Age and Sex Disparities in Discharge Statin Prescribing in the Stroke Belt: Evidence From the Reasons for Geographic and Racial Differences in Stroke Study

Cardiovascular Disease Prevalence in Non-Hispanic Black Individuals: U.S. Territories vs. Stroke Belt and Non-Stroke Belt States

INTRODUCTION

 Extensive research exists on the increased prevalence of cardiovascular disease (CVD) in the "Stroke Belt" states, compared to the remaining United States (U.S.). Social, environmental, and systemic factors and individual behaviors have been investigated, including Black race.  This study aims to assess whether residing in the U.S. territories, Stroke Belt, or non-Stroke Belt states is associated with differences in CVD prevalence among non-Hispanic Black adults.

METHODS

We analyzed cross-sectional data from the 2021 Behavioral Risk Factor Surveillance System (BRFSS). All non-Hispanic Black adults (18+) with complete information on key variables, including demographics, CVD outcomes, and relevant risk factors, were included. The prevalence of CVD was defined as self-reported coronary artery disease, stroke, or myocardial infarction. Univariate and multivariable logistic regression analyses were used to calculate crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs).  Results: Of the 31,246 individuals included in our study, 87 (8.7%) residing in the U.S. territories reported experiencing a cardiovascular event, compared to 1487 (10.1%) in the Stroke Belt and 1872 (8.2%) in the non-Stroke Belt regions. Compared to non-Hispanic Black adults residing outside the Stroke Belt, those living in the Stroke Belt had 23% higher odds of reporting CVD (OR 1.23, 95% CI 1.10-1.44) after adjusting for age and gender. In the fully adjusted model, which accounted for additional factors such as comorbidities and socioeconomic status, the odds were slightly attenuated but remained elevated (OR 1.14, 95% CI 0.97-1.35). For Black adults living in the U.S. territories, the odds of reporting CVD were not significantly different from those outside the Stroke Belt in both the age- and gender-adjusted model (OR 1.07, 95% CI 0.66-1.73) and the fully adjusted model (OR 0.93, 95% CI 0.49-1.74). Independent of residence, individuals with high blood pressure (OR 2.85, 95% CI 2.05-3.96), diabetes (OR 1.45, 95% CI 1.20-1.75), and high cholesterol (OR 1.55, 95% CI 1.27-1.89) had significantly higher odds of CVD. In contrast, smoking and income were associated with prevalent CVD, while self-reported diet, physical activity, and education level were not.

CONCLUSION

Contrary to our expectation, we found that non-Hispanic Black adults residing in the U.S. territories had similar self-reported CVD with those living in the non-Stroke Belt regions.  Further research is needed to investigate the socio-behavioral factors influencing cultural and historical disparities among non-Hispanic Black individuals in the U.S. and its territories.

Provider care segregation and hospital-region racial disparities for carotid interventions in the USA

BACKGROUND

Reasons for racial disparities in the utilization and outcomes of carotid interventions (carotid endarterectomy (CEA) and carotid artery stenting (CAS)) are not well understood, especially segregation of care associated with carotid intervention. We examined patterns of geographic and provider care segregation in carotid interventions and outcomes.

METHOD

We used de-identified Medicare datasets to identify CEA and CAS interventions between January 1, 2016 and December 31, 2019 using validated ICD-10 codes. For patients who underwent carotid intervention, we calculated (1) the proportion of White patients at the hospital, (2) the proportional difference in the proportion of White patients between hospital patients and the county, and (3) provider care segregation by the dissimilarity index for carotid intervention cases. We examined associations between measures of segregation and outcomes.

RESULTS

Despite higher proportions of Black patients in counties with hospitals that provide carotid intervention, lower proportions of Black patients received intervention. The difference in the proportion of White patients comparing CEA patients to the county race distribution was 0.143 (SD 0.297) at the hospital level (for CAS, 0.174 (0.315)). The dissimilarity index for CEA providers was high, with mean (SD) 0.387 (0.274) averaged across all hospitals and higher among CAS providers at 0.472 (0.288). Black patients receiving CEA and CAS (compared with Whites) had reduced odds of discharge home. Better outcomes (inpatient mortality and 30-day mortality) were independently associated with higher proportion of White CAS patients.

CONCLUSION

In this national study with contemporary data on carotid intervention, we found evidence for segregation of care of both CEA and CAS.

Disparate statin prescribing following hospital discharge for stroke or transient ischemic attack: Findings from COMPASS

BACKGROUND

Published guidelines recommend high-intensity statins following an ischemic stroke or transient ischemic attack (TIA). The authors examined the potential for disparate patterns of statin prescribing in a cluster randomized trial of transitional care following acute stroke or TIA.

