Antihyperlipidemic Medication Treatment Patterns and Statin Adherence Among Patients with ASCVD in a Managed Care Plan After Release of the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol

A Cohort Analysis of Statin Treatment Patterns Among Small-Sized Primary Care Practices

BACKGROUND

Small-sized primary care practices, defined as practices with fewer than 10 clinicians, delivered the majority of outpatient visits in the USA. Statin therapy in high-risk individuals reduces atherosclerotic cardiovascular disease (ASCVD) events, but prescribing patterns in small primary care practices are not well known. This study describes statin treatment patterns in small-sized primary care practices and examines patient- and practice-level factors associated with lack of statin treatment.

METHODS

We conducted a retrospective cohort analysis of statin-eligible patients from practices that participated in Healthy Hearts in the Heartland (H3), a quality improvement initiative aimed at improving cardiovascular care measures in small primary care practices. All statin-eligible adults who received care in one of 53 H3 practices from 2013 to 2016. Statin-eligible adults include those aged at least 21 with (1) clinical ASCVD, (2) low-density lipoprotein cholesterol (LDL-C) ≥ 190 mg/dL, or (3) diabetes aged 40-75 and with LDL-C 70-189 mg/dL. Eligible patients with no record of moderate- to high-intensity statin prescription are defined by ACC/AHA guidelines.

RESULTS

Among the 13,330 statin-eligible adults, the mean age was 58 years and 52% were women. Overall, there was no record of moderate- to high-intensity statin prescription among 5,780 (43%) patients. Younger age, female sex, and lower LDL-C were independently associated with a lack of appropriate intensity statin therapy. Higher proportions of patients insured by Medicaid and having only family medicine trained physicians (versus having at least one internal medicine trained physician) at the practice were also associated with lower appropriate intensity statin use. Lack of appropriate intensity statin therapy was higher in independent practices than in Federally Qualified Health Centers (FQHCs) (50% vs. 40%, p value < 0.01).

CONCLUSIONS

There is an opportunity for improved ASCVD risk reduction in small primary care practices. Statin treatment patterns and factors influencing lack of treatment vary by practice setting, highlighting the importance of tailored approaches to each setting.

Towards better reporting of the Proportion of Days Covered method in cardiovascular medication adherence: A scoping review and new tool TEN-SPIDERS

Although medication adherence is commonly measured in electronic datasets using the proportion of days covered (PDC), no standardized approach is used to calculate and report this measure. We conducted a scoping review to understand the approaches taken to calculate and report the PDC for cardiovascular medicines to develop improved guidance for researchers using this measure. After prespecifying methods in a registered protocol, we searched Ovid Medline, Embase, Scopus, CINAHL Plus and grey literature (1 July 2012 to 14 December 2020) for articles containing the terms “proportion of days covered” and “cardiovascular medicine”, or synonyms and subject headings. Of the 523 articles identified, 316 were reviewed in full and 76 were included (93% observational studies; 47% from the USA; 2 grey literature articles). In 45 articles (59%), the PDC was measured from the first dispensing/claim date. Good adherence was defined as 80% PDC in 61 articles, 56% of which contained a rationale for selecting this threshold. The following parameters, important for deriving the PDC, were often not reported/unclear: switching (53%), early refills (45%), in‐hospital supplies (45%), presupply (28%) and survival (7%). Of the 46 articles where dosing information was unavailable, 59% reported how doses were imputed. To improve the transparent and systematic reporting of the PDC, we propose the TEN‐SPIDERS tool, covering the following PDC parameters: Threshold, Eligibility criteria, Numerator and denominator, Survival, Presupply, In‐hospital supplies, Dosing, Early Refills, and Switching. Use of this tool will standardize reporting of the PDC to facilitate reliable comparisons of medication adherence estimates between studies.

Care gaps in achieving cholesterol targets in people with diabetes: A population-based study in a universal health care setting

AIMS

Statins are first line therapy in people with diabetes. Little is known about real-world statin intensity use and low-density lipoprotein cholesterol (LDL-C) levels achieved. We aimed to describe statin intensity used, achievement of LDL-C targets, and factors associated with achieving targets among adults with diabetes.

METHODS

This population based (∼4.3 million), retrospective observational study, used clinical and administrative databases. Statin use by intensity, adherence, and achievement of LDL-C targets in adults with diabetes were described. Multiple logistic regression assessed the factors associated with achieving targets.

