Suboptimal Statin Adherence and Discontinuation in Primary and Secondary Prevention Populations

Should We Target Patients with the Most to Gain?


  • Jeffrey J. Ellis PharmD, MS,

    Corresponding authorSearch for more papers by this author
  • Steven R. Erickson PharmD,

  • James G. Stevenson PharmD,

  • Steven J. Bernstein MD,

  • Renee A. Stiles PhD,

  • A. Mark Fendrick MD

  • Received from the Department of Pharmacy Services (JJE, SRE, JGS), University of Michigan Hospitals and Health Centers; Department of Clinical Sciences (JJE, SRE, JGS), College of Pharmacy, University of Michigan; VA Ann Arbor Healthcare System (SJB); Division of General Internal Medicine (SJB, AMF), Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Mich; Division of General Internal Medicine (RAS), Department of Internal Medicine, Vanderbilt University, Nashville, Tenn; and Department of Health Management and Policy (AMF), School of Public Health, University of Michigan, Ann Arbor, Mich.

    Dr. Ellis is now with the Department of Pharmacy, Cleveland Clinic Foundation, Cleveland, Ohio.

    This research was presented in part at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 7th Annual International Meeting, Arlington, Va, May 19–22, 2002.

Address correspondence and requests for reprints to Dr. Ellis: Cleveland Clinic Foundation, Department of Pharmacy—QQb5, 9500 Euclid Avenue, Cleveland, OH 44195 (e-mail:


OBJECTIVES:  To compare statin nonadherence and discontinuation rates of primary and secondary prevention populations and to identify factors that may affect those suboptimal medication-taking behaviors.

DESIGN:  Retrospective cohort utilizing pharmacy claims and administrative databases.

SETTING:  A midwestern U.S. university-affiliated hospital and managed care organization (MCO).

PATIENTS:  Non-Medicaid MCO enrollees, 18 years old and older, who filled 2 or more statin prescriptions from January 1998 to November 2001; 2,258 secondary and 2,544 primary prevention patients were identified.

MEASUREMENTS:  Nonadherence was assessed by the percent of days without medication (gap) over days of active statin use, a measurement known as cumulative multiple refill-interval gap (CMG). Discontinuation was identified by cessation of statin refills prior to the end of available pharmacy claims data.

RESULTS:  On average, the primary and secondary groups went without medication 20.4% and 21.5% of the time, respectively (P= .149). Primary prevention patients were more likely to discontinue statin therapy relative to the secondary prevention cohort (relative risk [RR], 1.24; 95% confidence interval [CI], 1.08 to 1.43). Several factors influenced nonadherence and discontinuation. Fifty percent of patients whose average monthly statin copayment was <$10 discontinued by the end of follow-up (3.9 years), whereas 50% of those who paid >$10 but ≤$20 and >$20 discontinued by 2.2 and 1.0 years, respectively (RR, 1.39 and 4.30 relative to <$10 copay, respectively).

CONCLUSIONS:  Statin nonadherence and discontinuation was suboptimal and similar across prevention categories. Incremental efforts, including those that decrease out-of-pocket pharmaceutical expenditures, should focus on improving adherence in high-risk populations most likely to benefit from statin use.