Multipronged approach pushed to optimize statin therapy in Singapore

There are several important barriers to statin therapy optimization among patients with hyperlipidaemia who are at very high risk of cardiovascular disease (CVD), as reported by a group of local researchers.

These barriers, such as patients’ lack of knowledge and awareness and time constraints during a consult, are complex and act at various levels, highlighting the importance of a multipronged approach.

“Although an approach tailored to meet the needs of individual patients may be ideal, strategies that could address barriers across several domains and build on facilitators identified by the primary care physicians (PCPs) in our study may prove to be more effective than those addressing barriers in a single domain. This in turn would lead to improved patient outcomes,” according to the researchers.

Multilevel domains

For the study, seven male and five female PCPs across four polyclinics in a public primary care institute in Singapore were interviewed to explore the barriers PCPs faced when optimizing statin therapy in patients with hyperlipidaemia in the very high-risk group. The resulting data revealed that barriers existed across the individual, interpersonal, organizational, and community and public policy levels.

The major barriers to statin optimization included patients’ lack of knowledge and awareness and patients’ fear of side effects (individual factors); negative external influences on patients and poor doctor–patient relationship (interpersonal factors); time constraint during consultations and physicians’ unfamiliarity with guidelines (organizational factors); and low health literacy among the local population and lack of strong national policy (community and public policy factors). [BMJ Open 2023;13:e073125]

On the other hand, the major facilitators identified were patient education, providing continuity of care, improving electronic medical record systems’ capabilities, physician education and public education.

Individual and interpersonal domains

“Lack of knowledge and awareness is universally recognized as a barrier to medication adherence,” the researchers pointed out. [Br J Gen Pract 2018;68:e408-e419; PLoS One 2018;13:e0191817]

“PCPs in our study acknowledged that patients’ lack of understanding of their illness and negative consequences of suboptimal control like cardiovascular events were major barriers to medication adherence. They felt that patients were reluctant to initiate statins out of fear of drug dependence, side effects, and increased pill burden,” they said.

It also doesn’t help that medication adherence is influenced by the patients’ cultural beliefs. For example, the notion of modern medicines as harms and fatalistic orientations towards escalation of doses and polypharmacy. [Front Pharmacol 2023;14]

“Importantly, these beliefs about medicines have been shown to be potentially modifiable by patient education and counselling. Some strategies that could be employed include using familiar language for patient education, patient empowerment on the benefits of medication optimisation, and combining individual risk assessment using computer programs with a shared decision-making process,” according to the researchers. [Clin Ther 2011;33:1180-1189; Front Pharmacol 2023;14; CJC Open 2020;2:530-538]

Public policy domains

Meanwhile, the limited time available to physicians is a recurring challenge that makes it difficult to fully implement multiple interventions, including statin optimization.

“Many PCPs in our study who manage patients with multiple medical issues prefer to prioritize the more urgent problems and leave statin therapy optimization to the next visit. Furthermore, they also felt that the inefficiencies of the electronic medical record systems contributed to the time constraint and suggested the use of artificial intelligence capacity in information gathering and documentation in these systems,” the researchers stated.

One strategy to overcome physician time constraints, as described in a previous study, is by incorporating a team-based approach with different team members working together with a harmonized protocol, with a goal to monitor and reinforce adherence. Another solution is to have a robust electronic medical record, with a reminder trigger system that activates once nonadherence in a patient is detected. [J Am Coll Cardiol 2015;66:184-192]

In the current study, the PCPs also acknowledged that unfamiliarity with clinical practice guidelines could affect how physicians risk stratify patients and approach statin optimization, and that there is not enough national attention or effort to combat hyperlipidaemia as opposed to diabetes mellitus.

To address such issues, the PCPs themselves suggested attending regular continuing medical education (CME) sessions to stay up to date on the latest hyperlipidaemia guidelines. They also mentioned the importance of engaging with a variety of stakeholders, such as the Ministry of Health, Ministry of Finance, pharmaceutical companies, patients, caregivers, societies, and academia, to develop a national roadmap for hyperlipidaemia management that is tailored to the local context and needs.