Statin Adherence Research Articles

Adherence to common cardiovascular medications in patients with schizophrenia vs. patients without psychiatric illness

The purpose of the study was to examine whether individuals with diagnoses of schizophrenia were differentially adherent to their statin or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) medications compared to individuals without psychiatric illness. Using electronic medical record data across 13 Mental Health Research Network sites, individuals with diagnoses of schizophrenia or schizoaffective disorder receiving two or more medication dispensings of a statin or an ACEI/ARB in 2011 (N=710) were identified and matched on age, sex and Medicare status to controls with no documented mental illness and two or more medication dispensings of a statin in 2011 (N=710). Medication adherence, and sociodemographic and clinical characteristics of the study population were assessed. Multivariable models indicated that having a schizophrenia diagnosis was associated with increased odds of statin medication adherence; the odds ratio suggested a small effect. After adjustment for medication regimen, schizophrenia no longer showed an association with statin adherence. Having a schizophrenia diagnosis was not associated with ACEI/ARB medication adherence. Compared to patients without any psychiatric illness, individuals with schizophrenia were marginally more likely to be adherent to their statin medications. Given that patterns of adherence to cardioprotective medications may be different from patterns of adherence to antipsychotic medications, improving adherence to the former may require unique intervention strategies.

Motivational effects of coronary artery calcium scores on statin adherence and weight loss.

The aim of this study was to assess the effect on adherence to statin therapy and assess the effect of beneficial changes in behavior that resulted in weight loss in patients who underwent coronary artery calcium (CAC) scoring with cardiac computed tomography. Despite convincing data demonstrating the benefits of HmGCoA inhibitors for both primary and secondary prevention of coronary heart disease, they remain underused. Also, despite convincing data demonstrating the benefits of weight loss for both primary and secondary prevention of coronary heart disease, it remains difficult to motivate behavioral changes resulting in weight loss. In this study, we assess whether higher CAC scores are associated with increased compliance with statin medication and whether higher CAC scores are associated with beneficial lifestyle behaviors resulting in weight loss. We retrospectively analyzed patients that had undergone baseline CAC testing and returned for a follow-up scan. All patients had weight documented and were administered a questionnaire regarding compliance to medications. The primary endpoint was measurable weight loss between visit one and visit two and the self-reported compliance to statin use. The study population with data regarding statin compliance consisted of 2608 individuals (72% men, mean age 58±8 years) who were followed for a mean of 4.1±3.2 years after an initial CAC scan. Overall, statin compliance was lowest (27.4%) among those with CAC=0, and gradually increased with higher CAC scores (1-99, 39.2%; 100-399, 53.6%; ≥400, 58.8%; P<0.001 for trend). In the group analyzed for weight loss the study population consisted of 1078 individuals (68% men, mean age 60±8 years) who were followed for a mean of 4.1±3.2 years after an initial CAC scan. Overall, behavioral modification resulting in weight loss was lowest (19.8%) among those with CAC=0, and gradually increased with higher CAC scores (1-99, 23.4%; 100-399, 30.8%; ≥400, 33.6%; P<0.001 for trend). In addition to being a robust risk stratification tool, a higher rate of adherences with statin therapy was observed in patients with higher CAC scores.

Association between trajectories of statin adherence and subsequent cardiovascular events

Trajectory models have been shown to (1) identify groups of patients with similar patterns of medication filling behavior and (2) summarize the trajectory, the average adherence in each group over time. However, the association between adherence trajectories and clinical outcomes remains unclear. This study investigated the association between 12-month statin trajectories and subsequent cardiovascular events. We identified patients with insurance coverage from a large national insurer who initiated a statin during January 1, 2007 to December 31, 2010. We assessed medication adherence during the 360 days following initiation and grouped patients based on the proportion of days covered (PDC) and trajectory models. We then measured cardiovascular events during the year after adherence assessment. Cox proportional hazards models were used to evaluate the association between adherence measures and cardiovascular outcomes; strength of association was quantified by the hazard ratio, the increase in model C-statistic, and the net reclassification index (NRI). Among 519 842 statin initiators, 8777 (1.7%) had a cardiovascular event during follow-up. More consistent medication use was associated with a lower likelihood of clinical events, whether adherence was measured through trajectory groups or PDC. When evaluating the prediction of future cardiovascular events by including a measure of adherence in the model, the best model reclassification was observed when adherence was measured using three or four trajectory groups (NRI = 0.189; 95% confidence interval: [0.171, 0.210]). Statin adherence trajectory predicted future cardiovascular events better than measures categorizing PDC. Thus, adherence trajectories may be useful for targeting adherence interventions.

