Background
Methods
Study setting
Procedures
Measures
Analysis
Results
Participant Type | All | Clinic Type | ||||||||
---|---|---|---|---|---|---|---|---|---|---|
Federally Qualified Health Center (FQHC) | Non-FQHC Community Clinic (CC) | County Ambulatory Care Clinic (CACC) | Hospital-based CACC (CACC-Hospital) | |||||||
N = 37 | N = 19 | N = 4 | N = 4 | N = 10 | ||||||
N | % | N | % | N | % | N | % | N | % | |
Clinic Leadership (Chief Medical Officer, Executive Director, Program Manager) (CL) | 6 | 14% | 4 | 21% | 1 | 25% | 1 | 25% | 0 | 0% |
Infectious Disease Specialist (ID) | 12 | 35% | 3 | 16% | 0 | 0% | 1 | 25% | 8 | 80% |
Primary Care Physician (PCP) | 6 | 14% | 2 | 11% | 1 | 25% | 1 | 25% | 2 | 20% |
Primary Care Physician–HIV Specialty (PCP-HIV) | 6 | 16% | 5 | 26% | 1 | 25% | 0 | 0% | 0 | 0% |
Primary Care Assistant or Nurse Practitioner (PA, NP) or Registered Nurses (RN)a | 7 | 16% | 5 | 26% | 1 | 25% | 1 | 0% | 0 | 0% |
Themes
Domain 1: current practices
Theme 1: CVD risk assessment for PLWH is considered standard practice, but there are several impediments to regular assessment
However, a handful of providers indicated that they are not always able to screen regularly for CVD risk among their PLWH patients due to several factors including having limited time, the clinic focus being more on treating HIV/AIDS than more general primary care, or lack of continuity between providers.I see it as a part of providing good primary care and always thinking about whether patients should be on a statin. I probably check cholesterol more than I should, telling people about it and exercise and healthy lifestyle and quitting smoking. I think it’s a very, very prominent part of my practice, just in general, controlling cardiovascular risk factors, counseling and thinking about optimizing prevention. (ID, FQHC)
I have to say that it is probably not the primary goal of the clinic just because we’re trying to do so many different things but as patients get older and they begin dealing with things like diabetes and hypertension it gets on [the] radar screen … (ID, CACC-Hospital)
Theme 2: there is variation in and uncertainty around frequency of CVD risk assessment
Well, we try to do [CVD risk assessment], at the very minimum, it’s yearly. I like to do them a little bit more often, so six months or so. (PA/NP/RN, FQHC)
I get a complete set of labs, including the lipid panel, probably every three months. (PCP-HIV, CACC)
Theme 3: Most providers use the atherosclerotic cardiovascular disease (ASCVD) risk calculator, but some are unsure of whether risk adjustments are needed for PLWH; practices vary within clinics and across providers
Other providers said they use the calculator on occasion “just to plug in the numbers” to facilitate discussing risk projections with patients.I usually do a lipid panel. You know, obviously we know whether they’re smoking or not. Then I do a CVD risk calculation. If it’s 7.5% or higher, I offer them a statin. (PCP-HIV, FQHC)
Some providers adjust the risk threshold to account for increased risk for CVD from HIV; others expressed being uncertain about whether or how to adjust the calculator for HIV.I like to go over all the results in the lipid panel, depending on their age, if they’re in that 40 to 70 or so range, then, if they are smoking or anything, I’ll talk about that, pull up the risk factors for it, and pull up the values right there, and just go in with them and say, “Hey, for the next ten years, this is what your risk would be,” and basically have that discussion with them, and that’s, you know, it’s going to, for the HIV patients, it’s another, I guess, I don’t remember all the tools they’re using for HIV, but I still plug in their other things, their smoking history, their age, their HDL values, their LDL values, and have that discussion with them. Now, I don’t do it on every single patient. It really depends on, you know, what I have on their history and then, what their lab values are. (PA/NP/RN, FQHC)
I mean we do talk about cardiovascular risk appearing to be greater in people with HIV even treated and suppressed. And – but I still use that calculator as sort of like the best available tool and might consider their risk even higher depending on their comorbidities and their age, and then maybe the duration of HIV infection. (ID, FQHC)
After we obtain labs for example we generally do use, some people still use the Framingham, but other people use the ASCVD scores to try and calculate whether or not they would benefit from a statin but we also know that it does not factor in HIV into those the ASCVD, and Framingham scores. And sometimes we just base it on a personal judgement based on patients own risk factors, any family history etcetera, etcetera. (PCP, FQHC)
Similarly, some participants were unsure if substance use, such as methamphetamines, cocaine, and opioids, requires adjusting a patient’s risk score or statin treatment and noted lack of guidelines.But it's probably more just about … we go off of like the lipid panel and ASCVD. Those are for the general population and not for HIV-specific populations. I'm not exactly sure for the coverage, and HIV-specific population guideline. (ID, CACC-Hospital)
A few providers said they never use the calculator. Some providers not using the calculator had an apologetic tone and wondered if they should be using it regularly.I would say maybe the third [resource needed] would be lack of guidelines for how the guidelines are different for patients with HIV or patients who have used meth for years now. You would think that those presumably would be higher priority for statin use. There’s no real difference in the guideline right now I don’t think. (PCP-HIV, FQHC)
