing adherence and adherence rate. RESULTS These studies were conducted in India (n = 11), Pakistan (n = 3), Bangladesh (n = 1), Nepal (n = 1) and Sri Lanka (n = 1). Adherence rates ranged from 32%-95% across studies. Of the 17 total publications included, 10 focused on assessing adherence to CVD medications and 7 focused on assessing the impact of interventions on medication adherence. The validated Morisky Medication Adherence Scale (MMAS) was used as the primary method of assessing adherence in five studies. Three studies used validated questionnaires similar to the MMAS, and one study utilized Medication Event Monitoring System caps, with the remainder of the studies utilizing pill count and self-report measures. As expected, studies using non-validated self-report measures described higher rates of adherence than studies using validated scale measurements and pill count. The included intervention studies examined the use of polypill therapy, provider education and patient counseling to improve medication adherence. CONCLUSION The overall medication adherence rates were low in the region, which suggest a growing need for future interventions to improve adherence.

Statin prescription rates and their facility-level variation in patients with peripheral artery disease and ischemic cerebrovascular disease: Insights from the Department of Veterans Affairs:

The 2013 American College of Cardiology/American Heart Association cholesterol guideline recommends moderate to high-intensity statin therapy in patients with peripheral artery disease (PAD) and ischemic cerebrovascular disease (ICVD). We examined frequency and facility-level variation in any statin prescription and in guideline-concordant statin prescriptions in patients with PAD and ICVD receiving primary care in 130 facilities across the Veterans Affairs (VA) health care system between October 2013 and September 2014. Guideline-concordant statin intensity was defined as the prescription of high-intensity statins in patients with PAD or ICVD ≤75 years and at least moderate-intensity statins in those >75 years. We calculated median rate ratios (MRR) after adjusting for patient demographic factors to assess the magnitude of facility-level variation in statin prescribing patterns independent of patient characteristics. Among 194,151 PAD patients, 153,438 patients (79.0%) were prescribed any statin and 79,435 (40.9%) were prescribed a guideline-concordant intensity of statin. PAD patients without ischemic heart disease were prescribed any statin and a guideline-concordant intensity of statin therapy less frequently (69.1% and 28.9%, respectively). Among 339,771 ICVD patients, 265,491 (78.1%) were prescribed any statin and 136,430 (40.2%) were prescribed a guideline-concordant intensity of statin. ICVD patients without ischemic heart disease were prescribed any statin and a guideline-concordant intensity of statin less frequently (70.9% and 30.5%, respectively). MRRs for both PAD and ICVD patients demonstrated a 20% and 28% variation among two facilities in treating two identical patients with statin therapy and guideline-concordant intensity of statin therapy, respectively. The prescription of statins, especially guideline-recommended intensity of statin therapy, is suboptimal in PAD and ICVD patients, with significant facility-level variation not explained by patient-level factors.

A dataset to assess providers׳ knowledge and attitudes towards the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guideline

We previously examined provider׳s understanding of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) cholesterol management guideline (DOI: http://dx.doi.org/10.1016/j.jacl.2015.11.002)(Virani et al., 2013) [1], and also assessed whether a case-based educational intervention could improve providers׳ knowledge gaps and attitudes towards the guideline (DOI: 10.1016/j.atherosclerosis.2015.12.044) (Pokharel, et al., 2016) [2]. Here we describe the dataset that we used to examine our objectives.

Premature Coronary Heart Disease in South Asians: Burden and Determinants

Purpose of ReviewWhile the burden of cardiovascular disease (CVD) is on the decline globally, it is on the rise among South Asians. South Asians are also believed to present early with coronary artery disease (CAD) compared with other ethnicities.Recent FindingsSouth Asians have demonstrated a higher burden of premature CAD (PCAD) compared with other ethnicities. These findings are not limited to non-immigrant South Asians but have also been found in immigrant South Asians settled around the world. In this article, we first discuss studies evaluating PCAD among South Asians residing in South Asia and among South Asian immigrants in other countries. We then discuss several traditional risk factors that could explain PCAD in South Asians (diabetes, hypertension, dietary factors, obesity) and lipoprotein-associated risk (low HDL-C levels, higher triglycerides, and elevated apolipoprotein B levels). We then discuss several emerging areas of research among South Asians including the role of dysfunctional HDL, elevated lipoprotein(a), genetics, and epigenetics. Although various risk markers and risk factors of CAD have been identified in South Asians, how they impact therapy is not well-known.SummaryPCAD is prevalent in the South Asian population. Large-scale studies are needed to identify how this information can be rationally utilized for early identification of risk among South Asians, and how currently available therapies can mitigate this increased risk.

Variation in Lipid-Lowering Therapy Use in Patients With Low-Density Lipoprotein Cholesterol ≥190 mg/dL: Insights From the National Cardiovascular Data Registry–Practice Innovation and Clinical Excellence Registry

Background: Patients with low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dL are at high risk of atherosclerotic cardiovascular disease events. Treatment guidelines recommend intensive treatment in these patients. Variation in the use of lipid-lowering therapies (LLTs) in these patients in a national sample of cardiology practices is not known. Methods and Results: Using data from the American College of Cardiology National Cardiovascular Data Registry–Practice Innovation and Clinical Excellence registry, we assessed the proportion of patients with LDL-C ≥190 mg/dL (n=49 447) receiving statin, high-intensity statin, LLT associated with ≥50% LDL-C lowering, ezetimibe, or a PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor between January 2013 and December 2016. We assessed practice-level rates and variation in LLT use using median rate ratio (MRR) adjusted for patient and practice characteristics. MRRs represent the likelihood that 2 random practices would differ in treatment of identical patients with LDL-C ≥190 mg/dL. The proportion of patients receiving a statin, high-intensity statin, LLT associated with ≥50% LDL-C reduction, ezetimibe, or PCSK9 inhibitor were 58.5%, 31.9%, 34.6%, 8.5%, and 1.5%, respectively. Median practice-level rates and adjusted MRR for statin (56% [interquartile range, 47.3%–64.8%]; MRR, 1.20 [95% confidence interval [CI], 1.17–1.23]), high-intensity statin (30.2% [interquartile range, 12.1%–41.1%]; MRR, 2.31 [95% CI, 2.12–2.51]), LLT with ≥50% LDL-C lowering (31.8% [interquartile range, 15.3%–45.5%]; MRR, 2.12 [95% CI, 1.95–2.28]), ezetimibe (5.8% [interquartile range, 2.8%–9.8%]; MRR, 2.42 [95% CI, 2.21–2.63]), and PCSK9 inhibitors (0.16% [interquartile range, 0%–1.9%]; MRR, 2.38 [95% CI, 2.04–2.72]) indicated significant gaps and >200% variation in receipt of several of these medications for patients across practices. Among those without concomitant atherosclerotic cardiovascular disease, even larger treatment gaps were noted (proportion of patients on a statin, high-intensity statin, LLT with ≥50% LDL-C reduction, ezetimibe, or PCSK9 inhibitor were 50.8%, 25.25%, 26.8%, 4.9%, and 0.74%, respectively). Conclusions: Evidence-based LLT use remains low among patients with elevated LDL-C with significant variation in care. System-level interventions are needed to address these gaps and reduce variation in care of these high-risk patients.