Visualization of Coronary Artery Calcification: Influence on Risk Modification

ObjectivesDirect health provider to patient presentation of coronary computed tomography angiography findings may increase adherence to preventive therapy and risk modification. The purpose of this study was to assess the influence of visualization of coronary artery calcification and lifestyle recommendations on cholesterol concentrations and other risk variables in symptomatic patients with nonobstructive coronary artery disease and hyperlipidemia. MethodsWe performed a prospective 2-center randomized controlled trial. Patients were randomized 1:1 to intervention or standard follow-up in general practice. The primary end point was change in plasma total cholesterol concentration at 6 months follow-up. ResultsWe included 189 patients (mean [± standard deviation] age 61 [12] years, 57% were male). Median (range) Agatston score was 166 (70-2054). The reduction in plasma total cholesterol concentrations tended to be higher in the intervention group than in the control group, 51.04 mg/dL versus 45.63 mg/dL (P = .181). In a subgroup including patients continuing statin therapy during follow-up (n = 147), the reduction in plasma total cholesterol concentrations was more pronounced in the intervention group than in the control group, 66.13 mg/dL versus 55.68 mg/dL (P = .027). In the intervention group, there was a higher degree of statin adherence and a higher proportion of patients who stopped smoking and commenced healthier dietary behavior than in the control group. ConclusionsVisualization of coronary artery calcification and brief recommendations about risk modification after coronary computed tomography angiography in symptomatic patients with nonobstructive coronary artery disease and hyperlipidemia may have a favorable influence on plasma total cholesterol concentration, adherence to statin therapy, and risk behavior. Further investigations are needed.

Patient adherence to generic versus brand statin therapy after acute myocardial infarction: Insights from the Can Rapid Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines Registry

Statins reduce mortality after acute myocardial infarction, but up to half of patients discontinue statin use within 1 year of therapy initiation. Although cost may influence medication adherence, it is unknown whether use of generic versus brand statins influences adherence. We linked detailed inhospital clinical data for 1421 non-ST-segment elevation myocardial infarction patients discharged on a statin in 2006 to Medicare Part D medication claims records to examine postdischarge medication use. One-year statin adherence was defined using the proportion of days covered with optimal adherence ≥80%. We examined the association of brand versus generic statin prescription and 1-year adherence after adjusting for demographics, clinical factors, predischarge lipid values, prior statin use, and socioeconomic status. Overall, 65.5% of statin fills were for brand-name statins. There were few baseline differences in demographics and clinical factors among generic versus brand users. Patient copay amounts were higher for brand versus generic statins (median = $25 vs $5, P < .001), yet the mean proportion of days covered over 1 year was similar (71.5% vs 68.9%; P = .97; unadjusted odds ratio 1.15 [95% CI 0.96-1.37]). Proportion of days covered ≥80% was low for both generic (56.2%) and brand statins (55.9%; P = .93). Statin adherence rates remained similar between generic and brand users after adjusting for demographics, clinical risk factors, lipid value, prior statin use, and socioeconomic status. In a cohort of older non-ST-segment elevation myocardial infarction patients, we found no evidence that use of generic versus brand drug was associated with higher adherence to statins at 1 year after hospital discharge.

Observing versus Predicting: Initial Patterns of Filling Predict Long-Term Adherence More Accurately Than High-Dimensional Modeling Techniques.

