Assessing baseline monitoring of liver function prior to statin therapy: an audit in general practice

Problem

Statins are a mainstay of primary and secondary prevention of cardiovascular and cerebrovascular disease and as such are one of the most heavily dispensed drugs in the community setting. Statins have had a long and controversial relationship with liver function. Although this is still not fully understood, it is clear that statins are contraindicated in active liver disease necessitating baseline liver function testing (LFT) in accordance with NICE recommendations. In light of this, it is important to assess if patients taking statins received baseline LFT assessment and if not why.

Approach

A retrospective audit was performed to identify patients undergoing statin therapy who did not have an LFT on record. The standard was set at 0% as all patients should have had an LFT prior to commencement of a statin. The audit population was all active patients of the surgery. The audit period was 12 months prior to the audit date.

A search of the surgery’s electronic patient records database was carried out. The parameters of the search was as follows:

• Either Simvastatin, fluvastatin, atorvastatin, pravastatin or rosuvastatin issued in the 12 months previous to 03/02/16

• Excluding patients who had an LFT on record – this included: ALT/SGPT serum level, Liverfunction test, Plasma alanine aminotransferase level and serum alanine aminotransferase level.

Findings

Of the 1293 patients issued a statin in the previous 12 months at this GP practice, 26 patients did not have an LFT on record. Of these 26 patients, 22 joined the surgery already on a statin. The patient records did not state if monitoring had been carried out. Of the remaining 4 individuals, 3 patients had had recent hospital admissions prior to statin commencement and received an LFT as an inpatient but this was not noted in the practice’s records. The remaining 1 patient did not have any documented reason for the lack of recorded LFT.

Consequences

This audit primarily identified a weakness in the practice system regarding documentation. A degree of due diligence is prudent when receiving new or recently hospital discharged patients to ensure appropriate monitoring has taken place but for this to be useful it needs to be documented before commencing or continuing a statin. This is especially relevant as next year’s Quality and Outcomes Framework may significantly increase the number of patients receiving statin therapy but this also has a further reaching impact applicable to any treatment requiring monitoring.