METHODS

Medications taken before hospitalization and statins prescribed at discharge among stroke and TIA patients at 27 participating hospitals were examined. Any statin and intensive statin prescribed at discharge were compared by age (<65, 65-75, >75 years), racial category (White vs. Black), sex (male vs. female), and rurality (urban vs. non-urban) using logistic mixed models.

RESULTS

Among 3211 patients (mean age 67 years; 47% female; 29% Black), 90% and 55%, respectively, were prescribed any statin or intensive statin therapy at discharge. White (vs. Black) patients (0.71, 0.51-0.98) less commonly received any statin prescription, while stroke (vs. TIA) patients (1.90, 1.38-2.62) and those residing in urban areas (1.66, 1.07-2.55) more commonly received any statin prescription. Among those prescribed a statin, only 42% of White and 51% of Black patients >75 years. were prescribed an intensive statin; the OR for intensive statin prescribing was 0.44 for patients >75 years and was similar in a subgroup not on a statin previously.

CONCLUSION/RELEVANCE

Following stroke or TIA, statin prescribing remains lower in White patients, in those with TIA, and in those in non-urban areas. Intensive statin prescribing remains limited, particularly in patients >75 years. These data may inform efforts to improve guideline concordant prescribing for post-stroke patients.

Structured discharge documentation reduces sex-based disparities in statin prescription in vascular surgery patients

OBJECTIVE

Perioperative statin use has been shown to improve survival in vascular surgery patients. In 2018, the Northern California Vascular Study Group implemented a quality initiative focused on the use of a SmartText in the discharge summary. We hypothesized that structured discharge documentation would decrease sex-based disparities in evidence-based medical therapy.

METHODS

A retrospective analysis was conducted using Vascular Quality Initiative eligible cases at a single institution. Open or endovascular procedures in the abdominal aorta or lower extremity arteries from 2016 to 2021 were included. Bivariate analysis identified factors associated with statin use and sex. Multivariate logistic regression was performed with the end point of statin prescription at discharge and aspirin prescription at discharge. An interaction term assessed the differential impact of the initiative on both sexes. Analysis was then stratified by prior aspirin or statin prescription. An interrupted time series analysis was used to evaluate the trend in statin prescription over time.

RESULTS

Overall, 866 patients were included, including 292 (34%) female and 574 (66%) male patients. Before implementation, statins were prescribed in 77% of male and 62% of female patients (P < .01). After implementation, there was no statistically significant difference in statin prescription (91% in male vs 92% in female patients, P = .68). Female patients saw a larger improvement in the adjusted odds of statin prescription compared with male patients (odds ratio: 3.1, 95% confidence interval: 1.1-8.6, P = .04). For patients not prescribed a statin preoperatively, female patients again saw an even larger improvement in the odds of being prescribed a statin at discharge (odds ratio: 6.4, 95% confidence interval: 1.8-22.7, P < .01). Interrupted time series analysis demonstrated a sustained improvement in the frequency of prescription for both sexes over time. The unadjusted frequency of aspirin prescription also improved by 3.5% in male patients vs 5.5% in female patients. For patients not prescribed an aspirin preoperatively, we found that the frequency of aspirin prescription significantly improved for both male (19% increase, P = .006) and female (31% increase, P = .001) patients. There was no significant difference in the perioperative outcomes between male and female patients before and after standardized discharge documentation.

CONCLUSIONS

A simple, low-cost regional quality improvement initiative eliminated sex-based disparities in statin prescription at a single institution. These findings highlight the meaningful impact of regional quality improvement projects. Future studies should examine the potential for structured discharge documentation to improve patient outcomes and reduce disparities.

Assessment of Trends in Statin Therapy for Secondary Prevention of Atherosclerotic Cardiovascular Disease in US Adults From 2007 to 2016

IMPORTANCE

Atherosclerotic cardiovascular disease (ASCVD) is highly prevalent in the US, with studies indicating substantial rates of nonadherence to and undertreatment with statin therapy. The 2013 American College of Cardiology/American Heart Association guideline recommended high-intensity statins for all patients age 75 years and younger with documented ASCVD in whom such therapy is tolerated, but there is limited evidence documenting population trends of statin use, adherence, and outcomes in the periods before and after the update to the guideline.

OBJECTIVE

To assess trends in the use, adherence, cost, and outcomes of statin therapy for secondary prevention in patients with different types of ASCVD between 2007 and 2016.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data from the OptumLab Data Warehouse database containing privately insured and Medicare Advantage enrollees with demographic characteristics similar to the national US population. Participants were adult patients (age ≥21 years) who had their first ASCVD event between January 1, 2007, and December 31, 2016. Data were characterized as belonging to 3 groups: (1) cardiovascular heart disease (CHD); (2) ischemic stroke or transient ischemic attack (TIA); and (3) peripheral artery disease (PAD). Data were analyzed from July 1 to August 1, 2018.

