Abstract
BackgroundDespite the proven benefits of aspirin therapy in the primary and secondary prevention of cardiovascular disease (CVD), utilization rates of aspirin remain suboptimal in relation to recommendations. We studied national trends of aspirin use among intermediate- to high-risk patients in the US ambulatory care settings and compared the priority given to aspirin versus statins for CVD risk reduction. We also examined patient and health care provider contributors to the underuse of aspirin.Methods and FindingsWe used the 1993–2003 US National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to estimate aspirin use by cardiovascular risk. Physician-noted cardiovascular diseases defined high risk. Intermediate risk was defined as having diabetes mellitus or multiple major risk factors. The proportion of patient visits in which aspirin was reported increased from 21.7% (95% confidence interval: 18.8%–24.6%) in 1993–1994 to 32.8% (25.2%–40.4%) in 2003 for the high-risk category, 3.5% (2.0%–5.0%) to 11.7% (7.8%–15.7%) for visits by patients diagnosed with diabetes, and 3.6% (2.6%–4.6%) to 16.3% (11.4%–21.2%) for those with multiple CVD risk factors. Beginning in 1997–1998, statins were prioritized over aspirin as prophylactic therapy for reducing CVD risk, and the gaps remained wide through 2003. In addition to elevated CVD risk, greater aspirin use was independently associated with advanced age, male gender, cardiologist care, and care in hospital outpatient departments.ConclusionImprovements in use of aspirin in US ambulatory care for reducing risks of CVD were at best modest during the period under study, particularly for secondary prevention, where the strongest evidence and most explicit guidelines exist. Aspirin is more underused than statins despite its more favorable cost-effectiveness. Aggressive and targeted interventions are needed to enhance provider and patient adherence to consensus guidelines for CVD risk reduction.
Highlights
Cardiovascular disease (CVD), including myocardial infarction and stroke, is the leading cause of morbidity and mortality in the United States
We studied national trends of aspirin use among intermediate- to high-risk patients in the US ambulatory care settings and compared the priority given to aspirin versus statins for cardiovascular disease (CVD) risk reduction
Aspirin is more underused than statins despite its more favorable cost-effectiveness
Summary
Cardiovascular disease (CVD), including myocardial infarction and stroke, is the leading cause of morbidity and mortality in the United States. Aspirin is unequivocally recommended as a secondary prevention strategy in non-contraindicated patients with known CVD [12,13]. As for primary prevention, the American Diabetic Association recommends regular aspirin for men and women with diabetes mellitus (DM) who are older than 40 y or have additional cardiovascular risk factors [14]. The latest results from the Women’s Health Study [7] suggest that careful ascertainment of the absolute benefit and risk on a case-by-case basis is essential to deciding on the use of aspirin therapy in men and, even more so, in women who have showed no clinical manifestations of CVD or diabetes. Despite the proven benefits of aspirin therapy in the primary and secondary prevention of cardiovascular disease (CVD), utilization rates of aspirin remain suboptimal in relation to recommendations. Greater aspirin use was seen most frequently in people of advanced age, who were male, who were being cared for by cardiologists (rather than general physicians or other specialists), and who were being seen in hospital outpatient departments (rather than private practices)
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