[Application of medical guidelines for the prescription of statins].
BACKGROUND
The efficacy of statins to prevent coronary heart disease (CHD) is well documented. This class of lipid-lowering drugs is now widely prescribed and was demonstrated to be cost effective in high risk patients.


OBJECTIVE
To assess the appropriateness of statins use, regarding initiation and follow-up of the treatment, as compared to the guidelines elaborated in 1996 by National Agency for the Development of Medical Evaluation (ANDEM). These guidelines were based on stratification of patients according to cardiovascular risk.


METHODS
Two groups of patients living in Ile-de-France region were defined, using Health Insurance computer database, on reimbursements. The first group named "new users" included patients in whom statin therapy was initiated during March 2000. The second group named "long term users" included patients who have been treated by statin therapy for one year or more. A sample of patients were randomly selected among these two groups. Trained Health Insurance advisors analyzed in depth the patients medical history and diet. All biological results were recorded and a complete history of medical therapy was assessed for each patient. An algorithm allowed the advisor to rate for nonadherence according to French medical guidelines.


RESULTS
"New users": the random sample consisted of 460 patients, among whom 398 (87%) were free of CHD in whom the nonadherence rate was 72.4% (68.0% to 76.8%). Nonadherence concerned: LDL cholesterol level not tested (32%) and/or absence of prior fat-free diet (37%) and/or LDL cholesterol value before drug therapy was below the guidelines/threshold. "Long term users": the random sample consisted of 582 patients, among whom 381 (65%) were free of CHD. The nonadherence rate was 71.1% (66.5% to 75.7%). In addition, the nonadherence rate for patients in secondary prevention was 82.1% (79.7% to 84.6%) respectively, corresponding to: LDL cholesterol level not tested (41% and 34%); and/or no change dietary (18% and 12%); and/or unreach the LDL-C target level (24% and 45%).


CONCLUSIONS
This study shows that the implementation of guidelines needs to be improved in clinical practice.
Chevalier
C
C
Service Médical Assurance-Maladie Ile-de-France, CNAMTS, 22, avenue Karl-Marx, 93016 Bobigny Cedex, France.
Giral
P
P
Chinaud
F
F
Carzon
M
M
Gartenlaub
D
D
Blanchon
B
B
Trutt
B
B
D000465:Algorithms; D008078:Cholesterol, LDL / Q000097:blood; D003663:Decision Trees; D018752:Diet, Fat-Restricted; D011307:Drug Prescriptions / Q000592:standards*; D017723:Drug Utilization Review; D005260:Female; D005602:France; D019983:Guideline Adherence / Q000592:standards*; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D006937:Hypercholesterolemia / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D008297:Male; D008875:Middle Aged; D020380:Needs Assessment; D017410:Practice Guidelines as Topic / Q000592:standards*; D012307:Risk Factors
D008078:Cholesterol, LDL; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors