Utilization of lipid-lowering drugs in men and women. a reflection of the research evidence?

Prescribing patterns of statins and associated factors among type 2 diabetes mellitus patients attended at Jugol General Hospital in eastern Ethiopia: A cross-sectional study

Background

Most clinical practice guidelines support the use of statins in patients with type 2 diabetes mellitus to lower the risk of cardiovascular disease. However, nothing is known about the prescribing patterns of statins at Jugol General Hospital in eastern Ethiopia.

Objective

This study aimed to assess the prescribing patterns of statins and associated factors among type 2 diabetes mellitus patients attended at Jugol General Hospital in eastern Ethiopia.

Methods

A retrospective cross-sectional study was conducted among 423 patients with type 2 diabetes mellitus who received follow-up care from 1 June 2017 to 1 June 2022. The study participants were enrolled consecutively using a convenience sampling technique. The data were extracted from patients' medical records using a data abstraction checklist. The extracted data were entered into EpiData, version 3.1, and exported to Statistical Package for the Social Sciences (SPSS), version 22, for analysis. Associations were considered to be statistically significant at a p-value < 0.05 and presented as adjusted odds ratios and 95% confidence intervals.

Result

The medical records of 423 patients were reviewed. The review revealed that medical records were complete for 410 of these patients, and these records were included in the analysis. The majority of the study participants were female (72.2%) and between the age of 40 and 65 years (61.2%). All of the study participants were eligible for statin prescription; however, statins were prescribed for only 257 (62.7%) study participants. Of the statins prescribed, moderate-dose-intensity statins were prescribed for 40 (15.6%) participants who were at high risk of cardiovascular disease. Atorvastatin was the most commonly (93.3%) prescribed statin. The presence of hypertension, coronary artery disease, and cerebrovascular events was significantly associated with statin prescribing.

Conclusion

The magnitude of prescribing statins for patients with type 2 diabetes mellitus was low in comparison with the clinical practice guidelines recommendation. This finding is alarming and is a call for action to improve the execution of clinical practice guidelines for the benefit of this high-risk population.

Statin Prescription Patterns and Associated Factors Among Patients with Type 2 Diabetes Mellitus Attending Diabetic Clinic at Muhimbili National Hospital, Dar es Salaam, Tanzania

PURPOSE

To determine statin prescription patterns and associated factors among type 2 diabetes patients attending the diabetic clinic at Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania.

PATIENTS AND METHODS

A hospital-based cross-sectional study involving outpatients was conducted from September 2020 to November 2020. Statin prescription history (both type and dosage) was obtained from patients as well as from the electronic medical records for determination of patterns. Participants were categorized as moderate or high risk for cardiovascular disease whereas prescription patterns were categorized as moderate and high intensity statins. Logistic regression was used to examine association, control confounders and effect modifier whereby p <0.05 was considered statistically significant.

RESULTS

Of 400 patients who were approached for the study, 395 (98.8%) were eligible for statin prescriptions. The mean (±SD) age of the study participants was 58.1±10.3 years, out of which 371 (93.9%) belonged to the age group ≥40 years. Two-thirds(241 61.0%) of the patients were female. About two-thirds(257; 69.4%) of patients had health insurance coverage. Statins were prescribed in 47.3% of the participants. Moderate intensity statin was the only pattern prescribed. In the adjusted model, insurance coverage (OR: 0.056; 95% CI: 0.03-0.12), and hypertension (OR: 0.259; 95% CI: 0.12-0.54) were associated with an increased likelihood of being prescribed a moderate intensity statin.

CONCLUSION

A significant number of patients at MNH diabetic clinic were not on statins despite qualifying for the prescription. The findings call for further studies on reasons for low statin prescription practices in this tertiary facility.

Moderate-intensity statin therapy seems ineffective in primary cardiovascular prevention in patients with type 2 diabetes complicated by nephropathy. A multicenter prospective 8 years follow up study

BACKGROUND

Although numerous studies and metanalysis have shown the beneficial effect of statin therapy in CVD secondary prevention, there is still controversy such the use of statins for primary CVD prevention in patients with DM. The purpose of this study was to evaluate the occurrence of total major adverse cardio-vascular events (MACE) in a cohort of patients with type 2 diabetes complicated by nephropathy treated with statins, in order to verify real life effect of statin on CVD primary prevention.

METHODS

We conducted an observational prospective multicenter study on 564 patients with type 2 diabetic nephropathy free of cardiovascular disease attending 21 national outpatient diabetes clinics and followed them up for 8 years. 169 of them were treated with statins (group A) while 395 were not on statins (group B).

