Patterns of statin initiation, intensification, and maximization among patients hospitalized with an acute myocardial
Suzanne V Arnold1, Mikhail Kosiborod, Fengming Tang
1From Saint Luke's Mid America Heart Institute, Kansas City, MO (S.V.A., M.K., F.T., J.A.S.); Eli Lilly, Indianapolis, IN (Z.Z., P.L.M., J.B.); and Eastern Colorado Health Care System, Denver, CO (T.M.M.).
Insights
Hospital initiation of statin therapy after acute myocardial infarction is high and consistent. However, intensifying and maximizing statin use varies significantly across hospitals, suggesting a need for improved quality measures.
Area of Science:
- Cardiology
- Pharmacology
- Health Services Research
Background:
- Intensive statin therapy significantly reduces morbidity and mortality post-acute myocardial infarction (AMI).
- While statin prescription rates are tracked, variations in initiating, intensifying, and maximizing statin therapy after AMI are not well understood.
- Understanding these variations is crucial for optimizing patient outcomes.
Purpose of the Study:
- To assess hospital-level variations in statin therapy initiation, intensification, and maximization among acute myocardial infarction patients.
- To identify potential areas for quality improvement in post-AMI statin management.
- To evaluate the consistency of statin therapy intensity across different healthcare facilities.
Main Methods:
- Analysis of data from 4340 acute myocardial infarction patients across 24 US hospitals (2005-2008).
- Utilized hierarchical models to estimate site variation in statin initiation (naïve patients), intensification (submaximal therapy), and discharge on maximal therapy.
- Employed median rate ratios to quantify inter-hospital variability after adjusting for patient factors.
Main Results:
- Statin initiation occurred in 87% of eligible, statin-naïve AMI patients with no significant hospital variation (median rate ratio, 1.02).
- Statin intensification was observed in 26% of patients on submaximal therapy, showing modest hospital variability (median rate ratio, 1.47).
- Only 23% of eligible patients were discharged on maximal statin therapy, with substantial hospital variability (median rate ratio, 2.79).
Conclusions:
- Nearly 90% of AMI patients received statin initiation during hospitalization, with uniform rates across hospitals.
- Rates of statin intensification and maximization post-AMI were low and exhibited significant variability among hospitals.
- Revising quality performance measures to incorporate statin therapy intensity could enhance patient care and outcomes.
Background:
Intensive statins are superior to moderate statins in reducing morbidity and mortality after an acute myocardial infarction. Although studies have documented rates of statin prescription as a quality performance measure, variations in hospitals' rates of initiating, intensifying, and maximizing statin therapy after acute myocardial infarction are unknown.
Methods And Results:
We assessed statin use at admission and discharge among 4340 acute myocardial infarction patients from 24 US hospitals (2005-2008). Hierarchical models estimated site variation in statin initiation in naïve patients, intensification in those undergoing submaximal therapy, and discharge on maximal therapy (defined as a statin with expected low-density lipoprotein cholesterol lowering ≥ 50%) after adjustment for patient factors, including low-density lipoprotein cholesterol level. Site variation was explored with a median rate ratio, which estimates the relative difference in risk ratios of 2 hypothetically identical patients at 2 different hospitals. Among statin-naïve patients, 87% without a contraindication were prescribed a statin, with no variability across sites (median rate ratio, 1.02). Among patients who arrived on submaximal statins, 26% had their statin therapy intensified, with modest site variability (median rate ratio, 1.47). Among all patients without a contraindication, 23% were discharged on maximal statin therapy, with substantial hospital variability (median rate ratio, 2.79).
Conclusions:
In a large, multicenter acute myocardial infarction cohort, statin therapy was begun in nearly 90% of patients during hospitalization, with no variability across sites; however, rates of statin intensification and maximization were low and varied substantially across hospitals. Given that more intense statin therapy is associated with better outcomes, changing the existing performance measures to include the intensity of statin therapy may improve care.
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