Perceptions of Patients With Primary Nonadherence to Statin Medications

Derjung M. Tarn, MD, PhD; Maureen Barrientos, BA; Mark J. Pletcher, MD, MPH; Keith Cox, MA; Jon Turner, PhD; Alicia Fernandez, MD; Janice B. Schwartz, MD


J Am Board Fam Med. 2021;34(1):123-131. 

In This Article

Abstract and Introduction


Background: Despite emphasis on efforts to prevent cardiovascular disease (CVD), 13% to 34% of people never fill a prescribed statin (primary nonadherence). This study determined perceptions of adults with primary nonadherence to statins.

Methods: Ten focus groups were conducted with 61 adults reporting primary nonadherence to statins (93% without known CVD). Participants were recruited from an academic medical center and nationwide Internet advertisements.

Results: Major themes related to primary nonadherence were 1) desire to pursue alternatives before starting a statin (eg, diet and/or exercise, dietary supplements), 2) worry about risks and adverse effects of statins, 3) perceptions of good personal health (suggesting that a statin was not needed), and 4) doubt about the benefits of statins in the absence of disease. Additional themes included mistrust of the pharmaceutical industry, mistrust of prescribing providers, inadequate provider communication about statins, and negative prior experiences with medication. Although rare, a few patients said that high cholesterol does not require treatment if it is genetic. One third noted during focus group discussions that they did not communicate their decision not to take a statin to providers.

Conclusions: Adults with primary nonadherence to statins describe seeking alternatives, avoiding perceived risks of statins, poor acceptance/understanding of CVD risk estimates, and doubts about the benefits of statins. Many do not disclose their decisions to providers, thus highlighting the need for provider awareness of the potential for primary nonadherence at the point of prescribing, and the need for future work to develop strategies to identify patients with potential primary nonadherence.


Cardiovascular disease (CVD) is the United States' leading cause of morbidity, mortality, and rising health care costs,[1] but proven population-based CVD risk reduction strategies are often not fully used. Many organizations seek to reduce CVD risk factors such as high cholesterol.[2–8] Patients not meeting goals after lifestyle modification are prescribed HMG-CoA reductase inhibitors, commonly referred to as "statins," for CVD prevention.[9,10] But patients often do not take statins as prescribed. Secondary nonadherence (stopping or taking a medication differently than prescribed) is a recognized problem,[11,12] but it is less well recognized that 13% to 34% of people never fill a new statin prescription (primary nonadherence).[13–18]

While existing studies have identified the incidence and demographics associated with primary nonadherence, none have exclusively explored the reasons, attitudes, and beliefs behind primary statin nonadherence. This study aims to address this gap in understanding. Previous studies in the United States, all from one managed care health care system, suggest that patients with primary nonadherence tend to be English speaking, younger, Black, on no other medications, and have fewer comorbidities,[17–19] suggesting that they were prescribed statins for primary prevention. One study showed that most respondents had "general concerns" about statins, were scared of side effects, or failed to understand why statins were prescribed or their purpose.[17] Outside of these findings, the literature lacks a deeper understanding of the attitudes and beliefs of patients with primary statin nonadherence, the information patients consider before deciding not to start statins, or how primary statin nonadherence might be avoided. This focus group study was designed to investigate attitudes, beliefs, and perceptions of patients who chose not to fill their first prescription for a statin.