Trends in Use of High-Intensity Statin Therapy After Myocardial Infarction, 2011 to 2014 Robert S. Rosenson, MD, Michael E. Farkouh, MD, Matthew Mefford, MS, Vera Bittner, MD, Todd M. Brown, MD, MSPH, Ben Taylor, PHD, Keri L. Monda, PHD, Hong Zhao, MSPH, Yuling Dai, MSPH, Paul Muntner, PHD Journal of the American College of Cardiology 1 Wan-Ting, Lin 2017/07/07 Introduction
Several randomized controlled trials have shown high-intensity statin therapy to be more efficacious than lower intensity ther apy for preventing recurrent atherosclerotic cardiovascular dis ease (CVD) events among patients hospitalized for acute coron ary syndrome (ACS). Analyses of registries and insurance claims databases have doc umented that between 20% and 40% of patients with ACS fill p rescriptions for high-intensity statins following hospital dischar ge.
2 Introduction Several events have occurred over the past several years that m ay have changed the use of high-intensity statins among patient s with ACS. In 2011,
the American Heart Association (AHA)/American College of Cardiology Fou ndation secondary prevention guidelines recommended adequate doses of statin therapy necessary to achieve specific low-density lipoprotein chol esterol thresholds. a black-box warning against new prescriptions for simvastatin 80 mg and t he generic availability of atorvastatin. In 2013, the American College of Cardiology (ACC)/AHA guidelin e on the treatment of blood cholesterol to reduce atheroscleroti c CVD risk in adults was published and recommended the use of high-intensity statin therapy for patients with established CVD.
3 Aim 4 The aim of this study was to examine trends and predicto rs of high-intensity statin use following hospital discharge for myocardial infarction (MI) between 2011 and 2014.
Study population MarketScan and Medicare beneficiaries hospitalized with overnight stays for MI between January 1, 2011, and N ovember 30, 2014 Inclusion criteria
5 hospital stays for their index MIs were 30 days30 days alive 30 days following hospital discharge had continuous MarketScan or Medicare fee-for-service insurance living in the United States from 365 days prior to hospital admission for t heir MIs through 30 days following discharge. Study population
Exclusion criteria Beneficiaries enrolled in Medicare Advantage plans (Medicare Part C) stays at skilled nursing facilities or hospice facilities within 30 days follow ing their index MIs with outpatient statin fills during their MI hospitalizations
To avoid overlap between the 2 samples 6 MarketScan <65 years of age Medicare 66 to 75 years of age Study population
We restricted these analyses to beneficiaries who filled statin prescriptions within 30 days following hospital discharge for M I. The first MI each beneficiary experienced that met these criter ia was included and is referred to as the index MI. 7 8
9 Statin use Statin use was identified by pharmacy prescription fills in Mark etScan claims and Medicare Part D pharmacy claims in combin ation with national drug codes. Statins included atorvastatin, fluvastatin, lovastatin, pitavastati n, pravastatin, rosuvastatin, and simvastatin.
10 Statin use High-intensity statins use prior to the index MI included atorva statin 40 or 80 mg, rosuvastatin 20 or 40 mg. Beneficiaries with any statin fills in the 365 days prior to their i ndex MI were categorized as prevalent statin users. 11
Beneficiary characteristics Age and sex were identified from the MarketScan Commercial Claims and Encounters database and the Medicare beneficiary summary file. Information on race/ethnicity is available for Medicare benefici aries through the beneficiary summary file, but information on race is not available for MarketScan beneficiaries.
Diabetes, CHD, stroke, heart failure, peripheral artery disease, chronic kidney disease, depression, Charlson comorbidity inde x, all-cause hospitalizations, cardiologist care, use of non-statin lipid-lowering therapy, and the total number of different medic ation prescriptions filled were identified using claims in the 36 5 days prior to hospital admission for MI and previously publis hed algorithms. 12 Statistical analysis
We calculated the percentage of MarketScan beneficiaries wh ose first prescription fills following their index MIs were for hig h-intensity statins. Characteristics of MarketScan beneficiaries filling and not fillin g high-intensity statin prescriptions following hospital discharg e for MI in 2014 were calculated among statin initiators and a mong prevalent low- and moderate-intensity and among high-i ntensity statin users separately. 13 Statistical analysis
We used Poisson regression with sandwich estimators to calcul ate the relative risks for a high-intensity statin as the first statin prescription fill within 30 days after discharge. Relative risks were calculated in unadjusted model demographic variables
other covariates We calculated the percentage of beneficiaries who switched fr om low- or moderate-intensity to high-intensity statins within 182 days following discharge. 14 Trends in stain prescription fills 15 Trends in stain prescription fills
16 17 18 19 Titrate to a high-intensity statin within 182 days of hospital discharge 2011 20
2012 2013 2014 Discussion Strengths
21 2 large cohorts, 1 of younger patients with commercial health insurance and 1 of older patients with government insurance Most U.S. adults >65 years of age have health insurance through Medicar e, providing a high degree of generalizability. The large sample size provided stable estimates. Discussion
Limitations 22 relied on pharmacy claims to identify statin use
Patient behavioral and social support characteristics and characteristics o f the prescribing physician are not available in MarketScan and Medicare claims. Data were available only through 2014 The present study relied on claims data, and we were unable to ascertain whether prescription fills for low- or moderate-intensity statins were app ropriate on the basis of drug interactions, intolerance to high-intensity st atins, or sufficient control of low-density lipoprotein cholesterol. Data were available only for statin prescription fills and not prescriptions written. Race/ethnicity data are not available in MarketScan. Conclusion
The percentage of U.S. adults filling high-intensity statin prescr iptions following hospital discharge for MI increased substantia lly between 2011 and 2014. The present study highlights the need to continue efforts to inc rease high-intensity statin use following hospital discharge for MI. 23
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