You know I honestly do not it use [the ASCVD risk calculator]. But I would say I should. But I'll be honest I do not use it. I think I use it once or twice in the last couple of years. So, no, to be honest, I don't. (PCP, CACC-Hospital)
Theme 4: Most providers reported that they prescribe statins for their PLWH patients but there is variation in prescribing practices
I don't always feel super strongly that they go on a statin. So, I give them enough to allow them to help with their decision versus other patients, but I don't feel super strongly. You know, I rate them differently so that I ensure they get started on statin. So, I think it just depends on your patient population, because in general, my patient population being a little bit younger, definitely don’t want to take another medication. I don't feel super strongly about it … but in older people, I feel strongly, then I'll play it differently to work harder to get them on a statin, and usually, that can happen. (ID, CACC-Hospital)
I do [regularly prescribe statins]. I feel like if I don’t it’s because more of a time constraint that I missed it kind of thing rather than a lack of desire to do it. (PCP-HIV, FQHC)
Domain 2: characteristics of statins
Theme 1: participants believe that statins are effective for PLWH and easy to prescribe
Most participants believe statins are relatively easy to prescribe. Several participants described the overall process involving electronic ordering, communicating with the pharmacy, and billing as straightforward and easy to navigate. A few noted that prescribing statins is easier and more straightforward than prescribing other medications.I mean, I think they are the best tool that we have. They do reduce most people’s cholesterol, and then they you know have an anti-inflammatory aspect as well, on top of the effects on the LDL directly. So, I think they’re pretty good. (ID, CACC-Hospital)
Theme 2: providers generally believe that stains are more effective than lifestyle changes alone
I mean we set sort of goals, like if their – if we can't modify their risk, like quantify it in terms of the cholesterol or stopping smoking in a certain timeframe, it's usually starts at it like six months. Then we will – you know, like as – like you have six months and then if we take it to where we need to be, then we'll start a statin. So, usually like a time frame on it. (ID, FQHC)
So I will first – and depending on how high their – how bad those [ASCVD score] numbers are, I will first talk to them about, like just healthier eating, exercise. I know that they may not have a lot of choices down here in these areas, just at the shelters. They don't have a lot of choice to food and what's served to them. And we can talk about whether or not they can make better choices with the limited options they have. So you don't have the second piece of cake … have one piece of cake or you drink water instead of soda. So we'll talk about things like that. For some of them where it's just not working, then I will go ahead and I will put them on medication and we'll still talk about, "You should still try to eat healthy. You should still try to exercise. This is not like, you can take a pill and do whatever you want." I've had some people actually think that. (PA/NP/RN, FQHC)
Theme 2: many providers have concerns about drug-drug interactions (DDI) between statins and antiretroviral medications, but concerns typically do not limit statin prescribing
I think before all these newer HAART regimens there was always this question of can I prescribe a statin, is there drug-drug interactions, which statin is the best to use, which statin isn’t. And that’s probably more back in like 2015, or 2014 when it was little tougher. But kind of know with the newer single tablet regimen, it doesn’t seem to be that big of a deal. (PCP, CACC-Hospital)
Others noted concern about interactions with specific types of antiretroviral medications and noted that they choose the statin and dosage based on which HIV medications the patient is taking.If they’re on one [HIV regimen] that doesn’t really interact with the statins, then of course, it’s very easy. That’s really the wave of the future, if the patient’s on – have HIV patients on HIV regimens that don’t really interact with the liver system that metabolizes the statins, but there are going to be some people that are still on some of the older drugs that do interact. So, in those patients on the older regimens, where there’s the DDI, it can be a little bit more challenging to get them on, you know, perhaps more aggressive statins that do interact with that system. (ID, CACC-Hospital)
Yeah, because we’re HIV [doctors], a lot of my patients are either on a booster PI or they’re on an integrase inhibitor. So generally we use Lipitor at a lower dose, but it’s either going to be Lipitor or Crestor. (PCP, Community Clinic)
Theme 3: atorvastatin is the preferred statin for PLWH, but statin preferences and rationale for using them vary
Reasons for medication preferences include perceptions that some are more tolerable with older or any antiretroviral therapies (pravastatin); are more effective generally (atorvastatin, rosuvastatin), have the most evidence, greater availability and more insurance coverage (atorvastatin); are better for prescribing at lower doses (atorvastatin), and are better for people with “higher [ASCVD] numbers” (rosuvastatin). One participant noted that some PCPs prescribe simvastatin for PLWH, which he believed doesn’t work well for PLWH on antiretroviral therapy and noted difficulties when PWLH come to an HIV clinic with prescriptions from PCPs not treating PLWH.“Well, I think the ones here there’s atorvastatin, pravastatin, I think those are the ones that have less drug interactions than some of the other ones.” (ID, CACC-Hospital)
