Is Treatment Inertia Unique to Publicly Funded Healthcare? Insights from the Guidelines Oriented Approach to Lipid lowering (GOAL) Canada Program

Anatoly Langer

doi:10.31579/2641-0419/154

Abstract

Background: We compared the use of lipid lowering therapy, low density-lipoprotein cholesterol (LDL-C) levels, and proportion achieving guideline-recommended LDL-C levels in patients with private vs. public insurance coverage for their lipid lowering treatment. Materials and Methods: Guidelines Oriented Approach to Lipid lowering (GOAL) Canada enrolled 2009 patients with cardiovascular disease (CVD) or heterozygous familial hypercholesterolemia (FH) and an LDL-C above the guideline-recommended target of <2.0 mmol/L despite maximally tolerated statin therapy. During two follow-up visits physicians received online reminders of treatment recommendations. Results: Of 2009 patients enrolled (median age 63 years, 42% female), there were 1284 (64%) patients with private and 725 (36%) with public insurance for lipid lowering therapy. Patients with private insurance were younger and less likely to have a history of heart failure or to be on bile acid sequestrants. There was no difference between the groups in their lipid levels or lipid lowering therapy at baseline. During the follow up, there was no difference in the use of ezetimibe; however, the use of PCSK9i was more frequent in patients with private insurance (31.7 % vs. 21%, p<0.0001), the mean LDL-C level was slightly lower (2.11±1.17 vs. 2.31±1.17 mmol/L, p = 0.001), and the proportion of patients achieving the guideline-recommended LDL-C level was greater (54% vs. 45.5%, p = 0.001). After adjustment for other factors in a multivariable model, private insurance was not a significant predictor of achieving the guideline-recommended LDL-C level in a multivariable model. Conclusion: While PCSK9i use was higher in patients with private insurance, the majority of patients with either private or public insurance experienced similar treatment inertia. The cost of non-generic medications does not appear to be the dominant reason for the continued care gap in lipid lowering of high-risk patients.

Highlights

Low-density lipoprotein cholesterol (LDL-C) level is a well-established risk factor for cardiovascular disease (CVD) and there is considerable evidence that lowering low density-lipoprotein cholesterol (LDL-C) reduces CVD morbidity and mortality. [1] Canadian Cardiovascular Society dyslipidemia guidelines [2] recommend initiation of LDL-C lowering with high intensity statin therapy with the addition of ezetimibe and / or PCSK9i as needed if LDL-C is not lowered by at least 50% or to the level below 2.0 mmol/L in patients with established CVD
While PCSK9i use was higher in patients with private insurance, the majority of patients with either private or public insurance experienced similar treatment inertia
There was no difference in LDL-C level between the two groups and no difference in the use of statin, including high intensity statin, or ezetimibe at baseline (Table 1)

Summary

Introduction

Low-density lipoprotein cholesterol (LDL-C) level is a well-established risk factor for cardiovascular disease (CVD) and there is considerable evidence that lowering LDL-C reduces CVD morbidity and mortality. [1] Canadian Cardiovascular Society dyslipidemia guidelines [2] recommend initiation of LDL-C lowering with high intensity statin therapy with the addition of ezetimibe and / or PCSK9i as needed if LDL-C is not lowered by at least 50% or to the level below 2.0 mmol/L in patients with established CVD. [1] Canadian Cardiovascular Society dyslipidemia guidelines [2] recommend initiation of LDL-C lowering with high intensity statin therapy with the addition of ezetimibe and / or PCSK9i as needed if LDL-C is not lowered by at least 50% or to the level below 2.0 mmol/L in patients with established CVD. For those with a recent acute coronary syndrome and established coronary disease, consideration is to be given to more aggressive lowering of LDL-C to below 1.8 mmol/L. We compared the use of lipid lowering therapy, low density-lipoprotein cholesterol (LDL-C) levels, and proportion achieving guideline-recommended LDL-C levels in patients with private vs. public insurance coverage for their lipid lowering treatment

Methods

Results

Discussion

Conclusion