Statin Prescribing Patterns During In-Person and Telemedicine Visits Before and During the COVID-19 Pandemic.

Abstract

HomeCirculation: Cardiovascular Quality and OutcomesVol. 14, No. 10Statin Prescribing Patterns During In-Person and Telemedicine Visits Before and During the COVID-19 Pandemic Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBStatin Prescribing Patterns During In-Person and Telemedicine Visits Before and During the COVID-19 Pandemic Atsushi Mizuno, MD, MBA, MHCI, PhD, Mitesh S. Patel, MD, MBA, Sae-Hwan Park, PhD, Allison J. Hare, BS, Tory O. Harrington, MHCI and Srinath Adusumalli, MD, MSHP, MBMI Atsushi MizunoAtsushi Mizuno Correspondence to: Atsushi Mizuno, MD, MBA, MHCI, PhD, Penn Medicine Nudge Unit, University of Pennsylvania, 3400 Civic Center Blvd, 14-176 South Pavilion, Philadelphia, PA 19104. Email E-mail Address: [email protected] https://orcid.org/0000-0002-7596-7633 Penn Medicine Nudge Unit (A.M., M.S.P., S.-H.P., A.J.H., T.O.H., S.A.), University of Pennsylvania, Philadelphia. Search for more papers by this author , Mitesh S. PatelMitesh S. Patel Penn Medicine Nudge Unit (A.M., M.S.P., S.-H.P., A.J.H., T.O.H., S.A.), University of Pennsylvania, Philadelphia. Perelman School of Medicine (M.S.P., A.J.H., T.O.H., S.A.), University of Pennsylvania, Philadelphia. The Wharton School (M.S.P.), University of Pennsylvania, Philadelphia. Crescenz VA Medical Center, Philadelphia, PA (M.S.P.) Search for more papers by this author , Sae-Hwan ParkSae-Hwan Park https://orcid.org/0000-0001-5297-5502 Penn Medicine Nudge Unit (A.M., M.S.P., S.-H.P., A.J.H., T.O.H., S.A.), University of Pennsylvania, Philadelphia. Search for more papers by this author , Allison J. HareAllison J. Hare https://orcid.org/0000-0002-7921-222X Penn Medicine Nudge Unit (A.M., M.S.P., S.-H.P., A.J.H., T.O.H., S.A.), University of Pennsylvania, Philadelphia. Perelman School of Medicine (M.S.P., A.J.H., T.O.H., S.A.), University of Pennsylvania, Philadelphia. Search for more papers by this author , Tory O. HarringtonTory O. Harrington Penn Medicine Nudge Unit (A.M., M.S.P., S.-H.P., A.J.H., T.O.H., S.A.), University of Pennsylvania, Philadelphia. Perelman School of Medicine (M.S.P., A.J.H., T.O.H., S.A.), University of Pennsylvania, Philadelphia. Search for more papers by this author and Srinath AdusumalliSrinath Adusumalli Penn Medicine Nudge Unit (A.M., M.S.P., S.-H.P., A.J.H., T.O.H., S.A.), University of Pennsylvania, Philadelphia. Perelman School of Medicine (M.S.P., A.J.H., T.O.H., S.A.), University of Pennsylvania, Philadelphia. Search for more papers by this author Originally published23 Sep 2021https://doi.org/10.1161/CIRCOUTCOMES.121.008266Circulation: Cardiovascular Quality and Outcomes. 2021;14Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: September 23, 2021: Ahead of Print Statins have been demonstrated to reduce major adverse cardiovascular events, including mortality. About half of patients meeting guideline-based indications for statin therapy have not been prescribed the medication.1 Recently, the coronavirus disease 2019 (COVID-19) pandemic brought about structural changes in care delivery, including rapid adoption of telemedicine for primary and hyperlipidemia care.2 Quality of care delivered via telemedicine visits during the COVID-19 pandemic has not been well-evaluated. In this study, our objective was to evaluate statin prescribing rates for eligible patients before and during the COVID-19 pandemic while care was being delivered through in-person and telemedical channels.We conducted a retrospective evaluation of statin prescribing rates by primary care physicians at 28 Penn Medicine practice sites in Pennsylvania and New Jersey from October 2019 to September 2020 for patients eligible but not already prescribed a statin. The data that support the findings of this study are available from the corresponding author upon reasonable request. Eligibility criteria developed by our health system were defined as (1) clinical atherosclerotic cardiovascular disease diagnosis; (2) history of familial hyperlipidemia; or (3) meeting the United States Preventive Services Task Force guidelines for statin therapy which includes age 40 to 75 years, at least one cardiovascular risk factor (eg, dyslipidemia, diabetes, hypertension, and smoking), and 10-year atherosclerotic cardiovascular disease risk score ≥10%. Patients were excluded if they (1) were already prescribed a statin; (2) were allergic to statins; (3) had a glomerular filtration rate <30 mL/min or were on dialysis; (4) had a prior adverse reaction to statins (including significant liver dysfunction, rhabdomyolysis, or other intolerance to statin); (5) were pregnant; (6) were breastfeeding; (7) were on hospice or at the end-of-life; or (8) were on a PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor