Among African Americans in Need of LDL Lowering: Less Statin Use, More Distrust of Doctors
Demographics and socioeconomic differences explain some, but not all, of the differences in statin use.
Not only are African American individuals who are eligible for statin therapy less likely to receive the LDL-lowering therapy than their white counterparts, but they are less likely to receive a statin at the guideline-recommended intensity when they are treated, according to a new analysis.
The reason for the discrepancy in management, say investigators, stems not only from demographic and socioeconomic differences between the two groups, but also from different beliefs and perceptions about statin therapy.
“While the differences in statin treatment were partially explained by demographic and clinical factors, other factors likely contributed,” lead investigator Michael Nanna, MD (Duke University Medical Center, Durham, NC), told TCTMD. “For example, African American patients were less likely than white patients to believe statins were safe or effective, and they were also less likely to trust their physician.”
The new study, an analysis of 5,689 patients in the Patient and Provider Assessment of Lipid Management (PALM) registry, was published online June 13, 2018, ahead of print in JAMA Cardiology.
Just 33% Receive Appropriate Statin Intensity
Previous studies have shown African American individuals are at a higher risk for cardiovascular disease than white patients and that they are less likely to receive statin therapy than white individuals. Despite this, the reasons underlying the racial differences in statin treatment have been poorly understood, said Nanna.
The PALM registry data revealed significant baseline differences between the 806 African American and 4,883 white individuals included in the analysis. African American participants were younger and more likely to be female and to have diabetes. They also had a higher median systolic blood pressure and body mass index. Although African American participants were less likely to have had prior atherosclerotic cardiovascular disease (ASCVD), they had a higher 10-year predicted risk of ASCVD compared with their white peers.
In addition, African Americans were more likely to report seeing an endocrinologist and less likely to see a cardiologist.
Overall, 70.6% of eligible African American individuals were prescribed a statin compared with 74.8% of whites (P = 0.02). When investigators analyzed treatment based on the 2013 American College of Cardiology/American Heart Association cholesterol guidelines that recommend moderate- or high-intensity statin therapy depending on patient risk, just 33.3% of African Americans received the appropriate statin intensity compared with 43.9% of whites.
The differences in treatment were reflected in LDL cholesterol levels, which were significantly higher in African Americans on statin therapy compared with white individuals (97.0 vs 85.0 mg/dL; P < 0.001).
In terms of patient perceptions, just 36.2% of African Americans felt statins were safe compared with 57.3% whites (P < 0.001). A much larger percentage felt the LDL-lowering agents were effective, but African Americans still had less confidence in the drugs than whites. Overall, 82.3% of African Americans trusted their physician compared with 93.8% of white individuals (P < 0.001).
Making Changes, Building Trust
Taking the 1,000-foot view to improve treatment, Nanna said a multidimensional approach is needed.
“We need to set up health systems where all patients can get treatment,” he said. “For example, there could be alerts in the electronic health record to identify patients who would benefit from treatment. Ultimately, though, we need to build trust with our patients and we need to be consistent in our application of guideline recommendations. We also need to educate patients and physicians on the appropriate therapies for risk reduction.”
Nanna noted that all treatments come with side effects, and said it’s important to educate patients on the risks and benefits of statin therapy. “We saw there were quite a few patients who had concerns about liver damage and memory loss with statins,” he said. “But if you take the time with a patient and really go through the benefit of statins, in most of the patients we evaluated they’d see the benefits outweigh the risks.”
In an editor’s note, Clyde Yancy, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), states that when differential care along racial/ethnic lines is identified, it is a “disquieting phenomenon that requires our attention and provokes changes in behavior.” The present study, with its ability to address patient perceptions and beliefs, “gets us closer to the truth and to actionable directions,” says Yancy. Consistent decision-making, managing trust, and patient education—regardless of the patient cohort—should be the clinical priority.
In terms of overall treatment patterns, Nanna said there’s room for improvement everywhere. Even among white individuals, 25% of those eligible for treatment weren’t on a statin and just 44% were treated at the appropriate intensity. “If we can raise the quality of care for everyone, then everybody is better off and hopefully the treatment gaps will improve,” he said.
Nanna MG, Navar AM, Zakroysky P, et al. 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. JAMA Cardiol. 2018;Epub ahead of print.
Yancy CW. Addressing cardiovascular disease disparities—are we getting closer to the truth? JAMA Cardiol. 2018;Epub ahead of print.
- The PALM registry has received funding from Sanofi, Regeneron, and the National Heart, Lung, and Blood Institute.
- Nanna and Yancy report no relevant conflicts of interest.