RESULTS

Notably, none of the patients was treated with a high-intensity statin therapy according to last ADA position statement. Total MACE occurred in 32 patients from group A and in 68 patients from group B. Fatal MACE occurred in 13 patients from group A and in 30 from group B; nonfatal MACE occurred in 19 patients from group A and in 38 patients from group B. The analysis of the Kaplan-Meier survival curves showed a not statistically significant difference in the incidence of total (p 0.758), fatal (p 0.474) and nonfatal (p 0.812) MACE between the two groups. HbA1c only showed a significant difference in the incidence of MACE between the two groups (HR 1.201, CI 1.041-1.387, p 0.012).

CONCLUSIONS

These findings suggest that, in a real clinical setting, moderate-intensity statin treatment is ineffective in cardiovascular primary prevention for patients with diabetic nephropathy. Trial registration ClinicalTrials.gov Identifier NCT00535925. Date of registration: September 24, 2007, retrospectively registered.

Pattern of statin use in southern italian primary care: can prescription databases be used for monitoring long-term adherence to the treatment?

Objectives

We sought to evaluate the prescribing pattern of statins according to national and regional health policy interventions and to assess specifically the adherence to the therapy in outpatient setting in Southern Italy.

Methods

A population-based study was performed on persons ≥15 years old, living in the catchment area of Caserta (Southern Italy), and registered in Arianna database between 2004 and 2010. Prevalence and incidence of new treatments with statins were calculated for each year and stratified by drug. Adherence to therapy was measured by Medication Possession Ratio. Sub-analyses by individual compound and type of cardiovascular prevention were performed.

Results

From 2004 to 2010, the one-year prevalence of statin use increased from 44.9/1,000 inhabitants to 79.8/1,000, respectively, consistently with the incidence of new use from 16.2/1,000 to 19.5/1,000, except a slight decrease after criteria reimbursement revision on 2005 (13.3/1,000). The incidence of new treatments decreased for atorvastatin, and increased for simvastatin over the study years. Overall, 43% of new users were still highly adherent to the treatment (MPR≥80%) after six months, while 26% after 4-years of follow-up. As compared with highly adherent patients, the probability to be non-adherent (MPR≤25%) at 4-years of follow-up was 26% higher for women than for men (full adj. odds ratio: 1.26; 95% CI: 1.10–1.45), and 64% higher in patients who started on primary rather than on secondary prevention (1.64; 1.29–2.07).

Conclusions

Prevalence and incidence of statin use increased consistently with health policy interventions. Only one-fourth of patients who newly initiated a statin were adherent to the treatment after 4-year of follow-up. Since the benefits of statins in terms of cardiovascular outcome and costs are associated with their chronic use, the identification of patient-related predictors of non-adherence such as gender, primary prevention could be suitable for physicians to improve the patients' compliance.

Statin utilization according to indication and age: a Danish cohort study on changing prescribing and purchasing behaviour

OBJECTIVE

Introduced to reduce mortality after myocardial infarction (MI), statins are now recommended for a range of other conditions, including asymptomatic individuals without cardiovascular disease or diabetes. The aim was to describe trends in Danish statin utilization according to indication and age during 1996-2009, and to analyse changing prescribing and purchasing behaviour during time intervals (driver periods) a priori defined by potential influential factors.

METHODS

A nationwide cohort (N=4,998,580) was followed in Danish individual-level registries. Based on a hierarchy of register markers of indications for statin prescribing, we analysed incidence and prevalence of use by age and indication (age ≥ 40). Applying Poisson regression, we calculated Incidence Rate Ratios (IRR) of statin treatment for the last year of each driver period, applying the first year as reference.

RESULTS

Treatment prevalence increased from 7/1000 to 187/1000, representing a shift towards lower-level indications and increased relatively more in individuals aged 75+. While treatment prevalence in MI-patients reached 780/1000, asymptomatic individuals represented 50% of incident statin-users in 2009. A marked increase in incidence of statin use occurred during 1999-2003 (IRR=3.05) across all indications, followed by a more moderate rise during 2003-2006 (IRR=1.29) and 2006-2008 (IRR=1.15) - most marked increases in asymptomatic individuals. A sudden decrease was observed in 2009 (IRR=0.82) for all indications and ages.

CONCLUSION

While patent expiry and lower prices most likely boosted the general increase in statin utilization, the gradually altered indication and age pattern seems to be driven by guidelines, influencing both reimbursement rules and general healthcare policies. A media debate on statin side effects may have modified the general attitudes.

