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Original Investigation
July 24, 2019

Association of Region and Hospital and Patient Characteristics With Use of High-Intensity Statins After Myocardial Infarction Among Medicare Beneficiaries

Author Affiliations
  • 1Division of Cardiovascular Disease, University of Alabama at Birmingham
  • 2Department of Epidemiology, University of Alabama at Birmingham
  • 3The George Institute for Global Health, University of New South Wales, Sydney, Australia
  • 4The George Institute for Global Health, University of Oxford, Oxford, United Kingdom
  • 5Department of Epidemiology, The Johns Hopkins University, Baltimore, Maryland
  • 6Icahn School of Medicine at Mount Sinai, New York, New York
  • 7Center for Observational Research, Amgen, Inc, Thousand Oaks, California
  • 8Department of Health Care Organization and Policy, University of Alabama at Birmingham
  • 9Department of Biostatistics, University of Alabama at Birmingham
JAMA Cardiol. Published online July 24, 2019. doi:10.1001/jamacardio.2019.2481
Key Points

Question  What drives variation in high-intensity statin use after acute myocardial infarction among older adults?

Findings  In this cohort study of 139 643 Medicare fee-for-service beneficiaries hospitalized for myocardial infarction, postdischarge high-intensity statin use increased from 23.4% in 2011 to 55.6% in 2015. In multivariable-adjusted models, geographic region was more strongly associated with high-intensity statin use after myocardial infarction than hospital or patient characteristics.

Meaning  These findings suggest that large geographic treatment disparities in high-intensity statin use after myocardial infarction are poorly understood and require further research and intervention.

Abstract

Importance  High-intensity statin use after myocardial infarction (MI) varies by patient characteristics, but little is known about differences in use by hospital or region.

Objective  To explore the relative strength of associations of region and hospital and patient characteristics with high-intensity statin use after MI.

Design, Setting, and Participants  This retrospective cohort analysis used Medicare administrative claims and enrollment data to evaluate fee-for-service Medicare beneficiaries 66 years or older who were hospitalized for MI from January 1, 2011, through June 30, 2015, with a statin prescription claim within 30 days of discharge. Data were analyzed from January 4, 2017, through May 12, 2019.

Exposures  Beneficiary characteristics were abstracted from Medicare data. Hospital characteristics were obtained from the 2014 American Hospital Association Survey and Hospital Compare quality metrics. Nine regions were defined according to the US Census.

Main Outcomes and Measures  Intensity of the first statin claim after discharge characterized as high (atorvastatin calcium, 40-80 mg, or rosuvastatin calcium, 20-40 mg/d) vs low to moderate (all other statin types and doses). Trends in high-intensity statins were examined from 2011 through 2015. Associations of region and beneficiary and hospital characteristics with high-intensity statin use from January 1, 2014, to June 15, 2015, were examined using Poisson distribution mixed models.

Results  Among the 139 643 fee-for-service beneficiaries included (69 968 men [50.1%] and 69 675 women [49.9%]; mean [SD] age, 76.7 [7.5] years), high-intensity statin use overall increased from 23.4% in 2011 to 55.6% in 2015, but treatment gaps persisted across regions. In models considering region and beneficiary and hospital characteristics, region was the strongest correlate of high-intensity statin use, with 66% higher use in New England than in the West South Central region (risk ratio [RR], 1.66; 95% CI, 1.47-1.87). Hospital size of at least 500 beds (RR, 1.15; 95% CI, 1.07-1.23), medical school affiliation (RR, 1.11; 95% CI, 1.05-1.17), male sex (RR, 1.10; 95% CI, 1.07-1.13), and patient receipt of a stent (RR, 1.35; 95% CI, 1.31-1.39) were associated with greater high-intensity statin use. For-profit hospital ownership, patient age older than 75 years, prior coronary disease, and other comorbidities were associated with lower use.

Conclusions and Relevance  This study’s findings suggest that geographic region is the strongest correlate of high-intensity statin use after MI, leading to large treatment disparities.

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