Prescription of suboptimal statin treatment regimens: a retrospective cohort study of trends and variation in English primary care

Curtis, Helen J; Walker, Alex J; MacKenna, Brian; Croker, Richard

doi:10.3399/bjgp20x710873

Cited by 15 publications

(9 citation statements)

References 20 publications

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“…Therefore, further research must urgently seek explanations for underprescribing of statins, particularly in African/African Caribbean people. If our findings are corroborated, a nationwide strategy for identifying prescribing inequities [25] and providing targeted education and prescribing interventions, followed by re-audit until equitability is achieved, is imperative and could lead to the prevention of substantial cardiovascular morbidity.…”

Section: Discussionmentioning

confidence: 69%

“…The pre-specified primary comparison of statin initiation in people of South Asian or African/African Caribbean versus European ethnicity was studied using multilevel Cox proportional hazards models with robust standard errors to account for within-practice clustering of prescribing patterns. Prescribing behaviour is similar for doctors working in the same practice [25] (i.e., clustering of prescribing patterns), resulting in individuals attending the same practice not being independent of each other with respect to statin initiation, which may in turn lead to underestimation of standard errors, i.e., excess type 1 errors. To counteract this, we fitted models using robust standard errors, with practice as the cluster variable.…”

Section: Discussionmentioning

confidence: 99%

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Ethnic differences in guideline-indicated statin initiation for people with type 2 diabetes in UK primary care, 2006–2019: A cohort study

et al. 2021

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Background Type 2 diabetes is 2–3 times more prevalent in people of South Asian and African/African Caribbean ethnicity than people of European ethnicity living in the UK. The former 2 groups also experience excess atherosclerotic cardiovascular disease (ASCVD) complications of diabetes. We aimed to study ethnic differences in statin initiation, a cornerstone of ASCVD primary prevention, for people with type 2 diabetes. Methods and findings Observational cohort study of UK primary care records, from 1 January 2006 to 30 June 2019. Data were studied from 27,511 (88%) people of European ethnicity, 2,386 (8%) people of South Asian ethnicity, and 1,142 (4%) people of African/African Caribbean ethnicity with incident type 2 diabetes, no previous ASCVD, and statin use indicated by guidelines. Statin initiation rates were contrasted by ethnicity, and the number of ASCVD events that could be prevented by equalising prescribing rates across ethnic groups was estimated. Median time to statin initiation was 79, 109, and 84 days for people of European, South Asian, and African/African Caribbean ethnicity, respectively. People of African/African Caribbean ethnicity were a third less likely to receive guideline-indicated statins than European people (n/N [%]: 605/1,142 [53%] and 18,803/27,511 [68%], respectively; age- and gender-adjusted HR 0.67 [95% CI 0.60 to 0.76], p < 0.001). The HR attenuated marginally in a model adjusting for total cholesterol/high-density lipoprotein cholesterol ratio (0.77 [95% CI 0.69 to 0.85], p < 0.001), with no further diminution when deprivation, ASCVD risk factors, comorbidity, polypharmacy, and healthcare usage were accounted for (fully adjusted HR 0.76 [95% CI 0.68, 0.85], p < 0.001). People of South Asian ethnicity were 10% less likely to receive a statin than European people (1,489/2,386 [62%] and 18,803/27,511 [68%], respectively; fully adjusted HR 0.91 [95% CI 0.85 to 0.98], p = 0.008, adjusting for all covariates). We estimated that up to 12,600 ASCVD events could be prevented over the lifetimes of people currently affected by type 2 diabetes in the UK by equalising statin prescribing across ethnic groups. Limitations included incompleteness of recording of routinely collected data. Conclusions In this study we observed that people of African/African Caribbean ethnicity with type 2 diabetes were substantially less likely, and people of South Asian ethnicity marginally less likely, to receive guideline-indicated statins than people of European ethnicity, even after accounting for sociodemographics, healthcare usage, ASCVD risk factors, and comorbidity. Underuse of statins in people of African/African Caribbean or South Asian ethnicity with type 2 diabetes is a missed opportunity to prevent cardiovascular events.

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Section: Discussionmentioning

confidence: 69%

Section: Discussionmentioning

confidence: 99%

Ethnic differences in guideline-indicated statin initiation for people with type 2 diabetes in UK primary care, 2006–2019: A cohort study

et al. 2021

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“…These findings are similar to those of other recent studies. In the UK, Curtis et al found that the proportion of practices prescribing high-intensity increased from 20% in 2011/2012 to 55% in 2019 18. This study evaluated prescribing data for all general practice patients, and not the very high-risk patients in our study, and only evaluated statin therapy.…”

Section: Discussionmentioning

confidence: 95%

“…In the UK, Curtis et al found that the proportion of practices prescribing high-intensity increased from 20% in 2011/2012 to 55% in 2019. 18 This study evaluated prescribing data for all general practice patients, and not the very high-risk patients in our study, and only evaluated statin therapy. In a large US health system, Sidebottom et al studied cohorts of patients age 40–75 in 2013 and 2017, including cohorts of patients with ASCVD.…”

