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

Abstract

Background: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. Hypothesis: High-intensity statins are associated with lower adherence compared with low-to moderateintensity statins. Methods: 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. Results: 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,) measure of statin adherence.Conclusions: 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 Use and Its Facility‐Level Variation in Patients With Diabetes: Insight From the Veterans Affairs National Database

“…However, using VA database we have previously shown that there is minimal reduction in statin adherence (of unknown clinical significance) when using high-intensity compared to low-moderate intensity statin therapy. 7 Most recent cholesterol guidelines recommend a “treat to risk” approach with a fixed dose using moderate to high intensity statin therapy in patients with diabetes and recommend that there is not enough evidence to use non-statin lipid lowering therapy in most patients. 3 Following contemporary lipid guidelines during our study period when the focus was “treat to LDL-C target” (goal LDL-C <100 in high risk and <70 mg/dL in very high risk patients, such as those with CVD), 17–20 providers may have elected not to use statin therapy in those who were already at their LDL-C goal or to use non-statin lipid lowering therapy only.…”

“…We used ICD 9-CM diagnoses and procedure codes as well as current procedural terminology codes to identify CVD and other variables (Online-only Supplemental Table) as described in previous studies. 7,8 …”

“…The DCG RSS is a ratio of predicted to the mean cost and has been used as a surrogate of illness burden in prior studies. 7,8 For example, a patient with a score of 1.9 is expected to be 90% more costly, reflecting 90% incremental illness burden than an “average” patient.…”

Facility‐level variation in diabetes and blood pressure control in patients with diabetes: Findings from the Veterans Affairs national database

“…We identified insulin use through filled prescriptions. ICD‐9‐CM diagnosis and procedure codes were used along with procedure terminology codes to identify presence of CVDs (ischemic heart disease, peripheral arterial disease, or ischemic cerebrovascular disease) as described in prior studies …”

“…We used patient‐level variables to calculate Diagnostic Cost Group (DCG) relative risk scores (RRS), which serve as an indirect measure of a patient's overall illness burden. DCG RRS has been used and validated in prior studies as a surrogate marker for disease burden . A patient with a DCG RRS score of 1.5, for example, reflects a 50% greater expected cost of care compared with an average patient (DCG RRS score = 1), reflecting a 50% greater disease burden.…”