Despite the proliferation of databases with increasingly rich patient data, prediction of medication adherence remains poor. We proposed and evaluated approaches for improved adherence prediction. We identified Medicare beneficiaries who received prescription drug coverage through CVS Caremark and initiated a statin. A total of 643 variables were identified at baseline from prior claims and linked Census data. In addition, we identified three postbaseline predictors, indicators of adherence to statins during each of the first 3months of follow-up. We estimated 10 models predicting subsequent adherence, using logistic regression and boosted logistic regression, a nonparametric data-mining technique. Models were also estimated within strata defined by the index days supply. In 77,703 statin initiators, prediction using baseline variables only was poor with maximum cross-validated C-statistics of 0.606 and 0.577 among patients with index supply ≤30days and >30days, respectively. Using only indicators of initial statin adherence improved prediction accuracy substantially among patients with shorter initial dispensings (C=0.827/0.518), and, when combined with investigator-specified variables, prediction accuracy was further improved (C=0.842/0.596). Observed adherence immediately after initiation predicted future adherence for patients whose initial dispensings were relatively short.

Statin adherence and LDL cholesterol levels. Should we assess adherence prior to statin upgrade?

BackgroundAdherence to statin therapy has been shown to be suboptimal. In statin-treated patients with residual elevated low density lipoprotein cholesterol (LDL-C) levels the physician must decide whether to switch to a more potent statin or try and achieve better adherence. We examined the association between adherence and LDL-C within low, moderate and high intensity statin groups in a “real world” setting. MethodsWe assessed annual adherence by the mean MPR (Medication Possession Ratio = number of purchased/prescribed daily doses) in unselected patient group. Statins were stratified (ACC/AHA Guideline) into low, moderate and high intensity groups. The impact of adherence on LDL levels was assessed by LOESS (locally weighted scatter plot smoothing). ResultsOut of 1183 patients 173 (14.6%) were treated with low, 923 (78.0%) with moderate and 87 (7.4%) with high intensity statins. Statin intensity was inversely associated with adherence (MPR 77±21, 73±22 and 69±21% for low, moderate and high intensity respectively, p=0.018). Non-adjusted LDL levels decreased with higher adherence: a 10% adherence increase resulted in LDL decrease of 3.5, 5.8 and 7.1mg/dL in low, moderate and high intensity groups. Analysis of the adherence effect on LDL levels adjusted for age, DM and ischemic heart disease showed that MPR above 80% was associated with an additional decrease in LDL levels only in the high intensity group. ConclusionsIncreased adherence to statins beyond an MPR of 80% improves LDL levels only among patients given high intensity therapy. Switching from lower to higher intensity therapy may be more effective than further efforts to increase adherence.

Does a cardiovascular event change adherence to statin treatment in patients with type 2 diabetes? A matched cohort design

Objective:To be effective, adherence to statin treatment is essential. We assessed the effect of an apparent first cardiovascular event on statin adherence rates in type 2 diabetes patients.Research design and methods:A matched cohort study was conducted among type 2 diabetes patients initiating statin treatment for primary prevention in the Groningen University IADB.nl pharmacy database. Patients who had a drug-treated cardiovascular event (index date) after statin initiation were matched to a reference patient without such an event with similar gender, age at statin initiation, initiation date, follow-up period and adherence level before the event. Adherence rates were measured as percentages of days covered (PDC), and shifts in adherence levels (non-adherent/partially adherent/fully adherent) and rates around the event were evaluated.Results:We could match 375 of the 855 eligible index patients to a reference patient. Index patients had on average a PDC of 81% after the index date; reference patients had a PDC of 71% (p < 0.001) while both had a PDC of 79% before the index date. Index patients were 4.5 times more likely than reference patients to shift from non-adherent to fully adherent (95% CI 1.1–18.8) and 1.8 times more likely to shift from partially adherent to fully adherent (95% CI 1.2–2.6). In the index group, 26% of patients became more adherent after the first cardiovascular event. In contrast, 20% of patients became less adherent.Limitations:Medication proxies were used, which could have caused misclassification. Furthermore, a substantial group of index patients could not be matched to a reference patient due to small ranges in matching criteria.Conclusions:The occurrence of a drug-treated cardiovascular event appeared to avert the declining statin adherence rate observed in diabetes patients without such an event. On the other hand, one in five patients became less adherent after the event, indicating that there are still important benefits to achieve.

