title: Patterns of Statin Use in a Real-World Population of Patients at High Cardiovascular Risk.
abstract: BACKGROUND
  Widespread use of statins has improved hypercholesterolemia management, yet a significant proportion of patients remain at risk for cardiovascular (CV) events. Analyses of treatment patterns reveal inadequate intensity and duration of statin therapy among patients with hypercholesterolemia, and little is known about real-world statin use, specifically in subgroups of patients at high risk for CV events.
  
  
  OBJECTIVE
  To examine patterns of statin use and outcomes among patients with high-risk features who newly initiated statin monotherapy.
  
  
  METHODS
  Adult patients (aged > 18 years) at high CV risk who received > 1 prescription for statin monotherapy and who had not received lipid-modifying therapy during the previous 12 months were identified from the Truven MarketScan Commercial and Medicare Supplemental databases (from January 2007 to June 2013). Patients with atherosclerotic cardiovascular disease (ASCVD) or diabetes were hierarchically classified into 5 mutually exclusive CV risk categories (listed here in order from highest to lowest risk): (1) recent CV event (subcategorized by hospitalization for acute coronary syndrome [ACS] or other non-ACS CV event within 90 days of index); (2) coronary heart disease (CHD); (3) history of ischemic stroke; (4) peripheral artery disease (PAD); and (5) diabetes. Outcomes of interest included changes in therapy, proportion of days covered (PDC), time to discontinuation, and proportion of patients with ASCVD-related inpatient visit during the follow-up period. Statin therapy was subdivided into high-intensity treatment (atorvastatin 40 mg or 80 mg, rosuvastatin 20 mg or 40 mg, or simvastatin 80 mg) or moderate- to low-intensity treatment (all other statins and statin dosing regimens). Follow-up data were obtained from the index date (statin initiation) until the end of continuous enrollment.
  
  
  RESULTS
  A total of 541,221 patients were included in the analysis. The majority of patients were stratified in the diabetes cohort (61.1%), followed in frequency by recent ACS event (15.8%), recent non-ACS CV event (9.9%), PAD (4.7%), CHD (4.4%), and history of ischemic stroke (4.1%). Only 15.0% of the population initiated therapy with a high-intensity statin, and 22.5% of these high-intensity statin initiators switched to a moderate- to low-intensity regimen during the follow-up period. Median time to statin discontinuation was approximately 15 months. Duration of treatment was longer among those who were treated with a high-intensity versus a moderate- to low-intensity statin regimen (21 and 15 months, respectively). The PDC was highest in the recent ACS hospitalization cohort (66.4%) and lowest in the diabetes cohort (55.5%). The PDC was significantly greater among patients who initiated treatment with a high-intensity statin regimen than with a moderate- to low-intensity statin regimen (62.1% vs. 57.5%, respectively; P< 0.001). At 1 year, Kaplan-Meier estimates of the cumulative rates for ASCVD-related hospitalizations ranged from 3.5% (diabetes) to 21.8% (recent ACS hospitalization).
  
  
  CONCLUSIONS
  Patients at high risk for CV events are suboptimally dosed with statins, have high rates of discontinuation, and have low rates of adherence. Despite the use of statin therapy, ASCVD-related inpatient visit rates were high, particularly among those patients at highest risk because of a recent ACS hospitalization. Future interventions are required to ensure that high-risk patients are effectively managed to reduce subsequent morbidity and mortality.
  
  
  BACKGROUND
  Support for this research was provided by Regeneron Pharmaceuticals, Tarrytown, New York, and Sanofi US, Bridgewater, New Jersey. Menzin and Lin are employees of Boston Health Economics, which received consulting fees from Sanofi. Friedman is a consultant to Boston Health Economics. Lin, Friedman, and Menzin have received research support from Sanofi US. Sung, Mallya, Panaccio, and Koren are employees of Sanofi US and also have ownership interest in Sanofi US. Sanchez is an employee of and has ownership interest in Regeneron Pharmaceuticals. Neumann has served on advisory boards for Merck & Co, Takeda Pharmaceutical Company, Genentech, Novartis, Bayer AG, UCB, Sanofi US, Robert Wood Johnson Foundation, and Cubist and serves as consultant for Boston Health Economics, Forrest, P urdue, and Smith and Nephew. This research has been presented in part at the International Society for Pharmacoeconomics and Outcomes Research, 20th Annual International Meeting, May 16-20, 2015, Philadelphia, Pennsylvania. All authors contributed to the study design, protocol development, and results interpretation. Lin and Menzin were responsible for conducting the study analyses. All authors were involved in manuscript development and approved the submitted version.
authors.affiliation: 1 Boston Health Economics, Waltham, Massachusetts.
authors.forename: Iris
authors.initials: I
authors.lastname: Lin
authors.affiliation: 2 Sanofi US, Bridgewater, New Jersey.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Sung
authors.affiliation: 3 Regeneron Pharmaceuticals, Tarrytown, New York.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Sanchez
authors.affiliation: 2 Sanofi US, Bridgewater, New Jersey.
authors.forename: Usha G
authors.initials: UG
authors.lastname: Mallya
authors.affiliation: 1 Boston Health Economics, Waltham, Massachusetts.
authors.forename: Mark
authors.initials: M
authors.lastname: Friedman
authors.affiliation: 2 Sanofi US, Bridgewater, New Jersey.
authors.forename: Mary
authors.initials: M
authors.lastname: Panaccio
authors.affiliation: 2 Sanofi US, Bridgewater, New Jersey.
authors.forename: Andrew
authors.initials: A
authors.lastname: Koren
authors.affiliation: 4 Tufts Medical Center, Boston, Massachusetts.
authors.forename: Peter
authors.initials: P
authors.lastname: Neumann
authors.affiliation: 1 Boston Health Economics, Waltham, Massachusetts.
authors.forename: Joseph
authors.initials: J
authors.lastname: Menzin
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002318:Cardiovascular Diseases / Q000453:epidemiology* / Q000517:prevention & control*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D007345:Insurance Claim Review; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D011159:Population Surveillance / Q000379:methods; D012189:Retrospective Studies; D012307:Risk Factors; D055815:Young Adult
chemical_list: D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors