Trends and inequalities in statin use for the primary and secondary prevention of cardiovascular disease between 2009 and 2021 in England

ObjectiveTo investigate trends and inequalities in statin use for the primary and secondary prevention of cardiovascular disease (CVD) DesignRepeated cross-sectional and historical cohort study designs SettingEnglish primary care electronic health records from the Clinical Practice Research Datalink (CPRD Aurum) linked to Hospital Episode Statistics Admitted Patient Care Participants5 million adults aged 25 years and older randomly sampled from CPRD Aurum between 1st April 2009 and 31st December 2021. Outcome measuresMonthly proportion of current statin users; adjusted odds ratios (aOR) for statin initiation; adjusted hazard ratios (aHR) for cardiovascular risk assessment, statin discontinuation and statin re-initiation and number of CVD events prevented with optimal statin use and estimated costs saved. ResultsThe overall monthly proportion of individuals prescribed statins for primary prevention increased from 22.3% in 2009 to 35.6% in 2021 among those aged 70+ years, and was stable in other age groups. The proportion of eligible individuals receiving a statin for secondary prevention was higher in all age groups (e.g. increasing from 68.1% to 73.7% over the same period, in those aged 70+). Overall prevalence of statin use was lowest among women, 25-39 age group, and black, mixed, and other ethnic groups for both primary and secondary prevention. Monthly proportion of CVD risk assessment, among those eligible, increased from 13.7% in May 2009 to 31.8% by November 2021. 79.0% of individuals were initiated statins within 60 days of a CVD event. Women (aOR 0.70; 95% CI, 0.68 - 0.72) and people of black ethnicity (aOR 0.71; 95% CI, 0.65-0.77) were less likely to be initiated statins compared to those of white ethnicity while people of south Asian ethnicity (aOR 1.53; 95% CI, 1.42-1.64) were more likely to be initiated statins than white people for secondary prevention. Statin discontinuation was most likely among women (aHR 1.08, 95% CI; 1.06-1.11) black people (aHR 1.76, 95% CI, 1.65-1.89) and the most deprived group (aHR 1.08, 95% CI; 1.04-1.12) compared to men, white people and the least deprived group, respectively, for primary prevention with similar associations seen for secondary prevention for ethnicity and deprivation. With optimal statin treatment, over 150,000 cardiovascular events could be prevented in the next 10 years for primary prevention and 5 years for secondary prevention resulting in a potential saving to the health service of over {pound}400 million in those eligible for statins. ConclusionStatin use remains suboptimal and inequalities particularly among women, people of black ethnicity and those in the most deprived socioeconomic groups persist across multiple stages of statin use for both primary and secondary prevention. To reduce these inequalities and avoid missed opportunities to prevent cardiovascular events and costs to the NHS, strategies are needed specifically targeting these patient groups to reduce the burden of CVD. Summary boxSection 1 What is already known on this topicO_LIPrevious studies have shown that statins are under-prescribed and under-used in both primary and secondary prevention of cardiovascular disease (CVD) resulting in missed opportunities to reduce CVD burden. C_LIO_LIFew studies have examined trends in statin use in recent years, including during the pandemic period. C_LIO_LIInequalities in statin use based on age, gender, ethnicity and deprivation have been identified previously, however it is unclear where, along the pathway from identification of eligible patients to initiation and continuation of statins, these inequalities manifest. C_LI Section 2 What this study addsO_LILevels of CVD risk assessment were suboptimal throughout the study period: a modest increase in the proportion of eligible individuals with a CVD risk assessment from 14% in May 2009 to 35% in February 2020 was followed by a decline during the COVID-19 pandemic. C_LIO_LIPrevalence of statin use increased between 2009 and 2021 but remained suboptimal throughout, and with important sociodemographic disparities. Women and people of black ethnicity were less likely to initiate statins for secondary prevention compared to men and the white ethnic group while people of south Asian ethnicity and the 60-69 age group were more likely to initiate statins compared to people of white ethnicity and the 25-39 age group, respectively. C_LIO_LIStatin discontinuation was higher among women than men (secondary prevention only), black ethnic groups compared to white ethnic groups, and the most deprived socioeconomic groups compared to the least deprived for both primary and secondary prevention. C_LIO_LIWe estimated that over 100,000 cardiovascular events could be prevented in the next 10 years if the observed missed opportunities for statin use in primary CVD prevention among eligible individuals were fully addressed, and a further 50,000 events could be prevented over 5 years for secondary prevention. The consequent potential saving to the health service was estimated to be over {pound}400 million. C_LI Summary of main results O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=123 SRC="FIGDIR/small/24317782v1_ufig1.gif" ALT="Figure 1"> View larger version (34K): org.highwire.dtl.DTLVardef@3343c0org.highwire.dtl.DTLVardef@1a4f988org.highwire.dtl.DTLVardef@1fa7477org.highwire.dtl.DTLVardef@1f44107_HPS_FORMAT_FIGEXP M_FIG C_FIG