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Drug subsidy failed to close racial gap in statin use

By Kathryn Doyle

NEW YORK (Reuters Health) - Among older Americans with heart disease or diabetes, blacks are still less likely to be on cholesterol medication than whites, despite federal prescription drug subsidies that lowered costs, according to a new study.

Older blacks are also less likely than whites to have their cholesterol under control, researchers found.

Because black patients are more likely to skip doses or to not take expensive medications at all for cost reasons, the Medicare Part D program that started in 2006 was expected to close a racial gap in the number of Americans with heart disease taking statins.

Since the medication gap has not closed after Part D, "It would appear that more than money is involved," said Joseph Hanlon, a professor of geriatric medicine at the University of Pittsburgh who led the study.

"Racial differences in medication use are only partially explained by health insurance," he told Reuters Health. "Differences in quality of care, health status, patient preferences and other factors may also play a role."

Hanlon and his coauthors compared the health data of 1,091 adults over age 70 with coronary heart disease or diabetes receiving Medicare benefits from year to year, checking in every six months from 1998 to 2008.

The data they looked at included cholesterol levels, use of cholesterol controlling drugs like the statin Lipitor and whether cholesterol levels were under control - meaning that low-density lipoprotein, or LDL, "bad" cholesterol was under 130 milligrams per deciliter.

Before 2006, 33 percent of black participants and 49 percent of whites were taking cholesterol medication. That rose to 48 percent and 65 percent, respectively, after 2006, so the gap did not change.

Before Medicare Part D, 55 percent of blacks and 62 percent of whites reported having prescription drug coverage, and that rose to 75 percent and 82 percent after Medicare Part D.

Average LDL cholesterol levels did not seem to improve either, increasing from 107 to 109 milligrams per deciliter for blacks and from 95 to 96 milligrams per deciliter for whites, according to the study results published in the American Heart Journal.

Diligent use of statins by people younger than 80 with heart disease can lower the risk of heart attack, stroke and death, the authors point out. But there is little evidence for benefits over age 85, and at that age the risks of cognitive damage and death due to the medication increase.

Since Lipitor went generic in 2011, it now costs about 50 cents per pill, and some retailers actually offer it for free with a prescription.

Even though cholesterol control didn't appear to change over time, that doesn't mean Medicare Part D had no effect on that health risk factor in the population, said Dr. Walid Gellad, a staff physician at the Pittsburgh VA Medical Center who was not involved in the study.

Just because people reported that they were taking statin drugs doesn't mean that they were taking them often enough, or correctly, Gellad told Reuters Health by email.

Dr. Jennifer G. Robinson, director of the Prevention Intervention Center at the College of Public Health at the University of Iowa in Iowa City, expected Medicare Part D to have had more of an effect.

"More recent studies have found the disparities in prevention and treatments have been narrowing between whites and blacks," she said.

The results may not reflect the effect of Medicare Part D in the nation as a whole, since medication use varies widely by region, Robinson noted. And the apparent overall increase in cholesterol medication use is encouraging, she said.

"It is critically important nationally for more people to achieve lipid control," Gellad said. "However, as the authors explain, it is not so clear how important it is to achieve lipid control for individuals once they reach 80, especially if they have evidence of limited life expectancy."

SOURCE: http://bit.ly/18QTulH American Heart Journal, online August 27, 2013.

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