RESULTS

Out of 331,312 individuals with diabetes, 88% had an index LDL-C test. At follow up, 31% overall did not achieve LDL-C targets and overall adherence was 66%. Failure to achieve targets was 49%, 30%, and 25% in low-, moderate-, and high-intensity statin groups, respectively. Those who were older, males, had a history of myocardial infarction, stroke, congestive heart failure, renal disease, better adherence, and higher intensity statin users were more likely to achieve targets.

CONCLUSIONS

One-third of people on statins did not achieve targets. Strategies to fill the gap between ideal and current levels of LDL-C achieved are needed if the benefits of statins demonstrated in trials are to be translated into practice.

Secondary Prevention Using Cholesterol-Lowering Medications in Patients with Prior Atherosclerotic Cardiovascular Disease Events: A Retrospective Cohort Analysis

Background: Secondary prevention with lipid-lowering medications in patients with atherosclerotic cardiovascular disease (ASCVD) is known to reduce the risk of clinical events and death. Current guidelines codify recommendations for implementing secondary prevention in appropriate patients. However, in real-world practice, secondary prevention is frequently initiated only after the patient experiences a cardiovascular-related hospitalization. The impact of these delays is not well known. Objectives: To estimate the effects of delaying treatment on the risk of cardiovascular-related hospitalization and on costs for patients who meet the criteria for secondary prevention as specified in the 2013 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Methods: This is a retrospective cohort analysis using Humana data. Eligible patients were categorized by treatment group: (1) patients who initiated treatment before an ASCVD-related hospitalization and (2) patients who either did not initiate treatment until after an ASCVD hospitalization or never initiated treatment. The associations between the timely initiation of cholesterol-lowering medications for secondary prevention and (1) the risk for an ASCVD hospitalization and (2) health-care costs over one year, were estimated using multivariate regressions. Results: A total of 272 899 secondary prevention patients were identified who met study selection criteria. Early treatment was associated with significant reductions in the risk of an ASCVD hospitalization at any time following the identification of the patient's eligibility for secondary prevention (by 33% compared to those treated late or never, P<.0001), but was significantly associated with higher total cost over the first post-index year (by US $509, P<.001). Patients whose low-density lipoprotein cholesterol (LDL-C) levels were >130 mg/dL experienced higher ASCVD hospitalization risks, and also larger risk reductions if treated before an ASCVD hospitalization compared to patients with lower LDL-C levels who were treated late or never treated. Conclusions: More widespread implementation of the treatment policies specified in the 2013 ACC/AHA Guidelines for secondary prevention should significantly reduce cardiovascular disease hospitalizations and reduce costs.

Differences in Beliefs About Cholesterol-Lowering Medications Among the Visegrad Group Countries: A Cross-Sectional Study

Background: New cholesterol guidelines highlight more personalized risk assessments and new cholesterol-lowering drugs for people at the highest risk for cardiovascular disease. Adherence due to fear of and lack of trust in medications prevents treatment to provide better health outcomes.

Objectives: The aim of our study was to investigate the possible differences in the beliefs about the necessity and concerns regarding lipid-lowering drugs among the Visegrad Group countries.

Methods: The Beliefs About Medicines Questionnaire (BMQ-Specific) was used in our research. The responses of 205 Hungarian, 200 Slovak, 235 Czech, and 200 Polish participants, all taking cholesterol-lowering medications, were compared to each other.

Results: Hungarian participants' belief in the necessity of cholesterol-lowering drugs was significantly lower compared to the Slovak (P = 0.001), Czech (P = 0.037), and Polish (P < 0.001) participants. While no difference was observed between the Czech and Slovak responses (P = 0.154), both the Czech (P < 0.001) and Slovak (P = 0.006) respondents' belief regarding necessity was lower than that of the Polish. Regarding concerns, the only significant difference was observed between the Czech and the Polish respondents (P = 0.011).

Conclusions: While the beliefs about benefits (necessity) are most prominent among the Polish participants, except in comparison to Czech responses, the Visegrad Group countries do not differ considerably regarding their beliefs about the fear (concerns) of the treatment.

Uptake of Statin Guidelines to Prevent and Treat Cardiovascular Disease

INTRODUCTION

In December 2013, cholesterol treatment guidelines changed the approach to statin therapy by recommending fixed doses of low-, medium-, or high-intensity statins based on cardiovascular risk. We sought to evaluate the guideline's adoption in a diverse group of practices.

METHODS

Using a mixed-methods approach, we analyzed electronic health record data the year before and 2 years following guideline publication in 45 practices across 8 states. We examined associations based on patient, clinician, and practice characteristics and interviewed 24 clinicians and practice leaders to inform findings.

