Primary nonadherence to statin medications: Survey of patient perspectives

A Systematic Review Uncovering Modifiable Influences on Statin Adherence

Statins are effective in reducing cardiovascular disease (CVD) risk, but adherence rates remain low globally. Understanding and addressing modifiable influences on adherence is key to improving outcomes. Existing reviews have methodological limitations, often failing to integrate qualitative and quantitative data or consider specific barriers to statin adherence. This systematic review aimed to identify modifiable barriers and facilitators to statin adherence using the Theoretical Domains Framework (TDF). A comprehensive search of Embase, MEDLINE, PsycINFO, and CINAHL was conducted, covering studies from January 1998 to November 2023. Data were coded to TDF domains and synthesized to identify specific influences on adherence. The nature of the evidence (qualitative or quantitative) was recorded for each influence, and variations among patient groups were noted. Seventy studies from 20 countries were included, with only one focused on ethnic minorities. The most commonly identified domains affecting adherence were "Beliefs about Consequences", "Knowledge", 'Environmental Context and Resources', and "Social Influences". Key factors included knowledge of disease, perceived disease threat, perceived benefits of statins, and patient-provider communication and trust. While side effects had inconsistent associations with adherence, forgetfulness was mainly addressed in quantitative studies, and social influences were highlighted in qualitative research. This review identified modifiable factors that could improve statin adherence. Future research should focus on addressing barriers faced by underrepresented groups to create more inclusive and effective interventions that enhance patient support and communication for better health outcomes.

Natural Product Use for Chronic Pain: A New Survey of Patterns of Use, Beliefs, Concerns, and Disclosure to Providers

Background

"Natural products" (NPs), including dietary supplements, are widely used, yet little is known about NP use for chronic pain and related conditions.

Objective

To develop a new NP survey to better understand reasons for NP use, beliefs, concerns, medication substitution, and provider disclosure.

Methods

Based on similar surveys and input from veteran focus groups and subject matter experts, a new brief NP survey was developed. The survey was piloted among 52 veterans with chronic pain enrolled in Veterans Health Administration (VA) primary care who endorsed NP use at baseline in a pragmatic trial comparing non-drug pain management approaches. Survey data was enriched with sociodemographic and clinical data from a parent trial. Descriptive frequencies and means were calculated.

Results

Of 55 surveys, 52 were completed (response rate, 94.5%). Respondents' mean age was 57.6 (SD+/-12.5); 42% were women, 21% identified as Black/African American, and 10% Hispanic/Latinx ethnicity. All had chronic pain; 80% experienced disabling pain daily; 67% were prescribed non-opioid pain medication; 15% were prescribed opioids. In the prior 3 months, the mean number of NPs used was 4.6 (SD+/-3.2); 90% reported daily use. Most frequently used NPs were vitamins/minerals (94%), herbals/botanicals (60%); and cannabis (40%); one-third reported substituting NPs for pain medications. The majority endorsed safety concerns about interactions of NPs either with pain medications (55%) or other NPs (52%). Nearly all (98%) believed providers should discuss NP use with their patients, though only 52% had disclosed NP use to their providers.

Conclusions

Among veterans with chronic pain in VA primary care enrolled in a pragmatic trial, a new NP survey revealed prevalent use of multiple NPs concurrently, and in some cases, as substitutes for prescribed medications. Most veterans expressed safety concerns, yet a significant proportion reported not discussing NP use with their providers.

Initial non-adherence to lipid-lowering medication: a systematic literature review

BACKGROUND

The impact on cardiovascular health is lost when a patient does not obtain a newly prescribed lipid-lowering medication, a situation termed "initial medication nonadherence" (IMN). This research summarizes the published evidence on the prevalence, associated factors, consequences, and solutions for IMN to prescribed lipid-lowering medication in the United States.

METHODS

A systematic literature search using PubMed and Google Scholar, along with screening citations of systematic reviews, identified articles published from 2010 to 2021. Studies reporting results of IMN to lipid-lowering medications were included. Studies that evaluated non-adult or non-US populations, used weaker study designs (e.g., case series), or were not written in English were excluded.

RESULTS

There were 19 articles/18 studies that met inclusion and exclusion criteria. Estimates of the prevalence of IMN to newly prescribed lipid-lowering medications ranged from 10 to 18.2% of patients and 1.4-43.8% of prescriptions (n = 9 studies). Three studies reported prescriber and patient characteristics associated with IMN. Hispanic ethnicity, Black race, lower Charlson Comorbidity Index score and no ED visits or hospitalization were associated with IMN. Lipid lowering prescriptions from primary care providers were also associated with IMN. Four studies described patient-reported reasons for IMN, including preference for lifestyle modifications, lack of perceived need, and side effect concerns. Four intervention studies reported mixed results with automated calls, live calls, or letters. One study reported worse clinical outcomes in patients with IMN: higher levels of low-density lipoprotein and greater risk of emergency department visits.

CONCLUSIONS

Up to one-fifth of patients fail to obtain a newly prescribed lipid-lowering medication but there is limited information about the clinical consequences. Future research should assess outcomes and determine cost-effective approaches to address IMN to lipid-lowering therapy.