Section: Discussionmentioning

confidence: 99%

Longitudinal evaluation of treatment patterns, risk factors and outcomes in patients with cardiovascular disease treated with lipid-lowering therapy in the UK

Danese¹,

Sidelnikov²,

Villa³

et al. 2022

BMJ Open

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ObjectivesTo compare treatment patterns, risk factors and cardiovascular disease (CVD) event rates in the UK from 2008 to 2017.DesignRetrospective cohort study using the Clinical Practice Research Datalink.SettingUK primary care.ParticipantsWe selected 10 annual cohorts of patients with documented CVD receiving lipid-lowering therapy and the subsets with myocardial infarction (MI). Each cohort included patients ≥18 years old, with ≥1 year of medical history and ≥2 lipid-lowering therapy prescriptions in the prior year.Primary and secondary outcome measuresFor each annual cohort, we identified cardiovascular risk factors and lipid-lowering therapy and estimated the 1-year composite rate of fatal and non-fatal MI, ischaemic stroke (IS) or revascularisation.ResultsThe documented CVD cohort mean age was 71.6 years in 2008 (N=173 424) and 72.5 (N=94 418) in 2017; in the MI subset, mean age was 70.1 years in 2008 (N=38 999) and 70.4 in 2017 (N=25 900). Both populations had larger proportions of men. In the documented CVD cohort, the proportion receiving high-intensity lipid-lowering therapy from 2008 to 2017 doubled from 16% to 32%; in the MI subset, the increase was 20% to 48%. In the documented CVD cohort, the proportion of patients with low-density lipoprotein cholesterol (LDL-C) <1.8 mmol/L increased from 28% to 38%; in the MI subset, the proportion with LDL-C <1.8 mmol/L increased from 32% to 42%. The composite event rate per 100 person-years declined over time, from 2.5 to 2.0 in the documented CVD cohort, and from 3.7 to 2.8 in the MI subset. After excluding revascularisation from the composite outcome, the decline in the event rate in both populations was substantially attenuated.ConclusionsDespite an increase in high-intensity therapy use and a decline in revascularisation, more than half of patients did not receive high-intensity lipid-lowering therapy by 2017 and incidence rates of MI and IS remained virtually unchanged.

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“…By adopting an open cohort design and accounting for statin type and intensity, the predicted statin response and event rates across time periods reflect real-world changes in practice over time. Both populations have experienced prescribing trends towards stronger statin intensity over time [ 7 , 28 ].…”

Section: Discussionmentioning

confidence: 99%

Determining propensity for sub-optimal low-density lipoprotein cholesterol response to statins and future risk of cardiovascular disease

et al. 2021

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Background Variability in low-density lipoprotein cholesterol (LDL-C) response to statins is underappreciated. We characterised patients by their statin response (SR), baseline risk of cardiovascular disease (CVD) and 10-year CVD outcomes. Methods and results A multivariable model was developed using 183,213 United Kingdom (UK) patients without CVD to predict probability of sub-optimal SR, defined by guidelines as <40% reduction in LDL-C. We externally validated the model in a Hong Kong (HK) cohort (n = 170,904). Patients were stratified into four groups by predicted SR and 10-year CVD risk score: [SR1] optimal SR & low risk; [SR2] sub-optimal SR & low risk; [SR3] optimal SR & high risk; [SR4] sub-optimal SR & high risk; and 10-year hazard ratios (HR) determined for first major adverse cardiovascular event (MACE). Our SR model included 12 characteristics, with an area under the curve of 0.70 (95% confidence interval [CI] 0.70–0.71; UK) and 0.68 (95% CI 0.67–0.68; HK). HRs for MACE in predicted sub-optimal SR with low CVD risk groups (SR2 to SR1) were 1.39 (95% CI 1.35–1.43, p<0.001; UK) and 1.14 (95% CI 1.11–1.17, p<0.001; HK). In both cohorts, patients with predicted sub-optimal SR with high CVD risk (SR4 to SR3) had elevated risk of MACE (UK HR 1.36, 95% CI 1.32–1.40, p<0.001: HK HR 1.25, 95% CI 1.21–1.28, p<0.001). Conclusions Patients with sub-optimal response to statins experienced significantly more MACE, regardless of baseline CVD risk. To enhance cholesterol management for primary prevention, statin response should be considered alongside risk assessment.

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Prescription of suboptimal statin treatment regimens: a retrospective cohort study of trends and variation in English primary care

Cited by 15 publications

References 20 publications

Ethnic differences in guideline-indicated statin initiation for people with type 2 diabetes in UK primary care, 2006–2019: A cohort study

Ethnic differences in guideline-indicated statin initiation for people with type 2 diabetes in UK primary care, 2006–2019: A cohort study

Longitudinal evaluation of treatment patterns, risk factors and outcomes in patients with cardiovascular disease treated with lipid-lowering therapy in the UK

Determining propensity for sub-optimal low-density lipoprotein cholesterol response to statins and future risk of cardiovascular disease

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