In the JournalsPerspective

Geographic region impacts high-intensity statin use after MI

Vera Bittner

An analysis of the associations of geographic region, beneficiary and hospital characteristics on high-intensity statin use after MI revealed that patients living in New England had 66% higher use compared those living in the West South Central region of the United States, according to findings published in JAMA Cardiology.

While region was the strongest correlate of post-MI high-intensity statin therapy, hospital characteristics including non-federal government ownership, larger hospital size and medical school affiliation were associated with greater likelihood of high-intensity statin use following MI.

“Our data show that there is significant regional variation in the utilization of high-intensity statins after myocardial infarction that is not explained by patient or hospital characteristics,” Vera Bittner, MD, MSPH, professor of medicine at the University of Alabama at Birmingham, told Cardiology Today. “This disparity in the utilization of high-intensity statins was quite consistent over the 4 years of data available for analysis. While all regions improved utilization of high-intensity statins after myocardial infarction between 2011 and 2015, the gap between regions with high utilization and regions with low utilization did not narrow substantially.”

In this retrospective cohort analysis, researchers evaluated enrollment data and administrative claims of 139,643 fee-for-service Medicare beneficiaries aged 66 years or older with a hospitalization for MI from January 2011 to June 2015 and had a statin prescription claim within 30 days of discharge.

Researchers examined the intensity of statin prescription — categorized as high or low to moderate — and associations with region, beneficiary and hospital characteristics. For this study, high-intensity statin use was defined as atorvastatin 40 to 80 mg or rosuvastatin 20 to 40 mg per day.

According to the results, overall high-intensity statin use increased from 23.4% to 55.6% from 2011 to 2015. The researchers found treatment gaps across regions, with the greatest use in New England (RR = 1.66; 95% CI, 1.47-1.87).

“We know that there is regional variation in cardiovascular risk factors and in cardiovascular morbidity and mortality,” Bittner said. “I thus expected some regional variation in the utilization of high-intensity statins post-myocardial infarction as well, but I was surprised by the magnitude of the variation even after adjustment for patient and hospital characteristics.”

Controlling for hospital characteristics and region, men were more likely than women to receive a prescription for high-intensity statins (risk ratio = 1.1; 95% CI, 1.07-1.13). Greater high-intensity statin use was also observed in patients who received a stent (RR = 1.35; 95% CI, 1.31-1.39), in hospitals with at least 500 beds (RR = 1.15; 95% CI, 1.07-1.23) and in hospitals with a medical school affiliation (RR = 1.11; 95% CI, 1.05-1.17).

Additionally, patients who presented with prior coronary disease, diabetes and chronic kidney disease, age older than 75 years and for-profit hospital ownership were associated with lower use of high-intensity statins.

“Individual practitioners and hospitals/health care systems should review their own practices, identify any gaps in the MI care processes and work diligently to improve utilization of high-intensity statins in high risk patients such as those after myocardial infarction,” Bittner said. “I also think that patients and their families should ask about a prescription for a high-intensity statin after myocardial infarction, if they don’t receive one. And, once they have such a prescription, it is critical that they fill the prescription and work with their providers to optimize adherence to the medication.” – by Scott Buzby

For more information:

Vera Bittner, MD, MSPH, can be reached at vbittner@uab.edu.

Disclosures: Bittner reports she serves on the executive steering committee of the ODYSSEY OUTCOMES trial (Sanofi) with personal compensation and serves as the national coordinator for STRENGTH (AstraZeneca). Please see the full study for all other authors’ disclosures.

Vera Bittner

An analysis of the associations of geographic region, beneficiary and hospital characteristics on high-intensity statin use after MI revealed that patients living in New England had 66% higher use compared those living in the West South Central region of the United States, according to findings published in JAMA Cardiology.

While region was the strongest correlate of post-MI high-intensity statin therapy, hospital characteristics including non-federal government ownership, larger hospital size and medical school affiliation were associated with greater likelihood of high-intensity statin use following MI.

“Our data show that there is significant regional variation in the utilization of high-intensity statins after myocardial infarction that is not explained by patient or hospital characteristics,” Vera Bittner, MD, MSPH, professor of medicine at the University of Alabama at Birmingham, told Cardiology Today. “This disparity in the utilization of high-intensity statins was quite consistent over the 4 years of data available for analysis. While all regions improved utilization of high-intensity statins after myocardial infarction between 2011 and 2015, the gap between regions with high utilization and regions with low utilization did not narrow substantially.”