RESULTS

The proportion of patients adherent with all recommendations 2 years after the guideline only increased from 18.5% to 20.3% (P < .01). There were clinically insignificant increases in statin use across risk strata (1.7% to 3.5%) and small increases in high-intensity statin use (2.6% to 4.6%). Only half of patients with cardiovascular disease (52.9%) were on any statin, not much different from patients at moderate (49.6% to 50.9%) or low (41.6% to 48.7%) risk. Multiple patient (risk, use of health care), clinician (age), and practice (type, rurality) factors were associated with statin use. Clinicians reported patient resistance to statins but liked having a risk calculator to guide discussions.

CONCLUSION

Despite general agreement with statin benefit, the guideline was poorly implemented. Marginal differences in statin use between the highest and lower risk strata of patients is concerning. Rather than intensifying statin potency and recommending more patients take statins, guidelines may want to focus on ensuring that those who will benefit most get treatment.

Examining the Nocebo Effect of Statins Through Statin Adverse Events Reported in the Food and Drug Administration Adverse Event Reporting System

BACKGROUND

This study aimed to evaluate whether the high frequency of reported statin adverse effects (AEs) may be associated with the nocebo effect. We compared nocebo-related subjective AEs with objective AEs and investigated factors potentially associated with the nocebo effect.

METHODS

A retrospective cohort study was conducted using the Food and Drug Administration Adverse Event Reporting System between January 2010 and December 2019 for statins, including, atorvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin. Subjective AEs included fatigue, subjective muscular, and nervous system AEs. Objective AEs were defined as hepatic and objective muscular AEs. We compared the number of subjective and objective AEs using the Mann-Whitney U test and examined trends in the frequency of subjective versus objective reports over time using linear regression with interaction terms. We evaluated the association between AEs and gender and country using linear regression. Quantitative detection of signals was estimated using proportional reporting ratio and reporting odds ratio for simvastatin.

RESULTS

Of 2 994 487 overall AE reports, more subjective than objective AEs were reported per quarter (mean±SD: 4777±1375.45 versus 999±276.95; P<0.0001), and over time during the study period (P<0.001). Women reported more subjective AEs than men per quarter (fatigue: 86.98 more per quarter, P=0.035; subjective muscular AE: 417.95, P<0.0001; nervous system AE: 273.60, P<0.0001), but fewer objective muscular AEs (-125.23 per quarter, P<0.0001). More subjective AEs and fewer objective AEs were reported per quarter in the United States relative to other countries. Simvastatin-associated reports showed signals for higher objective muscular AEs relative to all other statins (reporting odds ratio, 1.53 [95% CI, 1.49-1.58]).

CONCLUSIONS

This study found that significantly more subjective than objective AEs are reported for statins. Subjective statin AEs, potentially related to the nocebo effect are reported more often by women than by men, and in the United States than in other countries.

An Evaluation of Statin Use Among Patients with Type 2 Diabetes at High Risk of Cardiovascular Events Across Multiple Health Care Systems

BACKGROUND

Patients with more than one chronic condition often receive care from several providers and facilities, which may lead to fragmentation of care. Poor care coordination in dual health care system use has been associated with increased emergency department visits, hospitalizations, and costs.

OBJECTIVE

Dual health care system use is increasing among veterans, and we sought to evaluate the effect of dual health care system use on statin treatment in veterans with type 2 diabetes at high risk of cardiovascular events, using varying degrees of Centers for Medicare & Medicaid Services (CMS) services.

METHODS

This was a 10-year retrospective longitudinal cohort study of national clinical and administrative data that included 689,138 veterans with type 2 diabetes who were aged 65 years or older on January 1, 2006. Patients were followed from January 1, 2007, until December 31, 2016. Administrative and clinical data from the Veterans Health Administration's (VHA) Corporate Data Warehouse were merged with CMS inpatient, outpatient, and pharmacy data. Statin use was defined as any therapy and subcategorized as high versus low or moderate intensity per the American College of Cardiology/American Heart Association guidelines. Marginal generalized estimating equation-type models for longitudinal data were used to model the association between dual health care utilization status (< 50%, 50%-80%, and > 80% VHA utilization, with the first group serving as the reference group) and statin use after adjusting for measured covariates.

