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The American Journal of Managed Care September 2017
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Guideline Concordance of New Statin Prescriptions: Who Got a Statin?
Thomas Cascino, MD; Marzieh Vali, MS, BS; Rita Redberg, MD, MSc; Dawn M. Bravata, MD; John Boscardin, PhD; Elnaz Eilkhani, MPH; and Salomeh Keyhani, MD, MPH
The Effect of Narrow Network Plans on Out-of-Pocket Cost
Emily Meredith Gillen, PhD; Kristen Hassmiller Lich, PhD; Laurel Clayton Trantham, PhD; Morris Weinberger, PhD; Pam Silberman, JD, DrPh; and Mark Holmes, PhD
In-Gap Discounts in Medicare Part D and Specialty Drug Use
Jeah Jung, PhD; Wendy Yi Xu, PhD; and Chelim Cheong, PhD
Racial and Ethnic Differences in Hip Fracture Outcomes in Men
Lucy H. Liu, MD, MPH; Malini Chandra, MS, MBA; Joel R. Gonzalez, MPH, MPP; and Joan C. Lo, MD
Integrating Behavioral Health Under an ACO Global Budget: Barriers and Progress in Oregon
Jason Kroening-Roché, MD, MPH; Jennifer D. Hall, MPH; David C. Cameron, BA; Ruth Rowland, MA; and Deborah J. Cohen, PhD
Evaluation of a Packaging Approach to Improve Cholesterol Medication Adherence
Hayden B. Bosworth, PhD; Jamie N. Brown, PharmD, BCPS; Susanne Danus, BS; Linda L. Sanders, MPH; Felicia McCant, MSSW; Leah L. Zullig, PhD; and Maren K. Olsen, PhD
Treatment Barriers Among Younger and Older Socioeconomically Disadvantaged Smokers
Patrick J. Hammett, MA; Steven S. Fu, MD, MSCE; Diana J. Burgess, PhD; David Nelson, PhD; Barbara Clothier, MS, MA; Jessie E. Saul, PhD; John A. Nyman, PhD; Rachel Widome, PhD, MHS; and Anne M. Joseph, MD, MPH
Against the Current: Back-Transfer as a Mechanism for Rural Regionalization
Leah F. Nelson, MD, MS; Karisa K. Harland, PhD, MPH; Dan M. Shane, PhD; Azeemuddin Ahmed, MD, MBA; and Nicholas M. Mohr, MD, MS
Association Between FDA Black Box Warnings and Medicare Formulary Coverage Changes
Sanket S. Dhruva, MD, MHS; Pinar Karaca-Mandic, PhD; Nilay D. Shah, PhD; Daniel L. Shaw, BA; and Joseph S. Ross, MD, MHS

Guideline Concordance of New Statin Prescriptions: Who Got a Statin?

Thomas Cascino, MD; Marzieh Vali, MS, BS; Rita Redberg, MD, MSc; Dawn M. Bravata, MD; John Boscardin, PhD; Elnaz Eilkhani, MPH; and Salomeh Keyhani, MD, MPH
New statin prescriptions at the Veterans Health Administration were reviewed using a cross-sectional study design. Statins were frequently prescribed outside of guideline recommendations.
The rates of potential statin overuse appear high, but the possible harms to the patient from overuse of statins are difficult to assess and highly debated. Until recently, there was not a consensus definition of statin intolerance.26 The most commonly reported adverse effects (AEs) are muscle pains and weakness without elevations in creatinine kinase. The prevalence of these AEs in clinical practice is quite high (~20%), and these AEs are higher than those reported in randomized controlled trials.27-29 A high rate of statin discontinuation has been reported, including approximately 50% of patients who stop statins within the first year of prescription; intolerance has been suggested to be the primary source of discontinuation.28,30,31 Thus, the overall perception of negligible harms and the potential for a reduction in cardiovascular deaths may lead clinicians to overprescribe statins.32,33

For some individuals currently taking statins without guideline-based indications, there may be no clear benefits, and there are potential unintended consequences of these prescriptions that should also be taken into account.34-36 For example, it has been documented that statin users experience more weight gain and become more sedentary than statin nonusers, possibly from the false sense of protection from taking a statin, leading individuals to ignore their diet and physical activity.37 In these patients, efforts that are focused on reduction of risks including exercise, weight loss, tobacco cessation, and management of hypertension, rather than initiation of a cholesterol medication, should be the primary focus.36 

Overprescribing statins certainly may also have financial implications for the health system, given the widespread use and the potentially long time horizon for younger patients prescribed statins for primary prevention. Currently, the “Choosing Wisely” campaign of the American Board of Internal Medicine Foundation, building on the work of the National Physicians Alliance, aims to list procedures, tests, and medications whose use should be questioned.7,38,39 With an estimated $750 billion annually spent on unnecessary and inefficient care, identification and reduction of potential overuse is imperative.40,41 However, de-implementation of statin use, even in populations not recommended by current guidelines, may be very challenging because of the perceived lack of harm and potential promise of long-term clinical benefit. Patients 40 years or younger may be committed to primary prevention for life. It is not at all clear whether such long-term use will be as effective or as harmless as is generally assumed. 

