March 9th, 2010
Which Focus for Statin Therapy: Treat More Patients or Ensure Better Adherence?
JoAnne M. Foody, MD
Millions of people who take statins to reduce their cholesterol levels do not adhere to their prescribed regimens. That’s troubling in light of estimates from a recent analysis of data from more than 40,000 participants in the Melbourne Collaborative Cohort Study. It showed that if the percentage of patients with at least 80% adherence to their statin regimens increased from 50% to 75%, that improvement would prevent twice as many cardiovascular deaths as would lowering the threshold for statin treatment from a 20% or greater 10-year risk for heart disease to a 15.5% or greater 10-year risk.
Other research suggests that nonadherence to medications of all types costs the U.S. healthcare system about $100 billion per year in hospital admissions. Given numbers like these (in lives saved and dollars spent), has the time come to focus more on ensuring that high-risk patients actually adhere to statin therapy than on nibbling around the edges by extending statin therapy to lower- and lower-risk individuals? Or do you think that the battle against nonadherence is inevitably a losing one? Say what you think right here.
4 Responses to “Which Focus for Statin Therapy: Treat More Patients or Ensure Better Adherence?”
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A Patient Revolution
Poor adherence reflects structural factors (complexity and burden of treatment, costs) and volitional factors (treatment is inconsistent with patients’ knowledge or preferences) — but in the end, poor adherence reflects patient choice. As pointed out by Dr. Foody, evidence based medicine instructs clinicians to prescribe statins and ensure adherence to high risk patients — with the premise that if patients knew the evidence as well as clinicians did, then why would they choose not to take statins? Do we fully understand what are the contributing causes for poor adherence before implementing the solution? Clinicians need to do better at transferring knowledge to patients about individualized benefit to the patient with language and numbers that patients can understand — and then support the patient in a shared decision making model to allow patients to choose whether to take or not take the statin. In a patient-centered system, adherence can be reframed in domains of understanding knowledge of benefit, decisional conflict, and adherence to the decision to take or not take a statin.
Patient revolution (2)
I endorse Henry’s questions and statements. In addition:
Current paradigm: focus on LDL goals rather than on patient goals (live longer, feel better); focus on monitoring and dose adjustment or combination therapy rather than on staying on fixed doses of statins; risk-blind approach rather than a risk-sensitive approach (the same rate of prescriptions in high and low risk people).
Alternative paradigm (which I like): a threshold for initiating therapy based on estimated CHD risk determined by the patient in conjunction with their clinician, mindful of the patient’s context and comorbidities. A focus on reducing CHD risk rather than on reducing LDL levels. More prescriptions and more work to enhance adherence (multidimensional interventions) in higher risk people. A minimization of visits and tests (to adjust statins and check safety of high dose statins or combo therapy to achieve LDL levels) with less disruption to patient routines. A focus on prescribing affordable statins.
May I add one more?
The use of pictures – in particular a plaque imaging technology that allows the patient to see how their own arteries are doing (we use the carotids) – and in two RCTs has been shown to promote smoking adherence. If we can give the patients a visualization of plaque regression, they have a concrete rather than abstract reason to stay on their statin.
Does this really need to be an either/or issue? It’s a bit more than walking and chewing gum at the same time, I know, but why can’t we focus on improving adherence AND identifying other populations who can benefit from therapy?