How do you prescribe statins in the elderly?

13 Jun 2021 How do you prescribe statins in the elderly?

An individual Portrait on prescribing statins to patients age 70 and older was sent to approximately 5200 eligible family doctors in BC, randomized to receive this Portrait in two groups: an early group in November 2020 and a delayed group in June 2021. This Portrait was accompanied by Therapeutics Letter #130: Evidence for statins in people over 70.

Below is a sample Portrait containing fictional individual physician data. View this sample Portrait in PDF format, or click on the DOWNLOAD button above. If you are a BC family physician and wish to sign up for (or opt out of) receiving Portrait, click on the REGISTER button above.

Sample Portrait

References

1. Afilalo J, Duque G, Steele R, et al. Statins for secondary prevention in elderly patients: a hierarchical bayesian meta-analysis. J Am Coll Cardiol. 2008;51(1):37-45. doi: 10.1016/j.jacc.2007.06.063
2. Cholesterol Treatment Trialists’ Collaboration, Fulcher J, O’Connell R, et al. Efficacy and safety of LDL-lowering therapy among men and women: meta-analysis of individual data from 174,000 participants in 27 randomised trials. Lancet. 2015;385(9976):1397-1405. doi:10.1016/S0140-6736(14)61368-4
3. Therapeutics Initiative. Evidence for statins in people over 70. Therapeutics Letter. 2021 (Mar-Apr);130:1-2. https://ti.ubc.ca/letter130
4. ClinicalTrials.gov. A clinical trial of statin therapy for reducing events in the elderly (STAREE). 2020. https://clinicaltrials.gov/ct2/show/NCT02099123
5. ClinicalTrials.gov. Pragmatic evaluation of events and benefits of lipid-lowering in older adults (PREVENTABLE). 2020. https://clinicaltrials.gov/ct2/show/NCT04262206

Data definitions

Who received this portrait?

BC physicians meeting all of the following criteria received an individual statin prescribing Portrait:

• general practice physicians, including family practitioners, who were registered by the BC Medical Services Plan (MSP) as a private practice, and
• had a valid mailing address in BC according to the College of Physicians and Surgeons of British Columbia’s public physician information, and
• had ≥100 prescriptions filled at a community pharmacy in 2019 (early group) or 2020 (delayed group) according to PharmaNet claims data, and
• cared for ≥10 patients age 70 or older in their practice during 2019 (early group) or 2020 (delayed group), according to MSP fee-for-service data.

Physicians might have received a Portrait with masked or missing elements (i.e. no red bars are shown) because they met the above requirements but prescribed between 0 and 5 statin prescriptions for that section of the Portrait. Portrait’s data access agreement required the masking of data elements when <6 patients were included.

How were patients assigned to this Portrait?

Patients were included in a physician’s portrait if they met all of the following criteria:

• were continuously registered with the MSP in 2019 (early group) or 2020 (delay group), and
• were at least 70 years old in 2019 (early group) or 2020 (delay group), and
• had a medical encounter recorded in MSP fee-for-service claims with that physician’s billing number, and/or were prescribed a medication with that physician’s prescribing number in PharmaNet.

Prescription data for patients who are federally insured (e.g. Veterans, RCMP, Armed Forces and beneficiaries of Non-Insured Health Benefits) or formerly federally insured (First Nations Health Benefits – Plan W) were not included.

What prescriptions were included in this Portrait?

Statin prescriptions were taken from PharmaNet claims data and included all prescriptions filled at a community pharmacy in BC with a physician’s prescribing number. Reversed prescription claims, out-of-province prescriptions, or medication dispensed in hospital were not included.

Statins were identified by the Anatomical Therapeutic Chemical (ATC) Classification System and include simvastatin (C10AA01), lovastatin (C10AA02), pravastatin (C10AA03), fluvastatin (C10AA04), atorvastatin (C10AA05), rosuvastatin (C10AA07), or combination products containing these drugs.

How were secondary and primary prevention patients defined?

In this Portrait, patients were classified as secondary or primary prevention based on the presence or absence of occlusive vascular disease, respectively. A history of occlusive vascular disease was defined as discharges from BC hospitals between April 1, 2001 and December 31, 2019 (early group) or December 31, 2020 (delay group) for ischemic heart disease, cerebrovascular disease, or ischemic peripheral vascular disease. Diagnostic and procedure codes for occlusive vascular disease are listed below.