Statin prescription patterns, adherence, and attainment of cholesterol treatment goals in routine clinical care: a Danish population-based study.

PurposeTo examine the annual rate and cumulative prevalence of statin use in Denmark 2004–10, including adherence of use and attainment of cholesterol targets.MethodsWe included all individuals aged 18–86 years with a first statin prescription in Northern Denmark in 2004–10. We calculated the annual rate and cumulative prevalence of statin use. We examined cholesterol values before and after start of statins and the proportion reaching targets according to European guidelines and cardiovascular risk group.ResultsThe study population consisted of 161,646 new statin users (51% men; median age 62 years). The peak rate of new statin initiators occurred in 2008, and a cumulative prevalence of 94 users per 1,000 population was reached in 2010. In total, 98% of new users started with simvastatin. Eighty-eight percent (142,897) did not switch statin type during follow-up. Overall persistence was 84%. The reduction in median total cholesterol in new statin users was 28% (from 6.3 mmol/L to 4.5 mmol/L), while it was 43% (from 4.0 mmol/L to 2.3 mmol/L) for low-density lipoprotein cholesterol. Among patients with very high cardiovascular risk, 66% attained the recommended total cholesterol target; corresponding figures were 74% among high-risk patients and 80% among low- to moderate-risk patients. Corresponding figures for low-density lipoprotein cholesterol were 54%, 82%, and 88%, respectively.ConclusionsStatin use has become very prevalent in Danish adults, with high adherence. Cholesterol reduction after statin initiation is similar to that found in clinical trials, yet a substantial proportion of patients does not reach target cholesterol levels.

Uncontrolled hypertension prevalence, treatment and blood pressure levels: An analysis of New Zealand primary care data

Background: Prior studies suggest that only about twothirds of patients who present with an acute coronary syndrome (ACS) are maintained on a statin post-discharge. This could be due to sub-optimal initiation or poor longer-term adherence. The aim of this study was to identify the pattern of statin adherence following ACS from initial prescription to three years post-discharge. Methods: ANZACS-QI registry data for consecutive New Zealand residents hospitalised with ACS was anonymously linked to national datasets to derive a Statin Possession Ratio (SPR) to assess maintenance. Results: Of 1846 patients discharged alive 95% were prescribed a statin at discharge and 92% were dispensed a statin within 3 months, but only 75% had an adequate SPR 0.8 in the first year, and 67% in year 3. In year 3, 11% had no statin dispensed and another 21% had intermittent statin dispensing (SPR >0 to <0.8). Only 33% had an ideal SPR of 1. Statin prescribing at discharge was high across ethnic groups (94% to 97%), slightly higher in men than women (96% and 92%, respectively) and in those <65y than 65y (97% vs 93%). In the third year, on regression analysis, the independent predictors of inadequate maintenance were age<45 (p<0.05), female gender (p<0.05), no prior statin (p<0.01) and Pacific ethnicity (p=0.05). Conclusion: Ninety-five percent of ACS patients were prescribed a statin at discharge and nearly all had it dispensed. However, over the first year only three-quarters were adequately maintained on statin and by three years this fell to two-thirds.