RESULTS

The mean ages at baseline for each group were similar and ranged between 75.4 and 76.9 years. For the outcome of any statin use, the group with < 50% VHA utilization was significantly less likely to receive statin therapy compared with the group with > 80% VHA utilization (OR = 0.26, 95% CI = 0.26-0.26), while the group with 50%-80% VHA utilization was slightly more likely (OR = 1.05, 95% CI = 1.04-1.07). Similarly, for the high-intensity versus low-/moderate-intensity or no statins outcome, the group with < 50% VHA utilization was significantly less likely to receive a high-intensity statin compared with the group with > 80% VHA utilization (OR = 0.56, 95% CI = 0.55-0.57), while the group with 50%-80% VHA utilization was only slightly less likely (OR = 0.95, 95% CI =0.94-0.96).

CONCLUSIONS

Among veterans with diabetes at high risk of cardiovascular events, dual health care system utilization status appeared to affect statin use. We observed lower odds for any statin use and high-intensity statin therapy among the cohort with the lowest degree of VHA utilization (i.e., < 50%). Interventions to increase statin use among veterans at high risk of cardiovascular events with lower degrees of VHA utilization should be explored.

DISCLOSURES

This study was supported by a grant funded by the Department of Veterans Affairs' Health Services Research and Development Service and was undertaken at the Health Equity and Rural Outreach Center (HEROIC) at Ralph H. Johnson Veteran Affairs Medical Center, Charleston, SC. The authors report no potential conflicts of interest relevant to this article. This article represents the views of the authors and not those of the Medical University of South Carolina or Veteran Health Administration.

Lipid Testing Trends in the US Before and After the Release of the 2013 Cholesterol Treatment Guidelines

Background

The 2013 ACC/AHA cholesterol treatment guidelines removed the recommendation to treat adults at risk of cardiovascular disease to goal levels of low-density lipoprotein cholesterol (LDL-C). We anticipated that the frequency of LDL-C testing in clinical practice would decline as a result. To test this hypothesis, we evaluated the frequency of LDL-C testing before and after the guideline release.

Methods

We used the MarketScan^® Commercial and Medicare Supplemental claims data (1/1/2007–12/31/2016) to identify four cohorts: 1) statin initiators (any intensity), 2) high-intensity statin initiators, 3) ezetimibe initiators, and 4) patients at very high cardiovascular risk (≥2 hospitalizations for myocardial infarction or ischemic stroke, with prevalent statin use). Rates of LDL-C testing by calendar year quarter were estimated for each cohort. To estimate rates in the absence of a guideline change, we fit a time-series model to the pre-guideline rates and extrapolated to the post-guideline period, adjusting for covariates, seasonality, and time trend.

Results

Pre- and post-guideline rates (LDL-C tests per 1,000 persons per quarter) were 248 and 235, respectively, for 3.9 million statin initiators; 263 and 246 for 1.3 million high-intensity statin initiators; 277 and 261 for 323,544 ezetimibe initiators; and 180 and 158 for 42,108 very high-risk patients. For all cohorts, observed post-guideline rates were similar to model-predicted rates. On average, the difference between observed and predicted rates was 8.5 for patients initiating any statin; 2.6 for patients initiating a high-intensity statin; 11.4 for patients initiating ezetimibe, and −0.5 for high-risk patients.

Conclusion

We observed no discernible impact of the release of the 2013 ACC/AHA guidelines on LDL-C testing rates. Rather, there was a gradual decline in testing rates starting prior to the guideline change and continuing throughout the study period. Our findings suggest that the guidelines had little to no impact on use of LDL-C testing.

Real-world evaluation of the impact of statin intensity on adherence and persistence to therapy: A Scottish population-based study

Aim

To assess associations between statin intensity and adherence, persistence and discontinuation of statin therapy in Scotland.

Method

Retrospective cohort study, using linked electronic health records covering a period from January 2009 to December 2016. The study cohort included adult patients (≥18 years) newly initiating statins within Greater Glasgow and Clyde, Scotland. Study outcomes comprised adherence, discontinuation and persistence to treatment, stratified by three exposure groups (high, moderate and low intensity). Discontinuation and persistence were calculated using the refill‐gap and anniversary methods, respectively. Proportion of days covered (PDC) was used as a proxy for adherence. Kaplan‐Meier survival curves and Cox proportional hazard models were used to evaluate discontinuation, and associations between adherence/persistence and statin intensity were assessed using logistic regression.

Results

A total of 73 716 patients with a mean age of 61.4 ± 12.6 years were included; the majority (88.3%) received moderate intensity statins. Discontinuation rates differed between intensity levels, with high‐intensity patients less likely to discontinue treatment compared to those on moderate intensity (prior cardiovascular disease [CVD]: HR 0.43 [95% CI 0.34‐0.55]; no prior CVD: 0.80 [0.74‐0.86]). Persistence declined over time, and high‐intensity patients had the highest persistence rates. Overall, 52.6% of patients were adherent to treatment (PDC ≥ 80%), but adherence was considerably higher among high‐intensity patients (63.7%).

