Is lipid-lowering therapy underused by African Americans at high risk of coronary heart disease within the VA health care system?

Factors Associated With PCSK9 Inhibitor Initiation Among US Veterans

Background

Few adults at high risk for atherosclerotic cardiovascular disease events use a PCSK9i (proprotein convertase subtilisin/kexin type 9 inhibitor).

Methods and Results

Using data from the US Veterans Health Administration, we identified veterans who initiated a PCSK9i between January 2018 and December 2019, matched 1:4 to veterans who did not initiate this medication over this time period (case‐cohort study). Two cohorts of veterans were analyzed: (1) atherosclerotic cardiovascular disease, with a most recent low‐density lipoprotein cholesterol (LDL‐C) ≥70 mg/dL; and (2) severe hypercholesterolemia (ie, familial hypercholesterolemia or any prior LDL‐C ≥190 mg/dL, with most recent LDL‐C ≥100 mg/dL). Conditional logistic regression was used to analyze factors associated with PCSK9i initiation, adjusting for all factors, simultaneously. There were 2394 initiators and 9576 noninitiators in the atherosclerotic cardiovascular disease cohort (median LDL‐C, 141 and 96 mg/dL, respectively; P<0.001). Factors associated with a higher likelihood of PCSK9i initiation included age 65 to <75 versus <65 years, highest versus lowest quartile of median area‐level income, familial hypercholesterolemia, former statin use, and current ezetimibe use. PCSK9i initiation was lower among veterans of a race/ethnicity other than non‐Hispanic White. There were 245 initiators and 980 noninitiators in the severe hypercholesterolemia cohort (median LDL‐C, 183 and 151 mg/dL, respectively; P<0.001). Age ≥75 versus <65 years, history of chronic kidney disease, former statin use, and current ezetimibe use were associated with a higher likelihood of PCSK9i initiation.

Conclusions

Several patient‐level factors, including age, sex, and race/ethnicity, were significantly associated with PCSK9i initiation, suggesting an unmet treatment need in several patient groups.

Impact of Race and Location of Residence on Statin Treatment Among Veterans With Type 2 Diabetes Mellitus

Rural residence and ethnic-minority status are individually associated with increased cardiovascular (CV) mortality. Statin therapy is known to reduce the risk of cardiovascular mortality. Although ethnic disparities in statin treatment exist, the joint impact of urban/rural residence and race/ethnicity on statin prescribing is unclear. Veterans Health Administration (VHA) and Centers for Medicare and Medicaid data were used to perform a longitudinal study of Veterans with Type 2 diabetes mellitus from 2007 to 2016. Mixed effects logistic regression with a random intercept was used to model the longitudinal association between the primary exposure (race/ethnicity and residence) and statin prescribing. After adjusting for covariates, non-Hispanic White (NHW)-Rural Veterans were 7% (odds ratio [OR] = 1.07; confidence interval [CI] 1.05 to 1.08), non-Hispanic Black (NHB)-Rural Veterans were 4% (OR 1.04; CI 1.00 to 1.08), and Hispanic-Urban Veterans were 20% (OR 1.20; CI 1.17 to 1.23) more likely to be prescribed statins versus NHW-Urban Veterans; whereas, NHB-Urban Veterans were 14% (OR 0.86; CI 0.85 to 0.55) and Hispanic-Rural Veterans were 10% (OR 0.90; CI 0.85 to 0.96) less likely. When disability and dual use were removed from the full model, compared with NHW-Urban, the odds of statin prescribing in NHW-Rural Veterans remained unchanged (OR 1.06; CI 1.04 to 1.07) whereas the odds of statin prescribing in all other groups were higher. In conclusion, NHB-Urban and Hispanic-Rural Veterans had lower odds of statin prescribing versus NHW-Urban Veterans; whereas NHW-Rural, NHB-Rural and Hispanic-Urban Veterans had higher odds. The findings in ethnic-minorities changed when we accounted for markers of VHA care (i.e., disability, dual use) showing that these individuals are more likely to receive statins when they receive more VHA care.

Racial-Geographic Disparity in Lipid Management in Veterans with Type 2 Diabetes: A 10-Year Retrospective Cohort Study

Purpose: The prevalence of diabetes in U.S. veterans (20.5%) is nearly three times that of the general population. Minority veterans have higher rates of diabetes compared with their counterparts and urban/rural residence is also associated with uncontrolled cholesterol. However, the interplay between urban/rural residence and race/ethnicity on cholesterol control is unclear.

