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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.
DISCUSSION

It is widely accepted that guideline-concordant hyperlipidemia management is effective at reducing cardiovascular events and mortality across a broad range of patients. This study has 3 main findings. First, a substantial proportion of nearly 100,000 patients in the primary care and cardiology practices of a large academic medical center had no evidence of lipid screening. Second, a substantial proportion of those patients meeting criteria for statin therapy were not prescribed a statin. Third, both patient and physician factors significantly predicted guideline-concordant management.

Our findings regarding low rates of adherence to guideline-concordant statin prescription are in line with findings by other groups.12-15 However, there is less information about national rates of hyperlipidemia screening,16 and our work has contributed to identifying and providing insight into this issue.

Our findings have important implications for health systems, ambulatory clinics, and other stakeholders looking for ways to improve cardiovascular care across populations of patients. To our knowledge, this is among the first studies to simultaneously examine patient and physician factors related to evidence-based hyperlipidemia screening and statin prescription. Salami et al investigated national trends in statin use and found that patient predictors of statin use include increased age, racial/ethnic minority, and having qualifying clinical conditions for statin use (ie, ASCVD, clinical CVD), consistent with our findings.15 Al-Kindi et al found that age was the most important predictor for statin prescription, with other independent predictors including nonwhite race and self-pay status.13 However, these studies did not simultaneously examine or adjust for physician factors. The information found from this analysis can be used by other healthcare systems to inform their investigations into provider and patient demographics to better target interventions and improve screening and primary/secondary prevention rates for CVD. For example, our findings about lower rates of statin prescription based on training and experience of PCPs could prompt interventions at the health-system level as part of continued medical training. However, these findings should be confirmed in other health systems and regions.

We found that disparities in care existed. African American patients were more likely to be screened but less likely to be prescribed a statin. Patients with Medicaid or Medicare were less likely to be screened or prescribed a statin than those with private insurance, findings in line with previous work.22-24 Although patients with clinical conditions related to CVD, such as diabetes or hypertension, were more likely to be screened and prescribed a statin, patients with CKD and higher CCI scores were less likely. Physician characteristics were also associated with differences in outcomes, even after adjusting for patient characteristics. However, greater physician continuity was associated with higher rates of ordering lipid screening and prescribing a statin.

Limitations

Our study has several limitations. First, our findings are limited to a single health system; however, it is a large multihospital system and we examined more than 90,000 patients and more than 500 providers. Second, several practice guidelines exist, but our findings are limited to those used in this study. The guidelines used in this study were chosen because they were the most commonly practiced consensus guidelines during the study period. However, the USPSTF updated its guidelines in 2016, after the study period was over, to narrow the group of adults for whom primary screening is recommended. Future studies could evaluate these measures several years after the updated USPSTF guidelines to measure differences in care. Third, our screening outcomes are limited to ordering a lipid screening test in our system. Some patients may have received an LDL-C measurement elsewhere that was communicated to the index physician, eliminating the need for retesting, although this study did not have the data to quantify the number of patients to whom this would apply. Conversely, some may have had screening ordered many years before the study period. However, the USPSTF does not have an evidence-based guideline for the frequency of testing and allows for shared decision making based on the physician’s assessment of risk. If guidelines were to become more specific about screening frequency in the future, one could investigate with more granularity when tests were ordered. Fourth, we measured the ordering of a statin, not patients’ adherence to it. Incomplete medication adherence is profound and represents a large opportunity for health improvement. Although currently not possible, in the future it may be possible to combine information about a statin prescription with pharmacy data about refills to provide a better picture about adherence. Finally, although we evaluated a broad set of patient and physician factors, other data elements in the EHR, such as those within physician notes,25 might add further insight. An example in which physician notes may prove useful is in the evaluation of lower-risk patients for whom patient–physician decision making may have led to deferred lipid testing or lack of statin prescription. This likely applied to a portion of our population, and further studies can help elucidate the degree to which shared decision making affects statin prescription rates.

CONCLUSIONS

Overall, we found that rates of hyperlipidemia screening and statin prescription were suboptimal; the gaps were large enough to recommend broad, rather than targeted, efforts to close them. Both patient and physician factors significantly predicted greater guideline-concordant care. Further investigating physician factors that influence lipid screening and statin prescription will likely provide insights that can improve clinical outcomes. In addition, some of the disparities found in this work regarding screening and statin prescription among patient groups warrant further characterization to better target interventions.

Author Affiliations: Penn Medicine Nudge Unit, University of Pennsylvania Health System (SK, DAA, GWK, MSP), Philadelphia, PA; Perelman School of Medicine (SK, DAA, GWK, SH, SCD, MSP), and The Wharton School (DAA, MSP), University of Pennsylvania, Philadelphia, PA; Crescenz Veterans Affairs Medical Center (DAA, MSP), Philadelphia, PA.

Source of Funding: This study was funded by the University of Pennsylvania Health System through the Penn Medicine Nudge Unit. No one other than the authors had a role in the design, conduct, or analysis of the study, or preparation, review, or approval of the manuscript.

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 (SK, DAA, GWK, SCD, MSP); acquisition of data (SK, GWK, SH, SCD, MSP); analysis and interpretation of data (SK, DAA, GWK, SH, MSP); drafting of the manuscript (SK, MSP); critical revision of the manuscript for important intellectual content (SK, DAA, SH, SCD, MSP); statistical analysis (SK); obtaining funding (MSP); administrative, technical, or logistic support (GWK); and supervision (MSP).

Address Correspondence to: Sneha Kannan, MD, Massachusetts General Hospital, 55 Fruit St, Grey 7-730, Boston, MA 02114. Email: sneha.kannan@mgh.harvard.edu.
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