Is the high-risk strategy to prevent cardiovascular disease equitable? A pharmacoepidemiological cohort study

BMC Public Health

Morten Andersen⁴  Theis Lange²  Allan Krasnik⁵  Finn Diderichsen¹  Helle Wallach-Kildemoes³ 

[1] Social Medicine, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, 1014, Denmark;Biostatistics, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, 1014, Denmark;Centre for Healthy Aging, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, 1014, Denmark;Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, B. Winsløws Vej 9A, Odense, 5000, Denmark;Health Services Research, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, 1014, Denmark

关键词: Horizontal equity;    Socioeconomic gradient;    The high-risk strategy;    Statins to prevent cardiovascular disease;   

Others  :  1163365
DOI  :  10.1186/1471-2458-12-610

 received in 2012-04-23, accepted in 2012-07-20,  发布年份 2012

【 摘 要 】

Background

Statins are increasingly prescribed to prevent cardiovascular disease (CVD) in asymptomatic individuals. Yet, it is unknown whether those at higher CVD risk – i.e. individuals in lower socio-economic position (SEP) – are adequately reached by this high-risk strategy. We aimed to examine whether the Danish implementation of the strategy to prevent cardiovascular disease (CVD) by initiating statin (HMG-CoA reductase inhibitor) therapy in high-risk individuals is equitable across socioeconomic groups.

Methods

Design: Cohort study.

Setting and participants: Applying individual-level nationwide register information on socio-demographics, dispensed prescription drugs and hospital discharges, all Danish citizens aged 20+ without previous register-markers of CVD, diabetes or statin therapy were followed during 2002–2006 for first occurrence of myocardial infarction (MI) and a dispensed statin prescription (N = 3.3 mill).

Main outcome measures: Stratified by gender, 5-year age-groups and socioeconomic position (SEP), incidence of MI was applied as a proxy for statin need. Need-standardized statin incidence rates were calculated, applying MI incidence rate ratios (IRR) as need-weights to adjust for unequal needs across SEP.Horizontal equity in initiating statin therapy was tested by means of Poisson regression analysis. Applying the need-standardized statin parameters and the lowest SEP-group as reference, a need-standardized statin IRR > 1 translates into horizontal inequity favouring the higher SEP-groups.

Results

MI incidence decreased with increasing SEP without a parallel trend in incidence of statin therapy. According to the regression analyses, the need-standardized statin incidence increased in men aged 40–64 by 17%, IRR 1.17 (95% CI: 1.14-1.19) with each increase in income quintile. In women the proportion was 23%, IRR 1.23 (1.16-1.29). An analogous pattern was seen applying education as SEP indicator and among subjects aged 65–84.

Conclusion

The high-risk strategy to prevent CVD by initiating statin therapy seems to be inequitable, reaching primarily high-risk subjects in lower risk SEP-groups.