EXPOSURES

Calendar year of the initial ASCVD event.

MAIN OUTCOMES AND MEASURES

Trends in the statin use (within 30 days of discharge from hospitalization), adherence (proportion of days covered ≥80% within the first year), cost, major adverse cardiac events (1-year cumulative risk), and statin intolerance (within the first year).

RESULTS

Of the 284 954 patients with a new ASCVD event, 128 422 (45.1%) were women; the median age was 63 years (interquartile range [IQR], 54-72 years); 207 781 (72.9%) were White. The use of statins increased from 50.3% in 2007 to 59.9% in 2016, the use of high-intensity statins increased from 25.0% to 49.2%, and the adherence increased from 58.7% to 70.5% (P < .001 for all trends). Patients with CHD were more likely to receive statins and high-intensity statins and adhere to medications than patients with ischemic stroke, TIA, or PAD despite similar observed treatment benefit. In 2016, 80.9% of patients with CHD used a statin vs 65.8% of patients with ischemic stroke or TIA and 37.5% of patients with PAD. Out-of-pocket cost per 30-day decreased from a median of $20 (interquartile range, $7.6-$31.9) in 2007 to $2 (interquartile range, $1.6-$10.0) in 2016 (P < .001) with the increasing use of generic statins (42.0% in 2007 vs 94.9% in 2016; P < .001). Major adverse cardiac events decreased from 8.9% in 2007 to 6.5% in 2016 (P < .001) whereas statin intolerance increased from 4.0% to 5.1% (P < .001).

CONCLUSIONS AND RELEVANCE

There have been modest improvements in the use, adherence, and cardiovascular outcomes over the past decade for statin therapy in patients with ASCVD, but a substantial and persistent treatment gap exists between patients with and without CHD, between men and women.

Sex Differences in Management and Outcomes of Critical Limb Ischemia in the Medicare Population

BACKGROUND

Evidence about sex differences in management and outcomes of critical limb ischemia (CLI) is conflicting.

METHODS

We identified Fee-For-Service Medicare patients within the 5% enhanced sample file who were diagnosed with new incident CLI between 2015 and 2017. For each beneficiary, we identified all hospital admissions, outpatient encounters and procedures, and pharmacy prescriptions. Outcomes included 90-day mortality and major amputation.

RESULTS

Incidence of CLI declined from 2.80 (95% CI, 2.72-2.88) to 2.47 (95% CI, 2.40-2.54) per 1000 person from 2015 to 2017, P<0.01. Incidence was lower in women compared with men (2.19 versus 3.11 per 1000) but declined in both groups. Women had a lower prevalence of prescription of any statin (48.4% versus 52.9%, P<0.001) or high-intensity statins (15.3% versus 19.8%, P<0.01) compared with men. Overall, 90-day revascularization rate was 52%, and women were less likely to undergo revascularization (50.1% versus 53.6%, P<0.01) compared with men. Women had a similar unadjusted (9.9% versus 10.3%, P=0.5) and adjusted 90-day mortality (adjusted rate ratio, 0.98 [95% CI, 0.85-1.12], P=0.7) compared with men. Over the study period, unadjusted 90-day mortality remained unchanged for men (10.4% in 2015 to 9.9% in 2017, Pfor trend=0.3), and women (9.5% in 2015 to 10.6% in 2017, Pfor trend=0.2). Men had higher unadjusted (12.9% versus 8.9%, P<0.001) and adjusted risk of 90-day major amputation (adjusted rate ratio, 1.30 [95% CI, 1.14-1.48], P<0.001). One-third of patients with CLI underwent major amputation without a diagnostic angiogram or trial of revascularization in the preceding 90 days regardless of the sex.

CONCLUSIONS

Women with new incident CLI are less likely to receive statin or undergo revascularization at 90 days compared with men. However, the differences were small. There was no difference in risk of 90-day mortality between both sexes. Graphic Abstract: A graphic abstract is available for this article.

National Trends in Statin Medication Prescribing in Patients With a History of Stroke or Transient Ischemic Attack

BACKGROUND

Guidelines support statin therapy post-stroke or transient ischemic attack (TIA); however, previously reported utilization rates are suboptimal.

OBJECTIVE

This study investigates the incidence of statin usage in patients with a documented stroke or TIA while identifying predictors of statin use.

METHODS

A retrospective, cross-sectional study utilizing data from the National Ambulatory Medical Care Survey.

