Italiano Farmacia on line: comprare zithromax senza ricetta, acquistare zithromax internet.
Microsoft word - working papers--link-3-08.doc
ALFRED LERNER COLLEGE OF BUSINESS & ECONOMICS
WHO RECEIVES STATINS? VARIATIONS IN PHYSICIANS’
PRESCRIBING PATTERNS FOR PATIENTS WITH CORONARY
HEART DISEASE, DYSLIPIDEMIA, AND DIABETES
Simon Condliffe, Charles R. Link and Bryan Townsend
____________________________*http://lerner.udel.edu/economics/workingpaper.htm. 2007 by author(s). All rights reserved.
WHO RECEIVES STATINS? VARIATIONS IN PHYSICIANS’ PRESCRIBING
PATTERNS FOR PATIENTS WITH CORONARY HEART DISEASE,
DYSLIPIDEMIA, AND DIABETES
Simon Condliffe: Center for Applied Demography and Survey Research,
Delaware; Charles R. Link: Department of Economics,
University of Delaware, 408
Purnell Hall, Newark, Delaware 19716 (e-mail: firstname.lastname@example.org; TEL: (302) 831-
1921; FAX: (302) 831-6968); Bryan Townsend, University of Delaware.
Our objective is to estimate the extent to which clinical and non-clinical factors areassociated with physicians’ prescribing patterns for statins. The data are from theNational Ambulatory Medical Care Survey for the period 1992 through 2004. The threesamples examined included more than 14,000 patients who were diagnosed with coronaryheart disease, high cholesterol, or diabetes, individuals who are most likely to benefitfrom being prescribed a statin drug. Using a multinomial logit framework, we finddisparities in prescribing patterns based on non-clinical factors. Namely, whites andpatients who have private insurance are more likely to be prescribed a statin than non-whites and those with public insurance. Also, even though a large increase occurred inthe uptake of statins over the period 1992 to 2004, our results for 2004 show that onlyabout 50 percent of patients diagnosed with coronary heart disease were prescribed astatin. Because coronary heart disease is the leading cause of death in the U.S. andcurrently is estimated to cost over $150 billion annually in the U.S. in direct and indirectcosts, observed differences in prescribing patterns along these dimensions is troublingand should be part of discussions dealing with health care reform.
Key Words: Pharmaceuticals; Statins; Equity in Physician Prescribing Patterns; Insurance
The objective of the paper is to estimate the factors that influence whether
physicians prescribe statins and/or other lipid-lowering drugs to patients diagnosed with
coronary heart disease (CHD), dyslipidemia, and diabetes. In 2004, coronary heart
disease (CHD) affected 15.8 million people in the U.S., and is the leading cause of deaths
with over 450,000 deaths annually. Not only is CHD the leading cause of death, but in
2007 it is estimated to cost over $150 billion in direct and indirect costs (American Heart
Association, 2007).1 There are several risk factors for CHD, of which diabetes and high
levels of cholesterol, low-density lipoprotein cholesterol (LDL), are relevant to the
Given the well-documented success of statins in lowering cholesterol levels, do
people at risk for CHD have equal access to statins? That is, do disparities in prescribing
patterns of physicians exist across such factors as the type of insurance the patient has,
where the patient lives, or the patient’s ethnic/minority status. Doty and Holmgren
(2006), based on the Commonwealth Fund Biennial Health Insurance Survey (2005),
found that uninsured rates for Hispanic and African Americans are one and one-half to
three times higher than the rate for whites. A recent report by the Institute of Medicine
(IOM) (Smedley, Stith, and Nelson, 2002) has documented the inequalities in health care
received by minorities in the U.S., even in cases where there is similar access to health
care. Both the IOM study and the study by the Kaiser Foundation and the American
College of Cardiology Foundation (2002) found that minorities are less likely than whites
to receive invasive procedures such as angioplasty, bypass surgery, and thrombolytic
1 Direct costs include hospitals, nursing home, physicians/other professionals, and drugs, and other medicaldurables and home health care. Indirect costs include lost productivity/morbidity and lostproductivity/mortality.
therapy. The existence of racial disparities in care is important enough to have resulted in
a whole issue of Health Affairs
(2005) being devoted to the topic. Results of our study of
factors associated with physician prescribing patterns for statins will shed light on the
potential disparities in regards to the access to statins by Black Americans and Hispanics.
