Abstract
BackgroundStatins are increasingly prescribed to prevent cardiovascular disease (CVD) in asymptomatic individuals. Yet, it is unknown whether those at higher CVD risk – i.e. individuals in lower socio-economic position (SEP) – are adequately reached by this high-risk strategy. We aimed to examine whether the Danish implementation of the strategy to prevent cardiovascular disease (CVD) by initiating statin (HMG-CoA reductase inhibitor) therapy in high-risk individuals is equitable across socioeconomic groups.MethodsDesign: Cohort study.Setting and participants: Applying individual-level nationwide register information on socio-demographics, dispensed prescription drugs and hospital discharges, all Danish citizens aged 20+ without previous register-markers of CVD, diabetes or statin therapy were followed during 2002–2006 for first occurrence of myocardial infarction (MI) and a dispensed statin prescription (N = 3.3 mill).Main outcome measures: Stratified by gender, 5-year age-groups and socioeconomic position (SEP), incidence of MI was applied as a proxy for statin need. Need-standardized statin incidence rates were calculated, applying MI incidence rate ratios (IRR) as need-weights to adjust for unequal needs across SEP.Horizontal equity in initiating statin therapy was tested by means of Poisson regression analysis. Applying the need-standardized statin parameters and the lowest SEP-group as reference, a need-standardized statin IRR > 1 translates into horizontal inequity favouring the higher SEP-groups.ResultsMI incidence decreased with increasing SEP without a parallel trend in incidence of statin therapy. According to the regression analyses, the need-standardized statin incidence increased in men aged 40–64 by 17%, IRR 1.17 (95% CI: 1.14-1.19) with each increase in income quintile. In women the proportion was 23%, IRR 1.23 (1.16-1.29). An analogous pattern was seen applying education as SEP indicator and among subjects aged 65–84.ConclusionThe high-risk strategy to prevent CVD by initiating statin therapy seems to be inequitable, reaching primarily high-risk subjects in lower risk SEP-groups.
Highlights
Statins are increasingly prescribed to prevent cardiovascular disease (CVD) in asymptomatic individuals
The aim of this study was to examine whether the Danish implementation of the strategy to prevent CVD by initiating statin therapy in high-risk individuals is equitable across socioeconomic groups; hypothesising that this high-risk strategy will not adequately reach groups with a lower socioeconomic position (SEP), characterised by having a higher risk of CVD
Principal findings Applying indirect standardisation and myocardial infarction (MI)-incidence as a proxy for need, we developed a pharmacoepidemiological method to explore horizontal equity in initiation of preventive statin therapy across SEP-groups with unequal needs, adjusting the observed statin incidence according to relative needs across socio-demographic groups
Summary
Statins are increasingly prescribed to prevent cardiovascular disease (CVD) in asymptomatic individuals It is unknown whether those at higher CVD risk – i.e. individuals in lower socio-economic position (SEP) – are adequately reached by this high-risk strategy. The social gradient has widened over the last decades [4,5] and is to a large extent mediated by the conventional risk factors (i.e., smoking, high blood pressure and serum cholesterol) – when evaluated in absolute terms [1,6,7,8] This holds for the most important CVD component, myocardial infarction (MI) [9]. “The question of ‘at what lipid level to initiate treatment’ has to be replaced by ‘at what cardiovascular risk should statins be started’“[11]
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