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Practicum setting and question
The practicum site is a federally qualified health center serving about 9,000 adults. The medical director asked whether eligible patients are being offered statins for the primary prevention of cardiovascular disease. The site and its figures are illustrative.
The standard
The US Preventive Services Task Force (2022) recommends that clinicians prescribe a statin for the primary prevention of cardiovascular disease for adults aged 40 to 75 who have one or more risk factors (dyslipidemia, diabetes, hypertension or smoking) and an estimated 10-year cardiovascular risk of 10% or more (a B recommendation). It recommends that clinicians selectively offer a statin to adults with the same risk factors and a 10-year risk of 7.5% to less than 10% (a C recommendation), and finds the evidence insufficient for adults aged 76 and older (an I statement).
Current practice
A review of 200 randomly selected charts of patients aged 40 to 75 without known cardiovascular disease found:
| Measure | Result |
|---|---|
| Patients with a 10-year risk score documented | 38% |
| Patients with risk ≥10% and at least one risk factor | 64 of 200 |
| Of those, prescribed a statin | 29 (45%) |
| Of those not prescribed, documented reason or shared decision | 6 of 35 |
The gap
Fewer than half of the patients for whom the USPSTF recommends a statin were prescribed one, and most charts didn't show that risk had been calculated or discussed. The gap is partly in risk assessment and partly in acting on it.
Root causes
Interviews with four providers, three nurses and two medical assistants, together with a fishbone diagram, identified:
- Workflow: risk calculators aren't built into the record, so calculating risk takes extra time.
- Visit pressures: short visits with several acute problems.
- Patient factors: concerns about side effects and cost.
- Data: lipid panels are often out of date.
SWOT analysis
| Strengths | Weaknesses |
|---|---|
| Strong nurse care-management team; generic statins on the clinic formulary at low cost | No risk calculator in the record; no population reports |
| Opportunities | Threats |
| Quality incentive measures that reward statin use; a new EHR upgrade planned | Staff turnover; competing quality priorities |
Proposed change for Practicum II
- Embed a risk calculator in the record that pulls age, blood pressure, lipids, diabetes and smoking status automatically.
- Create a registry of patients aged 40 to 75 with a risk of 10% or more and no statin.
- Nurse-led outreach with a standing order for lipid panels and a scripted shared decision-making conversation, with the provider making the final prescribing decision.
- Patient materials on benefits, common side effects and cost, in English and Spanish.
Measures
- Process: percentage of eligible patients with a documented risk score; percentage with a documented statin discussion.
- Outcome: percentage of patients with risk ≥10% and a risk factor who are prescribed a statin, with a target of 70% in 6 months.
- Balancing: patient-reported side effects; provider time per visit.
References
US Preventive Services Task Force. (2022). Statin use for the primary prevention of cardiovascular disease in adults: US Preventive Services Task Force recommendation statement. JAMA, 328(8), 746–753. https://doi.org/10.1001/jama.2022.13044