Domain 3: characteristics of providers
Theme 1: providers indicated knowledge gaps and a need for standard of care information
I mean, some are stronger than others. I know people who are living with HIV probably have a higher risk of cardiovascular disease, so I don’t know if they should be prescribed more. I think that hasn’t been really determined yet how we would preferentially give them more, how the calculation would be different. (PCP-HIV, FQHC)
Perhaps what I'd like to do is a very simple algorithm that could be used in when to start the medication .... I think I know most of it … So, I think kind of simple flow chart of describing statins, which statin is the preferred statin. And perhaps how to adjust it [FOR HIV], because that's something I don't even know. This is something that I should have also I'm guessing with, you know, meaning how much to go up by with that and so on and so on. (PCP, CACC-Hospital)
Several participants were unsure of how statins inhibit cardiovascular incidents or reduce risk for PLWH; a few specifically noted wanting more information on the quantity of risk mitigation statins provide to PLWH.If they’re going to make these [infectious disease] specialists take care of primary care, then there needs to be education on what statins are, how they work, when to take them, just general information and for the doctors to understand that just because they have HIV doesn’t mean that they’re not going to get other things. (CL)
I think it can potentially reduce it for 10 to 20 points, but I don't know in terms of how much in risk mitigation it is doing in for reducing cardiovascular disease risk. (ID, CACC-Hospital)
Yeah. I guess the one thing we didn't [discuss is the] interaction between the antiretroviral and their med, or I'm maybe mentioning other kinds of things, but I think at least right now with most of the antiretrovirals especially as we mainly use integrase-based regimen, the interaction with statins are quite known, and especially with using stuff like atorvastatin or rosuvastatin or I guess the new one, pitavastatin. So they're [interactions] not so much an issue anymore... So I guess also for that type of, what's kind of the best if a patient needs to be on a PI or Genvoya what should we do about the statin? I think that would be useful. (ID, CACC-Hospital)
Theme 2: greater self-efficacy around communicating with PWLH about CVD and statins is needed to improve statin uptake
Nearly half of the participants were interested in more effective ways to communicate with patients about statins. Providers felt improving communication with patients would facilitate patient willingness to start on a statin.I am going to do diet and exercise and off the bat, like at that encounter I encourage that, but I think sadly as a physician, me personally, and I think physicians are really well trained in prescribing diet and exercise, and we don't have a necessarily or I don't necessarily have those skills and time to adequately [provide] counseling.” (ID, CACC-Hospital)
Several providers were interested in how to better advise patients to address lifestyle changes. Participants described discussion of lifestyle changes as highly relevant to discussing statins.And so, I guess [what’s needed is] more of an easy solution to calculating a risk that help ensure decision making but then also I think kind of that ability to do shared decision-making, and kind of include statins in the package of therapies. (PCP, CACC-Hospital)
A few providers were unsure how to address or negotiate with patients who are hesitant about taking statins, and a few were interested in alternatives.I mean, I think, you know, information on things that help people with lifestyle change, smoking cessation resources, you know, diet, exercise, especially for like, you know, low-income, you know, communities, where people struggle to pay for like, you know, food and other things like, you know, ways of managing and helping people improve, like, lifestyle and smoking cessation, I think would be really helpful, and I don’t really feel like that’s an area that I get anything from my community on stuff like that. (ID, FQHC)
Here's something … is there something else we can do other than statins? Like if somebody just clearly didn't want medication, are there alternatives, or something like that? (ID, CACC-Hospital)
Domain 4: inner setting
Theme 1: statin-prescribing is supported by clinic leadership and fits clinics’ mission and goals, but views about which providers “should” prescribe statins vary
However, some providers working with PLWH within primary care clinics do not view CVD risk assessment and management as their responsibility. This view was expressed more by ID specialists working with acutely ill PLWH. Some expressed deficits in training and self-efficacy as the reason for this while others expressed that their own specialty training and interests are not in the area of general primary care activities.Most of the HIV clinics are just like us – they’ve known for years about the risks of cardiovascular disease in HIV. So, almost all of the clinics that we know of, HIV doctors, they all give statins. It would be unusual if they weren’t giving them. (PCP, Community Clinic)