Direct to consumer Internet advertising of statins: an assessment of safety

PURPOSE

To evaluate a sample of Internet sites advertising statins for sale to the general public.

METHODS

A simulated customer search and evaluation of retrieved sites using evaluation tools focussing on quality (Q) and safe medicine use (SMU). Sites retrieved on 17 November 2010 were systematically analysed from 19 November to 23 December 2010.

RESULTS

One hundred eighty-four sites met the inclusion criteria: 40 each for atorvastatin, pravastatin, rosuvastatin, and simvastatin and 24 for fluvastatin. Sites originated from 17 different countries. Most sites scored less than half the maximum Q score (26; range 5-17). Mean total SMU scores for each statin group were lower than 50% of the maximum (45; range of 0-28). There were no statistically significant differences between statins. General contraindications were absent in 92.4% of sites and contraindicated medicines in 47.3%. Key warnings on the appearance of symptoms associated with myopathy, liver disease, hypersensitivity, and pancreatitis were absent in 37, 48.4, 91.3, and 96.2% of sites, respectively. Most websites presented a chaotic and incomplete list of known side effects; just 13 (7.1%) presented a list compatible with current prescribing information. Only two-thirds (65.8%) attempted to describe any in lay language.

CONCLUSIONS

A potential purchaser of statins is likely to encounter websites from a wide geographical base and of generally poor quality. This has potentially serious implications for the safety of purchasers who may not be aware of the problems associated with ordering medicines online or the actual medication, which they receive. Direct to consumer advertising websites need tighter controls.

Coronary risk estimates and decisions on lipid-lowering treatment in primary prevention: comparison between general practitioners, internists, and cardiologists

BACKGROUND

Quantitative assessment of an individual's absolute cardiovascular risk is essential for primary prevention. Although risk-scoring tools have been developed for this task, risk estimates are usually made subjectively. We investigated whether general practitioners (GPs), internists and cardiologists differ in their quantitative estimates of cardiovascular risk and their recommendations about lipid-lowering treatment for the same set of patients.

METHODS

Mail survey. Nine written clinical vignettes, four rated high-risk and five rated low-risk according to the Framingham equation, were mailed to 90 randomly selected GPs and to the same number of internists and cardiologists in Sicily. The doctors were then asked to estimate the 10-year coronary risk in each case and to decide whether they would recommend a lipid-lowering treatment.

RESULTS

In the majority of the nine cases, the cardiologists' risk estimates were significantly lower than those of the other two groups. A higher proportion of internists (mean value 0.68) decided to start treatment than GPs (0.54) or cardiologists (0.57). In all three groups, the doctors' willingness to begin treatment was over 90% when their risk estimate was above 20%, and less than 50% when it fell below this level. Internists were more prone to treat than the other two groups even when their patients' estimated risk was below 20%.

CONCLUSION

When presented with the same set of clinical cases, GPs, internists and cardiologists make different quantitative risk estimates and come to different conclusions about the need for lipid-lowering treatment. This may result in over- or under-prescription of lipid-lowering drugs and inconsistencies in the care provided by different categories of doctors.

Primary prevention of cardiovascular diseases by lipid-lowering treatment in German general practice: Results from GPs ignoring guidelines and risk calculators

OBJECTIVE

Guidelines/risk calculators for the primary prevention of cardiovascular disease have been developed, which could make decisions for or against therapy easier. However, it has been shown for different countries that there is still quite a discrepancy between what is done and what should be done according to guidelines/risk calculators. Usually, in Germany, neither guidelines nor risk calculators are used. On what basis, then, and with what result do German general practitioners decide for or against a treatment?

METHODS

26 GPs agreed to participate in the study. From their surgeries, data from a random sample of 401 patients diagnosed with hyperlipidaemia were taken, of which 290 were eligible for the study on primary prevention. Patient risk factors were taken from their files to analyse their need for treatment using risk calculators for ERCP III (US guideline) and the European guideline. These results were compared with the treatment they received from their GPs. In semi-structured interviews, GPs were asked about their decision-making process (in four randomly chosen patients from each surgery) concerning the chosen treatment. Additionally, GPs were asked about their attitude towards guidelines/risk calculators.

