Predictors of statin use among older adults: A nationwide cross-sectional study.

BACKGROUND: Statins comprise a key strategy for the prevention and treatment of arteriosclerotic cardiovascular disease, but prescribing remains suboptimal. OBJECTIVES: The objective of this study was to characterize the predictors of statin use among adults aged ≥65 years. METHODS: A cross-sectional study using Pharmaceutical Benefits Scheme (PBS) data on reimbursed prescriptions for a 10% random sample of the Australian population in 2016 was performed. Predictors of statin use were identified via multivariable logistic regression. Analyses were performed separately for people who were concessional beneficiaries (with a low, capped copayment) and other ("general") people. RESULTS: Among 351,471 (concessional = 295,875 and general = 55,596) older adults, 44.2% were dispensed statins (concessional = 46.4% and general = 32.2%). Among the concessional beneficiaries, people aged 75 to 84 years were more likely to use statins (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.06-1.10), whereas those aged ≥85 years were less likely to use statins (OR 0.71, 95% CI 0.69-0.72), compared with people aged 65 to 74 years. Men were more likely to use statins than women (OR 1.14, 95% CI 1.12-1.16). Diabetes was associated with over 2-fold (OR 2.48, 95% CI 2.43-2.53) increased likelihood of statin use. People with cardiovascular-related conditions including hypertension, angina, and congestive heart failure experienced increased likelihood of statin use as was being dispensed anticoagulant or antiplatelet medication. Having malignancy, psychotic illness, or pain were associated with lower likelihood of statin use. Similar predictors of statin use were noted for the general population. CONCLUSION: More than 40% of older adults in Australia used statins in 2016 with uptake dependent on individual-level factors such as demographics and comorbidities. Future research should examine the extent to which provider and/or health system-level factors contribute to the variable uptake of statin therapy.

The role of oral antiplatelet agents in atherothrombotic disease.

Atherothrombosis involves the mutually interactive dual mechanistic processes of atherosclerotic plaque progression and thrombus formation. In the setting of acute plaque rupture, resultant thrombus formation precipitates acute ischemic events such as acute coronary syndromes (ACS), stroke, and transient ischemic attack. Peripheral arterial disease is also a manifestation of atherothrombotic disease, and occurs both acutely and as a result of underlying disease progression. Atherothrombotic disease is highly prevalent and imposes a substantial burden on the community. For example, coronary artery disease was the single greatest cause of mortality among men and women in the US and accounted for an estimated US dollars 142.1 billion in health costs in 2005. Activated platelets are the prime mediators of arterial thrombus formation. This review discusses the evidence supporting the use of oral antiplatelet agents with other risk prevention strategies in the long-term secondary prevention of atherothrombotic disease. The most widely used oral antiplatelet agent is aspirin (acetylsalicylic acid), and both aspirin and clopidogrel have proven roles in the management of atherothrombotic disease. Clopidogrel should also be used in combination with aspirin in patients with non-ST-segment elevation ACS and those undergoing percutaneous coronary intervention. Recent data suggest that clopidogrel may have a significant role, with or without fibrinolytic therapy, in the immediate management of ST-segment elevation ACS.

Carotid atherosclerosis and cardiovascular risk stratification: role and cost-effectiveness of echo-Doppler examination in untreated essential hypertensives.

OBJECTIVE: To investigate the impact and cost-effectiveness of carotid ultrasonographic examination on total risk stratification in low-medium risk hypertensive patients in relation to age (< 50 and > 50 years) and gender. METHODS: Five hundred and eighty untreated hypertensives classified at low-medium risk, after the routine work-up recommended by the 2003 ESH/ ESC guidelines, were included in the study and total risk was reassessed by adding the results of carotid ultrasonography. RESULTS: According to the stratification based on routine work-up 16.3% of the whole population was considered at low added risk and 83.7% at medium added risk. Carotid subclinical damage was found in 158 patients (27.0%), who were then reclassified in the high-risk stratum. Prevalence rates of patients reclassified in the high-risk stratum as a consequence of carotid damage were as follows: 12.6% in men < 50 years, 14.1% in women < 50 years, 53.0% in men > or = 50 years and 40.1% in women > or = 50 years. The cost per detected case of carotid atherosclerosis was 473 euro in patients < 50 years and 133 euro in those > or = 50 years. CONCLUSIONS: Our results show that: (i) the use of carotid ultrasonography allows a much more accurate identification of high-risk individuals; (ii) its impact and cost-effectiveness on the risk stratification process differs markedly according to the age and gender; (iii) the selective use of this procedure in subjects at high risk of target organ damage may substantially improve the cost of primary prevention.

