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BMC Public Health. 2012; 12: 610.
Published online Aug 4, 2012. doi:  10.1186/1471-2458-12-610
PMCID: PMC3444315
Is the high-risk strategy to prevent cardiovascular disease equitable? A pharmacoepidemiological cohort study
Helle Wallach-Kildemoes,corresponding author1 Finn Diderichsen,2 Allan Krasnik,3 Theis Lange,4 and Morten Andersen5,6
1Centre for Healthy Aging, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, 1014, Denmark
2Social Medicine, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, 1014, Denmark
3Health Services Research, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, 1014, Denmark
4Biostatistics, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, 1014, Denmark
5Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, SE-171 77, Sweden
6Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, B. Winsløws Vej 9A, Odense, 5000, Denmark
corresponding authorCorresponding author.
Helle Wallach-Kildemoes: hewk/at/sund.ku.dk; Finn Diderichsen: fidi/at/sund.ku.dk; Allan Krasnik: alk/at/sund.ku.dk; Theis Lange: thla/at/sund.ku.dk; Morten Andersen: Morten.Andersen/at/ki.se
Received April 23, 2012; Accepted July 20, 2012.
Abstract
Background
Statins are increasingly prescribed to prevent cardiovascular disease (CVD) in asymptomatic individuals. Yet, it is unknown whether those at higher CVD risk – i.e. individuals in lower socio-economic position (SEP) – are adequately reached by this high-risk strategy. We aimed to examine whether the Danish implementation of the strategy to prevent cardiovascular disease (CVD) by initiating statin (HMG-CoA reductase inhibitor) therapy in high-risk individuals is equitable across socioeconomic groups.
Methods
Design: Cohort study.
Setting and participants: Applying individual-level nationwide register information on socio-demographics, dispensed prescription drugs and hospital discharges, all Danish citizens aged 20+ without previous register-markers of CVD, diabetes or statin therapy were followed during 2002–2006 for first occurrence of myocardial infarction (MI) and a dispensed statin prescription (N = 3.3 mill).
Main outcome measures: Stratified by gender, 5-year age-groups and socioeconomic position (SEP), incidence of MI was applied as a proxy for statin need. Need-standardized statin incidence rates were calculated, applying MI incidence rate ratios (IRR) as need-weights to adjust for unequal needs across SEP.Horizontal equity in initiating statin therapy was tested by means of Poisson regression analysis. Applying the need-standardized statin parameters and the lowest SEP-group as reference, a need-standardized statin IRR > 1 translates into horizontal inequity favouring the higher SEP-groups.
Results
MI incidence decreased with increasing SEP without a parallel trend in incidence of statin therapy. According to the regression analyses, the need-standardized statin incidence increased in men aged 40–64 by 17%, IRR 1.17 (95% CI: 1.14-1.19) with each increase in income quintile. In women the proportion was 23%, IRR 1.23 (1.16-1.29). An analogous pattern was seen applying education as SEP indicator and among subjects aged 65–84.
Conclusion
The high-risk strategy to prevent CVD by initiating statin therapy seems to be inequitable, reaching primarily high-risk subjects in lower risk SEP-groups.
Keywords: Statins to prevent cardiovascular disease, The high-risk strategy, Socioeconomic gradient, Horizontal equity
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