RESULTS

89% of the patients who received treatment would also have received it according to ERCP III. According to European guidelines, only 38% of those receiving treatment need it. Concerning those not receiving treatment, 54% would not receive it according to NCEP III and 89% would not according to the European guideline. In interviews, around 75% of doctors demonstrated that they follow a multifactorial approach and a high-risk strategy. However, about 50% and 70% explicitly stated not using guidelines or risk calculators, respectively, and even among those stating that they used them, the majority were unaware of names/sources. Patient values or wishes as well as the healthcare system influenced their decisions.

CONCLUSION

German GPs seem to follow quite effectively a high-risk strategy in primary prevention, usually using a multifactorial approach, even without using risk calculators/guidelines. This kind of personalized care is also reflected in the considered importance of patient wishes and values. It is difficult to judge GPs concerning their quality of care having as a "gold standard" different risk calculators/guidelines that define whether such different populations receive treatment or not.

Lipid-lowering drug use in Italian primary care: effects of reimbursement criteria revision

OBJECTIVE

To assess whether the prescribing pattern of lipid-lowering drugs (LLD) changed after reimbursement criteria revision in a general practice in southern Italy.

METHODS

From the Caserta-1 Local Health Service database, 93 general practitioners (GPs) who had consistently sent data about their patients during the years 2003-2005 were recruited. Prevalence of use and incidence of new treatments were calculated for each year, stratified by three drug cohorts: statins, omega-3 fatty acids, and fibrates. Subanalyses by gender, age, and indication of use were performed.

RESULTS

Overall, 1-year prevalence of LLD use increased from 2003 to 2004. After reimbursement criteria revision (November 2004), a slight decrease was observed for statins, from 41.1 (95% CI: 39.9-42.2) per 1,000 inhabitants in 2004 to 40.3 (39.2-41.5) in 2005, while omega-3 utilization fell markedly: 14.6 (13.9-15.3) vs. 5.4 (5.0-5.8). The use of both statins and omega-3 fatty acids was reduced particularly for primary prevention. On the other hand, utilization of statins increased in diabetic patients and as secondary prevention from 2004 to 2005. Concerning individual molecules, 1-year prevalence of use of any statin declined from 2004 to 2005, except for rosuvastatin.

CONCLUSIONS

Revision of reimbursement criteria led to significant changes in the trend in LLD use in general practice in southern Italy: (1) statin utilization was slightly reduced in 2005, although it increased in certain categories, such as diabetic patients, and (2) omega-3 fatty acid use was strongly reduced even though a higher use in postinfarction cases was reported.

Trends in the use of lipid-lowering drugs by outpatients with diabetes in Taiwan, 1997-2003

PURPOSE

To analyze recent trends in LLD use by outpatients with diabetes in Taiwan over a 7-year period and to see whether the trends are consistent with clinical trial outcomes and published guidelines.

METHODS

A cross-sectional survey was implemented using the National Health Insurance Research Database between January 1997 and December 2003. Adult outpatients who had diagnoses of diabetes and dyslipidemia and who had concurrent antidiabetic drug and LLD claim were identified. The prescribing trends were described in terms of the prescribing rates and patterns of LLDs in each study year.

RESULTS

Between 1997 and 2000, fibrates were the most widely prescribed major class of LLDs, while the rates showed a significant decline over time. The proportions of statin use increased 3.3-fold from 20.8% of all LLDs in 1997 to 69.0% in 2003. With the continuous increase in the use of statins, by 2001, they replaced fibrates as the most heavily used LLDs. Monotherapy was the most prominent prescribing pattern comprising 98.1% and 98.3% of all LLD prescriptions in 1997 and 2003, respectively. Among patients with diabetic dyslipidemia plus CHD, the use of statins increased almost threefold instead of a large reduction in the percentage with non-statin class.

CONCLUSIONS

The prescribing rates of LLDs shifted from the fibrates to statins, especially in newer statin. The majority of patients were maintained on monotherapy. These findings may imply that management of hyperlipidemia in patients with diabetes had a positive trend towards recent clinical trial outcomes and guideline's recommendation.

Statin use in Canadians: trends, determinants and persistence

BACKGROUND

Regular statin use is an important tool in chronic disease management, lowering cholesterol levels and reducing risk of cardiovascular disease (CVD). The objectives of this study are to describe statin use in Canada by comorbidity and lifestyle risk factors, and determine persistence in statin use.

METHODS

The longitudinal National Population Health Survey, 1994-2002, is a random sample of the 1994 Canadian population and five interviews were conducted at two-year intervals. A total of 8,198 respondents, aged 20 in 1994, completed all five interviews. Information collected included demographic variables, medication use, CVD lifestyle risk factors, CVD, diabetes and hypertension.

