Adherence to Statin Therapy Among US Adults Between 2007 and 2014

Background

Prior studies suggest that persistence with and adherence to statin therapy is low. Interventions to improve statin persistence and adherence have been developed over the past decade.

Methods and Results

This was a retrospective cohort study of adults aged ≥21 y with commercial or government health insurance in the MarketScan (Truven Health Analytics) and Medicare databases who initiated statins in 2007–2014 and (1) started treatment after a myocardial infarction (n=201 573), (2) had diabetes mellitus but without coronary heart disease (CHD; n=610 049), or (3) did not have CHD or diabetes mellitus (n=2 244 868). Persistence with (ie, not discontinuing treatment) and high adherence to statin therapy were assessed using pharmacy fills in the year following treatment initiation. In 2007 and 2014, the proportions of patients persistent with statin therapy were 78.1% and 79.1%, respectively, among those initiating treatment following myocardial infarction; 66.5% and 67.3%, respectively, for those with diabetes mellitus but without CHD; and 64.3% and 63.9%, respectively, for those without CHD or diabetes mellitus. Between 2007 and 2014, high adherence to statin therapy increased from 57.9% to 63.8% among patients initiating treatment following myocardial infarction and from 34.9% to 37.6% among those with diabetes mellitus but without CHD (each P_trend<0.001). Among patients without CHD or diabetes mellitus, high adherence did not improve between 2007 (35.7%) and 2014 (36.8%; P_trend=0.14). In 2014, statin adherence was lower among younger, black, and Hispanic patients versus white patients and those initiating a high‐intensity statin dosage. Statin adherence was higher among men and patients with cardiologist care following treatment initiation.

Conclusions

Persistence with and adherence to statin therapy remain low, particularly among those without CHD.

Predictors of statin adherence, switching, and discontinuation in the USAGE survey: understanding the use of statins in America and gaps in patient education

BACKGROUND

Although statins have been shown to reduce cardiovascular disease mortality, less than half of U.S. adults achieve their low-density lipoprotein cholesterol goal. In many patients initiated on a statin, adherence rates decrease over time.

OBJECTIVE

To characterize current and former statin users, identify reasons for the discontinuation or switching of statins, and identify factors associated with adherence.

METHODS

The USAGE survey is a cross-sectional, self-administered Internet-based survey of 10,138 U.S. adults fielded September to October 2011. The following statin users were identified and compared: adherent nonswitchers, adherent switchers, non-adherent switchers, and discontinuers. Univariate and multivariate models using a priori covariates for adherence and discontinuation were examined.

RESULTS

Most participants were current statin users who adhered with their prescribed statin (82.5%, n = 8371). Former statin users or discontinuers (12%, n = 1220) cited muscle pain, a side effect, as the primary reason for discontinuation (60%), followed by cost (16%), and then perceived lack of efficacy (13%). Discontinuers were less satisfied with their physicians' explanation of cholesterol treatment, more likely to use the Internet to research statins, and less likely to undergo frequent cholesterol monitoring. Among adherent statin users, the primary reasons for switching were muscle side effects (33%) and cost (32%). Individuals at risk for non-adherence included those with low household income, those who experienced muscle pain as a side effect while on statin therapy, and those taking medication for cardiovascular disease.

CONCLUSION

Statin-related muscle side effects are common and contribute significantly to rates of discontinuation, switching, and non-adherence. Improved physician patient communication about side effects and benefits of statins are necessary to improve both adherence and outcomes.

Mortality rate increases steeply with nonadherence to statin therapy in patients with acute coronary syndrome

BACKGROUND

In a prospective cohort of consecutive acute coronary syndrome (ACS) patients, we compared the adherence rate of statin usage and mortality rate during a median follow-up of 23 months.

HYPOTHESIS

Adherence to statin therapy after acute coronary syndrome affects mortality rate.

METHODS

We analyzed ACS patients (N = 1969; age, 65.9 ± 11.8 years; female 30.4%) who underwent angiography between March 2006 and March 2008. The postdischarge usage of statins was based on the purchase register of the Social Insurance Institution of Finland. The death rate was verified from Statistics Finland.

RESULTS

At discharge, the rate of statin prescription to patients was 95.4% (n = 1878). When comparing adherent patients (n = 1200; 61.7%), who purchased the medication systematically until the end of the median 23-month follow-up, with nonadherent patients (n = 94; 4.8%), who did not use the medication at all, there was a vast difference in absolute death rate between the groups: 4.9% vs 14.9%, respectively (P < 0.001). We conducted Cox proportional hazards model with ACS type, cerebrovascular attack, diabetes, age, 3-artery disease, and cancer as adjusted confounders. Compared with regular statin users, nonusers were associated with a >2× increased hazard ratio of mortality (hazard ratio: 2.70, 95% confidence interval: 1.49-4.90, P = 0.001).