Not obtaining a medication the first time it is prescribed: primary non-adherence to cardiovascular pharmacotherapy

Primary medication non-adherence describes the situation when a first prescription for a new medication is never filled. Primary non-adherence is an important, yet understudied aspect of reduced effectiveness of pharmacotherapy. This review summarizes the frequency, impact, reasons, predictors, and interventions regarding primary non-adherence to cardiovascular/cardiometabolic drugs. The current literature reveals a high prevalence of primary non-adherence. The individual risk of primary non-adherence is determined on multiple factors, e.g., primary non-adherence of lipid-lowering drugs is higher compared to antihypertensive medications. However, the overall rate of primary non-adherence is > 10%. Additionally, this review identifies specific areas for research to better understand why patients forgo evidence-based beneficial pharmacotherapy and to explore targeted interventions. At the same time, measures to reduce primary non-adherence-once proven to be effective-may represent an important new opportunity to reduce cardiovascular diseases.

Risk preferences over health: Empirical estimates and implications for medical decision-making

Mainstream health economic theory implies that an expected gain in health-related quality of life (HRQoL) produces the same value for consumers, regardless of baseline health. Several strands of recent research call this implication into question. Generalized Risk-Adjusted Cost-Effectiveness (GRACE) demonstrates theoretically that baseline health status influences value, so long as consumers are not risk-neutral over health. Prior empirical literature casts doubt on risk-neutral expected utility-maximization in the health domain. We estimate utility over HRQoL in a nationally representative U.S. population and use our estimates to measure risk preferences over health. We find that individuals are risk-seeking at low levels of health, become risk-averse at health equal to 0.485 (measured on a 0-1 scale), and are most risk-averse at perfect health (coefficient of relative risk aversion = 4.51). We develop the resulting implications for medical decision making, cost-effectiveness analyses, and the proper theory of health-related decision making under uncertainty.

Traditional Therapeutics and Potential Epidrugs for CVD: Why Not Both?

Cardiovascular disease (CVD) is the leading cause of death worldwide. In addition to the high mortality rate, people suffering from CVD often endure difficulties with physical activities and productivity that significantly affect their quality of life. The high prevalence of debilitating risk factors such as obesity, type 2 diabetes mellitus, smoking, hypertension, and hyperlipidemia only predicts a bleak future. Current traditional CVD interventions offer temporary respite; however, they compound the severe economic strain of health-related expenditures. Furthermore, these therapeutics can be prescribed indefinitely. Recent advances in the field of epigenetics have generated new treatment options by confronting CVD at an epigenetic level. This involves modulating gene expression by altering the organization of our genome rather than altering the DNA sequence itself. Epigenetic changes are heritable, reversible, and influenced by environmental factors such as medications. As CVD is physiologically and pathologically diverse in nature, epigenetic interventions can offer a ray of hope to replace or be combined with traditional therapeutics to provide the prospect of addressing more than just the symptoms of CVD. This review discusses various risk factors contributing to CVD, perspectives of current traditional medications in practice, and a focus on potential epigenetic therapeutics to be used as alternatives.

Examining the Impact of Polygenic Risk Information in Primary Care

BACKGROUND

Polygenic risk testing examines variation across multiple genes to estimate a risk score for a particular disease, including risk scores for many common, chronic health conditions. Although polygenic risk information (PRI) may be a promising tool for enhancing preventive counseling and facilitating early identification of disease, its potential impact on primary-care encounters and disease prevention efforts has not been well characterized.

METHODS

We conducted in-depth, semi-structured interviews of patients to assess their understandings of PRI and their beliefs about its relevance to disease prevention.

RESULTS

We completed interviews with 19 participants. Participants described enthusiasm for the generation of PRI and recognized its utility for disease prevention. Participants also described the value of PRI as limited if not corroborated by non-genetic risk factors. Finally, participants noted that PRI, by itself, would be insufficient as a trigger for initiating many preventive interventions.

CONCLUSION

PRI has the potential to become an important tool in primary care. However, patient views about PRI as well as the complexities of disease prevention in the primary care context may limit the impact of PRI on disease prevention.

Cardiovascular risk management in people with type 1 diabetes: performance using three guidelines

INTRODUCTION

Cardiovascular disease (CVD) is the leading cause of mortality in individuals with type 1 diabetes mellitus (T1DM). Cardiovascular risk management is therefore essential in the management of individuals with T1DM. This study describes the performance of lipid and blood pressure management in individuals with T1DM using three guidelines.

RESEARCH DESIGN AND METHODS

Individuals ≥18 years with T1DM, treated with insulin for ≥1 year, visiting Diabeter or the University Medical Center Groningen between January 1, 2018 and December 31, 2018, were included. Lipid and blood pressure management were examined using the Dutch, American Diabetes Association (ADA) and National Institute for Health and Care Excellence (NICE) guidelines. Concordance of recommended and prescribed lipid-lowering (LLM) or antihypertensive medication (AHM) was assessed per guideline and 10-year age groups. Achievement of treatment targets was assessed for those prescribed medication.

RESULTS

A total of 1855 individuals with T1DM were included. LLM and AHM was prescribed in 19% and 17%, respectively. In individuals recommended LLM, this was prescribed in 22%-46% according to Dutch, ADA or NICE guideline recommendations. For individuals recommended AHM, this was prescribed in 52%-75%. Recommended and actual prescription of LLM and AHM increased over age for all three guidelines. However, discordance between treatment recommendation and medication prescribed was higher in younger, compared with older, age groups. Low-density lipoprotein-cholesterol targets were achieved by 50% (without CVD) and 31% (with CVD) of those prescribed LLM. The blood pressure target was achieved by 46% of those prescribed AHM.

CONCLUSION

This study suggests that there is undertreatment of lipid and blood pressure according to guideline recommendations, particularly in younger age groups. Treatment targets are not met by most individuals prescribed medication, while guidelines recommendations differ considerably. We recommend to investigate the factors influencing undertreatment of lipid and blood pressure management in individuals with T1DM.