Using Healthcare Claims Data to Identify Health Disparities for Individuals with Diagnosed and Undiagnosed Familial Hypercholesterolemia

BackgroundIndividuals with familial hypercholesterolemia (FH) require intensive lipid-lowering therapy, starting with high-intensity statins and adding ezetimibe and PCSK9 inhibitors (PCSK9i) as needed to reach target LDL-C levels. There are limited data on disparities in the use of these therapies among individuals with FH in the US. MethodsWe queried a large US healthcare claims repository consisting of 324 million individuals, focusing on prescriptions for high-intensity statins, ezetimibe, and PCSK9i in two patient groups: those diagnosed with FH (ICD-10 E.78.01) and those not diagnosed with FH but identified as having probable FH (PFH) via the FIND-FH(R) machine learning algorithm. We used multivariable regression models to examine correlations with demographic/socioeconomic variables. ResultsIn the FH cohort (n = 85,457), 45.9% were female, 79.4% identified as White, 12.2% Black, and 8.4% as Hispanic. In the PFH cohort (n = 287,580), 42.2% were female, 78.2% White, 13.7% as Black, and 8.1% as Hispanic. Males were more likely to be prescribed high-intensity statins than females: odds ratio (OR) [95% confidence interval (CI)] = 2.05 [1.97, 2.13] and 1.60 [1.56,1.63] in the FH and the PFH cohorts, respectively. In both cohorts, White individuals were more likely to get ezetimibe, PCSK9i, or combination therapy compared to Black individuals (ORs: 1.12-1.40). Higher income was associated with increased odds of receiving these treatments (OR: 1.17-1.59 for incomes >$50,000). Higher education was linked to a higher likelihood of combination therapy (ORs [95% CI] = 1.49 [1.33, 1.68] and 1.18 [1.10, 1.27] in the FH and PFH cohorts, respectively). ConclusionsReal-world data indicate that more aggressive lipid-lowering therapy (ezetimibe and PCSK9i) is more often prescribed to White individuals, individuals with higher income, or those with advanced education, highlighting the need to improve equity in cardiovascular risk reduction for all individuals with FH. Clinical PerspectiveO_ST_ABSWhat is new?C_ST_ABSO_LIHealth disparities exist for individuals with FH, regardless of whether theyve been diagnosed. C_LIO_LIThe use of ezetimibe and PCSK9i is more likely to occur in individuals who are White, higher income, and advanced education. C_LI What are the clinical ImplicationsO_LIAddressing health disparities in FH requires a multifaceted approach, including systemic changes to reduce bias in healthcare systems. C_LIO_LIEnsuring equitable access to expensive lipid medications, such as PCSK9 inhibitors, is crucial for individuals from lower socioeconomic groups. C_LIO_LIProviding access to case managers and geneticists can enhance health education and support, ultimately improving treatment outcomes for individuals with FH. C_LI