medication. Monthly changes in the rate of new statin prescribing were evaluated throughout the study period. Multivariate models considering monthly interactions were fit using generalized estimating equations clustered by primary care physicians alone and adjusted for age, sex, race/ethnicity, median household income, and statin-intensity indication (moderate or high).3 This study was approved by the University of Pennsylvania Institutional Review Board. Analyses were conducted by using R version 4.0.2 (R Foundation for Statistical Computing).The sample comprised 158 primary care physicians and 20 374 patient encounters with mean (SD) patient age of 65.8 (11.0) years; 49.4 % were male. Clinical atherosclerotic cardiovascular disease diagnosis, history of familial hyperlipidemia, and 10-year atherosclerotic cardiovascular disease risk score ≥10% were observed in 5442 (26.7%), 104 (0.5%), and 14 930 (73.3%) encounters, respectively. In-person visit volumes declined during the start of the COVID-19 pandemic while telemedicine visit volumes increased. Telemedicine visits peaked in April 2020 and accounted for 21.9% (N=4467) of the visits during the study period. Among in-person visits, the overall new statin prescribing rate was 3.1%, decreasing from March but recovering to the previous level around August (Figure). The overall statin prescribing rate for telemedicine visits was 3.2%. In adjusted models, statin prescribing rates were significantly higher during telemedicine visits than in-person visits during April 2020 (odds ratio, 2.10 [95% CI, 1.01–4.37]; P=0.047) and May 2020 (odds ratio, 2.32 [95% CI, 1.02–5.29]; P=0.044). There was no significant difference in prescribing rates between telemedicine and in-person visits during the rest of the study period.Download figureDownload PowerPointFigure. Prescription rate among eligible patients. Solid blue bars represent total number of office visits, while dotted green bars represent total number of telemedicine visits. Solid blue line represents statin prescription rate during office visits, while dotted green line represents statin prescription rate during telemedicine visits.In this study, we found that overall statin prescribing rates were low, presenting an opportunity to improve the delivery of care. Decreased rates of in-person visits during the COVID-19 pandemic were offset by an increased rate of telemedicine visits. During the early pandemic period (April 2020 to May 2020), statin prescription rates were the same or higher during telemedicine visits as compared to in-person visits. This may indicate hyperlipidemia management is an effective use case for telemedical care delivery, particularly as the management of this condition does not always require a physical examination.4 Clinicians may also have had more time during telemedicine visits to address chronic conditions like hyperlipidemia as compared to in-person visits. This study has several limitations, including its observational design in a single academic health system and selection bias due to its retrospective nature. As the volume of telemedicine visits decreased in later months, we may have had less power to test for differences in prescribing rates relative to in-person visits. Additionally, among several available guidelines for management of hyperlipidemia, our health system adopted the United States Preventive Services Task Force guidelines in clinical practice, which could result in limited generalizability. Finally, the overall statin prescribing rate during this study may have been lower due to patient difficulty in obtaining cholesterol testing during the COVID-19 pandemic, which we were not able to directly assess.5 Future studies are needed to examine quality of care as clinicians and patients gain more experience with telemedicine.Nonstandard Abbreviations and AcronymsCOVID-19coronavirus disease 2019PCSK9proprotein convertase subtilisin/kexin type 9AcknowledgmentsDr Mizuno had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.Sources of FundingThis project was funded by the National Institute on Aging (R33AG057380) and the University of Pennsylvania Health System through the Penn Medicine Nudge Unit. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the article; and decision to submit the article for publication.Disclosures Dr Patel is the founder of Catalyst Health, a technology and behavior change consulting firm, and is on the medical advisory board for Healthmine Services, Life.io, and Holistic Industries. The other authors report no conflicts.FootnotesFor Sources of Funding and Disclosures, see page 1093.Correspondence to: Atsushi Mizuno, MD, MBA, MHCI, PhD, Penn Medicine Nudge Unit, University of Pennsylvania, 3400 Civic Center Blvd, 14-176 South Pavilion, Philadelphia, PA 19104. Email [email protected]upenn.edu