【 授权许可】

   
2012 Wallach Kildemoes et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1 .

【 参考文献 】

• [1]Lynch J, Davey SG, Harper S, Bainbridge K: Explaining the social gradient in coronary heart disease: comparing relative and absolute risk approaches. J Epidemiol Community Health 2006, 60(5):436-441.
• [2]Marmot MG, Smith GD, Stansfeld S, Patel C, North F, Head J, White I, Brunner E, Feeney A: Health inequalities among British civil servants: the Whitehall II study. Lancet 1991, 337(8754):1387-1393.
• [3]Mackenbach JP, Cavelaars AE, Kunst AE, Groenhof F: Socioeconomic inequalities in cardiovascular disease mortality; an international study. Eur Heart J 2000, 21(14):1141-1151.
• [4]Mackenbach JP, Bos V, Andersen O, Cardano M, Costa G, Harding S, Reid A, Hemstrom O, Valkonen T, Kunst AE: Widening socioeconomic inequalities in mortality in six Western European countries. Int J Epidemiol 2003, 32(5):830-837.
• [5]Palosuo H, Koskinen S, Lahelma E, Kostiainen E, Prättälä R, Martelin T, Ostamo A, Keskimaki I, Sihto M, Linnanmäki E (Eds): Trends in socioeconomic health differences between 1980–2005. , Finland; 2009. http://www.stm.fi/c/document_library/get_file?folderId=39503&name=DLFE-8648.pdf webcite
• [6]Lynch JW, Kaplan GA, Cohen RD, Tuomilehto J, Salonen JT: Do cardiovascular risk factors explain the relation between socioeconomic status, risk of all-cause mortality, cardiovascular mortality, and acute myocardial infarction? Am J Epidemiol 1996, 144(10):934-942.
• [7]Smith GD, Shipley MJ, Rose G: Magnitude and causes of socioeconomic differentials in mortality: further evidence from the Whitehall Study. J Epidemiol Community Health 1990, 44(4):265-270.
• [8]Singh-Manoux A, Nabi H, Shipley M, Gueguen A, Sabia S, Dugravot A, Marmot M, Kivimaki M: The role of conventional risk factors in explaining social inequalities in coronary heart disease: the relative and absolute approaches to risk. Epidemiology 2008, 19(4):599-605.
• [9]Manrique-Garcia E, Sidorchuk A, Hallqvist J, Moradi T: Socioeconomic position and incidence of acute myocardial infarction: a meta-analysis. J Epidemiol Community Health 2011, 65(4):301-309.
• [10]Scandinavian Simvastatin Survival Study group: Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994, 344(8934):1383-1389.
• [11]Ong HT: The statin studies: from targeting hypercholesterolaemia to targeting the high-risk patient. QJM 2005, 98(8):599-614.
• [12]Conroy RM, Pyorala K, Fitzgerald AP, Sans S, Menotti A, De Backer G, De Bacquer D, Ducimetiere P, Jousilahti P, Keil U, Njolstad I, Oganov RG, Thomsen T, Tunstall-Pedoe H, Tverdal A, Wedel H, Whincup P, Wilhelmsen L, Graham IM: Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 2003, 24(11):987-1003.
• [13]Manuel DG, Kwong K, Tanuseputro P, Lim J, Mustard CA, Anderson GM, Ardal S, Alter DA, Laupacis A: Effectiveness and efficiency of different guidelines on statin treatment for preventing deaths from coronary heart disease: modelling study. BMJ 2006, 332(7555):1419.
• [14]McElduff P, Jaefarnezhad M, Durrington PN: American, British and European recommendations for statins in the primary prevention of cardiovascular disease applied to British men studied prospectively. Heart 2006, 92(9):1213-1218.
• [15]Strandberg-Larsen M, Nielsen M, Vallgårda S, Krasnik A, Vrangbæk K: Health system review. Edited by Mossialos E. Health Systems in Transition: World Health Organisation, Denmark; 2007. 9(6)
• [16]Donaldson C, Gerard K: Economics of health care financing: The visible hand. 1st edition. Macmillan Press Ltd., London; 1993.
• [17]Pedersen KM: Pricing and reimbursement of drugs in Denmark. Eur J Health Econom 2003, 4:460-465.
• [18]van DE, Wagstaff A, der BH v, Christiansen T, De GD, Duchesne I, Gerdtham UG, Gerfin M, Geurts J, Gross L, Hakkinen U, John J, Klavus J, Leu RE, Nolan B, O’Donnell O, Propper C, Puffer F, Schellhorn M, Sundberg G, Winkelhake O: Equity in the delivery of health care in Europe and the US. J Health Econ 2000, 19(5):553-583.