Cost-effectiveness analysis of alternative screening and treatment strategies for heterozygous familial hypercholesterolemia in the United States

Background/objectivesFamilial hypercholesterolemia (FH) is a genetic disorder that leads to premature heart disease or stroke if untreated. Statins are effective for individuals with FH but less than 20% of actual cases are diagnosed in the US and many people are not adherent to treatment. Using new knowledge regarding mutations responsible for FH, some European countries have developed genetic FH screening strategies, many of which have been shown to be cost-effective. This study evaluates the cost-effectiveness of genetic screening and lipid-based screening with statin adherence measures compared to lipid-based screening alone in the US. MethodsA decision tree was used to estimate disease detection with the three screening strategies, while a Markov model was used to model disease progression until death, quality-adjusted life years (QALYs) and costs from a US societal perspective. ResultsThe results showed that Genetic Screening cost $15,594 for 18.29 QALYs per person and Lipid Screening with adherence measures cost $16,385 for 18.77 QALYs compared with $10,396 for 18.28 QALYs for Lipid Screening alone. The incremental cost-effectiveness ratio (ICER) of Genetic Screening versus Lipid Screening was $519,813/QALY and that of Lipid Screening with adherence measures versus Lipid Screening alone was $12,223/QALY. At a US willingness-to-pay threshold of $150,000/QALY Genetic Screening is not cost-effective compared with Lipid Screening. Sensitivity analyses showed that results were robust to reasonable variations in model parameters. ConclusionsAlthough genetic screening is currently not a cost-effective option in the US, health outcomes for FH individuals could benefit from adherence measures encouraging statin use.

Geospatial analysis of statin adherence using pharmacy claims data in the state of Michigan.

Research has demonstrated that variation in availability and utilization of health care resources exist on a range of scales, from regions of the United States, hospital referral regions, ZIP codes, and census tracts. Limited research using spatial analyses has found that variation in medication adherence exists across census tracts. Using spatial analysis, researchers may be able to effectively analyze geographically dispersed data to determine whether factors such as sociodemographics, local shared beliefs and attitudes, barriers to access such as availability of prescribers or pharmacies, or others are associated with variations in medication adherence in a defined geographic area. To (a) demonstrate that medication adherence may be mapped across an entire state using medication possession ratios and (b) determine whether a geographic pattern of adherence to statins could be identified at the ZIP code level for members of a statewide insurer. This study utilized pharmacy claims data from a statewide insurer. Insured statin users were aged greater than 30 years, had at least 1 statin prescription, and were continuously enrolled for the observation year. Patient medication possession ratios (MPR) were derived, which were then aggregated as a mean MPR for each ZIP code. ZIP codes were categorized as higher (MPR greater than 0.80) or lower (MPR less than 0.80) adherence and mapped using Arc GIS, a platform for designing and managing solutions through the application of geographic knowledge. Analysis included a determination of whether the MPRs of higher and lower adherence ZIP codes were significantly different. Hot spot analysis was conducted to identify clustering of higher, midrange, and lower adherent ZIP codes using the GetisORD Gi* Statistic. This test provides z-scores and P values to indicate where features with either high or low values cluster spatially. MPRs for these 3 categories were compared using one-way analysis of variance (ANOVA). Of 1,154 Michigan ZIP codes, 907 were represented by 212,783 insured statin users. The mean statin MPR by ZIP code was 0.79 ± 0.4. The mean MPR for higher adherent ZIP codes was 0.83 ± 0.03 and 0.76 ± 0.03 for lower adherent ZIP codes (P less than 0.001). Significant clustering of ZIP codes by adherence levels was evident from the hot spot analysis. The mean MPR was 0.84 ± 0.04 for high adherence areas, 0.79 ± 0.03 for midrange areas, and 0.74 ± 0.04 for lower adherent areas (overall P less than 0.001). Significant variations in adherence exist across ZIP codes at a state level. Future research is needed to determine locally relevant factors associated with this finding, which may be used to derive locally meaningful interventions.