Conclusion

High‐intensity statins were associated with better persistence and adherence to treatment, but overall long‐term persistence and adherence remain a challenge, particularly among patients without prior CVD. This needs addressing.

Effects of the 2013 American College of Cardiology/American Heart Association guidelines on racial and ethnic disparities in statin treatment among diabetics

BACKGROUND

Significant racial and ethnic disparities in statin prescribing and utilization have been constantly documented.

OBJECTIVE

To examine whether racial/ethnic disparities in statin treatment have decreased among the diabetic population after the release of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines.

METHODS

This retrospective study analyzed patients with diabetes aged 40-75 years old in the Medicare Expenditure Panel Survey (2011-2012 and 2014-2015). Racial and ethnic disparities in the likelihood of statin use and number of statin prescriptions were compared before and after the guideline release. Logistic and negative binomial regressions were used to adjust for patient characteristics. A difference-in-difference model (DID) was used to examine disparity changes.

RESULTS

This study included 2584 patients from 2011 to 2012 and 2610 from 2014 to 2015. During 2011-2012, racial/ethnic disparities were significant for the likelihood of statin use. For the number of statin prescriptions, racial disparity was significant, but not for the ethnic disparity. During 2014-2015, racial/ethnic disparities were significant for the likelihood of statin use but were not significant for the number of statin prescriptions. The DID model found that the 2013 guidelines were not associated with a reduction in racial and ethnic disparities in statin treatment.

CONCLUSIONS

This study found persistent disparities in the likelihood of statin use. The 2013 ACC/AHA guidelines were not associated with a reduction in racial and ethnic disparities in statin treatment.

Trends in Statin Use 2009-2015 in a Large Integrated Health System: Pre- and Post-2013 ACC/AHA Guideline on Treatment of Blood Cholesterol

Purpose

Implementation of the 2013 ACC/AHA cholesterol treatment guideline is likely to vary by statin benefit group. The aim of this study was to document trends in statin use before and after introduction of the ACC/AHA guideline.

Methods

We conducted a retrospective study with annual cohorts from 2009 to 2015 among members of Kaiser Permanente Southern California aged ≥ 21 years. Members were categorized into four mutually exclusive statin benefit groups: atherosclerotic cardiovascular disease (ASCVD), LDL-C ≥ 190 mg/dL in the last year, diabetes (aged 40–75 years), and 10-year ASCVD risk ≥ 7.5% (aged 40–75 years).

Results

The cohorts ranged from 1,993,755 members in 2009 to 2,440,429 in 2015. Approximately 5% of patients had ASCVD, 1% had LDL-C ≥ 190 mg/dL, 6% had diabetes, and 10% had a 10-year ASCVD risk ≥ 7.5% each year. Trends in statin use were stable for adults with ASCVD (2009 78%; 2015 80%), recent LDL-C ≥ 190 mg/dL (2009 45%; 2015 44%), and diabetes (2009 74%; 2015 73%), but increased for patients with 10-year ASCVD risk ≥ 7.5% (2009 36%; 2015 47%). High-intensity statin use also increased 142% and 54% among patients with LDL-C ≥ 190 mg/dL and those with ASCVD ≤ 75 years of age, respectively. Moderate-to-high intensity statin utilization increased over 50% among those with a 10-year ASCVD risk ≥ 7.5%.

Conclusions

Statin use increased substantially among patients with 10-year ASCVD risk ≥ 7.5% and use of appropriate statin dosage increased in each of the four statin benefit groups between 2009 and 2015; however, there is room for improvement.

Trends in low-density lipoprotein-cholesterol blood values between 2012 and 2017 suggest sluggish adoption of the recent 2013 treatment guidelines

BACKGROUND

Over a 14-year period, age-adjusted high total cholesterol (≥240 mg/dL) in the United States declined from 18.3% in 1999 to 2000 to 11.0% in 2013 to 2014, coinciding with the 2001 National Cholesterol Education Program Adult Treatment Panel (ATP)-III guidelines that endorsed low-density lipoprotein (LDL)-cholesterol blood value goals. Statin treatment recommendations were revised by the American College of Cardiology and the American Heart Association (ACC/AHA) in November 2013 to a "risk-based prescription" approach that did not utilize blood cholesterol values. This increased dosage and expanded the statin-eligible population by an estimated 12.8 million US adults. These changes should further lower total and LDL cholesterol concentrations nationally.

