Using deep learning-based natural language processing to identify reasons for statin nonuse in patients with atherosclerotic cardiovascular disease

Background Statins conclusively decrease mortality in atherosclerotic cardiovascular disease (ASCVD), the leading cause of death worldwide, and are strongly recommended by guidelines. However, real-world statin utilization and persistence are low, resulting in excess mortality. Identifying reasons for statin nonuse at scale across health systems is crucial to developing targeted interventions to improve statin use. Methods We developed and validated deep learning-based natural language processing (NLP) approaches (Clinical Bidirectional Encoder Representations from Transformers [BERT]) to classify statin nonuse and reasons for statin nonuse using unstructured electronic health records (EHRs) from a diverse healthcare system. Results We present data from a cohort of 56,530 ASCVD patients, among whom 21,508 (38%) lack guideline-directed statin prescriptions and statins listed as allergies in structured EHR portions. Of these 21,508 patients without prescriptions, only 3,929 (18%) have any discussion of statin use or nonuse in EHR documentation. The NLP classifiers identify statin nonuse with an area under the curve (AUC) of 0.94 (95% CI 0.93–0.96) and reasons for nonuse with a weighted-average AUC of 0.88 (95% CI 0.86–0.91) when evaluated against manual expert chart review in a held-out test set. Clinical BERT identifies key patient-level reasons (side-effects, patient preference) and clinician-level reasons (guideline-discordant practices) for statin nonuse, including differences by type of ASCVD and patient race/ethnicity. Conclusions Our deep learning NLP classifiers can identify crucial gaps in statin nonuse and reasons for nonuse in high-risk populations to support education, clinical decision support, and potential pathways for health systems to address ASCVD treatment gaps. Plain language summary Cardiovascular disease (CVD) is the leading cause of death worldwide. Statins are cholesterol-lowering drugs that are recommended by major guidelines to reduce the risk of heart attacks and death. However, despite being effective and generally well-tolerated, statins are concerningly underused, and reasons for such statin nonuse are not well-understood. Using artificial intelligence (AI) approaches that can analyze complex language data including written medical terminology, we identified statin nonuse and reasons for statin nonuse from clinical notes from electronic health records of CVD patients at a large health system. We found that nearly 2 in 5 patients