ICD = International Classification of Diseases
CCI = Canadian Classification of Health Interventions

Research component

The research objective is to determine the impact of the Portrait on physician prescribing of statins. This impact will be evaluated at an aggregated level over the coming year by comparing pooled prescribing data from physicians in the early mailing group to pooled prescribing data from physicians in the delayed group. All prescribing data analyzed for this evaluation will not contain names, only encrypted patient and physician numbers. No physician or patient will be identified in any reports or publications. As a reminder, Portrait’s data access agreement requires the masking of data elements when <6 individuals (patients or physicians) are included. Ethics approval for this evaluation will be obtained from the University of British Columbia Clinical Ethics Review Board. This evaluation will be led by Drs. Colin Dormuth and Greg Carney, University of British Columbia, Faculty of Medicine, Department of Anesthesiology, Pharmacology, & Therapeutics.

If you have any questions or would like further information with respect to this evaluation, you may contact the Portrait team at (604) 822-4887 or email Portrait@ti.ubc.ca

FAQ

Can I request the names of my patients included in this Portrait?

No. Portrait’s data access agreement only permits access to encrypted patient identifiers. There is no way for us to identify individual patients in the data or to provide you with a list.

However, other resources may be available for you. Contact your Practice Support Program (PSP) regional team to discuss how they might help you use your EMR to identify these patients.

I mainly prescribe statins covered by PharmaCare. Why does my Portrait say that most of my statin prescriptions are not covered?

We used PharmaCare Paid Cost when calculating the proportion covered by PharmaCare, so “covered” is calculated based on two elements: (1) PharmaCare formulary and pricing, and (2) patients’ deductible (patients or their private insurance are required to pay drug costs until they reach the deductible level). The presented data show the actual proportion of out-of-pocket expenses saddled on the patient (or their insurance). However, in some cases, these data do not reflect the physician’s statin choice well.

How does the Portrait statin profile actually know whether a patient got statins for primary or secondary prevention? Does this rely on the billed codes, as they can be inaccurate?

Please refer to “How were secondary and primary prevention patients defined?” above. The definition is based on hospital data, which is considered accurate. However, there may be patients with ischemic cardiovascular disease, ischemic cerebrovascular disease, or ischemic peripheral vascular disease who were not hospitalized and therefore not identified.

My practice profile is definitely unique and should not be compared to community primary care practitioners. Specifically, all the prescriptions I write are discharge prescriptions for hospitalized patients, and in many cases the therapy was recommended by a specialist (neurologist or cardiologist).

We identified physicians based on their registration information in the BC Medical Services Plan (MSP). We are unable to identify physicians whose registration information does not reflect their practice. Prescribing portraits are absolutely confidential. None of the Portrait group, nor anyone else, will ever see them. The project has 2 main purposes:

1. Draw to the attention of individual prescribers potentially interesting patterns in their own prescribing, and how that may compare with peer colleagues;
2. Provide the potential for randomized controlled pharmacoepidemiological research to assess whether Portraits have any effect on prescribing patterns, or health status.

The same point may apply to some hospital physicians who prescribe exclusively at discharge. Even if your hospital discharge prescriptions typically reflect the advice of hospital specialists for patients being discharged from hospital, the Portrait could still be useful to doctors working in roles similar to yours. One common response to polypharmacy, that we have encountered while teaching throughout BC, is that family practitioners may feel pressured to continue specialist prescriptions initiated in hospital, even when they are unsure whether all such prescriptions are in their patients’ best interests. It is up to each Portrait recipient to determine whether their unique prescribing pattern might suggest the potential for any productive changes – or not.

Most of the statin users in my practice are over age 70 for primary prevention, and they also have hyperlipidemia and either diabetes or chronic kidney disease. Is the recommendation to stop the statins when patients turn 70, even though those groups are apparently at high risk?

The statin prescribing Portrait and Therapeutics Letter #130 entitled “Evidence for statins in people over 70” do not make any recommendation whether an individual patient’s statin should be stopped at age 70 or at any other age. They present best evidence as of 2020-2021, which may change with results from the ongoing large RCTs underway in Australia and in the United States.

The Australian trial (STAREE) excludes people with a history of diabetes, a total cholesterol > 7.5mM, or “moderate or severe” CKD defined by urine ACR > 30mg/mmol or eGFR < 45ml/min/1.73m2. The US trial (PREVENTABLE) does not exclude people with diabetes or CKD, although the trial coordinators expect that people with “significant diabetes/CKD” may not be enrolled by local site investigators or collaborating clinicians. They note that “only about 50% of patients with diabetes over age 75 but without cardiovascular disease” are taking statins in the US as of 2020.

I don’t see my question here. Where can I find more information?

Please check out our program FAQ page. We also welcome your feedback. Questions can be directed to our Portrait team by phone (604) 822-4887 or email Portrait@ti.ubc.ca