METHODS

We examined data from 507 752 patients nationally aged ≥16 years whose fasting bloods were sent to Boston Heart Diagnostics for direct LDL-cholesterol measurements. Between 2012 and 2017, age-adjusted concentrations were examined by analysis of covariance and LDL-cholesterol ≥160 mg/dL by logistic regression.

RESULTS

Contrary to expectations, age-adjusted mean LDL-cholesterol concentrations (±SE, mg/dL) increased significantly (P < 10^-16 ) in men (2012:113.8 ± 0.3; 2013:115.3 ± 0.2; 2014:114.7 ± 0.2; 2015:116.0 ± 0.2; 2016:117.6 ± 0.2; and 2017:117.1 ± 0.2 mg/dL) and women (2012:119.5 ± 0.3; 2013:120.7 ± 0.2; 2014:119.8 ± 0.02; 2015:120.8 ± 0.2; 2016:122.7 ± 0.1; and 2017:123.8 ± 0.2 mg/dL). The percentage with LDL-cholesterol ≥160 mg/dL also increased significantly (P < 10^-9 ) in men and women. Similar results were obtained for ages 40 to 75 years olds (corresponding to ACC/AHA guidelines).

CONCLUSION

These results provide additional evidence that declining blood LDL-cholesterol levels observed following the ATP-III recommendations, did not further decline (actually increased) following the 2013 ACC/AHA recommendations.

Adherence to and Persistence With Statin Therapy in a Veteran Population

BACKGROUND

A relative cardiovascular risk reduction of 25% to 35% has been reported in patients starting a statin for elevated cholesterol; yet many patients fail to consistently take these medications as directed.

OBJECTIVE

To evaluate factors affecting adherence and persistence with statin therapy.

METHODS

This retrospective study analyzed data from a Veterans Affairs database of facilities west of the Rocky Mountains. Patient demographics, co-morbidities, and prescription information was collected for individuals newly prescribed a statin between July 1, 2007, and December 31, 2012. Adherence was determined using the medication possession ratio (MPR). Persistence was defined as the time from initiation of therapy until a refill gap of 135 days or greater occurred.

RESULTS

Of 164 687 unique patients, overall adherence to statins a mean MPR of 0.843. Approximately 63% of patients were persistent with statin therapy 675 days after statin initiation. Patients prescribed pravastatin, atorvastatin, lovastatin, and rosuvastatin and those who took more than 1 different statin during the follow-up period had statistically significantly higher rates of adherence than those prescribed simvastatin. Older patients and those with a greater number of active prescriptions were found to be more adherent to statin medications. Patients with hypertension were more adherent to a statin, and those with diabetes mellitus and/or posttraumatic stress disorder (PTSD) were less adherent. Conclusion and Relevance: In veterans, overall statin adherence was excellent. Certain populations may benefit from interventions targeted at improving statin adherence, including younger veterans, those prescribed fewer medications, those taking simvastatin, and veterans with PTSD or diabetes mellitus.

Trends in high-intensity statin use and low-density lipoprotein cholesterol control among patients enrolled in a clinical pharmacy cardiac risk service

BACKGROUND

Although high-intensity statin therapy (HIST) is recommended for most patients between 21 and 75 years of age with atherosclerotic cardiovascular disease (ASCVD), several recent analyses examining contemporary statin use trends have identified a clinical care gap in the utilization of HIST.

OBJECTIVE

The objective of this study was to assess secular trends in lipid management for patients with ASCVD enrolled in a clinical pharmacy program within an integrated health care delivery system.

METHODS

We performed serial cross-sectional studies over time, comprising 18,006 adults with both acute and chronic ASCVD, to assess trends in statin use and low-density lipoprotein cholesterol (LDL-C) levels from 2007 to 2016.

RESULTS

Although the use of statin therapy (any intensity) remained relatively consistent throughout the 10-year study period (89% in 2007, 87% in 2016), the proportion of patients receiving HIST increased over time (44% in 2007, 67% in 2016; P < .001 for trend). Population mean LDL-C levels ranged from 73 to 83 mg/dL with a downward trend over the 10-year study period (P < .001 for trend). By 2016, the proportion of patients attaining an LDL-C <100 mg/dL and <70 mg/dL was 85% and 54%, respectively. Nonstatin lipid-lowering therapy use decreased over the study period, which was primarily driven by decreased use of ezetimibe (24% in 2007, 2% in 2016; P < .001 for trend).

