• David A Frank, Amber E Johnson, HausmannLeslie R MLRM0000-0002-3909-6009Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, and Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylva, Walid F Gellad, Eric T Roberts, and Ravy K Vajravelu.
• Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, and Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania (D.A.F.).
• Ann. Intern. Med. 2023 Aug 1; 176 (8): 105710661057-1066.

BackgroundAlthough statins are a class I recommendation for prevention of atherosclerotic cardiovascular disease and its complications, their use is suboptimal. Differential underuse may mediate disparities in cardiovascular health for systematically marginalized persons.ObjectiveTo estimate disparities in statin use by race-ethnicity-gender and to determine whether these potential disparities are explained by medical appropriateness of therapy and structural factors.DesignCross-sectional analysis.SettingNational Health and Nutrition Examination Survey from 2015 to 2020.ParticipantsPersons eligible for statin therapy based on 2013 and 2018 American College of Cardiology/American Heart Association blood cholesterol guidelines.MeasurementsThe independent variable was race-ethnicity-gender. The outcome of interest was use of a statin. Using the Institute of Medicine framework for examining unequal treatment, we calculated adjusted prevalence ratios (aPRs) to estimate disparities in statin use adjusted for age, disease severity, access to health care, and socioeconomic status relative to non-Hispanic White men.ResultsFor primary prevention, we identified a lower prevalence of statin use that was not explained by measurable differences in disease severity or structural factors among non-Hispanic Black men (aPR, 0.73 [95% CI, 0.59 to 0.88]) and non-Mexican Hispanic women (aPR, 0.74 [CI, 0.53 to 0.95]). For secondary prevention, we identified a lower prevalence of statin use that was not explained by measurable differences in disease severity or structural factors for non-Hispanic Black men (aPR, 0.81 [CI, 0.64 to 0.97]), other/multiracial men (aPR, 0.58 [CI, 0.20 to 0.97]), Mexican American women (aPR, 0.36 [CI, 0.10 to 0.61]), non-Mexican Hispanic women (aPR, 0.57 [CI, 0.33 to 0.82), non-Hispanic White women (aPR, 0.69 [CI, 0.56 to 0.83]), and non-Hispanic Black women (aPR, 0.75 [CI, 0.57 to 0.92]).LimitationCross-sectional data; lack of geographic, language, or statin-dose data.ConclusionStatin use disparities for several race-ethnicity-gender groups are not explained by measurable differences in medical appropriateness of therapy, access to health care, and socioeconomic status. These residual disparities may be partially mediated by unobserved processes that contribute to health inequity, including bias, stereotyping, and mistrust.Primary Funding SourceNational Institutes of Health.

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