RESULTS

Age-adjusted rates of statin use increased from 1.6% to 7.8% over the period 1994-2002. Statin use was higher with increasing age, diabetes, BMI, physician visits, and insurance for prescription medication. Although persons with CVD were more likely to take statins than those without, by 2002 still only 32.7% of heart patients were taking statins. Statin use did not increase linearly with increasing numbers of CVD risk factors or comorbidities. Of the 441 persons reporting statin use in 2000, 74.6% were still taking them in 2002. People who completed their high school education were more likely to continue taking statins than those who did not complete high school.

CONCLUSION

While statin use increased over time, was associated with CVD and diabetes, and to a lesser extent with increased BMI, a substantive underuse in high-risk patients remains. Helping high-risk people to increase statin use continues to be a priority for health care professionals.

Case selection for statins was similar in two Canadian provinces: BC and Ontario

OBJECTIVES

Though statins are fully reimbursed by the public drug programs for seniors in British Columbia (BC) and Ontario, Canada, population-based rates of statin prescription are markedly higher in Ontario. We aimed to assess whether new statin users in BC and Ontario differ in terms of their risk for future coronary heart disease (CHD) events.

STUDY DESIGN AND SETTING

We collected information for 1998-2001 on demographics, outpatient prescriptions, physician visits, hospital admissions, and vital status from administrative databases to compare the proportions of new statin users aged 66 years and older who had evidence of an acute coronary syndrome (ACS), chronic CHD, neither ACS nor CHD but diabetes, or none of the above.

RESULTS

Approximately 15% and 20% of BC and Ontario seniors, respectively, had filled a statin prescription by 2001. Among new statin users in the two provinces, virtually identical proportions had evidence of ACS (8%), chronic CHD (25%), and diabetes (14%), for an overall proportion of roughly 50% at high risk for CHD events.

CONCLUSION

New statin users in BC and Ontario were at similar risk for future CHD events. Poorer case selection is unlikely to explain the relatively higher rates of statin prescription in Ontario.

Retrospective review of sex differences in the management of dyslipidemia in coronary heart disease: an analysis of patient data from a Maryland-based health maintenance organization

BACKGROUND

Coronary heart disease (CHD) is the leading cause of death in men and women in the United States, with a higher mortality in women, despite a lower prevalence. Statins effectively treat dyslipidemia and reduce the risk of CHD mortality.

OBJECTIVE

The objective of this study was to evaluate the treatment of dyslipidemia in patients with CHD and determine if sex differences exist.

METHODS

This was a retrospective chart review performed within a multioffice staff model health maintenance organization of approximately 70,000 members. An administrative database, containing inpatient and out-patient medical claims, was used to identify patients with CHD based on diagnostic codes. Charts were randomly selected and the following information was obtained from chart review: age; sex; risk factors for CHD; diagnosis and/or prescription for depression; blood low-density lipoprotein cholesterol (LDL-C) level; and drug, dosage, and duration of prescribed lipid-lowering therapy. Exclusion criteria included missing charts and unavailable LDL-C values. LDL-C values were classified as at target if LDL-C<2.59 mmol/L (<100 mg/dL). Patients receiving statin monotherapy were categorized into 3 potency groups, based on efficacy to lower LDL-C values: high (atorvastatin 20-80 mg, lovastatin 80 mg), medium (atorvastatin 10 mg, pravastatin 40 mg, simvastatin 200 mg), and low (fluvastatin 10-40 mg, lovastatin 10-40 mg, pravastatin 10-20 mg, simvastatin 5-10 mg).

RESULTS

A total of 1487 adult patients (64.4% male with a mean (SD) age of 65.7 (11.8) years were identified, based on diagnostic codes for CHD. Three hundred twenty charts were selected for review. After exclusion, the final study cohort was 290 patients. The cohort was 66.2% male (192/290) with no significant difference in mean (SD) age between men (65.2 [9.2] years) and women (66.9 [10.5] years). Weight of women ranged from 85 to 305 lbs; 134 to 288 lbs for men. Among the study cohort, 46.2% (134/290) of the patients achieved the target LDL-C of <2.59 mmol/L (<100 mg/dL), with significantly more men (51.0% [98/192]) than women (36.7% [36/98]) reaching target (P=0.021). Lipid-lowering therapy was prescribed to 68.6% (199/290) of the patients, with no significant sex differences (men, 71.4% [137/192]; women, 63.3% [62/98]). Of the patients prescribed lipid-lowering therapy (primarily statins), 53.8% (107/199) achieved target LDL-C. There was no significant sex difference in the potency groups prescribed, and the rate of LDL-C target attainment was similar across potency groups. Overall, 70.3% of patients who did not receive lipid-lowering therapy had inadequately controlled LDL-C (women, 31/36 [86.1%]; men, 33/55 [60.0%] [P=0.008]).

