Association of Patient Perceptions of Cardiovascular Risk and Beliefs on Statin Drugs With Racial Differences in Statin Use: Insights From the Patient and Provider Assessment of Lipid Management Registry

Abstract

Importance: African American individuals face higher atherosclerotic cardiovascular disease risk than white individuals; reasons for these differences, including potential differences in patient beliefs regarding preventive care, remain unknown.

Objective: To evaluate differences in statin use between white and African American patients and identify the potential causes for any observed differences.

Design, setting, and participants: Using the 2015 Patient and Provider Assessment of Lipid Management (PALM) Registry data, we compared statin use and dosing between African American and white outpatient adults who were potentially eligible for primary or secondary prevention statins. A total of 138 US community health care practices contributed to the data. Data analysis was conducted from March 2017 to May 2018.

Main outcomes and measures: Primary outcomes were use and dosing of statin therapy according to the 2013 American College of Cardiology/American Heart Association guideline by African American or white race. Secondary outcomes included lipid levels and patient-reported beliefs. Poisson regression was used to evaluate the association between race and statin undertreatment, a category combining people who were not taking a statin or those taking a dose intensity lower than recommended.

Results: A total of 5689 patients (806 [14.2%] African American) in the PALM registry were eligible for statin therapy. African American individuals were less likely than white individuals to be treated with a statin (570/807 [70.6%] vs 3654/4883 [74.8%]; P = .02). Among those treated, African American patients were less likely than white patients to receive a statin at guideline-recommended intensity (269 [33.3%] vs 2145 [43.9%], respectively; P < .001; relative risk, 1.07 [95% CI, 1.00-1.15]; P = .05, after adjustment for demographic and clinical factors). The median (interquartile range) low-density lipoprotein cholesterol levels of patients receiving treatment were higher among African American than white individuals (97.0 [76.0-121.0] mg/dL vs 85.0 [68.0-105.0] mg/dL; P < .001). African American individuals were less likely than white individuals to believe statins were safe (292 [36.2%] vs 2800 [57.3%]; P < .001) or effective (564 [70.0%] vs 3635 [74.4%]; P = .008) and were less likely to trust their clinician (663 [82.3%] vs 4579 [93.8%]; P < .001). Group differences in statin undertreatment were not significant after adjusting for demographic, clinical, and clinician factors, socioeconomic status, and patient beliefs (final adjusted relative risk, 1.03 [95% CI 0.96-1.11]; P = .35).

Conclusions and relevance: African American individuals were less likely to receive guideline-recommended statin therapy. Demographic, clinical, socioeconomic, belief-related, and clinician differences contributed to observed differences and represent potential targets for intervention.

Figure 1.. Statin Utilization in African American vs. Caucasian Patients

Statin treatment and guideline-recommended statin treatment in African Americans vs. Caucasians are presented here, categorized by overall, primary prevention, and secondary prevention sub-groups.

Figure 2.. LDL-C Levels Overall and On-treatment in African American vs. Caucasian Patients

LDL-C levels for all patients and only on-treatment patients are presented here for African Americans vs. Caucasians, categorized by overall, primary prevention and secondary prevention sub-groups. Abbreviations: LDL-C, low-density lipoprotein cholesterol

Figure 3.. A Sequential Modeling Approach for Racial Differences in Statin Undertreatment of African Americans

The relative risk of statin undertreatment of African American patients are presented here, both unadjusted and with sequential adjustment for relevant confounders. Statin undertreatment was defined as less than ACC/AHA guideline-recommended statin therapy. The following sequential models were created to evaluate how the relative risk of African American race for statin undertreatment:1) Model 1 adjusted for race alone; 2) Model 2 includes age and sex; 3) Model 3 adds clinical characteristics including prior ASCVD (grouped into coronary heart disease, cerebrovascular disease, and other ASCVD), diabetes, obesity, smoking, and hypertension; 4) Model 4 adds socioeconomic factors such as yearly income, insurance status, education level, and numeracy score; 5) Model 5 adds in patient beliefs and perceptions including worry about heart disease, clinician trust, beliefs about statin safety and effectiveness, and beliefs about high cholesterol and heart attack risk; 6) Model 6 adds provider factors including provider type (cardiologist vs. non-cardiologist), whether the patient’s provider reported using the 2013 ACC/AHA guideline as their primary resource for lipid management in the provider survey, and clinic setting (urban vs. rural). Abbreviations: ACC, American College of Cardiology; AHA, American Heart Association; CI, confidence interval; OR, odds ratio; SES, socioeconomic status