Area socioeconomic status and progressive CKD: the Atherosclerosis Risk in Communities (ARIC) Study.

BACKGROUND: Individual-level socioeconomic status (SES) has been found to be associated inversely with progressive chronic kidney disease (CKD); the effect of area-level SES on progressive CKD is less known. We conducted a cohort study of 12,856 Atherosclerosis Risk in Communities Study participants to examine the independent risk for progressive CKD associated with living in a low SES area. METHODS: Progressive CKD is defined as a creatinine level elevation of 0.4 mg/dL or greater (> or = 35 micromol/L) during a 9-year follow-up, hospitalization for CKD, or death. Area-level SES was characterized by using measures of income, wealth, education, and occupation for 1990 US Census block groups of residence. RESULTS: Age- and center-adjusted incidence rates (per 1,000 person-years) of progressive CKD by quartiles of area-level SES score showed increasing rates with decreasing SES for African-American women: quartile 1 (Q1; low) = 11.1, Q2 = 10.5, Q3 = 6.4, and Q4 = 7.1 and white men: Q1 = 6.6, Q2 = 4.8, Q3 = 4.0, and Q4 (high) = 3.5, but not for African-American men or white women. Cox proportional hazards models showed that living in the lowest versus the highest SES-area quartile was associated with a 60% greater risk for progressive CKD in white men after adjusting for age, center, baseline creatinine level, body mass index, and individual-level SES (hazard ratio, 1.6; 95% confidence interval, 1.0 to 2.5). This risk and trend persisted after adjusting for such potential mediators as health awareness, health care access, and behavioral and physiological factors. We found no significant association of progressive CKD risk and area SES in white women, African-American women, or African-American men after adjustment. CONCLUSION: For white men, living in a low SES area is independently associated with greater risk for progressive CKD. Future research is needed to examine this association, considering the disparate effects found by race/sex groups.

Echocardiographic quantification of atherosclerosis leads to cost-effective treatment with statins.

OBJECTIVE: Use of statins in prevention of atherosclerosis is effective but expensive. Patient selection gains wider public attention as medication costs in the US and Europe augment by 8% to 10% per year. We examined different clinical risk stratification strategies, particularly focusing on echocardiographic atherosclerosis quantification, for their impact on event reduction and cost-effectiveness in statin treatment. METHODS AND RESULTS: In a prospective, consecutive cohort of 336 patients referred to non-invasive cardiac examination, risk stratification was done by various combinations of risk factors and noninvasive atherosclerosis quantification. Atherosclerotic burden was determined through measuring "aortic elastance" by transthoracic echocardiogram, a validated non-invasive method. Cardiovascular events were recorded at a mean follow-up of one year. Echocardiographically determined atherosclerosis severity and event history, especially in combination, yielded the best selection strategies for statin treatment over a broad range of predetermined funding or required event reductions, surpassing conventional cardiovascular risk factors. From 26.8 statin-preventable events/1000 patients/year (assuming all patients treated), the best selection strategies could avoid: 24 with 66% of the cost for statin treatment (atherosclerosis and age criteria), 20.1 with <50% of the budget, 12.2 with <30% of the budget or 9.6 with <15% of the budget (using combinations of atherosclerosis and prior events), while conventional strategies without echo quantification of atherosclerosis were inferior. CONCLUSION: Non-invasive echocardiographic quantification of atherosclerosis improves efficiency and cost-effectiveness in statin treatment.

Rank in Self-Defense Forces and risk factors for atherosclerotic disease.