CONCLUSIONS

The majority of CHD patients from a Maryland-based health maintenance organization had elevated LDL-C values, despite a lipid-lowering prescription rate of 68.6%. A significant gap in dyslipidemia treatment in these CHD patients remained, particularly for women.

Drug utilization of ezetimibe in rehabilitation centres: registry analysis of factors influencing prescription and effectiveness of treatment

BACKGROUND

While randomized controlled trials (RCTs) generate informative data about clinical outcomes, by their nature they cannot provide information about drug utilization and factors influencing prescribing decisions. In the secondary prevention of patients with cardiac events, lipid lowering therapy with statins and other agents, such as cholesterol absorption inhibitors (CAI, e.g. ezetimibe) plays a pivotal role and is often initiated or modified in rehabilitation centres. The aims of the present study were to analyse factors that influence the prescribing decisions of physicians, and to investigate success rates of lipid lowering therapy with ezetimibe after adjustment for covariates.

METHODS

Ninety-three rehabilitation centres throughout Germany documented a total of 17029 patients in cardiac rehabilitation, of which 6976 (41.6%) were prescribed a CAI. A logistic regression model with forward selection based on 31 potential regressors for ezetimibe prescription (demographics, diagnosis, risk factors etc.) was used to construct a propensity score, which reflects the inclination of physicians to prescribe CAI. This score was subsequently used for bias reduction in the comparison of co-medications and success rates.

RESULTS

Nineteen variables were associated with ezetimibe prescriptions, the most important ones being total cholesterol, level of education, unstable angina pectoris and arterial hypertension. Ezetimibe was more frequently prescribed together with simvastatin and pravastatin than with other statins, and frequently together with aspirin or beta blockers, respectively. After adjustment for baseline lipid values and covariates, the probability of target level achievement appears to be substantially higher for patients on ezetimibe than for those without ezetimibe.

CONCLUSIONS

Other factors than conventional risk factors contribute to the CAI prescription habits of physicians. Additional lipid level reductions due to ezetimibe are seen in routine health care corresponding to findings from randomized studies.

Statin use after acute myocardial infarction: a nationwide study in Denmark

AIMS

To study outpatient statin use after first acute myocardial infarction (AMI) in Denmark between 1995 and 2002 and to determine the predictors of statin use.

METHODS

This is a nationwide population-based study using administrative registries. Patients with first AMI between 1995 and 2002 older than 30 years of age and alive 6 months after discharge (n = 45 219) were identified through the National Patient Registry. The statins purchased by these patients within 6 months after discharge were determined using the Registry of Medicinal Product Statistics, a nationwide prescription database.

RESULTS

Statin use following AMI increased from 13% in 1995 to 61% in 2002. In 2002, 81% of patients aged 30-64 years used statins. Older patients used fewer statins, but use increased more among patients aged 75-84 years: from 1.3% to 43%. Use in elderly patients did not differ according to gender in 2000-02, but young men used more than younger women. In 2000-02, patients with diabetes (odds ratio (OR): 0.84; 95% confidence interval (CI): 0.74-0.95) and with heart failure (OR: 0.70; 95% CI: 0.64-0.76) were undertreated; this trend was present throughout the period.

CONCLUSIONS

In this nationwide study, younger patients after AMI had high statin use in 2002, but high-risk patients such as those with diabetes and heart failure were still being undertreated.

Racial differences in lipid-lowering agent use in medicaid patients with cardiovascular disease

BACKGROUND

Racial differences in chronic cardiovascular disease (CVD) outcomes are well described, whereas less is known about the process of CVD preventive care and its potential contribution to disparate outcomes.

OBJECTIVE

The objective of this study was to examine the association between race and 1) prior use of a lipid-lowering agent (LLA), 2) LLA initiation, and 3) LLA discontinuation among individuals with an incident medical claim for CVD.

RESEARCH DESIGN

Retrospective claims analysis.

SUBJECTS

We studied continuously enrolled, fee-for-service Medicaid recipients <65 with a new medical claim for 1 of 15 CVD-related diagnoses or procedures from 1993 to 1998 (n = 14,833).