CONCLUSIONS

Statin medication is essential for discharged ACS patients. They should be strongly encouraged to purchase and use it.

Factors associated with screening or treatment initiation among male United States veterans at risk for osteoporosis fracture

Male osteoporosis continues to be under-recognized and undertreated in men. An understanding of which factors cue clinicians about osteoporosis risk in men, and which do not, is needed to identify areas for improvement. This study sought to measure the association of a provider's recognition of osteoporosis with patient information constructs that are available at the time of each encounter. Using clinical and administrative data from the Veterans Health Administration system, we used a stepwise procedure to construct prognostic models for a combined outcome of osteoporosis diagnosis, treatment, or a bone mineral density (BMD) test order using time-varying covariates and Cox regression. We ran separate models for patients with at least one primary care visit and patients with only secondary care visits in the pre-index period. Some of the strongest predictors of clinical osteoporosis identification were history of gonadotropin-releasing hormone (GnRH) agonist exposure, fragility fractures, and diagnosis of rheumatoid arthritis. Other characteristics associated with a higher likelihood of having osteoporosis risk recognized were underweight or normal body mass index, cancer, fall history, and thyroid disease. Medication exposures associated with osteoporosis risk recognition included opioids, glucocorticoids, and antidepressants. Several known clinical risk factors for fracture were not correlated with osteoporosis risk including smoking and alcohol abuse. Results suggest that clinicians are relying on some, but not all, clinical risk factors when assessing osteoporosis risk.

Predictors of statin adherence

Statin therapy plays a central role in decreasing the morbidity and mortality associated with cardiovascular disease. However, prescribed statins are only effective if they are taken by patients on a regular basis, known as medication adherence. The factors that influence patient adherence to statin therapy can be categorized into patient factors, physician factors, and health system factors, often with interactions between the categories. Patient factors include demographics, socioeconomic status, comorbidities, and side effects. Physician factors include the physician's own adherence to applying guideline recommendations, office visits, and their interactions with patients. Health system factors include issues such as cost and access to care. Physicians should be aware of the various elements that may influence a patient's likelihood to take statin medications to improve adherence and provide the best possible patient outcomes.

Reasons for not meeting coronary artery disease targets of care in ambulatory practice

INTRODUCTION

Four targets of care: control of blood pressure, control of low-density lipoprotein cholesterol level, taking aspirin daily, and not using tobacco improve outcomes for patients with coronary artery disease (CAD). We sought to identify why, in a large multispecialty group, these targets were not being met in patients with CAD.

METHODS

We thus conducted a retrospective review of patient records in the group practice's CAD registry, which is updated quarterly.

RESULTS

Of a random selection of 14,973 patients in the CAD registry, 353 charts were consecutively reviewed until theoretic saturation was achieved-that is, until no new information was found. We could not find any evidence of CAD in 14 patients, and we considered that all four targets had been met for 169 patients. The most frequent reasons for not meeting all targets of care among the 170 remaining patients were 1) the patient was in for a visit and the care team failed to address an unmet target of care (n = 98), 2) the patient was asked to come back for follow-up care but did not (n = 28), and 3) the patient declined an intervention that was offered (n = 14). Blood pressure and low-density lipoprotein cholesterol levels were the targets that were most frequently out of range.

CONCLUSION

Giving the health care team access to tools with which they can identify the concurrent care needs of their patients could significantly increase the proportion of patients with CAD for whom care targets are met. Lists generated by these tools would also be significantly more accurate than lists generated from quarterly reports.

American Academy of Dermatology evidence-based guideline development process: responding to new challenges and establishing transparency

BACKGROUND

Evidence-based clinical guidelines are developed to educate and inform physicians about best practices in patient care, and assist providers in the application of treatments and technologies that can improve outcomes. Clinical guidelines also aid appeal of payment decisions; serve as the basis for quality measure development, appropriateness criteria, and maintenance of certification modules; and help identify areas for further clinical research.

OBJECTIVE

For guidelines to serve dermatologists effectively in these diverse roles, they must be current, varied in clinical focus, and developed with a high degree of rigor that includes attention to potential conflicts of interest.

METHOD

To address these needs and keep pace with advances in medicine, the American Academy of Dermatology (AAD) recently revised the evidence-based guideline development process.

RESULTS

Key changes include development of a yearly needs assessment process to determine what guidelines are most needed, the development of focused guidelines that address rapidly evolving clinical topics, a formal method of vetting guidelines produced by other societies, and a scheduled reassessment of existing guidelines to ensure they provide current and practical information. The process for identifying and managing potential conflicts of interest was also revised and expanded to meet current expectations and evolving standards.

LIMITATIONS

The impact of these changes to the AAD's guideline development process will not be fully realized for several years.

CONCLUSIONS

These changes will help ensure the AAD will be able to provide its members with continued evidence-based guidance to support patient care across the scope of dermatologic practice.