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Objectives We set out to describe trends and variation in statin prescribing in England that breaches 2014 national guidance on “high-intensity” statins. We identify factors associated with breaching; and assess the feasibility of rapid prescribing behaviour change. Design, Setting and Participants Retrospective cohort study in NHS primary care in England, including all 8,142 standard general practices from August 2010 to March 2019. Main Outcome Measures We categorised statins as high or low/medium-intensity based on two different thresholds, and calculated the proportion prescribed below these thresholds across all practices. We plotted trends and geographical variation, carried out mixed effects logistic regression to identify practice characteristics associated with breaching guidance, and used indicator saturation to identify practices exhibiting sudden changes in prescribing. Results We included all 8,142 practices across the study period. The proportion of statin prescriptions below the recommended 40% LDL-lowering threshold decreased gradually since 2012 from 80% to 45%; the proportion below a pragmatic 37% threshold decreased from 30% to 18%. The 2014 guidance had minimal impact on these trends. We found wide variation between practices (interdecile ranges 20% to 85% and 10% to 30% respectively in 2018). Mixed effects logistic regression did not identify practice characteristics strongly associated with breaching guidance. Indicator saturation identified several practices exhibiting sudden changes in prescribing towards greater guideline compliance. Conclusions Breaches of English guidance on choice of statin remain common, with substantial variation between GP practices. Some practices and regions have implemented rapid change, indicating the feasibility of rapid prescribing behaviour change. We discuss the potential for a national strategic approach, using data and evidence to optimise care, including targeted education alongside audit and feedback to outliers through services such as OpenPrescribing. Summary What is already known on this topic English national guidance recommends the use of a high-intensity statin, capable of reducing LDL (low-density lipoprotein) cholesterol by 40% or more. Adherence at the time of guideline release was low, but has not been documented since. What this study adds Adherence is improving, but breaches of national guidance remain common, with 45% of prescriptions below the recommended strength, and there is very substantial variation between practices. Some practices have exhibited rapid positive change in prescribing, which indicates that better adherence could readily be achieved. We have produced a live data tool allowing anyone to explore any practice’s current statin prescribing behaviour.

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