MEASURES

Pharmacy claims history reflecting previous, new, and ongoing LLA use were reviewed for the 24-month period around a new CVD claim. Multivariable logistic regression assessed the independent effect of minority status on new and ongoing LLA use controlling for clinical and demographic characteristics.

RESULTS

A total of 3924 (26.4%) individuals submitted LLA pharmacy claims. A total of 3668 of 4668 (78.6%) previous or new users obtained > or =1 refill. Minorities were less likely to have previously used LLA (adjusted odds ratio [AOR], 0.64; 95% confidence interval [CI], 0.58-0.70), to receive a new prescription (AOR, 0.62; 95% CI, 0.54-0.71), or to continue use, as evidenced by subsequent refill claims (AOR, 0.74; 95% CI, 0.62-0.87).

CONCLUSIONS

Publicly insured minorities with prescription coverage benefit less often from preventive care before or after a CVD diagnosis, resulting, in part, from providers' failure to initiate therapy and patients' failure to continue it. To reduce widening disparities in cardiovascular outcomes, strategies that target LLA underuse by minorities throughout the process of care are needed.

Whom are we treating with lipid-lowering drugs? Are we following the guidelines? Evidence from a population-based study: the Troms� study 2001

OBJECTIVE

The beneficial effect of lipid-lowering drugs (LLDs) is well documented. Despite increasing sales of LLDs, little is known about what characterizes LLD users. Our objective was to describe LLD users in a general population according to socio-demographic factors, cardiovascular risk factors and coronary heart disease (CHD), and to study the achievement of cholesterol treatment goals according to national guidelines.

METHODS

The Tromso study is a population-based study of chronic diseases, risk factors and drug use in the municipality Tromso, in north Norway. The fifth survey was conducted in 2001 and included 7,973 men and women (attendance rate 78.1%). Self-reported use of LLDs and/or proprietary LLDs was included as LLD use in the analysis.

RESULTS

LLD use was reported in 9.6% of all women and 14.0% of all men, of whom 36.5% achieved the nationally recommended lipid goal. Among individuals with CHD, 49.9% of all women and 55.4% of all men were LLD users. The individuals with a risk condition (hypertension and/or diabetes) and total cholesterol level above the target of 5.0 mmol/l and the healthy individuals with total cholesterol level >/=8.0 mmol/l constituted 47.2% of the study population without CHD. In this group, which was eligible for primary prevention, 8.0% of the women and 7.4% of the men reported LLD use.

CONCLUSIONS

Only half of all subjects with CHD were taking a LLD. The large discrepancy between national recommendations and actual LLD use in primary prevention should be addressed in future revisions of the guidelines.

Health Care Utilization by Canadian Women

Health Issues

While women are reported to be more frequent users of health services in Canada, differences in women's and men's health care utilization have not been fully explored. To provide an overview on women's healthcare utilization, we selected two key issues that are important for public policy purposes: access to care and patterns of utilization. These issues are examined using primarily data from the 1998/99 National Population Health Survey, complemented by the 2000 Canadian Community Health Survey and the 2001 Health Service Access Survey.

Key Findings

• Women are twice as likely as men to report a regular family physician, but that proportion is very low (15.8%).

• Women report significantly shorter specialist wait times (20.9 days) than men (55.4 days) for mental health, while the reverse is true for asthma and other breathing conditions (10.8 for men, 78.8 for women).

• Reported mean wait times are significantly lower for men than for women pertaining to overall diagnostic tests: for MRI, 70.3 days for women compared to 29.1 days for men.

Data Gaps and Recommendations

• Measurement of possible system bias and its implication for equitable and quality healthcare for women requires larger provincial samples of the national surveys, along with a longitudinal design.

• Either a national database on preventive services, or better alignment of provincial databases pertaining to health promotion and preventive services, is needed to facilitate data linkage with national surveys to undertake longitudinal studies that support gender based analyses.

Factors Associated with Women's Medication Use

HEALTH ISSUE: Research has consistently shown that while women generally live longer than men, they report more illness and use of health care services (including medication). In the literature, the reasons for women's elevated medication use are not clear. This paper investigates the associations between over-the-counter (OTC) and prescription (Rx) medication use and selected social and demographic variables in men and women. KEY FINDINGS: While a larger proportion of women than men used medication throughout the study, the proportion of people using medication did not increase. The use of OTC and Rx medication increased by number of physician visits for women and men.Medication use increased with age, chronic disease and number of physician visits, and decreased with the perception of good to excellent health. The relationship with other factors varied for women and men depending on their education level, income and social roles. For women, the social roles of being married or previously married, being employed or being a parent did not increase their likelihood of medication use. Reported income adequacy is not associated with the chances of mediation use among highly educated women, but for women with low levels, medication use increases as income adequacy decreases. DATA GAPS AND RECOMMENDATIONS: More complete data are needed about social roles and their relation to mediation use. Data that would allow an assessment of the appropriateness of OTC and Rx drug use or the reasons for such use need to be collected. More research is needed to better understand the distribution and determinants of specific medication use.