RESULTS

A total of 2963 unweighted visits were included in the analysis, representing a total of 52 645 000 office visits when weighted. Statin therapy was initiated or continued in 35.7% (95% confidence interval [CI]: 32.4-39.0%) of office visits. Upon multivariate analysis, positive predictors of statin therapy included a diagnosis of hyperlipidemia (odds ratio [OR]: 3.60; 95% CI: 2.40-5.41), angiotensin-converting enzyme inhibitor (ACE-I) therapy (OR: 2.52; 95% CI: 1.69-3.76), aspirin therapy (OR: 2.02; 95% CI: 1.40-2.93), and clopidogrel therapy (OR: 2.60; 95% CI: 1.69-4.02). Negative predictors of statin therapy included office visits with neurologists when compared to visits with primary care practitioners (OR: 0.55; 95% CI: 0.33-0.90) and office visits in rural areas when compared to office visits in urban areas (OR: 0.64; 95% CI: 0.41-0.99).

CONCLUSION

Various factors impact statin therapy use with overall utilization being suboptimal, highlighting an opportunity for medication optimization.

Statins and the risk of intracerebral haemorrhage in patients with stroke: systematic review and meta-analysis

OBJECTIVE

Whether statins increase the risk of intracerebral haemorrhage (ICH) in patients with a previous stroke remains uncertain. This study addresses the evidence of statin therapy on ICH and other clinical outcomes in patients with previous ischaemic stroke (IS) or ICH.

METHODS

A systematic literature review and meta-analysis was performed in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to assess observational and randomised studies comparing statin therapy with control (placebo or no treatment) in patients with a previous ICH or IS. The risk ratios (RR) for the primary outcome (ICH) and secondary outcomes (IS, any stroke, mortality and function) were pooled using random effects meta-analysis according to stroke subtype.

RESULTS

Forty-three studies with a combined total of 317 291 patient-years of follow-up were included. In patients with previous ICH, statins had no significant impact on the pooled RR for recurrent ICH (1.04, 95% CI 0.86 to 1.25; n=23 695); however, statins were associated with significant reductions in mortality (RR 0.49, 95% CI 0.36 to 0.67; n=89 976) and poor functional outcome (RR 0.71, 95% CI 0.67 to 0.75; n=9113). In patients with previous IS, statins were associated with a non-significant increase in ICH (RR 1.36, 95% CI 0.96 to 1.91; n=103 525), but significantly lower risks of recurrent IS (RR 0.74, 95% CI 0.66 to 0.83; n=53 162), any stroke (RR 0.82, 95% CI 0.67 to 0.99; n=55 260), mortality (RR 0.68, 95% CI 0.50 to 0.92; n=74 648) and poor functional outcome (RR 0.83, 95% CI 0.76 to 0.91; n=34 700).

CONCLUSIONS

Irrespective of stroke subtype, there were non-significant trends towards future ICH with statins. However, this risk was overshadowed by substantial and significant improvements in mortality and functional outcome among statin users.

TRIAL REGISTRATION NUMBER

CRD42017079863.

Temporal trends, determinants, and impact of high-intensity statin prescriptions after percutaneous coronary intervention: Results from a large single-center prospective registry

BACKGROUND

High-intensity statins (HIS) are recommended for secondary prevention following percutaneous coronary intervention (PCI). We aimed to describe temporal trends and determinants of HIS prescriptions after PCI in a usual-care setting.

METHODS

All patients with age ≤75 years undergoing PCI between January 2011 and May 2016 at an urban, tertiary care center and discharged with available statin dosage data were included. HIS were defined as atorvastatin 40 or 80 mg, rosuvastatin 20 or 40 mg, and simvastatin 80 mg.

RESULTS

A total of 10,495 consecutive patients were included. Prevalence of HIS prescriptions nearly doubled from 36.6% in 2011 to 60.9% in 2016 (P < .001), with a stepwise increase each year after 2013. Predictors of HIS prescriptions included ST-segment elevation myocardial infarction/non-ST-segment elevation myocardial infarction (odds ratio [OR] 4.60, 95% CI 3.98-5.32, P < .001) and unstable angina (OR 1.31, 95% CI 1.19-1.45, P < .001) as index event, prior myocardial infarction (OR 1.48, 95% CI 1.34-1.65, P < .001), and co-prescription of β-blocker (OR 1.26, 95% CI 1.12-1.43, P < .001). Conversely, statin treatment at baseline (OR 0.86, 95% CI 0.77-0.96, P = .006), Asian races (OR 0.73, 95% CI 0.65-0.83, P < .001), and older age (OR 0.90, 95% CI 0.88-0.92, P < .001) were associated with reduced HIS prescriptions. There was no significant association between HIS prescriptions and 1-year rates of death, myocardial infarction, or target-vessel revascularization (adjusted hazard ratio 0.98, 95% CI 0.84-1.15, P = .84), although there was a trend toward reduced mortality (adjusted hazard ratio 0.71, 95% CI 0.50-1.00, P = .05).

CONCLUSION

Although the rate of HIS prescriptions after PCI has increased in recent years, important heterogeneity remains and should be addressed to improve practices in patients undergoing PCI.