Socioeconomic status is associated with prevalence of and risk for atherosclerotic disease. We investigated the relationship between rank in the Self-Defense Forces (SDFs) and risk factors for atherosclerotic disease among middle-aged, male, SDFs personnel. Subjects were classified into five groups according to their ranks in the SDFs, i.e., class 1 (lowest, n = 289), class 2 (low, n = 170), class 3 (middle, n = 229), class 4 (high, n = 197), and class 5 (highest, n = 89). Low rank was associated with current cigarette smoking, alcohol abstaining, and poorer vegetable consumption. It was also associated with prevalence of type 2 diabetes, elevated gamma-glutamyltransferase activity, and high white blood cell counts. Prevalence of obesity, hypertension, hypercholesterolemia, hypertriglyceridemia, or hyperuricemia was not associated with rank in this population. Rank may be regarded as one of the markers that reflect individual health states among middle-aged male personnel.

Peripheral arterial disease: the magnitude of the problem and its socioeconomic impact.

Peripheral arterial disease is a common disease in adults and its complications take a great toll in terms of quality of life and treatment costs. As healthcare budgets have taken up more of the economy, and as employers and patients have become concerned about the escalating costs of healthcare, we have entered an era in which individual doctors must become concerned about the costs of a service relative to its benefits. The purpose of this article is to review the literature on the pharmacoeconomics of the diagnostic and therapeutic procedures for peripheral arterial disease. It emerges that peripheral arterial disease places a great burden on healthcare systems and on society as a whole. Some of these costs, including indirect and intangible costs (i.e. those related to lost productivity, and reduced quality of life, respectively) could be reduced if the condition were to be recognized and correctly treated at an early stage.

Cost of routine screening for carotid and lower extremity occlusive disease in patients with abdominal aortic aneurysms.

OBJECTIVE: The burden of clinically relevant noncoronary atherosclerotic occlusive disease in patients with abdominal aortic aneurysms (AAAs) is poorly defined. Furthermore, the cost-effectiveness of routine versus selective preoperative noninvasive examination of the carotid and lower extremity arterial beds has not been established in patients who undergo elective AAA repair. METHODS: Diagnostic vascular laboratory study results were reviewed in 206 patients who underwent evaluation before AAA repair from 1994 to 1998. The patients underwent routine preoperative carotid duplex scan examinations and lower extremity Doppler scan arterial studies with ankle-brachial index (ABI) determinations. The medical records were reviewed for the identification of clinical evidence consistent with cerebrovascular or lower extremity arterial occlusive disease. The costs of routine screening and selective screening were determined with Medicare reimbursement schedules. RESULTS: The prevalence rate of advanced (80% to 100%) carotid artery stenosis (CAS) was 3.4%, and 18% of the patients had CAS between 60% and 100%. Advanced peripheral vascular occlusive disease (PVOD; ABI, <0.3) was found in 3% of the patients, and 12% of the patients had an ABI of less than 0.6. Most patients with advanced CAS (71%) or advanced PVOD (83%) had clinical indications of their disease. The absence of clinical evidence of disease had a negative predictive value of 99% for both advanced CAS and PVOD. The cost of routine screening for all patients for advanced CAS was $5445 per case. Routine screening for severe PVOD costs were $3732 per case discovered. In contrast, the costs for selective screening for advanced CAS or PVOD in patients with appropriate history or symptoms were $1258 and $785 per case found, respectively. CONCLUSION: Routine noninvasive diagnostic testing for the identification of asymptomatic CAS and PVOD in patients with AAA may not be justified. Preoperative screening is more clearly indicated for patients with AAAs who have clinical evidence suggestive of CAS or PVOD.

The economic impact of smoking in Germany.

