Trends in Provision of Medications and Lifestyle Counseling in Ambulatory Settings by Gender and Race for Patients With Atherosclerotic Cardiovascular Disease, 2006-2016

Abstract

Importance: Atherosclerotic cardiovascular disease (ASCVD) continues to be highly prevalent in the US. The 2013 American College of Cardiology and American Heart Association (ACC/AHA) treatment guidelines reevaluated evidence-based practices for reduction of ASCVD in men and women from high-quality randomized trials and meta-analyses recommending the use of statin therapy, aspirin prescription, and lifestyle counseling for adults with ASCVD. Population trends in secondary prevention strategies for patients with ASCVD among primary care settings is currently lacking, limiting ability to evaluate impact of guideline implementation.

Objective: To examine temporal and sociodemographic trends in secondary prevention strategies in patients with ASCVD between 2006 and 2016 in a nationally representative, ambulatory care database.

Design, setting, and participants: This cross-sectional study analyzed data from the National Ambulatory Medical Care Survey (NAMCS), which is an annual survey conducted to represent the national US population and contains information on ambulatory office-based patient visits, including medical conditions, services provided, and demographic characteristics. Participants were adults aged 21 years and older with prevalent ASCVD identified via International Classification of Disease codes between 2006 and 2016. Data were extracted and analyzed in March 2021.

Main outcomes and measures: Data were separated by calendar year pre-2013 (2006 to 2013) and post-2013 (2014 to 2016). Outcomes included statin therapy, aspirin prescription, and lifestyle counseling (eg, nutrition, exercise, weight reduction) service provided at clinic visits.

Results: There were 11 033 visits for adults with ASCVD, representing a weighted total of 275.3 million visits nationwide; 40.7% (112.1 million [weighted]) were women, 9.2% (25.4 million [weighted]) were Hispanic, 9.9% (19.0 million [weighted]) were non-Hispanic Black, 90.1% (172.7 million [weighted]) were non-Hispanic White, and 40.6% (112.1 million [weighted]) were from cardiology clinics. Of 11 033 patient visits, 5507 patients (49.9%) were prescribed statin therapy, 5165 patients (46.8%) were using aspirin, 2233 patients (20.2%) received lifestyle counseling. Statin therapy increased from 9.3 million individuals (45.3%) in 2006 to 14.9 million individuals (46.5%) in 2016, and aspirin prescriptions increased from 8.5 million individuals (41.3%) in 2006 to 15.2 individuals (47.5%) in 2016. Women were less likely than men to receive medications for secondary prevention: among women, 48.8 million (43.3%) received statins (vs 85.9 million men [52.7%]), 44.7 million (39.8%) received aspirin (vs 79.1 million men [48.5%]), and 25.7 million (22.9%) received lifestyle counseling services (vs 37.5 million men [23.0%]).

Conclusions and relevance: These findings suggest only modest increases in statin and aspirin prescription since 2006; however, lifestyle counseling use decreased in recent years. Women and Black patients continued to be less likely to receive secondary prevention ASCVD treatment. Adherence to guideline-directed secondary prevention recommendations remained low (less than 50%) in patients with ASCVD, especially with regards to lifestyle counseling, suggesting the need for more implementation research.

Figure.. Trends in Secondary Prevention Therapies Among Patients With Atherosclerotic Cardiovascular Disease in Ambulatory Settings, 2006 to 2016

Temporal trends from 2006 to 2016 of each secondary prevention intervention among adult patients with atherosclerotic cardiovascular disease in the National Ambulatory Medical Care Survey.