Abstract 14646: Internal Medicine Housestaff Perceptions of Statins and ACC/AHA Blood Cholesterol Guidelines

Background: Statins are integral in the prevention of atherosclerotic cardiovascular disease (ASCVD). Provider perceptions and prescribing practices of statins vary. Internal medicine housestaff (HS) perceptions of statins and new ACC/AHA cholesterol guidelines have not previously been assessed. Methods: We examined internal medicine HS perceptions of statins and ACC/AHA cholesterol guidelines through a 48-question survey. We surveyed HS at three academic training programs. Anonymous responses were collected via a secure website. Results: 99 respondents’ results (84% categorical residents) were examined from Emory, Johns Hopkins, and UTSW. HS report observing low rates of statin side effects: 64% and 91% reported rates of &lt;3% and &lt;10%. Majority of side effects were myalgias (69%), transaminitis (23%), and gastrointestinal symptoms (5%). Over half (54%) of respondents check transaminases prior to statin therapy. If transaminitis &gt;1-2x upper limit of normal (ULN) develop only 6% of residents stop statin therapy, though 62% stop therapy if transaminitis &gt;3x ULN. In stable liver disease, 13% use non-statin therapy. Most residents (73%) agree that patients understand why they are prescribed statins and feel compliance is influenced by experienced/perceived risk of side effects (44%), cost (30%), and medical benefit (13%). However, HS do not discuss side effects in 25% of patients and only 44% agree patients frequently ask about side effects. Additionally, only 51% of HS discuss ASCVD risk with a majority of patients. HS perceive high rates of statin adherence (87% state &gt;50% adherence at one year). Of 61 HS, 72% learned of new lipid guidelines through residency training. Nearly all (89%) read a portion of the guidelines and are likely to implement them (97%). However, only 57% agree the guidelines are clear or straightforward to apply in clinical practice and 66% agreed the guidelines will improve/reduce ASCVD risk. Only 48% agree new guidelines will improve quality of patient care. Conclusion: Practice patterns of statin therapy vary among medicine HS. Side effects and ASCVD risk are not frequently discussed with patients. Though HS are aware of new cholesterol guidelines, a gap exists between implementation and perceived benefits/ASCVD risk reduction.

When compliance is an issue-how to enhance statin adherence and address adverse effects.

Cardiovascular disease is prevalent and costly. Interventions and therapies that reduce morbidity and mortality associated with cardiovascular disease could have an enormous impact on clinical and economic outcomes. Statins reduce atherosclerotic cardiovascular disease-related morbidity and mortality; however, adherence to statins is less than optimal. It is important for clinicians as well as health plan managers to be aware of the patient- and insurance plan-specific factors that have been shown to influence adherence. Perceived statin-related side effects may also decrease adherence. Statin-related myalgia may be difficult to distinguish from myalgia caused by other conditions, and statin therapy may be discontinued unnecessarily in patients who would otherwise benefit. It is imperative that clinicians work closely with patients to improve adherence to statin therapy and be knowledgable in managing potential statin-related side effects.

Is high-intensity statin therapy associated with lower statin adherence compared with low- to moderate-intensity statin therapy? Implications of the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guidelines.

The recent cholesterol guideline recommends high-intensity statins in cardiovascular disease (CVD) patients. High-intensity statins are associated with more frequent side effects. Therefore, it may be of concern that these recommendations might reduce statin adherence. High-intensity statins are associated with lower adherence compared with low- to moderate-intensity statins. In a national database of 972,532 CVD patients from the Veterans Health Administration, we identified patients receiving statins between October 1, 2010, and September 30, 2011. We assessed statin adherence by calculating proportion of days covered (PDC) and determined whether high-intensity statin therapy was independently associated with a lower PDC. Statins were prescribed in 629,005 (64.7%). Of those, 229,437 (36.5%) received high-intensity statins. Mean PDC (0.87 vs 0.86, P < 0.0001) and patients with PDC ≥ 0.80 (76.3% vs 74.2%, P < 0.0001) were slightly higher for those receiving low- to moderate-intensity compared with high-intensity statins. In adjusted analyses, high-intensity statin use was associated with a significant but modest PDC reduction compared with low- to moderate-intensity statin use, whether PDC was assessed as a continuous (β-coefficient: -0.008, P < 0.0001) or categorical (PDC ≥ 0.80 [odds ratio: 0.94, 95% confidence interval: 0.93-0.96]) measure of statin adherence. An approach of high-intensity statin therapy will lead to a significant practice change, as the majority of CVD patients are not on high-intensity therapy. However, this change may be associated with a very modest reduction in statin adherence compared with low- to moderate-intensity therapy that is unlikely to be of clinical significance.

