Determining and targeting reasons for low statin use to improve guideline-concordant statin therapy in high-risk patients

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Background: Optimal statin therapy is associated with a lower risk of cardiovascular events in patients with established cardiovascular disease (CVD). The VA External Peer Review Program (EPRP) also recommends moderate-high intensity statins in patients with CVD. We have shown that a large proportion of Veterans with CVD (41%) are on suboptimal statin therapy. Guideline concordant statin treatment over 5 years could potentially prevent 20,611 vascular events including 3,435 deaths in Veterans with CVD. Suboptimal statin use may be due to statin associated side effects or due to provider clinical inertia. We have shown that side effects and statin intolerance are not well captured in the structured datasets, and are usually documented in the free text notes by clinicians. It is therefore important to identify the reasons for suboptimal statin utilization and to design an intervention to increase receipt of guideline recommended care in appropriate CVD patients. Objective: Our objective is to examine patterns of medication use from currently available structured datasets and the use of natural language processing (NLP) to identify the CVD patients not on a guideline concordant statin therapy due to statin intolerance or provider clinical inertia. We will also perform a pilot study providing succinct information to patient aligned care teams (PACTs) in the form of a point-of-care communication aid which targets these gaps. Aim 1: To identify reasons (allergy, intolerance, or clinical inertia) Veterans with CVD are not receiving guideline-recommended statin therapy based on structured data and automated information extraction with NLP. Aim 2: To understand provider and patient understanding of statin intolerance and to describe providers' lipid management strategies addressing intolerance through qualitative interviews. Based on these interviews, we will refine a succinct communication aid targeted towards PACT providers which will allow them to effectively initiate and/or titrate statins to evidence-based doses in CVD patients (including patients who are intolerant to statins). Aim 3: To pilot test a communication aid in Houston and Nashville VA PACTs to determine whether its use is associated with an increase in guideline-concordant statin therapy use in patients with CVD compared to usual care. Methods: For Aim 1, we will randomly identify CVD patients from throughout the VA system (500 on optimal statins, 500 on statin but on less than moderate-intensity dose, and 500 not on a statin) and randomly partition them into training and a test set. We will then train our NLP system to achieve a sensitivity and specificity of >90%, compared with manual chart review. In Aim 2, we will conduct qualitative interviews with providers and patients in VISN 16 to elicit their perspectives on clinical inertia and intolerance related to statins. These interviews will help facilitate the refinement of the content of the communication aid for use during the pilot phase of the proposed study. In Aim 3, we will conduct a pilot trial with Houston and Nashville VAMC PACTs serving as the intervention sites. All PACTs at the intervention sites will receive the communication aid to assist them with statin initiation and/or titration in patients with CVD on suboptimal statins. At usual care sites (community based outpatient clinics affiliated with the Houston and Nashville VAMC), PACT providers will only receive a quarterly report of the proportion of their CVD patients on suboptimal statins. Our primary outcome is the change in the proportion of CVD patients receiving optimal (at least a moderate intensity) statin therapy. Anticipated Impact on Veteran's Healthcare: Our results will be important as they will identify the vast majority of high-risk Veterans not on optimal statin therapy due to intolerance versus clinical inertia. Our communication aid will identify strategies to initiate or titrate statins in high-risk Veterans who stand to derive the most benefit from this life saving therapy by addressing both patient intolerance and clinical inertia. Finally, these results will be important for the VA Health Care System to identify high-risk patients with “true statin intolerance” who will be future candidates for highly expensive new drugs recently approved by the FDA.