Use of a tiered review for evaluation of appropriate use of hydroxymethylglutaryl coenzyme A reductase-inhibitor therapy

Despite abundant evidence of the benefits of lipid lowering in reducing mor tality from all causes in high-risk patients with or without coronary arter y disease (CAD) and the wide availability of guidelines for targeting such patients more aggressively, there are indications that this population is s till being treated suboptimally. Our study sought to ascertain the appropri ateness of prescribing practices of the hydroxymethylglutaryl coenzyme A-re ductase (HMG-CoA) inhibitor pravastatin that was used at our facility at th e time. We conducted a drug utilization review of a randomly chosen sample of patients receiving prescriptions for pravastatin at the outpatient clini cs of a tertiary care, academically affiliated Veterans Affairs medical cen ter. The algorithm we used was based on National Cholesterol Education Prog ram Adult Treatment Panel-2 guidelines. Patient charts were reviewed for th e presence of CAD and standard cardiac risk factors and for lipid determina tions performed since 1986, when laboratory test results began to be compil ed electronically. The initial review was performed by a pharmacist; cases the pharmacist identified as involving possible suboptimal prescribing prac tices were subsequently reviewed and classified by a cardiologist. From the pharmacy database, we derived a random sample of 118 patients who were rec eiving doses >20 mg (high-dose cases) and 100 patients receiving doses of l ess than or equal to 20 mg (standard-dose cases). The pharmacist's review f ound 57 (48%) high-dose cases and 47 (47%) standard-dose cases that were qu estionable; the cardiologist's review of these cases determined that 43 (36 %) high-dose cases and 38 (38%) standard-dose cases involved suboptimal pre scribing practices. The deficiencies noted in patients receiving standard-d ose pravastatin were generally minor; however, 23% of the deficiencies note d in patients receiving high-dose therapy were serious ones that may have e xposed the patients to unnecessary therapy or caused a delay in their recei ving appropriate therapy. In conclusion, slightly more than one third of a randomly selected sample of patients treated with an HMG-CoA reductase inhi bitor at a tertiary care medical center were receiving suboptimal therapy. Suboptimal prescribing practices have both clinical and economic implicatio ns, and a tiered, multidisciplinary review process allows convenient monito ring of prescribing practices.