CLINICAL INVESTIGATION The Variation of Statin Use Among Nursing Home Residents and Physicians: A Cross-Sectional Analysis Michael A. Campitelli, MPH, a Colleen J. Maxwell, PhD, a,b Vasily Giannakeas, MPH, a Chaim M. Bell, MD, PhD, a,c,d Nick Daneman, MD, MSc, a,c,e,f Lianne Jeffs, RN, PhD, FAAN, f,g,h Andrew M. Morris, MD, SM(Epi), c,d Peter C. Austin, PhD, a,f,i David B. Hogan, MD, j Dennis T. Ko, MD, MSc, a,c,f,i,k Kate L. Lapane, PhD, l Laura C. Maclagan, MSc, a Dallas P. Seitz, MD, PhD, a,m and Susan E. Bronskill, PhD a,f,i OBJECTIVES: To examine the variability of statin use among nursing home residents and prescribing physicians, and to assess statin use by resident frailty. DESIGN: Population-based, cross-sectional analysis. SETTING: All nursing home facilities (N = 631) in Ontario, Canada between April 1, 2013 and March 31, 2014. PARTICIPANTS: All adults aged 66 years and older who received a full clinical assessment while residing in a nurs- ing home facility and their assigned, most responsible, physician. MEASUREMENTS: Statin use on date of clinical assess- ment. Resident- and physician-level characteristics ascer- tained through clinical assessment and health administrative data. Resident frailty was derived using a previously validated index. RESULTS: Among 76,226 nursing home residents assigned to 1,919 physicians, 25,648 (33.6%) were statin users. There were 13,331 (30.1%) statin users among the 44,290 residents categorized as frail. In an adjusted mixed- effects logistic regression model, frail residents (adjusted odds ratio = 0.62, 95% confidence interval 0.58–0.65) were significantly less likely to be statin users compared with non-frail residents. After adjustment for resident characteristics, the intraclass correlation coefficient indi- cated that between-physician variability accounted for 9.1% of the residual unexplained variation in statin use (P < .001). Among the 894 physicians assigned 20 or more residents, funnel plots confirmed there were more low-out- lying (17.4%) and high-outlying (12.0%) prescribers of statins than expected by chance. Physicians who were high-outlying prescribers had higher historical rates of sta- tin prescribing. CONCLUSIONS AND RELEVANCE: Statin prescribing was substantial within nursing homes, even among frail residents. After controlling for resident characteristics, the likelihood of statin prescribing varied significantly across physicians. Further studies are required to evaluate the risks and benefits of statin use, and discontinuation, among nursing home residents to better inform clinical practice in this setting. J Am Geriatr Soc 2017. Key words: nursing homes; long-term care; statins; medication use; physician; prescribing patterns S tudies in nursing home settings have documented larger than expected variation in the prescribing of several medication classes, including antipsychotics, 1–4 antimicro- bials, 5,6 and antidepressants. 7,8 Emerging findings from this research illustrate that, after controlling for underlying resident characteristics, the prescribing practices of physi- cians contribute to variation in drug use within nursing From the a Institute for Clinical Evaluative Sciences, Toronto, Ontario; b Schools of Pharmacy and Public Health & Health Systems, University of Waterloo, Waterloo; c Department of Medicine, University of Toronto; d Division of General Internal Medicine, Mount Sinai Hospital; e Division of Infectious Diseases, Sunnybrook Health Sciences Centre; f Institute of Health Policy, Management and Evaluation, University of Toronto; g Keenan Research Centre of the Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario; h Lawrence S Bloomberg Faculty of Nursing, University of Toronto; i Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario; j Divison of Geriatric Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta; k Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; l Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worchester, Massachusetts; and m Division of Geriatric Psychiatry, Queen’s University, Kingston, Ontario, Canada. Address correspondence to Michael Campitelli, Institute for Clinical Evaluative Sciences, G1-06, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5. E-mail: michael.campitelli@ices.on.ca Susan Bronskill, Institute for Clinical Evaluative Sciences, G1 06, 2075 Bayview Avenue, Toronto, Ontario, Canada, M4N 3M5. E-mail: susan.bronskill@ices.on.ca DOI: 10.1111/jgs.15013 JAGS 2017 © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society 0002-8614/17/$15.00