Despite recommendations in national guidelines, the majority of Medicare beneficiaries do not receive high-intensity statin therapy after hospitalization for coronary heart disease (CHD), according to new research.
The retrospective cohort study was published in the Journal of the American College of Cardiology.
For the study, Robert S. Rosenson, MD, of the Icahn School of Medicine at Mount Sinai, New York, and colleagues used a 5% random sample of Medicare beneficiaries aged 65 to 74 years. Beneficiaries were included if they filled a statin prescription after a CHD event — either myocardial infarction (MI) or coronary revascularization — between 2007 and 2009.
Atorvastatin (40 mg to 80 mg), rosuvastatin (20 mg to 40 mg) and simvastatin (80 mg) were defined as the high-intensity statin regimens.
In all, 8,762 Medicare beneficiaries were included in the analysis.
After discharge, only 27% of the first prescription fills were for a high-intensity statin: 15.7% of beneficiaries received atorvastatin, 7.8% received simvastatin and 3.5% received rosuvastatin.
In subgroup analysis, the rate of patients filling a high-intensity statin post-discharge was 23.1% for beneficiaries not taking statins pre-hospitalization; 9.4% for those taking low- to moderate-intensity statins; and 80.7% for those taking high-intensity statins before their CHD event.
Multivariable adjusted analysis indicated that compared with Medicare beneficiaries not on statin therapy before hospitalization, risk ratios for filling a high-intensity statin were 4.01 (95% CI, 3.58–4.49) for patients taking high-intensity statins and 0.45 (95% CI, 0.40–0.52) for those on low- to moderate-intensity statins before their CHD event.
Furthermore, in the year following discharge, only 11.5% of participants whose first post-discharge statin fill was for a low- to moderate-intensity statin filled a high-intensity statin prescription. Also at 1 year, 35% of beneficiaries filled a high-intensity statin at any time.
“The underutilization of high-intensity statin therapy observed in the current study should be interpreted in the context of data from multiple clinical trials and clinical practice guidelines recommending this practice,” Dr. Rosenson and colleagues wrote, adding that future research should examine the causes of this pattern so that interventions can be designed to improve evidence-based care.
Commenting on the study, Prakash Deedwania, MD, of the University of California, San Francisco School of Medicine, wrote in an accompanying editorial that implementation of guideline-directed medical therapy (GDMT) remains worrisome, especially in light of the recent data suggesting the benefit of optimal medical therapy in patients with coronary artery disease. “… On the patient side, this lag [in GDMT implementation] could reflect real or perceived medication cost issues, polypharmacy (especially in the elderly), noncompliance and nonadherence.”
Deedwania added that the lag deprives patients of evidence-based therapy and “exposes them to future risk of major acute cardiovascular events that could be significantly reduced with proper secondary prevention,” he wrote. “Also, continued use of expensive interventions rather than evidence-based [optimal medical therapy] may lead to loss of trust in the physicians involved. Thus, actions must be taken to improve GDMT implementation in clinical practice.”