To be honest, I think we think of ourselves as infectious disease specialists and not as primary care doctors. We're not as up on the evolution of diabetes management, hypertension, or cardiovascular risk tools, because they changed a lot. And we're busy keeping up in our sub-specialty. So I think there is some tension between the primary care role and the specialty role …I mean I became a specialist because I wanted to be a specialist and not because I wanted to manage people with diabetes.(ID, CACC-Hospital)
Theme 2: time and clinic and provider priorities are closely linked and affect whether CVD is addressed
I don't think I have concerns about prescribing [statins]. In terms of workflow, you know, sometimes I forget. It just depends on, you know, how many other things and what's more pressing. So it might be that it's important, but maybe I need to get them through ABC before I can get to D. Because the ABC are what's gonna hurt them first or that's what's causing them the most distress. (NP/PA/RN, FQHC)
Certainly if they were a well-controlled HIV patient, it fits into their workflow very well. I think, on the other hand, if you have a patient with whom is about to die from an infection, like a meningitis patient, we’re kind of more dealing with the more immediate life-threatening issues. Some of them were primary care issues, kind of are not as prioritized in that situation. We may not be addressing if their blood pressure is 150/85 and if their cholesterol is a little bit high, because, you know, any moment, they could die of meningitis, or something else, but in those patients who are well-controlled, and their infectious issues are not on the forefront, then I think it works very well within the workflow.(ID, CACC-Hospital)
Domain 5: patient factors
Theme 1: addressing patient psychosocial and housing issues can take precedence over CVD risk assessment and statins
Providers also noted that psychosocial and housing issues all greatly affect the ability of PLWH to adhere to their HIV medications; many providers noted this challenge and said that if patients are not adhering to their HIV medications they likely cannot begin or adhere to a statin, or attend follow-up visits.But we also have a small to moderate amounts of patients who are homeless or have a bit of psychosocial issues, and that can take priority over the visits. And so, the statin issue just gets pushed ‘til later. I would say that's probably the biggest issue. I mean, ideally, I think all of us would want to make sure everyone's top in mind as much as possible, but other things just come up (ID, CACC-Hospital)
Some providers also noted that low health literacy may interfere with willingness to take or ability to adhere to statins.Then we have other things to discuss. I think the other barrier is there are other things the patient is dealing with that are higher priority at the moment or it feels like they’re at a higher priority. Either they’re not taking their meds or they’re regularly using drugs or they’re homeless. Those things tend to be the things we focus on first to kind of stabilize the patient and get them to even take their HIV meds regularly. If they’re not taking their HIV meds regularly, me throwing on atorvastatin, probably they’re less likely to take it. If they are making an effort, I will put it on. (PCP-HIV, FQHC)
Several providers noted an inherent paradox with these issues among PLWH—the patients who need statins the most are the ones who do not have the resources to adhere to them or to pursue lifestyle alternatives to lower their risk.The more important problem is to make sure they’ll take the statin, and that is just partly due to the kind of patients that I have. It’s a relatively poor environment up here. A lot of my patients are not well-educated. They don’t know much about medicines. A lot of them are homeless. They’re on drugs and so forth, and those kind of people are not adherent. I mean, they won’t even take their HIV meds. (PCP-HIV, CACC)
Theme 2: patients prefer trying to make lifestyle changes before taking a statin
… I am just like look I know we’re doing due diligence in trying and attempting on these things [diet, exercise] on our own but it looks like we need a little help, I think in the meantime to be safe you know let’s do this. Let’s use a statin and use something else. And generally, after two or three visits of realizing they can’t do this on their own they do agree to start [the statin]. (PCP, FQHC)
I think they’re generally willing if we explain to them why it’s important. I think the younger patients are maybe a little bit more reluctant to start meds and they wanna give a trial of diet and exercise, some of them. And we would support that to see what happens. (ID, CACC-Hospital)
Theme 3: providers believe most patients eventually are willing to take statins, particularly after shared decision-making
I’ve had, I’d say, a very good [uptake]. I’ve had a handful of patients who they’d rather not take another pill, or they want to work on their diet. I can then say I’ll cut down on, you know, whatever they need to. But I would say 90% of patients are accepting of it, once you explain, you know, the rationale, and why it’s important. (PCP-HIV, FQHC)
One administrator noted the importance of the provider’s relationship with patients in facilitating treatment:You know it’s shared decision-making, and …it is just kind of laying out the reasons for why the medication is indicated try to educate the patient on their risk, to make sure they have a good understanding of it, and then just kind of leave the decision up to them.(PCP, CACC-Hospital)
I think in general the patients here love the providers, and if a provider told them to jump into cold water every day because it was going to make them better, they would probably do it. (CL).