The importance of equity in prescribing practices is magnified when a drug is
effective in treating a serious medical condition. Numerous studies have shown that
statins are more effective than predecessors of similar function in decreasing both LDL
cholesterol and triglycerides, which are important risk factors for heart disease. Recent
studies have also suggested that statins may serve not only as a treatment for reducing
high LDL cholesterol levels, but also in the prevention of other conditions such as stroke,
deep vein thrombosis, dementias (including Alzheimer’s disease), and as treatment to
slow the progression of multiple sclerosis (Noonan, 2003, Manning, 2004). We were
unable to find other multivariate studies dealing with prescribing patterns by physicians
as they relate to statins, so our paper provides initial evidence relating to the equity issues
According to Pearson (2007), compliance studies indicate that patients often do
not follow up on the therapies prescribed by their physicians. Since our study deals only
with whether or not the physician prescribes a statin drug, and we do not know whether
the patient actually filled the prescription, our results provide upper-bound estimates of
the proportion of the patients who actually end up taking the drugs. Nonetheless, our
findings should be of interest to policy makers whose objective is to reduce racial/ethnic
disparities in cardiac care and health outcomes in general.
Section 1 includes a brief discussion of why the particular diagnoses were chosen.
Section 2 discusses the methodology, including the data source, variables included in the
analysis, and econometric models underlying the estimations. Results are shown in
section 3. Section 4 includes a summary and conclusions.
1. Why CHD, Dyslipidemia, and Diabetes?
Cardiovascular related diseases have been for many years and continue to be the
leading cause of death for males and females in the United States (American Heart
Association, 2007). In 2004, in the U.S., it was estimated that 79.3 million people age 20
and older had LDL cholesterol levels considered ‘borderline high’ or worse; and high
LDL cholesterol levels are a risk factor for CHD (Centers for Disease Control, 2006a,
2006b, American Heart Association, 2007).2 The incidence of and death rates associated
with cardiovascular diseases are greater for Blacks compared to whites (American Heart
Diabetes affects over 20 million people in the United States and was the sixth
leading cause of death in the U.S. in 2004. Type-2 diabetes is the most common type,
with risk factors including obesity, inactivity, older age, high blood pressure, high
cholesterol, a family history of diabetes, and ethnicity. Compared to Caucasians,
Hispanic/Latino Americans, African Americans, and Asian Americans are twice as likely
to develop Type-2 diabetes (1 on 1 Health, Centers for Disease Control, 2003, 2005,
2 Levels of 130-159 are borderline high.
Statins have been effective in lowering LDL cholesterol levels. Use of statins as
sole means of primary or secondary treatment has been shown to reduce the incidence of
CHD by 25 to 60 percent and reduce the risk of death from any other heart disease or
condition by 30 percent (Knopp, 1999). The use of statins, in addition to providing large
and significant reductions in deaths due to CHD, does not appear to increase non-CHD or
cancer related deaths (Hebert et al, 1997). Reductions in risk for CHD were similar for
men and women and for elderly and middle-aged patients (LaRosa et al, 1999). Although
these results suggest the potential for reducing cholesterol levels in large numbers of
persons at risk for CHD, other studies have shown that only one-third of eligible patients
are receiving statins as secondary prevention (Majumdar et al, 1999). Data from the
Third Report of the Expert Panel on Detection, Evaluation and Treatment of High Blood
Cholesterol in Adults (2007) cites results consistent with Majumdar and further notes that
even among the highest risk patients less than half are getting lipid lowering medications.
Specific at risk populations in danger of not receiving statins include minorities and
patients lacking insurance coverage for prescription drugs.
One of the most detrimental side effects of diabetes is heart disease and stroke,
the leading cause of death among diabetics. For those having diabetes, heart disease
occurs earlier in life, is two to four times more common than in non-diabetics, and is
more likely to be fatal. The use of statins to control cholesterol levels in diabetics is an
increasingly important method of allowing patients to live with diabetes.3
3 Studies suggest that all diabetics, including those with high blood pressure, wouldbenefit from the use of a statin. One study included approximately 6,000 diabeticpatients and only half of these 6,000 showed signs of cardiovascular disease at the time ofthe study. Interestingly, it found that a daily dose of simvastatin (40 mg) decreased therisk of an initial heart attack or stroke by around 30% for diabetes patients and also
2. Data and Methodology
The data set utilized in the current study is from the National Ambulatory Medical
Care Survey (NAMCS) for the years 1992 through 2004 (Schappert S.M. & Nelson C.R.
