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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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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.
Data

Patient data were obtained using Clarity, an Epic reporting database, including demographics, comorbidities, lipid levels, statin prescription, PCP, number of clinic visits during the study period, presence of a visit with a cardiologist, and insurance type. Clinical comorbidities were assessed using International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis codes. Statin prescription was determined via broad search and then manual review. Household income was estimated by zip code of residence from 2015 US Census data.20 PCPs were from internal medicine and family medicine and included faculty attending physicians, residents, physician assistants, and nurse practitioners. Data on PCP training and experience were based on information from the National Provider Index and included clinical degree, years of practice, and specialty.

Statistical Analysis

In unadjusted comparisons, we estimated the proportion of eligible patients screened and prescribed a statin by each patient and physician factor. The outcome measure for lipid screening was based on the presence of an order for an LDL-C blood test captured in the EHR at any point since 1999. The outcome measure for statin prescription was an order for a statin captured in the EHR since 1999. Multivariate logistic regression models were fit to the outcome measures and adjusted for patient demographics (age, sex, race/ethnicity and median household income), insurance, number of visits with a PCP, presence of a visit with a cardiologist, clinical characteristics or diagnoses (diabetes, hypertension, congestive heart failure [CHF], CVD, tobacco use, body mass index, and GFR), and Charlson Comorbidity Index (CCI) score,21 as well as physician demographics, provider type, medical degree, specialty, and years of experience. Similar to a prior study,15 the CCI was modified to reduce collinearity by excluding acute myocardial infarction, cerebrovascular disease, CHF, diabetes, and peripheral vascular disease. The patient factors either were clinically relevant to the guidelines10,11 or were shown to affect statin prescription in previous work.15 The provider factors were chosen because they were felt to characterize the providers in the ways that provider training could influence statin prescription. The statin prescription model was further adjusted for liver function tests and history of PCI or CABG. We used 2-sided hypothesis tests and a significance level of 0.05; analyses were conducted using Stata, version 12.1 (StataCorp LP; College Station, Texas).

RESULTS

Lipid Screening

There were 97,189 patients with 521 PCPs who were eligible for lipid screening, among whom 76,641 (78.9%) had an order placed for screening. In unadjusted comparisons, patients with CVD, CHF, diabetes, and hypertension had greater lipid screening order rates than patients without those conditions (Table 1 [part A and part B]). PCPs with an allopathic medical degree had greater lipid screening order rates (82.9%) than those with an osteopathic degree (68.9%) or other degree (67.6%). PCPs in internal medicine had greater lipid screening order rates (88.6%) than those in family medicine (69.8%) (Table 1).

In adjusted models (Table 1), significant patient predictors of greater odds of having lipid screening ordered included black race (odds ratio [OR], 1.77; 95% CI, 1.54-2.03; P <.001), visit with a cardiologist (OR, 1.71; 95% CI, 1.54-1.91; P <.001), and a history of diabetes (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 patient predictors of lower odds of having lipid screening ordered were female sex (OR, 0.93; 95% CI, 0.87-0.99; P = .016), Medicaid insurance (OR, 0.64; 95% CI, 0.56-0.73; P <.001), Medicare insurance (OR, 0.72; 95% CI, 0.66-0.78; P <.001), and chronic kidney disease (CKD) with a GFR of 45 to 59 mL/min (OR, 0.74; 95% CI, 0.62-0.88; P <.001) or 30 to 44 mL/min (OR, 0.58; 95% CI, 0.47-0.72; P <.001).

Significant physician predictors of lower odds of a patient being ordered for lipid screening included being a resident (OR, 0.63; 95% CI, 0.43-0.93; P = .021), having an osteopathic degree (OR, 0.73; 95% CI, 0.55-0.96; P = .026), and specializing in family medicine (OR, 0.37; 95% CI, 0.30-0.47; P <.001).

Statin Prescription

There were 40,845 patients eligible for statin therapy, among whom 22,906 (56.1%) were prescribed a statin. In unadjusted comparisons, patients with elevated ASCVD 10-year risk scores, CVD, history of a PCI/CABG, CHF, diabetes, and hypertension had greater statin prescription rates than patients without those conditions. PCPs with an allopathic medical degree had greater statin prescription rates (56.7%) than those with an osteopathic degree (52.6%) or other degree (53.8%). PCPs in internal medicine had greater statin prescription rates (57.6%) than those in family medicine (54.0%) (Table 2 [part A, part B, and part C]).

In adjusted models (Table 2), significant patient predictors of greater odds of statin prescription included age (OR, 1.05 for each year of age; 95% CI, 1.03-1.06; P <.001), history of hypertension (OR, 1.58; 95% CI, 1.38-1.81; P <.001), diabetes (OR, 2.70; 95% CI, 2.32-3.13; P <.001), CVD (OR, 2.26; 95% CI, 1.85-2.76; P <.001), PCI/CABG (OR, 4.16; 95% CI, 1.98-8.75; P <.001), and stage IIIB CKD (OR, 1.71; 95% CI, 1.02-2.86; P = .041). Significant patient predictors of lower odds of statin prescription included black race (OR, 0.72; 95% CI, 0.59-0.86; P = .001) and female sex (OR, 0.84; 95% CI, 0.72-0.98; P = .029).

Significant physician predictors of lower odds of statin prescription included being a female PCP (OR, 0.82; 95% CI, 0.70-0.96; P = .015), training as a physician assistant (OR, 0.65; 95% CI, 0.52-0.81; P <.001), and more years of experience (OR, 0.99 for each year; 95% CI, 0.98-0.99; P <.001).

Most patients received moderate-intensity treatment, and the most common statin prescribed was atorvastatin (Lipitor) (Table 3).


 
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