Quality standard

Quality statement 3: Statins for people with CKD

Quality statement 3: Statins for people with CKD

Quality statement

Adults with chronic kidney disease (CKD) are offered atorvastatin 20 mg. [new 2017]

Rationale

There is a higher risk of cardiovascular disease (CVD) in people with CKD. After discussing the risks and benefits of starting statin therapy with a healthcare professional, adults with CKD may choose statin therapy as an appropriate treatment to reduce their risk of first CVD events, or of future CVD events in adults who have already had an event, such as a heart attack or stroke. Statins are a clinically effective treatment for preventing CVD, and reducing the risks associated with CVD, for people who have CKD. Atorvastatin 20 mg is recommended as the preferred initial high-intensity statin because it is clinically and cost effective for the primary and secondary prevention of CVD.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Structure

a) Evidence of the availability of atorvastatin 20 mg within local service providers.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from local formularies.

b) Evidence of local systems to check whether adults with CKD are taking atorvastatin 20 mg and invite them to discuss starting treatment if not.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from local protocols and service specifications.

Process

Proportion of adults with CKD who receive atorvastatin 20 mg.

Numerator – the number in the denominator who receive atorvastatin 20 mg.

Denominator – the number of adults with CKD.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from audit of health records. CVD Prevent's indicator CVDP010CHOL reports the percentage of patients aged 18 and over with GP-recorded CKD (G3a to G5), who are currently having treatment with lipid-lowering therapy. This measures lipid-lowering therapies and is not specific to a statin.

Outcomes

a) Prevalence of cardiovascular disease among people with CKD.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from audit of health records.

b) Incidence of cardiovascular events for people with CKD.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from audit of health records.

c) Cardiovascular mortality rates among people with CKD.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from audit of health records.

d) Proportion of people with CKD on a statin without a diagnosis of CVD with a greater than 40% reduction in non-high-density lipoprotein (HDL) cholesterol.

Numerator – the number in the denominator with a greater than 40% reduction in non-HDL cholesterol.

Denominator – the number of people with CKD on a statin without a diagnosis of CVD.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from audit of health records.

e) Proportion of adults with CKD and CVD on a statin who have a low-density lipoprotein (LDL) cholesterol level of 2.0 mmol per litre or less, or non-HDL cholesterol level of 2.6 mmol per litre or less.

Numerator – the number in the denominator who have an LDL cholesterol level of 2.0 mmol per litre or less, or non-HDL cholesterol level of 2.6 mmol per litre or less.

Denominator – the number of adults with CKD and CVD on a statin.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.

What the quality statement means for different audiences

Service providers (such as general practices and secondary care services, including renal, cardiology, diabetes and rheumatology clinics) ensure that systems are in place for adults with CKD to be offered atorvastatin 20 mg. For example, this may be done through incorporating treatment algorithms into software applications to provide users with patient-specific recommendations on treatment.

Healthcare professionals (such as GPs, nephrologists, cardiologists, diabetologists, rheumatologists, nurses and pharmacists) check whether adults with CKD are taking a statin, and discuss the risks and benefits of starting statin therapy if not. They offer atorvastatin 20 mg and increase the dose if an adequate response to treatment is not achieved and eGFR is 30 ml/min/1.73 m2 or more. If a person is not able to tolerate atorvastatin 20 mg or reports adverse effects, they discuss alternative options such as stopping the statin or changing the dose or type of statin.

Commissioners ensure that they commission services in which adults with CKD are offered atorvastatin 20 mg. Commissioners may do this by seeking evidence of practice through clinical audits.

Adults with CKD are at a higher risk of heart attacks and strokes. To help reduce the risk they are offered a type of medicine called a statin, which lowers the level of cholesterol (sometimes called lipids) in the blood. If their cholesterol level does not decrease enough, they may change to a higher dose. If the statin causes any side effects, their doctor might ask them to stop taking it for a while to check that they are caused by the statin. Their doctor might discuss reducing the dose or changing to a different statin.

Definitions of terms used in this quality statement

Adults with CKD

CKD is defined as abnormalities of kidney function or structure present for more than 3 months, with implications for health. This includes:

  • people with markers of kidney damage, including albuminuria (albumin:creatinine ratio [ACR] more than 3 mg/mmol), urine sediment abnormalities, electrolyte and other abnormalities due to tubular disorders, abnormalities detected by histology, structural abnormalities detected by imaging or a history of kidney transplantation

  • people with a glomerular filtration rate (GFR) of less than 60 ml/min/1.73 m2 on at least 2 occasions separated by a period of at least 90 days (with or without markers of kidney damage).

[NICE's guideline on chronic kidney disease, terms used in this guideline]

Adults with CKD and CVD

Adults with a diagnosis of CKD and angina, previous myocardial infarction, revascularisation, ischaemic stroke or TIA (excluding a history of haemorrhagic stroke) or symptomatic peripheral arterial disease. [NICE indicator NM212]