(1999); U.S Department of Health and Human Services (2000)). The NAMCS includes
data from patient visits to non-federally employed office-based physicians who focus
mainly on direct patient care.4 Data for selected patients are entered onto the patient
record form and include diagnoses, treatments, symptoms, services performed,
prescriptions given, and various pieces of demographic information. The physician or
office staff, and not the patient, enter data into the survey forms. Specially trained
interviewers meet with physicians prior to survey participation, and provide them with
materials and instruction on how to complete the instrument. Each physician is randomly
assigned to a one-week reporting period, during which data for a random sample of visits
reduced the probability of a repeat attack in those who had already suffered one (TheDoctor's Lounge, 2003). Other studies of statins and diabetes yielded similar results. Dr.
Collins as a result of his study, specifically directed towards diabetics states, “Loweringyour cholesterol will lower your risk of heart disease, irrespective of what yourcholesterol level is. Taking a statin will lower your risk by a third. And if you continueto take it, you will continue to lower your risk.” (DeNoon, 2003)
4 Certain specialties, including anesthesiology, pathology, and radiology are not included in the survey.
Data was obtained on the National Center for Health Statistics (NCHS) website in the format of self-extracting files, which contained all survey data as well as descriptions of the survey, record format, codesfor medications, generic drugs, and various other information files.
5 See http://www.cdc.gov/nchs/about/major/ahcd/namcsdes.htm
Three samples we examine include 6,205 patients whose primary diagnosis is
coronary heart disease, 2,057 with dyslipidemia, and 6,215 diagnosed with diabetes. The
primary diagnosis is based on the International Classification of Diseases (ICD-9) coding
scheme. Patients with coronary heart disease were those whose primary diagnosis code
fell between 410.00 and 414.90. These patients are broadly defined as having ischemic
heart disease.6 Patients with dyslipidemia were those whose primary diagnosis code fell
between 272.00 and 272.90, a group that is broadly defined as having disorders of lipid
metabolism.7 The patients who had an ICD-9 code having the first three digits 250
include a group that is broadly defined as having type-1 or type-2 diabetes.8
A patient’s insurance coverage and source of payment for the office visit was
indicated by one of several options. The insurance variables were recoded so that a
patient fell into one of five insurance categories, reflecting the likelihood that the
patient’s insurance provided prescription drug coverage. These groups are: 1) Medicaid,
2) HMO/Private, 3) Medicare, 4) self-pay, and 5) unknown/blank. In cases when a
patient’s record indicated more than one type of insurance, the patient was placed in the
group among those indicated on his or her record that was most likely to provide
6 More specific sub-groups include acute myocardial infarction (410), other acute and subacute
forms of ischemic heart disease (411), old myocardial infarction (412), angina pectoris (413), and otherforms of chronic ischemic heart disease (414).
7 Specific sub-groups within this coding range include hypercholesterolemia (272.0),
hypertriglyceridemia (272.1), mixed hyperlipidemia (272.2), hyperchylomicronemia (272.3), otherhyperlipidemia (272.4), lipoprotein deficiencies (272.5), lipodystrophy (272.6), lipidoses, (272.7), otherdisorders of lipid metabolism (272.8), and unspecified disorders of lipid metabolism (272.9).
8 Patients with gestational diabetes were not included in our analysis.
prescription drug coverage. For example, if the record indicated Medicaid and Medicare,
the patient was placed in the Medicaid group.
The Logit Model
We estimate a multinomial logit model of the probability of a patient being
prescribed a statin in which independent variables, described more fully below, include
demographic characteristics, medical condition, and insurance status. The dependent
variable has three outcomes: no treatment, prescribed a statin9, and prescribed a lipid-
explanatory variables utilized in the logit regressions are dummy
variables for calendar year; patient’s age (<45, 45-64, and 65-74); gender; race/ethnicity
(Black, Asian, and Hispanic); and residence (Midwest, South, and West; Nonmetro).