Limitations and Strengths

This study has several limitations. We initiated this study in 2013 using 2012 data and planned to use existing guidelines. The issuance of new guidelines by the AHA in 2013 complicated our study but also provided an opportunity to use both guidelines in assessing care. Second, our study is based on national VHA data and there may have been some under-recognition of risk factors, including family history used to calculate risk in the ATP III guidelines, and race used to determine risk in the ACC/AHA guidelines, because individuals of unknown race were assumed to be white. However, the VHA health record information is among the richest data sources available and we used previously developed algorithms, when available, to characterize patients.20,21,24 Third, we used VHA pharmacy data to ascertain new statin use. Some veterans may receive medications outside the VHA and may have been current users and not new users. In these patients, the cholesterol test may have been acquired while on a non-VHA statin, and therefore it would be incorrect to interpret the results as a baseline nonstatin value. We attempted to limit this possibility by requiring our cohort to have at least 2 VHA primary care visits prior to receipt of a statin prescription to largely confine our cohort to patients who receive primary care in the VHA. To assess how much non-VHA statin use affected our conclusions, we examined a random sample of 20 charts for patients whose receipt of statins was not concordant with either guideline. We did not identify any patients who received non-VA prescriptions in this group. To further evaluate non-VA statin use, we reviewed a random sample of 20 charts in patients with an LDL-C value of less than 70 mg/dL. We identified 4 patients (20%) in this select group who had evidence of non-VA statin use. These data suggest that the potential bias in the results related to missing data about non-VA medications is present but likely small in magnitude. Fourth, our sample is a predominantly male sample and may not be generalizable to statin use in the nonveteran US population. Finally, we have probably underestimated overuse of statins in the VHA because we did not examine statin use in populations that are unlikely to benefit, such as those who are receiving dialysis, have congestive heart failure, or have limited life expectancy. Overuse of statins among patients on established prescriptions—as opposed to new prescriptions—may be more common because there may be inertia related to stopping medications.42 

A major strength of the study is the population-based analysis of statin use in a national health system. By examining statin use across the entire VHA system, we gain an understanding of national prescribing patterns much more so than would be possible in smaller studies.10-15,17-19 By understanding national prescribing patterns, we can potentially identify high-value areas of quality improvement. Based on our study, increasing awareness among physicians about the lack of efficacy of statin use in young patients without ASCVD, or in patients with an LDL-C value of less than 70 mg/dL, might reduce inappropriate prescriptions and is a potential target to decrease overuse. 


Low-value statin use is common in the VHA. The finding of common use of statins outside established guidelines represents an opportunity to improve the quality and value of the healthcare delivery.

Author Affiliations: Department of Medicine, Division of Cardiovascular Medicine, University of Michigan (TC), Ann Arbor, MI; San Francisco VA Medical Center (TC, MV, JB, EE, SK), San Francisco, CA; Department of Medicine, Division of Cardiology (RR) and Division of General Internal Medicine (SK), and Department of Epidemiology and Biostatistics (JB), University of California, San Francisco, San Francisco, CA; VHA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center (DMB), Indianapolis, IN; Department of Internal Medicine, Indiana University School of Medicine (DMB), Indianapolis, IN.

Source of Funding: VA HSR&D RRP 13-420.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Authorship Information: Concept and design (TC, SK); acquisition of data (TC, MV, EE, SK); analysis and interpretation of data (TC, MV, RR, DMB, JB, SK); drafting of the manuscript (TC, DMB, SK); critical revision of the manuscript for important intellectual content (TC, DMB, JB, SK); statistical analysis (TC, MV, RR, JB, SK); provision of patients or study materials (EE); obtaining funding (DMB, SK); administrative, technical, or logistic support (TC, EE); and supervision (SK). 

Address Correspondence to: Thomas Cascino, MD, University of Michigan, 2386-B CVC SPC 5853, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5853. E-mail:

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