• [19]van Doorslaer E, Koolman X, Jones AM: Explaining income-related inequalities in doctor utilisation in Europe. Health Econ 2004, 13(7):629-647.
• [20]Wagstaff A, van Doorslaer E: Measuring and testing for inequity in the delivery of health care. J Hum Resour 2000, 35(4):716-733.
• [21]Rasmussen JN, Rasmussen S, Gislason GH, Abildstrom SZ, Schramm TK, Torp-Pedersen C, Kober L, Diderichsen F, Osler M, Madsen M: Persistent socio-economic differences in revascularization after acute myocardial infarction despite a universal health care system-a Danish study. Cardiovasc Drugs Ther 2007, 21(6):449-457.
• [22]Gundgaard J: Income related inequality in prescription drugs in Denmark. Pharmacoepidemiol Drug Saf 2005, 14(5):307-317.
• [23]Rasmussen JN, Gislason GH, Rasmussen S, Abildstrom SZ, Schramm TK, Kober L, Diderichsen F, Osler M, Torp-Pedersen C, Madsen M: Use of statins and beta-blockers after acute myocardial infarction according to income and education. J Epidemiol Community Health 2007, 61(12):1091-1097.
• [24]Gundgaard J: Income-related inequality in utilization of health services in Denmark: Evidence from Funen County. Scand J Public Health 2006, 34(5):462-471.
• [25]Pammolli F, Riccaboni M, Magazzini L: The sustainability of European health care systems: beyond income and aging. Eur J Health Econ 2011. E-pub ahead of print
• [26]Chappell NL, Hollander MJ: An evidence-based policy prescription for an aging population. Healthc Pap 2011, 11(1):8-18.
• [27]Getz L, Sigurdsson JA, Hetlevik I, Kirkengen AL, Romundstad S, Holmen J: Estimating the high risk group for cardiovascular disease in the Norwegian HUNT 2 population according to the 2003 European guidelines: modelling study. BMJ 2005, 331(7516):551.
• [28]Ward S, Lloyd JM, Pandor A, Holmes M, Ara R, Ryan A, Yeo W, Payne N: A systematic review and economic evaluation of statins for the prevention of coronary events. Health Technol Assess 2007, 11(14):1-160.
• [29]Sigurdsson EL, Thorgeirsson G: Primary prevention of cardiovascular diseases. Scand J Prim Health Care 2003, 21(2):68-74.
• [30]Rose G: The strategy of preventive medicine. Oxford University Press, Oxford, New York, Tokyo; 1992.
• [31]Emberson J, Whincup P, Morris R, Walker M, Ebrahim S: Evaluating the impact of population and high-risk strategies for the primary prevention of cardiovascular disease. Eur Heart J 2004, 25(6):484-491.
• [32]Manuel DG, Lim J, Tanuseputro P, Anderson GM, Alter DA, Laupacis A, Mustard CA: Revisiting Rose: strategies for reducing coronary heart disease. BMJ 2006, 332(7542):659-662.
• [33]Marmot M, Friel S, Bell R, Houweling TA, Taylor S: Closing the gap in a generation: health equity through action on the social determinants of health. Lancet 2008, 372(9650):1661-1669.
• [34]Atkinson T: Social inclusion and the European Union. Journal of Common Market Studies 2002, 40(4):625-643.
• [35]Capewell S, Graham H: Will cardiovascular disease prevention widen health inequalities? PLoS Med 2010, 7(8):e1000320.
• [36]Tunstall-Pedoe H, Woodward M: By neglecting deprivation, cardiovascular risk scoring will exacerbate social gradients in disease. Heart 2006, 92(3):307-310.
• [37]Usher C, Bennett K, Feely J: Regional variation in the prescribing for diabetes and use of secondary preventative therapies in Ireland. Pharmacoepidemiol Drug Saf 2005, 14(8):537-544.
• [38]Ward PR, Noyce PR, St Leger AS: How equitable are GP practice prescribing rates for statins?: an ecological study in four primary care trusts in North West England. Int J Equity Health 2007, 6:2. BioMed Central Full Text