Statin treatment non-adherence and discontinuation: clinical implications and potential solutions.

Statins are the most powerful lipid lowering drugs in clinical practice. However, the efficacy of statin therapy, as seen in randomized control trials, is undermined by the documented non-adherence observed in clinical practice. Understanding the clinical consequences of statin non-adherence is an important step in implementing successful interventions aimed at improving adherence. Our previous systematic review included a literature search up to January 2010 on the effects of statin non-adherence or discontinuation on cardiovascular (CV) and cerebrovascular outcomes. We provide an update to this publication and a review of promising interventions that have reported a demonstrated improvement in statin adherence. Through a systematic literature search of PubMed, Ovid Medline, Ovid Embase, CINAHL, Cochrane Library and Web of Science, out of the 3440 initially identified, 13 studies were selected. Non-adherence in a primary prevention population was associated with a graded increase in CV risk. Individuals taking statins for secondary prevention were at particular risk when taking statin with highly variable adherence. Moreover, particular attention is warranted for non-adherence in diabetic and rheumatoid arthritis populations, as non-adherence is significantly associated with CV risk as early as 1 month following discontinuation. Statin adherence, therefore, represents an important modifiable risk factor. Numerous interventions to improve adherence have shown promise, including copayment reduction, automatic reminders, mail-order pharmacies, counseling with a health professional, and fixed-dose combination therapy. Given the complexity of causes underlying statin non-adherence, successful strategies will likely need to be tailored to each patient.

Statin treatment patterns and clinical profile of patients with risk factors for coronary heart disease defined by National Cholesterol Education Program Adult Treatment Panel III

Objective:To compare clinical characteristics, statin treatment patterns and adherence among patients at different risk for coronary heart disease (CHD) as defined by National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III guidelines.Methods:Patients ≥18 years old with ≥1 claim for dyslipidemia, ≥1 statin claim, or ≥1 LDL-C value ≥100 mg/dL were identified from 1 January 2007 to 31 July 2012. Patients were classified as low risk (LR) (0–1 risk factor: hypertension, age ≥45 years [men] or ≥55 years [women], or low HDL-C), moderate/moderately high risk (MR) (≥2 risk factors), high risk (HR) (CHD or CHD risk equivalent), or very high risk (VHR) (acute coronary syndrome, or established cardiovascular disease plus diabetes or metabolic syndrome). Medication use and lipid levels during the 12 months before and statin use during the 6 months after index were compared across risk groups.Results:There were 1,524,351 LR, 242,357 MR, 188,222 HR, and 57,469 VHR patients identified. Statin use was observed in 15% of all patients, but was higher in the VHR group (45%) versus LR (12%), MR (18%), and HR (29%) groups. Simvastatin accounted for 50%–52% of all statin use, and average statin dose was higher among VHR patients compared with all other groups. Adherence was low overall (mean proportion of days covered [PDC]: 0.57), but higher among VHR (0.69) versus others (mean PDC: 0.55, 0.59, and 0.59 in LR, MR, and HR groups, respectively).Conclusions:Statin treatment was low across all risk groups, and VHR patients had higher doses and better adherence compared with other risk groups. However, adherence was not optimal, indicating a potential limited benefit from statin treatment.

Statin initiation and treatment non-adherence following a first acute myocardial infarction in patients with inflammatory rheumatic disease versus the general population.