Insurance status is categorized into four categories: Medicaid
, Medicare, Selfpay
Classification of secondary diagnoses is based on the patient’s secondary
diagnosis in the ICD-9 group: CHD2
(codes 410.00 to 414.90); Hypertension
to 405.90); Other Heart Disease
(420.00 to 429.90); Vascular Disease
(250.00 to 250.93); Dyslipidemia
(272.00 to 272.90); and All Other
ICD-9 groups. For the Diabetes sample only, we also include a variable to measure
whether a patient’s secondary diagnosis is both dysliplidemia and coronary heart disease.
9 Statins include Atorvastatin or Lipitor, Cerivastatin or Baycol, Fluvastatin or Lescol,Lovastatin or Mevacor (Altocor), Pravastatin or Pravachol, Rosuvastatin or Crestor,Simvastatin or Zocor, Simvastatin + Ezetimibe or Vytorin. Note that Baycol waswithdrawn from the market in 2001. The FDA approved Crestor in August 2003 andVytorin in July 2004.
10 The following drugs are included in the other lipid lowering drugs: Cholestyramine,Questran, Lo-Cholest, Prevalite, Colesevelam,WelChol, Colestipol,Colestid, Fenofibrate,Tricor, Gemfibrozil, Lopid, Clofibrate, Atromid S, Niacin (nicotinic acid),Ezetimibe,Zetia, and Ezetrol.
The omitted groups in the logit regressions include the following variables: the
year 1992, older than age 74, female, white, paid through private insurance (“HMO/Other
prepaid,” “Private/Commercial Insurance,” “Blue Cross/Blue Shield,” or “Other private
insurance”), northeast, metro area, and had no co-morbidities (secondary diagnoses).
Time dummy variables are included to give us information about the uptake and
diffusion of statins over the period 1992 through 2004. We expect their coefficients will
indicate increased use of statins over time. Age is a risk factor for CHD and diabetes.
Clinical guidelines indicate that persons in our three primary condition categories should
be treated more aggressively for high cholesterol if they exhibit secondary conditions
(risk factors) such as hypertension, dyslipidemia (for patients with CHD and diabetes),
and CHD (for patients with diabetes and dyslipemia). Positive coefficients are expected
for the variables indicating risk factors for CHD. The race/ethnicity variables indicate the
presence or absence of disparities in access to statins along the lines found by the
Institute of Medicine in regards to cardiac care for minorities. Although males are more
likely than females to have CHD, and since statin treatment is effective in both genders,
we have no a priori prediction for the sign of the coefficient. The variables indicating the
method of payment for the office visit will shed light on the importance of the source of
payment as a potential determinant of whether or not a patient is prescribed a statin drug
by his or her physician. We expect that private insurance will be associated with a
greater likelihood of the patient receiving a statin. Information about a person’s
residence--the region of residence in the U.S. and whether he or she lives in a
metropolitan area--will allow us to determine whether or not where one lives (which is
not part of clinical guidelines) affects who is prescribed a statin.
In this section we first show the demographic and clinical conditions associated
with each of the three samples under study. The logit results are then discussed.
Table 1 shows the means for variables associated with the three samples of
respondents diagnosed with a primary condition of coronary heart disease (CHD, column
1), dyslipidemia (DYS, column 2), and diabetes (column 3). Since males are more likely
to have CHD, the fact that they comprise 63 percent of the sample diagnosed with CHD
is not surprising. The percent male drops to around 50 percent for persons diagnosed
with dyslipidemia or diabetes. Whites make up more than 83 percent of the CHD and
DYS samples but only about 70 percent of diabetics. Blacks comprise between six to
seven percent percentage of the CHD and DYS samples, while for Hispanics the
percentages are between 4.7 and 5.8 percent. These percentages for diabetics jump to 10
percent for Hispanics and 15.9 percent for Blacks. The low percentages of Blacks and
Hispanics in the coronary heart disease and dyslipidemia samples are consistent with
evidence that minorities comprise a smaller percentage of the samples visiting
physicians’ offices in ambulatory settings when compared to the percentage they
comprise of the whole population in the U.S. This is probably due to Medicaid, where
the number of solo physicians not accepting new Medicaid patients over the period 1996-
1997 to 2004-2005 has risen from 29 to 35.3 percent. Similarly for small groups of
physicians, the percentage declining new Medicaid patients rose from 16.2 percent to 24
percent over the same period (Cunningham and May, 2006). Reasons for the increased
likelihood of physicians’ refusal to take on Medicaid patients include the low payments
compared to private insurance along with high administrative costs. More than half of
the 52 million Medicaid beneficiaries are from minority groups, more than 20 percent of
non-elderly African Americans and Latinos (Llanos and Palmer, 2006).