Methods: Veterans Health Administration Corporate Data Warehouse and Centers for Medicare and Medicaid data were used to create unique dataset and perform longitudinal study of veterans with type 2 diabetes from 2006 to 2016. Logistic regression was used to model the association between low-density lipoprotein (LDL) control and the primary exposures (race/ethnicity and location of residence) after adjusting for all measured covariates, including the interaction between location of residence and race/ethnicity.

Results: There was a significant interaction between race/ethnicity and rural residence. Rural non-Hispanic Black (NHB) veterans had higher odds for LDL >100 mg/dL (odds ratio [OR]=1.70, 95% confidence interval [CI] 1.50–1.60) and for LDL >70 mg/dL (OR=1.59, 95% CI 1.53–1.64) compared with urban non-Hispanic White (NHW) veterans. Similarly, compared with urban NHW, urban NHB veterans had higher odds of LDL >100 mg/dL (OR=1.45, 95% CI 1.43–1.47) and LDL >70 mg/dL (OR=1.36, 95% CI 1.34–1.38).

Conclusion: This study highlights health disparities for veterans with type 2 diabetes. Future research is needed to evaluate interventions for mitigating these disparities in cholesterol management among veterans with diabetes.

Temporal Trends of High-Intensity Statin Therapy Among Veterans Treated With Percutaneous Coronary Intervention

BACKGROUND

The 2013 American College of Cardiology/American Heart Association blood cholesterol guideline recommends high-intensity statin therapy among certain groups of patients, but full implementation of the guideline has not yet been satisfactory. We aimed to investigate the temporal trends and predictors of high-intensity statin therapy among veterans who had been treated with percutaneous coronary intervention (PCI) and followed up by cardiologists within the Veterans Health Administrative system.

METHODS AND RESULTS

A retrospective cohort study was conducted at the Veterans Health Administrative system including all patients >18 years old who had their PCI procedure between October 2010 and September 2016. National Veterans Health Administrative databases were used to retrieve study participant's demographics, comorbid conditions, statin type and dose within 90 days before and after the PCI procedure. There were 48 862 patients who underwent a PCI procedure during the study period. High-intensity statin use at 90 days post-PCI rose from 23% in 2010 to 37% before release of the 2013 American College of Cardiology/American Heart Association cholesterol guideline, then rose sharply to 80% by 2016. The projected 10-year risk of arteriosclerotic cardiovascular disease events among our study population was projected to be ≈1841 fewer if the cohort had received high-intensity statin therapy versus moderate-intensity statin.

CONCLUSIONS

By 2016, the 2013 American College of Cardiology/American Heart Association blood cholesterol guideline was well implemented among veterans who had a PCI procedure in the Veterans Health Administrative system, suggesting systems of care can be improved to increase rates of high-intensity statin initiation.

Racial/Ethnic Disparities in VA Services Utilization as a Partial Pathway to Mortality Differentials Among Veterans Diagnosed With TBI

Objective:

Primary: To examine Veterans Administration (VA) utilization and other potential mediators between racial/ethnic differentials and mortality in veterans diagnosed with traumatic brain injury (TBI).

Design:

A national cohort of veterans clinically diagnosed with TBI in 2006 was followed from January 1, 2006 through December 31, 2009 or until date of death. Utilization was tracked for 12 months. Differences in survival and potential mediators by race were examined via K-Wallis and chi-square tests. Potential mediation of utilization in the association between mortality and race/ethnicity was studied by fitting Cox models with and without adjustment for demographics and co-morbidities. Poisson regression was used to study the association of race/ethnicity with utilization of specialty services potentially important in the management of TBI.

Setting:

United States (US) Veterans Administration (VA) Hospitals and Clinics.

Participants:

14, 690 US veterans clinically diagnosed with TBI in 2006.

Interventions:

Not Applicable. The study is a secondary data analysis.

Main Outcome Measures:

Mortality, Utilization.

Results:

Hispanic veterans were found to have significantly higher unadjusted mortality (6.69%) than Non-Hispanic White veterans (2.93%). Hispanic veterans relative to Non-Hispanic White were found to have significantly lower utilization of all services examined, except imaging. Neurology was found to be the utilization mediator with the highest percent of excess risk (3.40%) while age was the non utilization confounder with the highest percent of excess risk (31.49%). In fully adjusted models for demographics and co-morbidities, Hispanic veterans relative to Non-Hispanic Whites were found to have less total visits (IRR 0.89), TBI clinic (IRR 0.43), neurology (IRR 0.35), rehabilitation (IRR 0.37), and other visits (IRR 0.85) with only higher mental health visits (IRR 1.53).

