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

Disclosures

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

In This Article

Discussion

The focus group interviews in this study elucidated why adults might choose primary nonadherence to statins. Participants discussed 4 major themes influencing their decisions: 1) desire for alternative treatments, 2) worry about the risks of statins, 3) perceptions of good personal health, and 4) uncertainty about the benefits of statin use. Existing literature shows that patients in general do not wish to take new medications, and may go to extremes to avoid using them.[30] Many themes identified in this study echoed those found in other studies examining patient perspectives toward statins and on reasons underlying nonadherence to other medications such as antihypertensive drugs.[31,32] However, with its focus on primary nonadherence to statins (mostly for primary CVD prevention), this study goes beyond the existing literature by illustrating that primary nonadherence to statin medications reflects a decision making process that is weighted toward belief in individual ability to alter lifestyle, diet, or exercise to reduce cholesterol levels, and minimization of personal risk and the potential benefit of a statin in the absence of symptomatic conditions/disease. Laboratory cutoff points and guideline-based risk assessments did not seem to convince participants that a statin medication was necessary.

It makes intuitive sense that people who perceive themselves to be at low risk for an adverse medical outcome may want to delay starting a newly prescribed chronic medication and to first try alternative measures. While we did not examine participant medical records or calculate CVD risks, limited medication use and young mean age of participants support their lack of reported CVD. Participant preferences for lifestyle or dietary modifications align with most guidelines recommending initial primary prevention in people with high cholesterol without CVD.[3,6] It is reassuring that most participants would reconsider statin use if their efforts failed to lower their cholesterol, if their cholesterol levels increased, or if they developed CVD. Thus, this decision may be mutable but may require time for individuals to process information or try alternatives. Providers need to find better ways to convey concepts regarding CVD risk, achievable goals from lifestyle modification, and the lack of evidence for dietary supplements in improving CVD risk, as well as the evidence of benefits of statins. Discussions about 10-year risk calculators may need proper context and framing for patients who worry mostly about their immediate risks for adverse outcomes.

One-third of all focus group participants did not inform their providers about their nonadherence to the statin. This finding is limited and requires additional exploration because not all participants commented on this topic. In the absence of this communication, there is no opportunity to address poor understanding about the role of statins for primary prevention of CVD, the risks of statin therapy and ways to monitor or minimize them, or the opportunity to develop a plan to reduce their cardiovascular risk over time.

Previous studies have shown lapses in provider communication around newly prescribed medications.[33,34] In this study, some participants revealed that gaps in communication contributed to their unwillingness to start a statin. Providers often are reluctant to question or confront patients about nonadherence,[23] but our data suggest that it is important to assess a patient's stance toward statins at the time of prescribing, to make sure patients know providers are considering their individual situations, to tailor discussions to address individual patient concerns, and to ensure that patients have follow-up appointments to assess adherence. Reluctant patients would likely benefit from a trial of lifestyle or dietary changes, or other preferred treatment modalities. Providers could use discussions regarding the duration and goals of the trial. Follow-up visits would ascertain success in meeting goals, address individual patient concerns about the benefits and risks of statins, and help patients better understand their personal risks for cardiovascular events.[35] If goals were met in the short term, a plan for future reassessment could be established.

Mistrust was commonly raised during the focus group discussions. Mistrust of the pharmaceutical industry led some participants to question the validity of scientific guidelines, and even their providers' motives for prescribing statins. This erosion of trust likely influences people's ability to trust that population-based guidelines apply to individuals, and to accept that the benefits of statins outweigh the risks. Thus, for some patients, restoring trust in the pharmaceutical industry or strengthening trust in their physician may be crucial to their acceptance of treatments that are beneficial to their health.

Study limitations include those inherent to focus group studies, such as potential lack of transferability due to participant self-selection.[36] Electronic health record identification of patients with primary nonadherence was inaccurate and yielded insufficient numbers of patients for purposive sampling based on patient characteristics. Thus, most of our participants were recruited from online advertisements, and the majority of the participants used the Internet. However, Internet usage is growing, with 87% and 66% of adults aged 50 to 64 years and aged 65+ years, respectively, using the internet in 2018.[37] We discovered during focus group discussions that a small number of participants in 3 focus groups had secondary, rather than primary, nonadherence. All the themes raised by these patients were consistent with those mentioned by patients with primary nonadherence. The majority of patients in this study were prescribed a statin for primary, rather than for secondary CVD prevention, so additional studies may be needed to assess potential differences in attitudes of those prescribed a statin for secondary prevention.

In conclusion, this study describes patients' wishes to choose their own lifestyle or dietary changes, their concerns regarding the risks of statins, and their lack of understanding of personal risks necessitating statin use and potential benefits of statin therapy as major contributors to primary nonadherence to statins in people without CVD. In addition, we found that patients often do not communicate their decision not to take a statin to their providers. The work identifies promising targets for improvement that could help reduce cardiovascular risks.

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