By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Most of us forget the basics and wonder why the specifics don’t work.“

-Garrison Wynn

In 2019, about 40% of PHC members with diabetes were not being prescribed recommended cholesterol-lowering medications. For patients with diagnosed cardiovascular disease, about 20% had not received statin therapy.

Statin therapy prescriptions and patient adherence to prescribed statin treatment are NCQA HEDIS measures that we will be focusing on in the years ahead. We urge clinician leaders to look at the rates of prescriptions in your practice and remind clinicians of the importance of prescribing statins in these two groups. If you can, set alerts in your Electronic Health Record system (EHRs) to remind clinicians to consider this therapy.

Clinical Background:
Cardiovascular disease is the leading cause of death in the United States. Patients with clinical Atherosclerotic Cardiovascular Disease (ASCVD) are at high risk for future cardiovascular events, including myocardial infarction, stroke, and death from Cardiovascular Disease (CVD). Lipid abnormalities are also common in patients with diabetes, and contribute to an increased risk for developing ASCVD. The American College of Cardiology and American Heart Association (ACC/AHA) as well as the American Diabetes Association (ADA) recommend statin therapy to prevent cardiovascular disease and reduce ASCVD risk.

Summary of Recommendations:
Therapy to reduce the risk of subsequent cardiovascular events includes addressing modifiable risk factors such as smoking, hypertension, diabetes, and elevated levels of low-density lipoprotein cholesterol (LDL-C). The ACC/AHA guidelines state that statins of high intensity or maximally tolerated statin doses are recommended for adults age 75 or under with established clinical ASCVD regardless of the baseline LDL-C. A maximally tolerated statin dose should be used to reduce LDL-C levels by 50% or more.

In patients with diabetes (but without clinical ASCVD), the ADA and the 2019 ACC/AHA guidelines recommend statins for primary prevention of cardiovascular disease, based on age and other risk factors. Moderate-intensity statin therapy can be initiated without calculating a 10-year ASCVD risk. For patients with diabetes who are at higher risk, especially those with multiple ASCVD risk factors or aged 50 to 70 years, high-intensity statin therapy should be considered to reduce the LDL-C level by 50% or more. Consideration may be given for addition of a SGLT-2 inhibitor or GLP-1 receptor agonist with proven CVD benefit to improve glycemic control and reduce CVD risk in patients at higher risk.

The HEDIS Measures
The HEDIS measure Statin Therapy for Patients with Cardiovascular Disease assesses the percentage of males 21–75 years of age and females 40–75 years of age with clinical ASCVD who have received and adhered to statin therapy.
The HEDIS measure Statin Therapy for Patients with Diabetes assesses the percentage of adults 40-75 years of age who do not have diagnosed ASCVD.

Best Practices
Here is a summary of best practices for adding appropriate statin therapy and improving adherence for patients with diabetes and/or cardiovascular disease:

1. Review medication list to confirm a statin has been prescribed when indicated.
2. Provide patient education: explaining goals of statin therapy and need for adherence.
3. Prescribe statins as 90 day supplies, once therapy is stable.
4. Ask your patients open-ended questions to monitor for adverse drug reactions, drug-drug interactions, and other obstacles that may hinder medication adherence.
5. Collaborate with dispensing pharmacies to identify and address medication adherence gaps.
6. Specific medication recommendations:
   1. For high intensity statin therapy (lowers LDL-C by >50%), consider atorvastatin 40-80 mg or rosuvastatin 20-40 mg.
   2. For moderate intensity statin therapy (lowers LDL-C by 30% to <50%), consider atorvastatin 10-20 mg, rosuvastatin 5-10 mg, or simvastatin 20-40 mg.

Thanks for passing this along to your front line clinicians.