title: A cluster randomised controlled trial of a pharmacist-led collaborative intervention to improve statin prescribing and attainment of cholesterol targets in primary care.
abstract: BACKGROUND
  Small trials with short term follow up suggest pharmacists' interventions targeted at healthcare professionals can improve prescribing. In comparison with clinical guidance, contemporary statin prescribing is sub-optimal and achievement of cholesterol targets falls short of accepted standards, for patients with atherosclerotic vascular disease who are at highest absolute risk and who stand to obtain greatest benefit. We hypothesised that a pharmacist-led complex intervention delivered to doctors and nurses in primary care, would improve statin prescribing and achievement of cholesterol targets for incident and prevalent patients with vascular disease, beyond one year.
  
  
  METHODS
  We allocated general practices to a 12-month Statin Outreach Support (SOS) intervention or usual care. SOS was delivered by one of 11 pharmacists who had received additional training. SOS comprised academic detailing and practical support to identify patients with vascular disease who were not prescribed a statin at optimal dose or did not have cholesterol at target, followed by individualised recommendations for changes to management. The primary outcome was the proportion of patients achieving cholesterol targets. Secondary outcomes were: the proportion of patients prescribed simvastatin 40 mg with target cholesterol achieved; cholesterol levels; prescribing of simvastatin 40 mg; prescribing of any statin and the proportion of patients with cholesterol tested. Outcomes were assessed after an average of 1.7 years (range 1.4-2.2 years), and practice level simvastatin 40 mg prescribing was assessed after 10 years.
  
  
  RESULTS
  We randomised 31 practices (72 General Practitioners (GPs), 40 nurses). Prior to randomisation a subset of eligible patients were identified to characterise practices; 40% had cholesterol levels below the target threshold. Improvements in data collection procedures allowed identification of all eligible patients (n = 7586) at follow up. Patients in practices allocated to SOS were significantly more likely to have cholesterol at target (69.5% vs 63.5%; OR 1.11, CI 1.00-1.23; p = 0.043) as a result of improved simvastatin prescribing. Subgroup analysis showed the primary outcome was achieved by prevalent but not incident patients. Statistically significant improvements occurred in all secondary outcomes for prevalent patients and all but one secondary outcome (the proportion of patients with cholesterol tested) for incident patients. SOS practices prescribed more simvastatin 40 mg than usual care practices, up to 10 years later.
  
  
  CONCLUSIONS
  Through a combination of educational and organisational support, a general practice based pharmacist led collaborative intervention can improve statin prescribing and achievement of cholesterol targets in a high-risk primary care based population.
  
  
  BACKGROUND
  International Standard Randomised Controlled Trials Register ISRCTN61233866.
authors.affiliation: Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Glasgow, Scotland, United Kingdom.
authors.forename: Richard
authors.initials: R
authors.lastname: Lowrie
authors.affiliation: Robertson Centre for Biostatistics, Boyd Orr Building, University of Glasgow, Glasgow, Scotland, United Kingdom.
authors.forename: Suzanne M
authors.initials: SM
authors.lastname: Lloyd
authors.affiliation: Robertson Centre for Biostatistics, Boyd Orr Building, University of Glasgow, Glasgow, Scotland, United Kingdom.
authors.forename: Alex
authors.initials: A
authors.lastname: McConnachie
authors.affiliation: General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom.
authors.forename: Jill
authors.initials: J
authors.lastname: Morrison
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000924:Anticholesteremic Agents / Q000627:therapeutic use; D002318:Cardiovascular Diseases / Q000188:drug therapy* / Q000378:metabolism; D002784:Cholesterol / Q000378:metabolism; D011307:Drug Prescriptions / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D058006:General Practice / Q000706:statistics & numerical data; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D009726:Nurses / Q000706:statistics & numerical data; D017063:Outcome Assessment, Health Care / Q000379:methods / Q000706:statistics & numerical data; D010595:Pharmacists / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000379:methods / Q000706:statistics & numerical data*; D024382:Professional Role; D019821:Simvastatin / Q000627:therapeutic use
chemical_list: D000924:Anticholesteremic Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D002784:Cholesterol; D019821:Simvastatin