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The American Journal of Managed Care August 2018
Impact of a Medical Home Model on Costs and Utilization Among Comorbid HIV-Positive Medicaid Patients
Paul Crits-Christoph, PhD; Robert Gallop, PhD; Elizabeth Noll, PhD; Aileen Rothbard, ScD; Caroline K. Diehl, BS; Mary Beth Connolly Gibbons, PhD; Robert Gross, MD, MSCE; and Karin V. Rhodes, MD, MS
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Andrew M. Heekin, PhD; John Kontor, MD; Harry C. Sax, MD; Michelle S. Keller, MPH; Anne Wellington, BA; and Scott Weingarten, MD
Precision Medicine and Sharing Medical Data in Real Time: Opportunities and Barriers
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Michael Budros, MPH, MPP, and A. Mark Fendrick, MD
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Patient and Physician Predictors of Hyperlipidemia Screening and Statin Prescription
Sneha Kannan, MD; David A. Asch, MD, MBA; Gregory W. Kurtzman, BA; Steve Honeywell Jr, BS; Susan C. Day, MD, MPH; and Mitesh S. Patel, MD, MBA, MS
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Hye-Young Jung, PhD; Qijuan Li, PhD; Momotazur Rahman, PhD; and Vincent Mor, PhD

Patient and Physician Predictors of Hyperlipidemia Screening and Statin Prescription

Sneha Kannan, MD; David A. Asch, MD, MBA; Gregory W. Kurtzman, BA; Steve Honeywell Jr, BS; Susan C. Day, MD, MPH; and Mitesh S. Patel, MD, MBA, MS
Physician and patient predictors of hyperlipidemia screening and statin prescription at a large, multihospital regional health center based on electronic health record data.
ABSTRACT

Objectives: Appropriate lipid management has been demonstrated to reduce cardiovascular events, but rates of hyperlipidemia screening and statin therapy are suboptimal. We aimed to evaluate patient and physician predictors of guideline-concordant hyperlipidemia screening and statin prescription.

Study Design: Retrospective study of patients with primary care provider (PCP) visits from 2014 to 2016 at the University of Pennsylvania Health System.

Methods: Data on patients, screening orders, and prescriptions were obtained from the electronic health record. Multivariate logistic regression models were fit to binary outcomes of lipid screening and statin prescription.

Results: Among 97,189 eligible patients, 79.9% had an order for hyperlipidemia screening. In adjusted models, significant patient predictors of greater odds of having screening ordered included a history of diabetes (odds ratio [OR], 1.19; 95% CI, 1.10-1.29; P <.001) or hypertension (OR, 1.16; 95% CI, 1.10-1.23; P <.001). Significant provider predictors of lower odds of having screening ordered were being a resident PCP (OR, 0.63; 95% CI, 0.43-0.93; P = .021) or being trained in family medicine (OR, 0.37; 95% CI, 0.30-0.47; P <.001). Among 40,845 eligible patients, 56.1% were prescribed a statin. In adjusted models, significant patient predictors of greater odds of being prescribed a statin were if they had a history of diabetes (OR, 2.70; 95% CI, 2.32-3.13; P <.001) or clinical cardiovascular disease (OR, 2.26; 95% CI, 1.85-2.76; P <.001). Significant provider predictors of lower odds of being prescribed a statin were being a physician assistant (OR, 0.65; 95% CI, 0.52-0.81; P <.001) or female (OR, 0.82; 95% CI, 0.70-0.96; P = .01).

Conclusions: Both patient and provider factors significantly predicted guideline-concordant care for hyperlipidemia screening and statin therapy.

Am J Manag Care. 2018;24(8):e241-e248
Takeaway Points

Both hyperlipidemia screening and guideline-concordant statin prescription rates are suboptimal. This study investigated predictors affecting hyperlipidemia screening and, specifically, physician predictors of guideline-concordant statin prescription.
  • The findings from this study can be used to better target interventions at a health-system level based on physician factors, like level and type of training, and patient factors, like race or clinical comorbidity. In addition, these findings should be validated in other practice settings.
  • This study builds on previous work to advance our understanding of factors that affect hyperlipidemia screening rates, an area previously poorly understood.
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the United States.1,2 Management of hyperlipidemia has been demonstrated to reduce cardiovascular mortality and events by more than 30%.3-8 National guidelines have been established to provide recommendations for hyperlipidemia screening and statin therapy.9-11 Despite these benefits and guidelines, many patients do not receive guideline-recommended management.12-15 In national evaluations, nearly one-third of eligible patients were not screened for hyperlipidemia16 and more than 40% of patients with established atherosclerotic cardiovascular disease (ASCVD) were not taking a statin.15

The steps toward improved lipid management involve both patients and physicians.17 Although several studies have investigated patient predictors of statin use,13-15 none have adequately adjusted for physician factors, such as demographics, training, and experience. Even less is known about patient and physician predictors of hyperlipidemia screening.16,18,19

The objective of this study was to evaluate patient and physician factors that predict guideline-concordant lipid management, including lipid screening and statin prescription. We examined patients with a primary care provider (PCP) visit during a 2-year period at a large academic medical center.

METHODS

The University of Pennsylvania Institutional Review Board approved this study. A waiver of informed consent was granted because the study posed minimal risks and would have otherwise been infeasible.

Participants

The sample was composed of patients aged 40 to 75 years with a PCP at the University of Pennsylvania Health System (Philadelphia, Pennsylvania) and at least 1 clinic visit with the PCP between October 1, 2014, and September 30, 2016. Patients with a PCP who completed residency during the study period and those with incomplete clinical or demographic data from the electronic health record (EHR) to establish if guidelines were met for hyperlipidemia screening or statin prescription were excluded.

For the lipid screening cohort, we used the 2008 US Preventive Services Task Force (USPSTF) guidelines,11 which recommend screening men 35 years or older and women 45 years or older or those with CVD (myocardial infarction, stroke, cerebrovascular disease, peripheral vascular disease, and history of percutaneous coronary intervention/coronary artery bypass graft [PCI/CABG]) or a risk factor for that disease (diabetes, hypertension, obesity, and/or current tobacco use).

To identify patients who meet evidence-based guidelines for the statin prescription cohort, we used the 2013 American Heart Association/American College of Cardiology (AHA/ACC) guidelines for patients aged 40 to 75 years.10 These criteria identified 4 benefit groups: (1) patients with evidence of clinical CVD (as defined above), (2) patients with low-density lipoprotein cholesterol (LDL-C) levels of at least 190 mg/dL, (3) patients with diabetes and without clinical CVD aged 40 to 75 years with LDL-C levels between 70 and 189 mg/dL, and (4) patients without clinical CVD or diabetes with LDL-C levels between 70 and 189 mg/dL and estimated 10-year ASCVD risk of more than 7.5%. Patients with EHR documentation of statin allergy or adverse reaction were excluded. Because the AHA/ACC guidelines do not comment on patients with end-stage renal disease, we excluded patients with a glomerular filtration rate (GFR) less than 30 mL/min. In addition, because the AHA/ACC guidelines comment on adults aged 40 to 75 years, the cohort for screening was restricted to men 40 years and older.


 
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