Guideline-recommended statin treatment ‘hampered’ by clinician beliefs

Clinicians’ personal beliefs about the safety and efficacy of statins play a larger role in their likelihood of prescribing the medications than their knowledge of cholesterol guidelines, according to a study published Jan. 4 in the American Journal of Cardiology.

Angela Lowenstern, MD, and colleagues with Duke Clinical Research Institute surveyed 774 physicians and advanced practice providers about their knowledge of the 2013 American College of Cardiology/American Heart Association cholesterol guidelines, their belief in the benefits of statins and their safety concerns with the drugs. Clinicians were considered to have good guideline knowledge if they answered at least three of four hypothetical scenarios in concordance with guideline recommendations.

Nearly two-thirds of clinicians demonstrated good guideline knowledge—63.9 percent—but that didn’t have a significant effect on whether their patients received statins or achieved LDL cholesterol levels below 100 mg/dL. The study included 6,839 patients treated by the surveyed clinicians, including 5,312 who met a guideline indication for primary or secondary prevention with statins.

Clinicians’ answers regarding beliefs about the safety and effectiveness of statins, however, appeared to influence their prescribing patterns. Patients of clinicians who reported strong belief in the benefit of statins were more likely to receive guideline-recommended doses of the medications (41.9 percent versus 36.9 percent), and concerns about safety were even more impactful on treatment strategies and cholesterol-lowering efforts.

Physicians or advanced practice providers who expressed safety concerns prescribed guideline-recommended intensities of statins less often—36.8 percent of the time compared to 42.5 percent for other clinicians. Their patients were also 25 percent less likely to have LDL cholesterol below 100 mg/dL after multivariable adjustment.

“This study shows that uptake of one of the most studied cardiovascular medication groups, with clear treatment benefit, remains hampered by underlying clinician beliefs rather than a lack of guideline knowledge,” Lowenstern et al. wrote. “Clinically, this translates to large groups of patients receiving suboptimal care, for primary and secondary prevention of ASCVD (atherosclerotic cardiovascular disease). While current health system-based initiatives are testing interventions to increase clinician awareness of treatment eligibility, broader initiatives to address clinicians’ underlying beliefs and biases are needed.”

Cardiologists, who represented 48.8 percent of clinicians surveyed, were more likely to believe in the benefits of statins and less likely to be concerned about their safety compared to non-cardiologists and clinicians in academic settings.

The study was limited by its observational nature, along with providers’ reasoning for specific treatment decisions being unavailable. Because of this, the authors weren’t able to assess whether clinician-patient risk discussions took place or whether statin therapy was avoided due to prior medication intolerance.  

Still, they believe this report highlights a reason why many guideline-indicated patients go untreated.

“Interventions specifically targeting these underlying clinician beliefs and ongoing discussions of the benefit-to-risk ratio of statin medications will be important to continue improving the guideline-directed care of patients,” Lowenstern and coauthors wrote.