Why Are Statins Underused With Black Patients?
The color of a patient's skin appears to influence the medical care they receive for high cholesterol levels, a new study shows.
Blacks are less likely than whites to receive appropriate treatment with cholesterol-lowering statins, the researchers report.
The reasons behind this racial gap in care are a complex brew of economic status, financial barriers, clinical factors and even the patients' own beliefs regarding the medications, said lead researcher Dr. Michael Nanna, a cardiology fellow with Duke University Medical Center in Durham, N.C.
"African-Americans were less likely than white patients to believe statins are safe, or to believe statins are effective," Nanna said. "They also were less likely to trust their clinician."
Blacks have a higher risk for heart disease than whites, but previous studies have shown that they are less likely to be prescribed statins, the researchers said in background notes.
"The reasons underlying these racial differences in statin treatment are poorly understood, so we wanted to see if African-Americans in contemporary medicine are treated less aggressively than whites and, if so, we wanted to look at the reasons why," Nanna said.
To explore the issue, Nanna and his colleagues surveyed nearly 5,700 patients from a nationwide registry who were eligible for statin therapy, either because they had heart disease or were at high risk for hardening of the arteries. Participants filled out the surveys on an iPad while waiting to be seen by a doctor.
Overall, blacks were only slightly less likely than whites to be prescribed any sort of statin, about 71 percent compared with 74 percent, researchers found.
However, blacks were much less likely to be prescribed a dose of statin that would do them any good.
Only one-third of black patients had been prescribed a statin dose high enough to meet treatment guidelines, compared with 44 percent of whites, researchers found.
Blacks received inadequate doses of statins even though their average levels of "bad" LDL cholesterol were higher than those of white patients, Nanna added.
The black patients in this study also had more high blood pressure, diabetes and hardening of the arteries, all of which are heart risk factors that would indicate the need for statin therapy, said Dr. Usman Baber, an assistant professor of internal medicine with the Icahn School of Medicine at Mount Sinai in New York City.
"Therapeutic intensity does not match patient-level risk," said Baber, who was not involved with the study. "It's troubling to see there's a racial gap where African-American patients are even less likely than white patients to receive needed medicine."
But why is this happening?
The surveys identified many of the usual suspects. Blacks were more likely to be covered by Medicaid rather than private insurance, which could have affected their access to health care. They also had lower economic and educational levels than their white counterparts.
Further, black patients were less likely to be treated by a cardiologist or doctor familiar with guidelines for treating high cholesterol, the researchers found.
But black patients' own perceptions about statins and about their doctors also appeared to play a role, Nanna said.
Blacks were less likely than whites to believe statins are safe (36 percent versus 57 percent) or effective (70 percent versus 74 percent), the study found.
Blacks were also less likely to trust their doctor, 82 percent versus 94 percent of whites.
"We need to build trust with our patients," Nanna said. "We need to be consistent in our application of guideline recommendations, and educate both clinicians and patients on the appropriate therapies for risk reduction."
There's one additional factor that the study did not investigate, Baber noted -- the beliefs and thought processes of the doctors treating these patients.
"We don't know what the physicians were perceiving," Baber said. "For example, were clinicians less likely to prescribe medications because their perceptions about the patients with respect to risk or tolerance or adherence also differed by race?"
It's also possible that there were solid medical reasons why doctors chose not to prescribe heavier doses of statins to blacks, the researchers noted. Because doctors weren't included in the study, there's no way to tell.
The study was published June 13 in the journal JAMA Cardiology.
The American Heart Association has more about blacks and heart disease.
SOURCES: Michael Nanna, M.D., cardiology fellow, Duke University Medical Center, Durham, N.C.; Usman Baber, M.D., assistant professor, internal medicine, Icahn School of Medicine at Mount Sinai, New York City; June 13, 2018, JAMA Cardiology