Abstract
INTRODUCTION: While prior studies have documented suboptimal lipid management and low rates of low-density lipoprotein cholesterol (LDL-C) goal achievement in patients with atherosclerotic cardiovascular disease (ASCVD), the degree of variability in lipid-lowering therapy (LLT) practice patterns between clinicians is less well described. METHODS: In this cohort study, we evaluated the use of LLTs and achievement of LDL-C <70 mg/dL among adults with ASCVD (coronary artery disease, peripheral arterial disease, or ischemic cerebrovascular disease) followed by a cardiology physician or advanced practice provider (APP) at a large academic medical center in north Texas from 01/01/22-06/30/24. LLT utilization and LDL-C goal achievement were modeled using mixed-effects logistic regression with clustering at the clinician level, adjusting for patient age, insurance, ASCVD type, and diabetes. We quantified clinician-level variability using the adjusted median odds ratios (aMORs) from these models. RESULTS: Among 9098 patients with ASCVD (median age 71.0 years, 61.6% male, 70.5% White) seen across 77 cardiology clinicians (56 physicians, 21 APPs), 52.8% were on a high-intensity statin, 17.1% were on ezetimibe, 7.8% were on novel LLT (proprotein convertase subtilisin/kexin type 9 monoclonal antibody, inclisiran, or bempedoic acid). Of those with an available lipid panel in the past year (n = 7122), 48.5% achieved an LDL-C <70 mg/dL. Lipid management strategies varied substantially across clinicians. In mixed-effects models adjusting for patient-level factors, significant clinician-level variation was observed in the use of high-intensity statins (aMOR 1.44, 95% CI 1.34-1.59), ezetimibe (aMOR 1.68, 95% CI 1.52-1.91), and novel LLT (aMOR 2.21, 95% CI 1.90-2.68). Variation in achieving LDL-C <70 mg/dL was more modest (aMOR 1.31, 95% CI 1.23-1.42). Sequential adjustment for clinician prescribing patterns explained nearly half of the observed variability in LDL-C goal achievement, reducing the aMOR to 1.16 (95% CI 1.09-1.27). CONCLUSION: We found suboptimal rates of high-intensity statin and LDL-C control among patients with ASCVD. Even among cardiology clinicians at the same academic medical center, practice patterns varied widely in using LLT and achieving LDL-C goals for secondary prevention. Understanding the reasons for this variability and standardizing lipid management across the specialty may improve quality of care for patients with ASCVD.