• [39]Ohlsson H, Lynch K, Merlo J: Is the physician’s adherence to prescription guidelines associated with the patient’s socio-economic position? An analysis of statin prescription in South Sweden. J Epidemiol Community Health 2010, 64(8):678-683.
• [40]Selmer R, Sakshaug S, Skurtveit S, Furu K, Tverdal A: Statin treatment in a cohort of 20 212 men and women in Norway according to cardiovascular risk factors and level of education. Br J Clin Pharmacol 2009, 67(3):355-362.
• [41]Reid FD, Cook DG, Whincup PH: Use of statins in the secondary prevention of coronary heart disease: is treatment equitable? Heart 2002, 88(1):15-19.
• [42]Shin H, Kim J: Differences in income-related inequality and horizontal inequity in ambulatory care use between rural and non-rural areas: using the 1998–2001 U.S. National Health Interview Survey data. Int J Equity Health 2010, 9:17. BioMed Central Full Text
• [43]Kildemoes HW, Sorensen HT, Hallas J: The Danish National Prescription Registry. Scand J Public Health 2011, 39(Supple 7):38-41.
• [44]WHO Collaborating centre for Drug Statistics Methodology: Guidelines for ATC classification and DDD assignment, 2010. Norwegian Institute of Public Health, Oslo; 2010.
• [45]Wallach Kildemoes H, Hendriksen C, Andersen M: Drug utilization according to reason for prescribing: a pharmacoepidemiologic method based on an indication hierarchy. Pharmacoepidemiol Drug Saf 2011.
• [46]Mackenbach JP, Kunst AE: Measuring the magnitude of socio-economic inequalities in health: an overview of available measures illustrated with two examples from Europe. Soc Sci Med 1997, 44(6):757-771.
• [47]Madsen M, Davidsen M, Rasmussen S, Abildstrom SZ, Osler M: The validity of the diagnosis of acute myocardial infarction in routine statistics: a comparison of mortality and hospital discharge data with the Danish MONICA registry. J Clin Epidemiol 2003, 56(2):124-130.
• [48]Efron B: Nonparametric Estimates of Standard Error - the Jackknife, the Bootstrap and Other Methods. Biometrika 1981, 68(3):589-599.
• [49]Woodward M, Brindle P, Tunstall-Pedoe H: Adding social deprivation and family history to cardiovascular risk assessment: the ASSIGN score from the Scottish Heart Health Extended Cohort (SHHEC). Heart 2007, 93(2):172-176.
• [50]Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, Minhas R, Sheikh A, Brindle P: Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2. BMJ 2008, 336(7659):1475-1482.
• [51]Thomsen TF, McGee D, Davidsen M, Jorgensen T: A cross-validation of risk-scores for coronary heart disease mortality based on data from the Glostrup Population Studies and Framingham Heart Study. Int J Epidemiol 2002, 31(4):817-822.
• [52]Brugts JJ, Deckers JW: Statin prescription in men and women at cardiovascular risk: to whom and when? Curr Opin Cardiol 2010, 25(4):484-489.
• [53]Henderson R, Keiding N: Individual survival time prediction using statistical models. J Med Ethics 2005, 31(12):703-706.
• [54]Law MR, Wald NJ, Morris JK: The performance of blood pressure and other cardiovascular risk factors as screening tests for ischaemic heart disease and stroke. J Med Screen 2004, 11(1):3-7.
• [55]Rose G: Sick individuals and sick populations. Int J Epidemiol 1985, 14(1):32-38.
• [56]Diederichsen AC, Sand NP, Norgaard B, Lambrechtsen J, Jensen JM, Munkholm H, Aziz A, Gerke O, Egstrup K, Larsen ML, Petersen H, Hoilund-Carlsen PF, Mickley H: Discrepancy between coronary artery calcium score and HeartScore in middle-aged Danes: the DanRisk study. Eur J Prev Cardiol 2012, 19(3):558-564.
• [57]Smith GD, Hart C, Watt G, Hole D, Hawthorne V: Individual social class, area-based deprivation, cardiovascular disease risk factors, and mortality: the Renfrew and Paisley Study. J Epidemiol Community Health 1998, 52(6):399-405.
• [58]Suadicani P, Hein HO, von Eyben FE, Gyntelberg F: Metabolic and lifestyle predictors of ischemic heart disease and all-cause mortality among normal weight, overweight, and obese men: a 16-year follow-up in the Copenhagen Male Study. Metab Syndr Relat Disord 2009, 7(2):97-104.