In this retrospective cohort analysis, researchers evaluated enrollment data and administrative claims of 139,643 fee-for-service Medicare beneficiaries aged 66 years or older with a hospitalization for MI from January 2011 to June 2015 and had a statin prescription claim within 30 days of discharge.

Researchers examined the intensity of statin prescription — categorized as high or low to moderate — and associations with region, beneficiary and hospital characteristics. For this study, high-intensity statin use was defined as atorvastatin 40 to 80 mg or rosuvastatin 20 to 40 mg per day.

According to the results, overall high-intensity statin use increased from 23.4% to 55.6% from 2011 to 2015. The researchers found treatment gaps across regions, with the greatest use in New England (RR = 1.66; 95% CI, 1.47-1.87).

“We know that there is regional variation in cardiovascular risk factors and in cardiovascular morbidity and mortality,” Bittner said. “I thus expected some regional variation in the utilization of high-intensity statins post-myocardial infarction as well, but I was surprised by the magnitude of the variation even after adjustment for patient and hospital characteristics.”

Controlling for hospital characteristics and region, men were more likely than women to receive a prescription for high-intensity statins (risk ratio = 1.1; 95% CI, 1.07-1.13). Greater high-intensity statin use was also observed in patients who received a stent (RR = 1.35; 95% CI, 1.31-1.39), in hospitals with at least 500 beds (RR = 1.15; 95% CI, 1.07-1.23) and in hospitals with a medical school affiliation (RR = 1.11; 95% CI, 1.05-1.17).

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Additionally, patients who presented with prior coronary disease, diabetes and chronic kidney disease, age older than 75 years and for-profit hospital ownership were associated with lower use of high-intensity statins.

“Individual practitioners and hospitals/health care systems should review their own practices, identify any gaps in the MI care processes and work diligently to improve utilization of high-intensity statins in high risk patients such as those after myocardial infarction,” Bittner said. “I also think that patients and their families should ask about a prescription for a high-intensity statin after myocardial infarction, if they don’t receive one. And, once they have such a prescription, it is critical that they fill the prescription and work with their providers to optimize adherence to the medication.” – by Scott Buzby

For more information:

Vera Bittner, MD, MSPH, can be reached at vbittner@uab.edu.

Disclosures: Bittner reports she serves on the executive steering committee of the ODYSSEY OUTCOMES trial (Sanofi) with personal compensation and serves as the national coordinator for STRENGTH (AstraZeneca). Please see the full study for all other authors’ disclosures.

    Perspective
    Udho Thadani

    Udho Thadani

    This study identifies that regional differences existed regarding the use of high-intensity statins from 2011 to 2015. Use was higher in New England than the West South-Central region. Use was also lower in patients aged greater than 75 years, and in those with prior CAD and comorbidities.

    This would imply that physicians in the West South-Central region were not following the guidelines. Another explanation for these findings could be that physicians in the West South Central region were indeed practicing good medicine as they were taking into consideration the LDL values before using high-intensity statins, especially in the elderly. Many had questioned the safety of high-intensity statins in patients aged older than 75 years during the study period. If the LDL values were less than 100 mg/dL, it is possible that the treating physician may not have used high-intensity statins after MI.

    In 2019, a lot of new data have been published showing that the lower the LDL level, the better the clinical outcome, with little safety concerns. Therefore, one is not sure if these regional differences identified in the current publication by Dr. Bittner and colleagues in prescribing high-intensity statins are still relevant in 2019.

    More recent data are needed to confirm or refute these findings of regional disparities, of the use of high intensity use after MI.

    • Udho Thadani, MD, MRCP, FRCPC, FACC, FAHA, FCCS
    • Cardiology Today Editorial Board Member
      University of Oklahoma Health Sciences Center and VA Medical Center

    Disclosures: Thadani reports he is a local principal investigator for studies unrelated to statins for which his institution received funding from various pharmaceutical companies, the NIH and the VA and he reports consulting for Amgen, AstraZeneca, Bayer, Bristol-Myers Squibb, Merck and other pharmaceutical companies.

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