IntroductionTo compare statin initiation and treatment non-adherence following a first acute myocardial infarction (MI) in patients with inflammatory rheumatic disease (IRD) and the general population.MethodsWe conducted a retrospective cohort study using a population-based linked database. Cases of first MI from July 2001 to June 2009 were identified based on International Classification of Diseases (ICD-10-AM) codes. Statin initiation and adherence was identified based on pharmaceutical claims records. Logistic regression was used to assess the odds of statin initiation by IRD status. Non-adherence was assessed as the time to first treatment gap using a Cox proportional hazards model.ResultsThere were 18,518 individuals with an index MI over the time period surviving longer than 30 days, of whom 415 (2.2%) were IRD patients. The adjusted odds of receiving a statin by IRD status was significantly lower (OR =0.69, 95% CI: 0.55 to 0.86) compared to the general population. No association between IRD status and statin non-adherence was identified (hazard ratio (HR) =1.12, 95% CI: 0.82 to 1.52).ConclusionsStatin initiation was significantly lower for people with IRD conditions compared to the general population. Once initiated on statins, the proportion of IRD patients who adhered to treatment was similar to the general population. Given the burden of cardiovascular disease and excess mortality in IRD patients, encouraging the use of evidence-based therapies is critical for ensuring the best outcomes in this high risk group.Electronic supplementary materialThe online version of this article (doi:10.1186/s13075-014-0443-y) contains supplementary material, which is available to authorized users.

Impact of statin adherence on cardiovascular disease and mortality outcomes: a systematic review.

While suboptimal adherence to statin medication has been quantified in real-world patient settings, a better understanding of its impact is needed, particularly with respect to distinct problems of medication taking. Our aim was to synthesize current evidence on the impacts of statin adherence, discontinuation and persistence on cardiovascular disease and mortality outcomes. We conducted a systematic review of peer-reviewed studies using a mapped search of Medline, Embase and International Pharmaceutical Abstracts databases. Observational studies that met the following criteria were included: defined patient population;statin adherence exposure; defined study outcome [i.e. cardiovascular disease (CVD), mortality]; and reporting of statin-specific results. Overall, 28 studies were included, with 19 studies evaluating outcomes associated with statin adherence, six with statin discontinuation and three with statin persistence. Among adherence studies, the proportion of days covered was the most widely used measure, with the majority of studies reporting increased risk of CVD (statistically significant risk estimates ranging from 1.22 to 5.26)and mortality (statistically significant risk estimates ranging from 1.25 to 2.54) among non-adherent individuals. There was greater methodological variability in discontinuation and persistence studies. However, findings of increased CVD (statistically significant risk estimates ranging from 1.22 to 1.67) and mortality (statistically significant risk estimates ranging from 1.79 to 5.00) among nonpersistent individuals were also consistently reported. Observational studies consistently report an increased risk of adverse outcomes associated with poor statin adherence. These findings have important implications for patients and physicians and emphasize the importance of monitoring and encouraging adherence to statin therapy.

Reasons for (non)compliance with intervention following identification of 'high-risk' status in the NHS Health Check programme.

BackgroundThe Department of Health introduced a risk assessment, management and reduction programme, NHS Health Checks, which aimed to reduce premature morbidity and mortality from cardiovascular diseases for those aged 40–74. Those identified as at increased risk of CVD are offered prophylactic medication and lifestyle advice to reduce their risk. Health gains will only be achieved if patients are compliant with advice/intervention however. This study sought to understand factors that influenced adherence to medication and advice in ‘high-risk’ patients.MethodsQualitative data were collected through 29 semi-structured interviews with a purposive sample of individuals who had been identified as at high-risk of CVD. Participants had been offered lifestyle advice, lipid lowering medications and attended at least one annual review.ResultsFindings explore the challenges and experiences confronting ‘high-risk’ individuals when making decisions about engaging with intervention. Key findings explore: statin adherence, as well as adherence to advice about diet, physical activity, alcohol consumption and smoking cessation.ConclusionsAttention needs to be paid to the way prophylactic medications are prescribed and explained to high-risk patients. Consistent provision of tailored lifestyle advice and access to appropriate services could facilitate sustained changes to factors that increase CVD risk.