• [59]Dominguez H, Schramm TK, Norgaard ML, Abildstrom SZ, Kober L, Jorgensen C, Guterbaum TJ, Poulsen HE, Torp-Pedersen C, Gislason GH: Initiation and persistence to statin treatment in patients with diabetes receiving glucose-lowering medications. Open Cardiovasc Med J 2009, 3:152-159.
• [60]Forde I, Chandola T, Raine R, Marmot MG, Kivimaki M: Socioeconomic and ethnic differences in use of lipid-lowering drugs after deregulation of simvastatin in the UK: the Whitehall II prospective cohort study. Atherosclerosis 2011, 215(1):223-228.
• [61]Stocks NP, Ryan P, McElroy H, Allan J: Statin prescribing in Australia: socioeconomic and sex differences. A cross-sectional study. Med J Aust 2004, 180(5):229-231.
• [62]Brookhart MA, Patrick AR, Dormuth C, Avorn J, Shrank W, Cadarette SM, Solomon DH: Adherence to lipid-lowering therapy and the use of preventive health services: an investigation of the healthy user effect. Am J Epidemiol 2007, 166(3):348-354.
• [63]McCaffery K, Wardle J, Nadel M, Atkin W: Socioeconomic variation in participation in colorectal cancer screening. J Med Screen 2002, 9(3):104-108.
• [64]von Wagner C, Good A, Whitaker KL, Wardle J: Psychosocial Determinants of Socioeconomic Inequalities in Cancer Screening Participation: A Conceptual Framework. Epidemiol Rev 2011, 33(1):135-147.
• [65]Capewell S: Will screening individuals at high risk of cardiovascular events deliver large benefits? No. BMJ 2008, 337:a1395.
• [66]Perreault S, Blais L, Dragomir A, Bouchard MH, Lalonde L, Laurier C, Collin J: Persistence and determinants of statin therapy among middle-aged patients free of cardiovascular disease. Eur J Clin Pharmacol 2005, 61(9):667-674.
• [67]Golomb BA, Evans MA: Statin adverse effects : a review of the literature and evidence for a mitochondrial mechanism. Am J Cardiovasc Drugs 2008, 8(6):373-418.
• [68]Bates TR, Connaughton VM, Watts GF: Non-adherence to statin therapy: a major challenge for preventive cardiology. Expert Opin Pharmacother 2009, 10(18):2973-2985.
• [69]Huser MA, Evans TS, Berger V: Medication adherence trends with statins. Adv Ther 2005, 22(2):163-171.
• [70]Lindman AS, Veierod MB, Pedersen JI, Tverdal A, Njolstad I, Selmer R: The ability of the SCORE high-risk model to predict 10-year cardiovascular disease mortality in Norway. Eur J Cardiovasc Prev Rehabil 2007, 14(4):501-507.
• [71]Hingorani AD, Hemingway H: How should we balance individual and population benefits of statins for preventing cardiovascular disease? BMJ 2011, 342:c6244.
• [72]Marshall T: Targeted case finding for cardiovascular prevention. BMJ 2010, 340:c1376.
• [73]Wald DS, Wald NJ: The polypill in the primary prevention of cardiovascular disease. Fundam Clin Pharmacol 2010, 24(1):29-35.
• [74]Malekzadeh F, Marshall T, Pourshams A, Gharravi M, Aslani A, Nateghi A, Rastegarpanah M, Khoshnia M, Semnani S, Salahi R, Thomas GN, Larijani B, Cheng KK, Malekzadeh R: A pilot double-blind randomised placebo-controlled trial of the effects of fixed-dose combination therapy (‘polypill’) on cardiovascular risk factors. Int J Clin Pract 2010, 64(9):1220-1227.
• [75]Vos T, Carter R, Barendregt J, Mihalopoulos C, Veerman J, Magnus A, Cobiac L, Bertram M, Wallace A: Assessing cost-effectiveness in prevention (ACE-Prevntion): Final report. University of Queensland, Brisbane and Deakin University, Melbourne; 2010. http://www.sph.uq.edu.au/bodce-ace-prevention webcite
• [76]Diderichsen F, Andersen I, Manual C: Health inequalities - determinants and policies. University of Copenhagen & Danish Ministry of Health, Copenhagen; 2011. http://www.sst.dk/~/media/English/Health%20promotion%20and%20disease%20prevention/International/Health%20Inequality%20-%20determinants%20and%20policies.ashx\ webcite