Method of payment for the physician visit varies by primary diagnosis. Medicaid
patients comprise 5 percent of the visits for CHD, 2.5 percent for dyslipidemia, and 9.9
percent for diabetes. The percentages for Medicare are 45 percent for CHD, 32 percent
for diabetics, and 25 percent for those diagnosed with dyslipidemia. Payment by private
insurance varies from around 45-48 percent for CHD and diabetes, to 62 percent for
dyslipidemia. The age composition of the sample with CHD rises from 3.5 percent for
those under age 45, to around one-third for each of the three age groups 45-64, 65-74,
and 75 and older. The distribution by age differs for patients with dyslipidemia and
diabetes where the peak of 42 to 47 percent occurs in the 45 – 64 age-group.
Approximately one third of the patients in each diagnosis category resided in the South,
while the remainder was evenly divided between the other three regions of the U.S. The
vast majority of patients lived in metro areas.
Within each diagnosis, the presence of co-morbidities is likely to influence
physicians’ decisions about whether or not to prescribe lipid-lowering drugs. Of persons
diagnosed with CHD, 11 percent also had other heart conditions, 15.1 percent had
dyslipidemia, 6.5 percent had diabetes, and 13.8 percent had hypertension. Patients with
dyslipidemia and diabetes were most likely to have hypertension as the only other
secondary condition. About 40 percent of the patients diagnosed with dyslipidemia and
diabetes had a secondary condition unrelated to the conditions included in table 1. The
percentages of respondents diagnosed with CHD, dyslipidemia, and diabetes, but who
have no secondary conditions, are 27, 36, and 23 percent respectively.
The results from the logit regressions are shown in table 2 columns 1-2 for CHD,
columns 3-4 for dyslipidemia, and columns 5-6 for diabetes. Table 3 shows the resulting
The coefficients for the year dummy variables should be interpreted with respect
to 1992. As expected, statin utilization rates increased over time for each diagnosis
category, and uptake in their usage reflects a substitution for other lipid-altering drugs
and a decrease in the probability of receiving ‘no treatment.’ Evaluating the logit results
at the mean values, the probability of receiving a statin in 1992 if the patient had CHD,
dyslipidemia, or diabetes as the primary condition, was respectively 13.3 percent, 20.9
percent, and 3.3 percent. By 2004 these probabilities rose to 50.3 percent, 51.6 percent
and 28 percent respectively (see Table 3). The probability of a patient diagnosed with
CHD not receiving any treatment dropped from 82 to 48 percent.
For persons diagnosed with coronary heart disease, coefficients for all age groups
are positive and statistically significant at the 10 percent level or higher (2 of 3 significant
at the 5 percent level), indicating these patients are more likely to receive statins than are
patients 75 and over. Although the coefficients are not all statistically significant, a
similar pattern is observed for other lipid lowering drugs. This pattern is likely to reflect
the controversy surrounding statins and their use on the elderly. While studies have
shown benefits of reducing LDL cholesterol in reducing the risk of heart attacks and
stroke, some research suggests that lowering cholesterol in the oldest age group may
increase the risk of death (MayoClinic.com, 2005).
Persons with dyslipidemia under the age of 45 were less likely to receive a statin
than were the oldest patients. Being in the 65 - 74 age cohort increases the probability of
being prescribed a statin compared to people in the over 75 age group. There is no age
pattern in the prescribing patterns for other lipid lowering drugs. In the case of diabetics,
no significant differences by age existed in prescribing patterns for statins. Diabetics
aged from 45 through 74 are more likely than the oldest cohorts to be prescribed other
Since men are generally at higher risk of developing CHD than women in the
same age group, we might expect that statins would be more likely to be prescribed to
men (other factors the same).11 Although the coefficient is positive, it is only significant
at the 10 % level, thus providing little support for this conclusion. For those with
dyslipidemia and diabetes, gender is not associated with prescribing patterns of statins or
Blacks and Hispanics with CHD are less likely than whites to be prescribed
statins, with the coefficients of each negative and significant at the 10% level. Hispanics
and Asians with dyslipidemia are also less likely than whites to receive a statin, with
11 See http://www.mayoclinic.com/health/coronary-artery-disease/DS00064
coefficients significant at the 5% level. There are no statistically significant racial
differences in prescribing patterns for statins for diabetes patients in the time period
under study. The only racial/ethnic differences in the ‘other lipid lowering drugs’
occurred with Black and Hispanic persons diagnosed with diabetes, where they are less
likely than whites to be prescribed OLAD drugs.