Undertreatment and overtreatment with statins: the Oslo Health Study 2000-2001

OBJECTIVE

We examined the prevalence and factors associated with use of cholesterol-lowering statins in the population.

METHODS

Demographic, medical, anthropometric and lifestyle data was obtained from 6233 men and 7521 women born in 1924/25, 1940/41, 1955 and 1960 that participated in the Oslo Health Study 2000-2001. A nonfasting blood sample was collected.

RESULTS

Of subjects with a heart attack, angina, stroke or diabetes 45% of men and 35% of women were taking a statin (P < 0.001). Of subjects with cardiovascular disease (CVD) or diabetes taking statins 61% of men and 40% of women achieved total serum cholesterol levels < or =5 mmol L(-1). The odds ratio for taking a statin was increased amongst subjects who also took antihypertensive drug(s) or acetylsalicylic acid, subjects with a family history of coronary heart disease (CHD) and women who had visited the general practitioner within the last year. Amongst presumed healthy subjects use of statins increased from about 1% in women aged 40-45 years, to 7% at age 60 and to 12% at age 75 whilst the corresponding figures for men were 3%, 8% and 9%, respectively. About 22% of men but <2% of women aged 60 who were not taking statins had a 10-year Framingham CHD risk score >20%. Determinants of statin use were similar to those amongst subjects with CVD or diabetes.

CONCLUSION

People with CVD or diabetes remain undertreated with statins, women more so than men. Use of other preventive drugs, the family history and recent contact with the general practitioner were the most important determinants of statin use in primary and secondary prevention. Amongst healthy subjects aged 60 or 75 years women received statins disproportionately to their low CHD risk compared with men.

Review of evidence and explanations for suboptimal screening and treatment of dyslipidemia in women. A conceptual model

Screening and treatment rates for dyslipidemia in populations at high risk for cardiovascular disease (CVD) are inappropriately low and rates among women may be lower than among men. We conducted a review of the literature for possible explanations of these observed gender differences and categorized the evidence in terms of a conceptual model that we describe. Factors related to physicians' attitudes and knowledge, the patient's priorities and characteristics, and the health care systems in which they interact are all likely to play important roles in determining screening rates, but are not well understood. Research and interventions that simultaneously consider the influence of patient, clinician, and health system factors, and particularly research that focuses on modifiable mechanisms, will help us understand the causes of the observed gender differences and lead to improvements in cholesterol screening and management in high-risk women. For example, patient and physician preferences for lipid and other CVD risk factor management have not been well studied, particularly in relation to other gender-specific screening issues, costs of therapy, and by degree of CVD risk; better understanding of how available health plan benefits interact with these preferences could lead to structural changes in benefits that might improve screening and treatment.

Gender-specific implications for cardiovascular medication use in the elderly optimizing therapy for older women

Sex should be considered during the selection of cardiovascular medications and dosages of cardiovascular medications. There is mounting evidence that clinically important differences between the sexes exist in the pharmacokinetic processes that determine drug concentrations and in the pharmacodynamic processes that determine physiologic responses to pharmacologic agents. Although aging also affects these processes, aging does not eliminate the sex-related differences. The major pharmacokinetic differences between the sexes, on average, are lower weight and distribution volumes in women compared with men and lower renal drug clearance in women compared with men. Sex-related differences in hepatic drug clearance are less predictable. Pharmacodynamic responses that differ between the sexes include increased adverse cardiovascular drug effects in women compared with men (torsade de pointes arrhythmias, increased risk of hemorrhagic consequences of anticoagulation or thrombolytic therapy, electrolyte abnormalities with diuretics, myopathy with HMG Co-A reductase inhibitors, cough with ACE inhibitors, and increased incidence of thrombosis). Recommendations for optimizing cardiovascular drug therapy for the older women include individualization of drug selection to minimize the number of medications and side effects; dosage adjustment based on age, size, and sex; close monitoring for side effects; and consideration of cost and access to medications. Optimal care for the older woman with cardiovascular disease will also require investigation of cardiovascular medications in older women and of therapies for cardiovascular diseases that are more common in women than men.