Abstract
BackgroundSince 2014 English national guidance recommends ‘high-intensity’ statins, reducing low-density lipoprotein (LDL) cholesterol by ≥40%.AimTo describe trends and variation in low-/medium-intensity statin prescribing and assess the feasibility of rapid prescribing behaviour change.Design and settingA retrospective cohort study using OpenPrescribing data from all 8142 standard NHS general practices in England from August 2010 to March 2019.MethodStatins were categorised as high- or low-/medium-intensity using two different thresholds, and the proportion prescribed below these thresholds was calculated. The authors plotted trends and geographical variation, carried out mixed-effects logistic regression to identify practice characteristics associated with breaching of guidance, and used indicator saturation to identify sudden prescribing changes.ResultsThe proportion of statins prescribed below the recommended 40% LDL-lowering threshold has decreased gradually from 80% in 2011/2012 to 45% in 2019; the proportion below a pragmatic 37% threshold decreased from 30% to 18% in 2019. Guidance from 2014 had minimal impact on trends. Wide variation was found between practices (interdecile ranges 20% to 85% and 10% to 30% respectively in 2018). Regression identified no strong associations with breaching of guidance. Indicator saturation identified several practices exhibiting sudden changes towards greater guideline compliance.ConclusionBreaches of guidance on choice of statin remain common, with substantial variation between practices. Some have implemented rapid change, indicating the feasibility of rapid prescribing behaviour change. This article discusses the potential for a national strategic approach, using data and evidence to optimise care, including targeted education alongside audit and feedback to outliers through services such as OpenPrescribing.
Highlights
This article discusses the potential for a national strategic approach, using data and evidence to optimise care, including targeted education alongside audit and feedback to outliers through services such as OpenPrescribing
Statins are very widely used to control serum cholesterol and reduce the risk of cardiovascular disease (CVD), with up to 7 million of the UK population (64.6 million) taking them in 2014.1 This makes statins the most commonly prescribed class of drugs in England, with 72.5 million prescriptions costing >200 million GBP dispensed during 2017.2,3 The 2014 guidance on lipid modification by the National Institute for Health and Care Excellence (NICE)[4] recommends the use of high-intensity statins, capable of reducing low-density lipoprotein (LDL) cholesterol by ≥40%, for both primary and secondary prevention.[5]
When measuring the proportion under a pragmatic 37% reduction threshold, to account for patients not being reviewed/ switched if they were already on statins very close to the NICE threshold, the proportion declined from a peak of 30% in 2013 to 18% in 2019 (Figure 1b)
Summary
Statins are very widely used to control serum cholesterol and reduce the risk of cardiovascular disease (CVD), with up to 7 million of the UK population (64.6 million) taking them in 2014.1 This makes statins the most commonly prescribed class of drugs in England, with 72.5 million prescriptions costing >200 million GBP dispensed during 2017.2,3 The 2014 guidance on lipid modification by the National Institute for Health and Care Excellence (NICE)[4] recommends the use of high-intensity statins, capable of reducing low-density lipoprotein (LDL) cholesterol by ≥40%, for both primary and secondary prevention.[5] This recommendation was made on the basis that higher-intensity treatment offers substantially greater reduction in cardiovascular risk, with similar adverse effects and cost. Fluvastatin is medium-intensity at its highest dose; and pravastatin is low-intensity at all doses. 2014 English national guidance recommends ‘high-intensity’ statins, reducing low-density lipoprotein (LDL) cholesterol by ≥40%
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