1. Journal of the American College of Cardiology
Trends in Use of High-Intensity Statin Therapy After Myocardial Infarction, 2011 to 2014
Robert S. Rosenson, MD, Michael E. Farkouh, MD, Matthew Mefford, MS, Vera Bittner, MD, Todd M. Brown, MD, MSPH, Ben Taylor, PHD, Keri L. Monda, PHD, Hong Zhao, MSPH, Yuling Dai, MSPH, Paul Muntner, PHD
Journal of the American College of Cardiology
Wan-Ting, Lin
2017/07/07

2. Introduction
Several randomized controlled trials have shown high-intensity statin therapy to be more efficacious than lower intensity therapy for preventing recurrent atherosclerotic cardiovascular disease (CVD) events among patients hospitalized for acute coronary syndrome (ACS).
Analyses of registries and insurance claims databases have documented that between 20% and 40% of patients with ACS fill prescriptions for high-intensity statins following hospital discharge.

3. Introduction
Several events have occurred over the past several years that may have changed the use of high-intensity statins among patients with ACS.
In 2011,
the American Heart Association (AHA)/American College of Cardiology Foundation secondary prevention guidelines recommended “adequate” doses of statin therapy necessary to achieve specific low-density lipoprotein cholesterol thresholds.
a black-box warning against new prescriptions for simvastatin 80 mg and the generic availability of atorvastatin.
In 2013, the American College of Cardiology (ACC)/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic CVD risk in adults was published and recommended the use of high-intensity statin therapy for patients with established CVD.

4. Aim
The aim of this study was to examine trends and predictors of high-intensity statin use following hospital discharge for myocardial infarction (MI) between and 2014.

5. Study population MarketScan and Medicare beneficiaries
hospitalized with overnight stays for MI between January 1, 2011, and November 30, 2014
Inclusion criteria
hospital stays for their index MIs were ≦30 days
alive 30 days following hospital discharge
had continuous MarketScan or Medicare fee-for-service insurance
living in the United States from 365 days prior to hospital admission for their MIs through 30 days following discharge.

6. Study population Exclusion criteria
Beneficiaries enrolled in Medicare Advantage plans (Medicare Part C)
stays at skilled nursing facilities or hospice facilities within 30 days following their index MIs
with outpatient statin fills during their MI hospitalizations
To avoid overlap between the 2 samples
MarketScan  <65 years of age
Medicare  66 to 75 years of age

7. Study population
We restricted these analyses to beneficiaries who filled statin prescriptions within 30 days following hospital discharge for MI.
The first MI each beneficiary experienced that met these criteria was included and is referred to as the index MI.

10. Statin use
Statin use was identified by pharmacy prescription fills in MarketScan claims and Medicare Part D pharmacy claims in combination with national drug codes.
Statins included atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, and simvastatin.

11. Statin use
High-intensity statins use prior to the index MI included atorvastatin 40 or 80 mg, rosuvastatin 20 or 40 mg.
Beneficiaries with any statin fills in the 365 days prior to their index MI were categorized as prevalent statin users.

12. Beneficiary characteristics
Age and sex were identified from the MarketScan Commercial Claims and Encounters database and the Medicare beneficiary summary file.
Information on race/ethnicity is available for Medicare beneficiaries through the beneficiary summary file, but information on race is not available for MarketScan beneficiaries.
Diabetes, CHD, stroke, heart failure, peripheral artery disease, chronic kidney disease, depression, Charlson comorbidity index, all-cause hospitalizations, cardiologist care, use of non- statin lipid-lowering therapy, and the total number of different medication prescriptions filled were identified using claims in the 365 days prior to hospital admission for MI and previously published algorithms.

13. Statistical analysis
We calculated the percentage of MarketScan beneficiaries whose first prescription fills following their index MIs were for high-intensity statins.
Characteristics of MarketScan beneficiaries filling and not filling high-intensity statin prescriptions following hospital discharge for MI in 2014 were calculated among statin initiators and among prevalent low- and moderate-intensity and among high-intensity statin users separately.

14. Statistical analysis
We used Poisson regression with sandwich estimators to calculate the relative risks for a high-intensity statin as the first statin prescription fill within 30 days after discharge.
Relative risks were calculated in
unadjusted model
demographic variables
other covariates
We calculated the percentage of beneficiaries who switched from low- or moderate-intensity to high-intensity statins within 182 days following discharge.

15. Trends in stain prescription fills

16. Trends in stain prescription fills

20. Titrate to a high-intensity statin within 182 days of hospital discharge
2011
2012
2013
2014

21. Discussion
Strengths
2 large cohorts, 1 of younger patients with commercial health insurance and 1 of older patients with government insurance
Most U.S. adults >65 years of age have health insurance through Medicare, providing a high degree of generalizability.
The large sample size provided stable estimates.

22. Discussion Limitations
relied on pharmacy claims to identify statin use
Patient behavioral and social support characteristics and characteristics of the prescribing physician are not available in MarketScan and Medicare claims.
Data were available only through 2014
The present study relied on claims data, and we were unable to ascertain whether prescription fills for low- or moderate-intensity statins were appropriate on the basis of drug interactions, intolerance to high- intensity statins, or sufficient control of low-density lipoprotein cholesterol.
Data were available only for statin prescription fills and not prescriptions written.
Race/ethnicity data are not available in MarketScan.

23. Conclusion
The percentage of U.S. adults filling high-intensity statin prescriptions following hospital discharge for MI increased substantially between 2011 and 2014.
The present study highlights the need to continue efforts to increase high-intensity statin use following hospital discharge for MI.