Smoking is a high-risk behaviour affecting health and economic welfare of society. Thus it is important to quantify the economic burden smoking places on social institutions in Germany. Approximately 33.4% of the male and 20.4% of the female population are current smokers. This study investigates the health care costs of smoking based on 1996 figures, focusing on the seven most frequent diseases associated with the inhalation of tobacco smoke: chronic obstructive pulmonary disease (COPD, international classification of diseases (ICD) 490-491); lung cancer (ICD 162); stroke (ICD 434-438); coronary artery disease (ICD 410-414); cancer of the mouth and larynx (ICD 140-149, 161) and artherosclerotic occlusive disease (ICD 440). A data search was carried out on MEDLINE, the German Institute for Medical Documentation and Information, and the Internet as well as in databases of health insurance companies and the German Federal institute of statistics. Direct and indirect costs were calculated separately. The results estimate the total smoking related health care costs (attributable fraction due to smoking) for COPD to be 5.471 billion EURO (73%), for lung cancer 2.593 billion EURO (89%), for cancer of the mouth and larynx 0.996 billion EURO (65%), for stroke 1.774 billion EURO (28%), for coronary artery disease 4.963 billion EURO (35%) and for atherosclerotic occlusive disease 0.761 billion EURO (28%). The economic burden of smoking related health care costs for Germany is 16.6 billion EURO. Smoking is therefore responsible for 47% of the overall costs of these diseases (35.2 billion EURO). In the view of the high costs for smoking, of which almost 50% are due to respiratory disease, pneumologists should enhance their effort in primary, secondary and tertiary prevention.

Procedure costs and outcomes associated with pharmacologic management of peripheral arterial disease in the Department of Defense.

This study was undertaken to determine if differences existed between pharmacologic treatments of peripheral arterial disease (PAD) with respect to PAD-related costs and health care outcomes in the United States Department of Defense health care system. We performed a retrospective review of hospital and prescription data to explore the effects of at least 90 days of aspirin, pentoxifylline, papaverine, or dipyridamole on 4 PAD-related outcomes: number of PAD-related invasive procedures (INV), number of PAD-related examination procedures (EXM), number of PAD-related hospitalization days (HDAYS), and cost of PAD-related procedures (COST) during 5 years. A covariate representing the number of PAD-related hospitalizations before the study period was used to attempt to control for severity of disease state. General linear models were used in the analyses. A statistically significant difference was seen between treatment groups for a linear combination of INV, EXM, HDAYS, and COST when controlling for past PAD-related hospitalizations (P < 0.014). A statistically significant relationship existed between treatment groups and INV (P < 0.041). The pentoxifylline treatment group had a statistically significant higher covariate-adjusted mean INV compared with the aspirin treatment group (P < 0.043). Also, PAD-related past hospitalizations were significantly related to EXM (P < 0.006). Our results appear to support the use of aspirin as a preventive treatment in PAD compared with pentoxifylline or dipyridamole.

Atherosclerosis: a unifying disorder with diverse manifestations.

The epidemiology, costs, and comorbidities associated with atherosclerosis and the role of newer antiplatelet agents are reviewed. Cardiovascular disease is the leading cause of death in the United States. More than 60 million Americans have one or more types of cardiovascular disease. The total annual cost of coronary heart disease has been estimated at $95 billion. Patients with an existing atherosclerotic disease in one vascular bed are at high risk of having an ischemic vascular event in the same or another vascular bed. Peripheral arterial disease is a strong marker for underlying cerebrovascular and cardiovascular disease. The common link among these diseases is atherosclerosis leading to atherothrombosis. Platelets play an integral role in atherosclerosis and the formation of arterial thrombus as well as in subsequent acute events such as ischemic stroke, myocardial infarction, and vascular death. Arterial thrombosis can be mediated by shear-stress-induced platelet aggregation. Currently, only one third to one half of all eligible patients with stroke, myocardial infarction, or peripheral arterial disease receive antiplatelet therapy. Thienopyridines such as ticlopidine and clopidogrel are effective inhibitors of shear-stress-induced and endothelial-injury-induced platelet aggregation. Advances in antiplatelet therapy provide an opportunity to use newer antiplatelet agents in the prevention of atherosclerosis-related morbidity and mortality; therapeutic approaches should be directed toward recognizing atherosclerosis as a generalized disease process and preventing ischemic events in multiple vascular beds.