Conclusions:

We found evidence that utilization is a partial mediator between race/ethnicity and mortality, especially neurology utilization. We also found that Hispanic veterans receive significantly less TBI clinic, neurology, rehabilitation and other types of utilization. The use of innovative system factors (decision aids, information tools, patient activation, and adherence support interventions) could be valuable in enhancing utilization of specific TBI related services, especially among ethnic minorities.

Despite improved quality of care in the Veterans Affairs health system, racial disparity persists for important clinical outcomes

Both government and private health care systems have engaged in efforts to improve quality, but the effect of these initiatives on racial and ethnic disparities has not been well studied. In the decade following an organizational transformation, the Veterans Affairs (VA) health care system achieved substantial improvements in quality of care with minimal racial disparities for most process-of-care measures, such as rates of cholesterol screenings. However, in our study we observed a striking disconnect between high levels of performance on widely used process measures and modest levels of improvement in clinical outcomes, such as control of blood pressure, blood glucose, and cholesterol levels. We also observed a gap in clinical outcomes of as much as nine percentage points between African American veterans and white veterans. Almost all of the disparity in outcomes in the VA was explained by within-facility disparity, which suggests that VA medical centers need to measure and address racial gaps in care for their patient populations. Moreover, because cardiovascular disease and diabetes are major contributors to racial disparities in life expectancy, the findings of this study and others underscore the urgency of focused efforts to improve intermediate outcomes among African Americans in the VA and other settings.

Appropriateness of cholesterol management in primary care by sex and level of cardiovascular risk

A study was undertaken to ascertain the appropriateness of lipid screening and management per the Third Report of the Adult Treatment Panel National Cholesterol Education Program (ATP III) guideline in a sample of North Carolina primary care practices. Demographics, cholesterol values, and comorbid conditions were abstracted from the medical records from 60 community practices participating in a randomized practice-based trial (Guideline Adherence for Heart Health). Eligible patients were aged 21 to 84 years, seen during the baseline period of June 1, 2001, through May 31, 2003, and who were not taking lipid-lowering therapy. Multivariable logistic regression was utilized to assess whether age, sex, race/ethnicity, diabetes, cardiovascular disease, ATP III risk category, or pretreatment low-density lipoprotein (LDL) influenced treatment. Among 5031 eligible patients, 1711 (34.5%) received screening lipid profiles. Screening rates were higher with older age, diabetes, and cardiovascular disease. No large differences were seen by sex. Among patients screened (mean age, 51.6 years; 57.9% female), 76.6% were appropriately managed within 4 months. In adjusted analyses, older age was associated with less appropriate treatment (odds ratio [OR] per 5 years, 0.91; P=.01), and patients with LDL cholesterol <or=130 mg/dL (OR, 18.8; P<.001) and the low-risk group (OR, 27.5; P<.001) were more likely to be managed appropriately compared with patients with LDL >or=190 mg/dL and those at high risk. Among 375 patients eligible for drug treatment, those with LDL levels between 131 and 159 mg/dL were much less likely to be treated (OR, 0.15; P<.001) compared with those with LDL >190 mg/dL, whereas risk category did not influence treatment. The challenge facing implementation of ATP III guidelines is much greater for intermediate- and high-risk patients than for low-risk patients.

Lifestyle therapy changes and hypercholesterolemia: identifying risk groups in a community sample of Blacks and Whites

OBJECTIVE

To examine diet and exercise lifestyle therapy change (LTC), behaviors and their relation to hypercholesterolemia in a community sample of Blacks and Whites.

DESIGN

Latent class analysis (LCA) was employed to identify homogeneous subgroups of community dwelling Blacks and Whites related to LTC for hypercholesterolemia. LCA is a statistical technique used to identify subgroups of individuals who share a similar pattern of responses to a set of observations. The relation between hypercholesterolemia and latent class membership was assessed.

PARTICIPANTS

Adults age 18 and over who participated in a county-level adaptation of the Behavioral Risk Factor Surveillance System.

MAIN OUTCOME MEASURE

Hypercholesterolemia (absence or presence).

RESULTS

Eleven unique latent classes of LTC behavior emerged from LCA models. Exercisers and Fat Reducers represented between 19% and 29% of each race-sex group. Latent class membership probabilities varied substantially across race and sex. Only Black women had a class of Contemplators (21.5%). Overall, men and Blacks with self reported hypercholesterolemia were more likely to engage only in fat reduction but not increase in vegetable consumption, reduction of fat or regular exercise (odds ratios range from 1.8-3.5).

