1 Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
2 Health Policy, Quality & Informatics Program, Michael E DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
Vasc Med. 2018 Jun;23(3):232-240. doi: 10.1177/1358863X18758914. Epub 2018 Mar 30.
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.
2013 年美国心脏病学会/美国心脏协会胆固醇指南建议在患有外周动脉疾病（PAD）和缺血性脑血管疾病（ICVD）的患者中进行中高强度他汀类药物治疗。我们在 2013 年 10 月至 2014 年 9 月期间，检查了在退伍军人事务部（VA）医疗保健系统的 130 个医疗设施中接受初级保健的 PAD 和 ICVD 患者中任何他汀类药物的处方频率和设施水平差异，以及符合指南的他汀类药物处方。符合指南的他汀类药物强度定义为 PAD 或 ICVD≤75 岁的患者处方高强度他汀类药物，而>75 岁的患者处方至少中度强度他汀类药物。我们在调整了患者人口统计学因素后计算了中位数率比（MRR），以评估他汀类药物处方模式在独立于患者特征的情况下的设施水平差异的大小。在 194151 名 PAD 患者中，有 153438 名（79.0%）患者处方了任何他汀类药物，有 79435 名（40.9%）患者处方了符合指南的他汀类药物强度。没有缺血性心脏病的 PAD 患者更常被处方任何他汀类药物和符合指南的他汀类药物强度治疗（分别为 69.1%和 28.9%）。在 339771 名 ICVD 患者中，有 265491 名（78.1%）患者处方了任何他汀类药物，有 136430 名（40.2%）患者处方了符合指南的他汀类药物强度。没有缺血性心脏病的 ICVD 患者更常被处方任何他汀类药物和符合指南的他汀类药物强度治疗（分别为 70.9%和 30.5%）。PAD 和 ICVD 患者的 MRR 表明，在治疗两名接受他汀类药物治疗和符合指南的他汀类药物强度治疗的相同患者时，两个设施之间存在 20%和 28%的差异。他汀类药物的处方，尤其是指南推荐的他汀类药物强度治疗，在外周动脉疾病和缺血性脑血管疾病患者中并不理想，存在显著的设施水平差异，无法用患者水平因素来解释。