CONCLUSIONS

Among adults with ASCVD enrolled in a clinical pharmacy cardiac risk reduction service, guideline-directed use of HIST significantly increased over the past 10 years and coincided with decreased population LDL-C levels.

Comparison of Adherence to the 2013 ACC/AHA Cholesterol Guideline in a Teaching Versus Nonteaching Outpatient Clinic

BACKGROUND

Little information is available regarding prescribers' adherence rate to the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol guideline, especially that from a teaching versus a nonteaching setting.

OBJECTIVES

We aim to evaluate adherence rates to the 2013 ACC/AHA cholesterol guideline in a teaching versus a nonteaching practice site. In addition, the impact of a pharmacist-led seminar on adherence rate to the guideline was assessed.

METHODS

This study is a 2-part retrospective chart review. Part 1 consists of patients who were initiated on statin therapy between December 2013 and November 2014. Patients were analyzed to determine if they received concordant statin therapy as recommended by the guideline. For the second part, we evaluated the impact of a seminar on the adherence rate to the guideline.

RESULTS

Of the 325 patients who received a statin prescription, 233 were included in the study. Prescriber adherence to the guideline was 42.9%, which was significantly lower than the 65.8% observed in a study previously conducted at a teaching outpatient clinic ( P < 0.0001). For the second part of our study, prescriber adherence to the guideline 3 months before the pharmacist-led seminar was 53.5%, and this adherence rate remained virtually unchanged at 54.2% at 3 months after the educational session.

CONCLUSION

The overall adherence rate to the 2013 ACC/AHA cholesterol guideline from this nonteaching outpatient clinic was significantly lower than that previously observed in a teaching outpatient clinic. The single pharmacist-led seminar did not significantly affect prescribers' adherence rate to the guideline.

Lipid management in contemporary community practice: Results from the Provider Assessment of Lipid Management (PALM) Registry

BACKGROUND

The latest cholesterol guidelines have shifted focus from achieving low-density lipoprotein cholesterol (LDL-C) targets toward statin use and intensity guided by atherosclerotic cardiovascular disease (ASCVD) risk.

METHODS

Statin use and intensity were evaluated in 5,905 statin-eligible primary or secondary prevention patients from 138 PALM Registry practices.

RESULTS

Overall, 74.7% of eligible adults were on statins; only 42.4% were on guideline-recommended intensity. Relative to primary prevention patients, ASCVD patients were more likely to be on a statin (83.6% vs 63.4%, P<.0001) and guideline-recommended intensity (47.3% vs 36.0%, P<.0001). Men were more likely than women to be prescribed recommended intensity for primary (odds ratio [OR] 1.87, 95% CI 1.49-2.34) and secondary (OR 1.47, 95% CI 1.26-1.70) prevention. In primary prevention, increasing age, diabetes, obesity, hypertension, and lower 10-year ASCVD risk were associated with increased odds of receiving recommended intensity. Among ASCVD patients, those with coronary artery disease were more likely to be on recommended intensity than cerebrovascular or peripheral vascular disease patients (OR 1.71, 95% CI 1.41-2.09), as were those seen by cardiologists (OR 1.43, 95% CI 1.12-1.83). Median LDL-C levels were highest among patients not on statins (124.0 mg/dL) and slightly higher among those on lower-than-recommended intensity compared with recommended-therapy recipients (88.0 and 84.0 mg/dL, respectively; P≤.0001).

CONCLUSIONS

In routine contemporary practice, 1 in 4 guideline-eligible patients was not on a statin; less than half were on the recommended statin intensity. Untreated and undertreated patients had significantly higher LDL-C levels than those receiving guideline-directed statin treatment.

Initiation Patterns of Statins in the 2 Years After Release of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Management Guideline in a Large US Health Plan

BACKGROUND

The purpose of this study was to characterize changes in statin utilization patterns in patients newly initiated on therapy in the 2 years following the release of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) cholesterol management guideline in a large US health plan population.