Table 3 presents the predicted probabilities of being prescribed a statin drug by
race/ethnicity group in 2004 for those with CHD, the main diagnosis group where race
disparities exist. The probabilities for Blacks, Hispanics, and whites in 2004 are
respectively 45 percent, 43.3 percent, and 50.9 percent. For persons with dyslipidemia,
the corresponding percentages are 53.8, 43.6, and 51. For diabetics, the figures for
Blacks, Hispanics, and whites are 25.8%, 31.8%, and 27.6.
Inclusion of variables indicating the method of payment for the patient’s visit
helps in determining the importance of insurance coverage on prescribing patterns of
physicians.12 Type of insurance coverage is important in the case of coronary heart
disease, where the coefficients of Medicare and Medicaid were negative and statistically
significant at the 5 percent level. Patients whose main source of payment was Medicaid
or Medicare were less likely to be prescribed a statin compared to patients with private
insurance. None of the other payment variables appear to be important explanatory
factors in the prescribing process for either statins or non-statin lipid-lowering drugs. For
samples including individuals diagnosed with dyslipidemia and diabetes, the insurance
12 Also to note is the likelihood that these insurance data are reflective of more than a price variable. Sincesocioeconomic data are not available in the NAMCS, method of payment may also be picking up effects offactors such as family income and education of the patient.
variables were never significant determinants of whether or not a patient received a statin
other than for unknown insurance where the patient was less likely than a privately
insurance patient to receive a statin. As shown in table 3, the probability of a CHD patient
being prescribed a statin in 2004 varies from 54.8 percent for those having private
insurance to 47.6 percent for those in the Medicare category and 38.3 percent for those
The presence of co-morbidities is stressed in clinical guidelines as an important
factor affecting decisions to prescribe lipid lowering drugs. The presence of a secondary
condition has a positive and statistically significant impact on the probability of being
prescribed a statin in 19 out of 32 combinations. Although the remaining coefficients are
not statistically significant, they are with three exceptions positive. 13
Table 3 shows the probabilities associated with the presence or absence of
secondary conditions for the samples with coronary heart disease, dyslipidemia, and
diabetes respectively. The probabilities of being prescribed a statin in 2004 are
calculated with all variables held at their means except for time (= 2004) and the
secondary condition indicated. The probability standing out for CHD patients occurs
when dyslipidemia is also present. In this case the probability rises to 75.4% (compared
to the mean for 2004 of 50.3%). Patients with dyslipidemia who have a secondary
condition of CHD, hypertension, or diabetes each have a probability of about 62% of
being prescribed a statin (compared to the probability at the means of 51.6%). Diabetics
at the mean values of the variables in 2004 have a probability of 28% of being prescribed
13 The only negative coefficients never approached statistical significance.
a statin. When the person had a secondary condition of CHD, dyslipidemia, or
dyslipidemia and CHD combined, the probabilities jumped to 44.9%, 57.9%, and 80.1%
respectively. All of these results support the clinical guidelines that persons with primary
conditions of CHD, dyslipidemia, and diabetes should be treated more aggressively than
those not having secondary conditions. Patients diagnosed with a primary condition of
CHD, dyslipidemia, or diabetes but no secondary condition, have a significantly lower
probability of receiving a statin drug, 44%, 45.8%, and 19.4% respectively.
The logit models reveal geographic disparities in prescribing patterns in the case
of CHD and dyslipidemia. The probability of being prescribed a statin tends to be lower
in all regions compared to the Northeast. CHD Patients residing in the Midwest and
South are also less likely to be prescribed other lipid lowering drugs than similarly
situated patients in the Northeast. Obviously, no clinical guidelines suggest that a patient
living in one region of the country should be more likely to receive statins. These
disparities add further support to the already documented differences in prescribing
patterns across the United States (Burton, 2001); such disparities no longer come as a
surprise, although they continue to foster concerns.
