Currently there is a national debate launched by the American Board of Internal Medicine to decrease unnecessary procedures, tests and medications in the US health care system. This initiative is targeting practicing US physicians. Each specialty has been called upon to create a list of top 5 services that are delivered to patients without any evidence of health benefit. The VA has taken up this call and promoted a program of "de-implementation" of unnecessary care. The Stroke QUERI has begun to examine and develop measures of overuse in ambulatory care.
Stroke is the fourth leading cause of death and a leading cause of disability among adults in the US and stroke prevention is an important focus of the Stroke QUERI. While significant attention has been paid to improving adherence to cholesterol lowering and antiplatelet agents through clinical reminders in the VA, less attention has been paid to the unnecessary use of these medications in secondary prevention of stroke and transient ischemic attack and the primary prevention of stroke and cardiovascular disease. Patients with limited life expectancy are commonly continued on cholesterol lowering agents despite a lack of benefit and a potential harm from drug-drug interactions, increased drug concentrations and muscle toxicity. Patients placed on Statins for primary prevention may never be "de-implemented" despite development of diseases that may significantly impact life expectancy. It is unclear how often Statins are used in populations that may not benefit in the VA.
In addition many patients are also provided with dual antiplatelet therapy after stroke despite the fact there is no evidence that dual antiplatelet therapy actually reduces the rate of subsequent stroke. In addition to a lack of benefit from this dual treatment, this combination therapy places patients at increased risk of bleeding complications and therefore is a clear target for de-implementation in the VA. In this RRP we propose to develop the research foundation necessary to develop two overuse measures that can be tracked and reported upon for the purposes of reducing unnecessary ambulatory care in the VA.
Aim1: To examine the unnecessary use of Statins for cardiovascular or stroke Prevention.
Aim 2: To examine the unnecessary use of dual antiplatelet therapy in secondary stroke prevention.
Using national data, we identified every patient who had received a new statin prescription (no statin use in the prior year) in the VA in 2012. Patients were excluded if they had incomplete data. Data on age, risk factors, and clinical conditions were extracted. Framingham and ACC-AHA 2013 cardiovascular risk calculator scores were calculated to determine estimates of 10-year risk for ASCVD for all patients. Statin use was compared with the recommendations of ATP III and the ACC-AHA guidelines. We considered all age ranges to be concordant with the guideline. Furthermore, for exploring the prevalence of inappropriate dual antiplatelet therapy in VA, all patients with a diagnosis of TIA or stroke in 2012 were identified. Patients with coronary artery disease or peripheral vascular disease were excluded and a cohort of patients with cerebrovascular disease without an indication for dual antiplatelet therapy were identified.
We identified 266,008 new statin prescriptions in 2012 in the VA, of which, 156,756 patients had complete data. Among statin prescriptions, 85% (133,434 of 156,756) were prescribed for primary prevention and 15% (23,322 of 156,756) were prescribed for secondary prevention. Mean age was 62 and 68 among patients receiving statins for primary and secondary prevention, respectively. The respective median Framingham risk score and ACC-AHA scores were 16 (IQR 10 to 20), and 19.26 (IQR 11to 32) among patients receiving statins for primary prevention. Among patients receiving statins for primary prevention, 23% (31,085 of 133,434) did not have an indication supported by the ATP III guidelines and 20% (26,413 of 133,434) did not have an indication supported by the ACC/AHA guideline. Within patients who received a statin for primary prevention, 9% (11,716 of 133,434) were less than 45 years old, 14% (18,210 of 133,434) were greater than 75 years old, 0.28% (373 of 133,434) were receiving dialysis, 2% (2,702 of 133,434) had evidence of terminal cancer or were receiving end of life care, and 0.06% (83 of 133,434) had evidence of severe congestive heart failure or severe chronic obstructive pulmonary disease.
Among veterans, the majority of statins are prescribed for primary prevention. One in 5 veterans received a statin for an indication not supported by either guideline. These findings present an opportunity to reduce inefficient care.
The results from prevalence of inappropriate dual antiplatelet therapy analysis show that from 37,684 patients 3% have received both Aspirin and Clopidogrel, 6.3% have received Aspirin and Dipyridamole and Clopidogrel, 0.02% have received Aspirin and Cilostazol, and 0.01% have received Clopidogrel and Cilostazol in an overlapping 6 months period in 2012. The prevalence of inappropriate dual antiplatelet therapy even in a window as large as 6 months is low.
Ineffective and unnecessary treatments expend resources that could be used elsewhere to improve the health of veterans. Low value use of statins is common in the VA and future work should focus on reducing low value statin use.
None at this time.