Statins Underprescribed in PAD Before and After Interventions
Patients treated surgically were almost twice as likely as those who had an endovascular intervention to receive a first prescription for statins.
Fewer than one in three patients who are not on a statin prior to a peripheral vascular intervention receive a prescription for one after their procedure, a new study suggests. This is in spite of evidence that statins reduce future cardiovascular and limb events, including amputation.
“When patients don't take medications, that's one thing. But we have to identify why providers are not prescribing these medications. It seems like potentially a lack of awareness or knowledge,” said lead author Nikhil Singh, MD (The University of Chicago, IL).
In the study by Singh and colleagues, published today in JAMA Network Open, patients who had a surgical revascularization were almost twice as likely as those who had an endovascular intervention to receive a first prescription for statins after treatment (41% vs 26%).
Singh said that finding was surprising and raises timely concerns in light of increasing rates of endovascular procedures, which could grow higher if results of the ongoing BEST-CLI trial—comparing best endovascular therapy with best open surgical treatment in patients eligible for both—ultimately favors minimally invasive treatment. A potential explanation is that patients who are in the hospital after surgery have a higher likelihood that someone other than the operator will interact with them during the stay and prescribe the statin.
In an editorial, E. Hope Weissler, MD, and W. Schuyler Jones, MD (Duke University School of Medicine, Durham, NC), say while the findings are not surprising given other evidence that shows patients with PAD and CV risk factors are more likely than those without CV risk factors to get statins, the study details serious missed opportunities in PAD care.
“To be more blunt, even given an opportunity in the form of a revascularization event, clinicians are not prescribing statins at adequate levels,” they write. Importantly, the fragmented nature of PAD care among a variety of disciplines, ranging from surgeons to cardiologists, primary care physicians, and even podiatrists, sets up a situation in which “clinicians may not have an opportunity to prescribe guideline-based treatments; alternatively, it may also lead to a ‘tragedy of the commons,’ in which each clinician believes statin prescription falls under another clinician’s purview,” Weissler and colleagues say.
Women, Previously Revascularized Patients
Using the Society for Vascular Surgery’s Vascular Quality Initiative (VQI), a multicenter national registry, Singh and colleagues retrospectively looked at data on 37,139 surgical bypass or endovascular revascularization procedures (30,865 patients) from 2014 through 2019. Only 30% of patients who were not on a statin at the time of revascularization were sent home with one.
Compared with patients given a statin after their procedure, those not given one tended to be older, be having an elective procedure, and have a lower body mass index. In both the surgery and endovascular patient groups, a new statin prescription was more likely to be given in those with chronic limb threatening ischemia (CLTI) or acute limb ischemia, and in those with other CV comorbidities including smoking, diabetes, and CAD (P < 0.001 for all comparisons). Compared with men, women were less likely to receive a new statin prescription (OR 0.90; 95% CI 0.84-0.96), as were patients with a prior peripheral revascularization (OR 0.76; 95% CI 0.72-0.81), and those already on an antiplatelet (OR 0.75; 95% CI 0.71-0.80).
We have to identify why providers are not prescribing these medications. It seems like potentially a lack of awareness or knowledge. Nikhil Singh
Over the study period, preprocedure statin use increased from 70% to 81%, with similar percentages among the endovascular and surgery groups. Similarly, the percentage of patients on a statin after revascularization increased from 75% to 87% overall, but it remained consistently higher in the surgery group. When endovascular patients did get a new statin prescription after their procedure, it was more likely to happen in an inpatient than an outpatient setting (37.8% vs 18.9%; P < 0.01). In the surgery group, patients with chronic obstructive pulmonary disease had a lower likelihood of being prescribed a statin at discharge (OR 0.89; 95%CI 0.81-0.97), while patients who were Black had an increased odds of receiving one (OR 1.18; 95%CI 1.05-1.32).
‘Moments of Obligate Contact’
“Whether statin under prescription is associated with lack of knowledge, lack of initiative, or lack of consequences, it is clear that current quality incentives alone are insufficient,” write Weissler and Jones. They suggest that one solution may be to link statin prescription with procedural reimbursement “in recognition of the fact that revascularization events are moments of obligate contact between patients with PAD and PAD experts.”
The editorialists do note some important limitations of the current study, including lack of data on between-institution variation in the rates of new statin prescription after revascularization. Identifying high-performing centers, they say, will help shed light on “the drivers of those centers’ success, and to propagate those learnings elsewhere.” Other limitations, which the study authors acknowledge, are not knowing if some patients may have been given statin prescriptions at follow-up visits after the procedure and not knowing the intensity of the statins that were prescribed.
Singh agreed with Weissler and Jones that there may be a perception among some clinicians that statin prescribing is not in their purview because it’s not specifically related to the revascularization itself.
Alternatively, he said it is possible that some clinicians “see that patients are not on statins, they are aware of the fact that this patient would benefit from it, but [they assume] there must be a reason that another provider didn't put them on it.”
Weissler and Jones say the bottom line, given the emerging data on the importance of aggressive cholesterol treatment in lowering the risk of cardiovascular and limb events in PAD, is that clinicians need to “collectively step up, take responsibility, and think creatively” to remove barriers to the prescribing of statins and take advantage of newer therapies like PCSK9 inhibitors.
Singh N, Ding L, Devera J, et al. Prescribing of statins after lower extremity revascularization procedures in the US. JAMA Network Open. 2021;4(12):e2136014.
Weissler EH, Jones WS. Who will own the responsibility to prescribe statins? tragedy of the commons. JAMA Network Open. 2021;4(12):e2137605.
- Singh, Weissler, and Jones report no relevant conflicts of interest.