4. Summary and Conclusions
Coronary heart disease is the leading cause of death in the United States and high
levels of LDL cholesterol, along with diabetes, are risk factors for cardiovascular disease.
This, along with the fact that statin therapy lowers LDL cholesterol and is beneficial to
patients at risk for heart disease, including diabetics, led us to examine the prescribing
patterns of physicians for samples of patients who have primary diagnoses of coronary
heart disease, dyslipidemia, and diabetes. Obviously, the benefits from statins can be
realized only if physicians are prescribing them to patients at risk of CHD.
Our results provide further evidence of racial/ethnic disparities, in this instance
with respect for prescription drugs, since Blacks and Hispanics diagnosed with the
primary condition of coronary heart disease (CHD) are less likely to be prescribed a
statin. The predicted probabilities in 2004 for Blacks, Hispanics and whites are
respectively 45%, 43.3%, and 51% respectively. This result is troubling but consistent
with the results of the recent study conducted by the Institute of Medicine (IOM), which
found that in many aspects of health care, including cardiac, minorities receive lower
quality care compared to whites. The IOM study found persistent racial/ethnic
differences in care even after controlling for such factors as access to the system,
insurance status, and socioeconomic status.
Another major result is that CHD patients covered by Medicare or Medicaid were
less likely to have been prescribed a statin compared to their counterparts who have
private insurance. Medicaid (Medicare) patients were 16.5 (7.2) percentage points less
likely to receive a statin compared to similarly situated persons having private health
Patients having a risk factor along with their primary diagnosis were more likely
to receive a statin than those without a secondary condition. For example, the probability
is 75.4% for coronary heart patients who also have dyslipidemia. Diabetics exhibiting
co-morbidities of coronary heart disease or a combination of both coronary heart disease
and dyslipidemia have probabilities of 44.9 and 80.1 percent, respectively.
While the probability of being prescribed a statin has increased significantly over
time for persons of all races and insurance types, the disparity in probabilities across
races and insurance types has widened considerably. If this trend continues, non-white
and publicly insured persons will trail by an ever greater margin white and privately
insured persons for access to statins. Because of the racial issues associated with health
insurance as well as access to care, equity in regards to prescription drugs must be a
major issue in discussions of health care reform in the U.S.
American Heart Association (2005), Heart Disease and Stroke Statistics—2005 Update,
Dallas, Texas: American Heart Association. (2007), “Heart Disease and Stroke
Statistics -- 2007 Update At-a-Glance,” American Heart.org/statistics, Dallas, Texas:
American Heart Association. 1 On 1 Health: Diabetes Basics.
Burton T. M. (2001), “Study Finds Prescription Drug Use Varies Widely from State to
State.” The Wall Street Journal
. June 19.
Centers for Disease Control and Prevention (CDC), U.S Department of Health and
Human Services (2006a), “Chronic Disease – Preventing Heart Disease and
(http://apps.nccd.cdc.gov), Atlanta, GA.
Centers for Disease Control and Prevention (CDC), U.S Department of Health and
Human Services, (2006b), Division for Heart Disease and Stroke Prevention,
“Addressing the Nations’ Leading Killers, 2006, Strategies for a Heart-Healthy
and Stroke-Free America,” Centers for Disease and Control and Prevention
(http://apps.nccd.cdc.gov), Atlanta, GA.
Centers for Disease Control and Prevention (CDC) (2003), “National Diabetes Fact
Sheet: General Information and National Estimates on Diabetes in the United
States, 2003,” Atlanta, GA: U.S Department of Health and Human Services.
Centers for Disease Control and Prevention (CDC) (2005), “National Diabetes Fact
Sheet: General Information and National Estimates on Diabetes in the United States,
2005”, Atlanta, GA: U.S Department of Health and Human Services.
Cunningham, P.J., and May, Jessica H. (2006) “Medicaid Patients Increasingly
Concentrated Among Physicians.” Tracking Report 16, Center for Studying
Health System Change. Washington D.C.
DeNoon, Daniel (2003), WebMD Health: “Statins Cut Diabetes Heart Risk.”
The Doctor’s Lounge (2003), “Diabetics Should Receive Statins, New Study Says,”
Doty, Michelle M., Holmgren, Alyssa L. (2006), “Health Care Disconnect: Gaps in
Coverage and Care for Minority Adults: Findings from the Commonwealth Fund
Biennial Health Insurance Survey (2005).