CONCLUSIONS

The distribution of diet and exercise related LTC behaviors in relation to self-reported hypercholesterolemia can help to identify, understand and tailor culturally and sex specific interventions based on the proportions of men and women in different latent classes.

Racial and ethnic disparities in the VA health care system: a systematic review

OBJECTIVES

To better understand the causes of racial disparities in health care, we reviewed and synthesized existing evidence related to disparities in the "equal access" Veterans Affairs (VA) health care system.

METHODS

We systematically reviewed and synthesized evidence from studies comparing health care utilization and quality by race within the VA.

RESULTS

Racial disparities in the VA exist across a wide range of clinical areas and service types. Disparities appear most prevalent for medication adherence and surgery and other invasive procedures, processes that are likely to be affected by the quantity and quality of patient-provider communication, shared decision making, and patient participation. Studies indicate a variety of likely root causes of disparities including: racial differences in patients' medical knowledge and information sources, trust and skepticism, levels of participation in health care interactions and decisions, and social support and resources; clinician judgment/bias; the racial/cultural milieu of health care settings; and differences in the quality of care at facilities attended by different racial groups.

CONCLUSIONS

Existing evidence from the VA indicates several promising targets for interventions to reduce racial disparities in the quality of health care.

Assessment of racial disparities in chronic kidney disease stage 3 and 4 care in the department of defense health system

BACKGROUND AND OBJECTIVES

Racial disparities in provision of healthcare are widespread in the United States but have not been specifically assessed in provision of chronic kidney disease (CKD) care.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a retrospective cohort study of the clinical database used in a Department of Defense (DOD) medical system. Beneficiaries studied were DOD-eligible beneficiaries with CKD stage 3 (n = 7729) and 4 (n = 589) using the modified Modification of Diet in Renal Disease (MDRD)-estimated GFR formula but requiring manual correction for Black race. Compliance with selected Kidney Disease Outcomes Quality Initiative (KDOQI) CKD recommended targets (monitoring of recommended laboratory data, prescription of recommended medications, and referral to nephrology) was assessed over a 12-mo period, stratified by CKD stage. Logistic regression analysis was used to assess whether race (White, Black, or other) was independently associated with provider compliance with targets, adjusted for demographic factors and burden of comorbid conditions.

RESULTS

Among the targets, only monitoring of LDL cholesterol was significantly less common among Blacks. For all other measures, compliance was either not significantly different or significantly higher for Black compared with White beneficiaries. However, patients categorized as "Other" race were in general less likely to achieve targets than Whites, and at stage 3 CKD significantly less likely to achieve targets for monitoring of phosphorous, hemoglobin, and vitamin D.

CONCLUSIONS

In the DOD health system, provider compliance with selected CKD stage 3 and 4 targets was not significantly lower for Black beneficiaries than for Whites, with the exception of LDL cholesterol monitoring. Patients classified as Other race were generally less likely to achieve targets than Whites, in some patients significantly so.

Cardiovascular health disparities: a systematic review of health care interventions

Racial and ethnic disparities in cardiovascular health care are well documented. Promising approaches to disparity reduction are increasingly described in literature published since 1995, but reports are fragmented by risk, condition, population, and setting. The authors conducted a systematic review of clinically oriented studies in communities of color that addressed hypertension, hyperlipidemia, physical inactivity, tobacco, and two major cardiovascular conditions, coronary artery disease and heart failure. Virtually no literature specifically addressed disparity reduction. The greatest focus has been African American populations, with relatively little work in Hispanic, Asian, and Native American populations. The authors found 62 interventions, 27 addressing hypertension, 9 lipids, 18 tobacco use, 8 physical inactivity, and 7 heart failure. Only 1 study specifically addressed postmyocardial infarction care. Data supporting the value of registries, multidisciplinary teams, and community outreach were found across several conditions. Interventions addressing care transitions, using telephonic outreach, and promoting medication access and adherence merit further exploration.

Beyond guidelines: achieving the optimum in LDL cholesterol control

PURPOSE OF REVIEW

Despite clear treatment guidelines, a major part of the population is not achieving the recommended LDL cholesterol target levels. This fact is more prominent among high-risk populations in which the majority of patients are untreated or undertreated.

RECENT FINDINGS

The review will elaborate on the key issues of treating large populations: patient compliance, drug efficacy, cost-benefit, and physician quality of care.

SUMMARY

A programme aimed at improving control of hyperlipidemia should address all four issues. The primary care physician should be empowered and given tools for optimizing treatment.