METHODS AND RESULTS

This retrospective, observational study used administrative medical and pharmacy claims data to identify patients newly initiated on statin therapy over 4 quarters prior to and 8 quarters following the release of the guideline (average N/quarter=3596). Patients were divided into the 4 statin benefit groups (SBGs) based on risk factors and laboratory lipid levels as defined in the guideline: SBG1 (with atherosclerotic cardiovascular disease [ASCVD]; N=1046/quarter), SBG2 (without ASCVD, with low-density lipoprotein cholesterol ≥190 mg/dL; N=454/quarter), SBG3 (without ASCVD, aged 40-75 years, with diabetes mellitus, low-density lipoprotein cholesterol 70-189 mg/dL; N=1391/quarter), SBG4 (no ASCVD or diabetes mellitus, age 40-75 years, low-density lipoprotein cholesterol 70-189 mg/dL, estimated 10-year ASCVD risk of ≥7.5%; N=705/quarter). Demographic variables, statin utilization patterns, lipid levels, and comorbidities were analyzed for pre- and postguideline periods. Postguideline, gradually increased high-intensity statin initiation occurred in SBG1, SBG2, and in SBG3 patients with 10-year ASCVD risk ≥7.5%. Moderate- to high-intensity statin initiation gradually increased among SBG4 patients. Recommended-intensity statin choice changed to a greater degree among patients treated by specialty care physicians. Regarding sex, target-intensity statin initiation was lower in women in all groups before and after guideline release.

CONCLUSIONS

Prescriber implementation of the guideline recommendations has gradually increased, with the most marked change in the increased initiation of high-intensity statins in patients with ASCVD and in those treated by a specialist.

A systematic review to assess adherence and persistence with statins

OBJECTIVE

To identify and assess studies published over a 10 year period up to February 2016 which measure adherence or persistence with statins, to summarize their methods, strengths and weaknesses and to summarize evidence linking statin adherence/persistence with risk of cardiovascular events.

METHODS

Electronic databases and abstracts from four major cardiovascular disease conferences were searched from January 2005 to February 2016. The study selection process was performed by two reviewers working independently. Studies were included if they reported data regarding patient adherence or persistence with statins in adults with primary hypercholesterolemia, using any type of study design or length of follow-up. One reviewer extracted the study data and assessed study quality, which was checked by a second reviewer independently. Given the heterogeneity between the included studies a narrative critique and summary is presented.

RESULTS

We report on 84 real world studies which aimed to assess adherence or persistence with statins. The majority of studies concluded that good adherence/persistence was associated with reduction in cardiovascular events and mortality. In two studies high intensity statin regimens were associated with poorer patient adherence when compared to low intensity statins. Adherence and persistence with statin therapy also has an impact on hospitalization costs and other cardiovascular disease (CVD) related costs.

CONCLUSIONS

Adherence and persistence are associated with a reduction in CVD events and mortality. There was limited evidence to suggest that high intensity statin regimens are associated with poorer treatment adherence when compared to lower intensity regimens. Hence, more robust studies are required to establish this association. As recommended by the 2013 ACC/AHA, 2016 ESC and several other clinical guidelines, clinicians and pharmacy managers should regularly monitor statin therapy adherence.

Effect of 2013 ACC/AHA Blood Cholesterol Guidelines on Statin Treatment Patterns and Low-Density Lipoprotein Cholesterol in Atherosclerotic Cardiovascular Disease Patients

Background

Preceding release of the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol guidelines, prescribers aimed for specific low‐density lipoprotein cholesterol (LDL‐C) goals in patients with atherosclerotic cardiovascular disease (ASCVD). The 2013 guidelines changed this focus to treating patients with appropriate statin intensity given their ASCVD risk. We examined statin use and LDL‐C levels before and after the 2013 ACC/AHA guidelines in patients with clinical ASCVD as defined in the guidelines.

Methods and Results

We conducted a retrospective cohort study of adult commercial and Medicare Advantage health plan enrollees in the Optum Research Database. Patients had ≥1 claim with a diagnosis of clinical ASCVD between November 1, 2012 and December 31, 2014 and were continuously enrolled 6 months before (baseline) and 7 months after (follow‐up) the first ASCVD visit. Patients were assigned to monthly cohorts based on ASCVD event month. Statin use and intensity were measured at baseline and first month of follow‐up. LDL‐C changes were assessed using ordinary least squares regression. For 90 287 patients, mean (SD) age was 68 (12) years; 50% were female; and 30% had commercial insurance. Statin use remained consistent before and after guidelines (32% and 31%, respectively). Of patients receiving statins, high‐intensity use increased by 4 percentage points 1 year after guidelines (P<0.001). Mean LDL‐C levels were 2.4 mmol/L (94 mg/dL) both pre‐ and postguidelines.

Conclusions

Statin use and mean monthly LDL‐C before and after the guidelines remained largely unchanged; statin intensity increased modestly. More effort may be needed to increase guideline understanding and adherence to improve treatment of high‐risk patients.