” The Commonwealth Fund, August
Inglehart, John K. ed. (2005), Health Affairs
Hebert, P.R., Gaziano, J.M., et al (1997) “Cholesterol Lowering with Statin Drugs, Risk
of Stroke, and Total Mortality: An Overview of Randomized Trials.” Journal of
the American Medical Association
Kaiser Family Foundation, American College of Cardiology Foundation (2002),
Racial/Ethnic Differences in Cardiac Care: The Weight of the Evidence. Menlo
Park, CA: Henry J. Kaiser Family Foundation.
Knopp, R.H. (1999), “Drug Treatment of Lipid Disorders”. New England Journal of
LaRosa, J.C., He, J., Vupputuri, S. (1999), “Effect of Statins on Risk of Coronary
Disease. A Meta-analysis of Randomized Control Trials.” Journal of the
American Medical Association
Llanos, Karen and Palmer, Lindsay (2006), “Using Data on Race and Ethnicity to
Improve Health Care Quality for Medicaid Beneficiaries,” Center for Health Care
Strategies, Inc., Lawrenceville, NJ.
Manning, Anita (2004), “Statins Gain Wonder Status: But Dangers Mean Drug Is Not
For Everyone,” USA Today
, June 29, 2004, p. D1.
Mayo Clinic (2005), http://www.MayoClinic.com/health/highcholesterol/AN01079)
Mayo Clinic website (2007), http://www.mayoclinic.com/health/coronary-artery-
Pearson, Thomas A., (2007) “The Prevention of Cardiovascular Disease: Have We Really
Made Progress?” Health Affairs
, 26 (1), pp. 49-60.
Majumdar, Sumit R, Gurwitz, Jerry.H., Steven B. Soumerai, (1999) “Undertreatment of
Hyperlipidemia in the Secondary Prevention of Coronary Artery Disease.”
Journal of General Internal Medicine
Noonan, David (2003), “You Want Statins with That?” Newsweek,
July 14, 2003, pp. 48-
Smedley, B. D., Stith A.Y., Nelson, A.R. eds. (2002), Unequal Treatment: Confronting
Racial and Ethnic Disparities in Health Care, Institute of Medicine of the
National Academies. Washington, DC: National Academies Press.
Schappert S.M., & Nelson C.R. (1999), National Ambulatory Medical Care Survey,
1995-96 Summary, National Center for Health Statistics, Vital Health Stat 13
Szabo, Liz. “Hospital Inequalities Widen the Care Gap,” USA Today
, October 25, 2005,
U.S Department of Health and Human Services (2000), “1999 NAMCS Micro-Data File
Documentation,” Rockville, MD: National Center for Health Statistics.
Table 1: Selected Sample Means by Condition, NAMCS, 1992-2004
Table 2: Multinomial Logit Estimates for the Probability that a Statin is Prescribed by a
Physician, by Medical Condition of the Patient, 1992-2004 (Standard errors in
** = Significant at the 5% level.
* = Significant at the 10% level. No coronary heart disease sufferers who are prescribedan other lipid altering drug reported self pay insurance, resulting in a fixed parameter forthe combination of chd/olad/self pay.
Table 3: Predicted Probabilities Associated with a Patient Being Prescribed a Statin in
*The first (second) row is calculated at the means for all variables in 1992 (2004). Allother rows are for 2004, and assume that all variables but the one indicated in the row ofinterest are at their mean values for 2004.
Arbetsgruppsmaterial inför SDM-workshop 21 augusti 2013 5. Shared decision making for in-patients with schizophrenia. Hamann J, Langer B, Winkler V, Busch R, Cohen R, Leucht S, Kissling W Acta Psychiatry Scand. 2006 Oct;114(4): 265-73 SDM har i denna studie använts för att engagera patienterna i heldygnsvård i medicinska beslut för att förbättra resultatet av den medicinska behandling
Clinical course of sepsis in children with acute leukemia admitted to the pediatric intensive care unit* Kanakadurga Singer, MD, MA; Perla Subbaiah, PhD; Raymond Hutchinson, MD;Folafoluwa Odetola, MD, MPH; Thomas P. Shanley, MD Objective: To describe the clinical course, resource use, and inotropic and/or vasopressor drugs ( p ؍ .01), and renal replace- mortality of patients wi