NIHR DC Discover

Patient taking medication and being advised by doctor

NIHR Signal People take prescribed statins more reliably after discussing their advantages and disadvantages

Published on 11 September 2018

doi: 10.3310/signal-000642

Patients want to know more about how statins work, the reasons for prescribing them and their possible side effects.

Statins lower cholesterol and reduce the risk of recurrent stroke or heart attack. They also help prevent cardiovascular disease developing in people at high risk. At a population, level statins reduce the overall incidence of cardiovascular disease for people at moderate risk, but the benefits for an individual are less clear-cut.

This review found that people are happy to take statins if they believe they will prolong good quality of life.  Barriers include mistrust and scepticism about over-prescribing. Worry about possible debilitating side effects, toxicity and fear of long-term dependence on statins were also identified.

Frank conversations about the benefits and risks for each individual with discussion addressing the patient’s specific concerns, priorities and goals are an important step in facilitating statin use and adherence.

Share your views on the research.

Why was this study needed?

Cardiovascular disease (CVD) is an umbrella term for conditions affecting the heart and blood vessels. These cause over 150,000 deaths and cost the UK economy about £19 billion each year. Though death rates from CVD are falling, hospital admissions for CVD appear to be rising.

Over half of adults in England have raised cholesterol (>5mmol/l), increasing their risk of CVD. In people with an increased risk, a reduction of 1mmol/l cholesterol by taking statins would decrease their incidence of heart attacks and strokes by 20 to 24%.

As there are clear benefits at a population level, GPs have been incentivised to prescribe statins. But this has created mistrust as the benefits for individuals at moderate risk may be minimal and not outweigh the drawbacks.

This study explores factors affecting people’s decision to take statins as the majority of those eligible are not using them.

What did this study do?

This systematic review reported on the perspectives of 888 adults about taking statins. The 32 qualitative studies were conducted across eight countries, mostly in the UK and US. At least 41% of participants had taken statins. Studies included people who were at risk of developing CVD (primary prevention) and people who were advised to take statins to prevent a further heart attack or stroke (secondary prevention). Most studies used face-to-face interviews.

Many of the studies were not reported comprehensively. Information regarding comorbidities was often unavailable. Nevertheless, the study provides valuable insights into a broad range of opinions that are likely to be representative of the UK general population.

What did it find?

  • Five main themes emerged as barriers to the use of statins: scepticism about clinician’s motivation; side effects and possible toxicity; cost; unclear benefits, and fear of dependence on statins.
  • Two themes drove statin usage: believing statins work and are a positive step to prolonging good quality of life, and convenience of fitting them into the daily routine.
  • Those who took statins reported noticeable improvements in their cholesterol levels from blood tests which encouraged further use.
  • When used for secondary prevention, patients felt that statins were the main reason for improvement in their condition. They were viewed as more effective than behavioural and dietary modification.
  • To enable informed decision making, patients wanted more specific information on the mechanism of action of statins.

What does current guidance say on this issue?

The NICE 2014 guideline on CVD recommends that the decision to start statins should occur after an informed discussion between the patient and clinician. This should explore risks and benefits, patient preference, comorbidities, polypharmacy (taking multiple medications), general frailty and life expectancy. The aim is to reduce total cholesterol to less than 5mmol/l.

The NICE clinical guideline on medicines adherence also recommends that any interventions should be considered on a case˗by˗case basis, addressing the concerns and needs of individual patients.

What are the implications?

The current recommendations in this study are broadly in line with NICE’s recommendations about informed discussion. This paper provides useful conversation points for primary care practitioners to have with their patients. Building trust and a focus on the patient’s specific concerns, priorities and goals will help with shared decision-making on whether or not to take statins.

Citation and Funding

Ju A, Hanson CS, Banks E, et al. Patient beliefs and attitudes to taking statins: systematic review of qualitative studies. Br J Gen Pract. 2018;68(671):e408-19.

This work is supported by a National Health and Medical Research Council Partnership Grant (NHMRC) (1092674) (Australia), including support from the National Heart Foundation of Australia, and an NHMRC Program Grant (1092597). Allison Tong and Emily Banks are supported by NHMRC Fellowships (1106716 and 1042717, respectively).

Bibliography

Bhatnagar P, Wickramasinghe K, Wilkins E, et al. Trends in the epidemiology of cardiovascular disease in the UK. Heart. 2016;102(24):1945-52.

BHF. CVD statistics – BHF UK factsheet. London: British Heart Foundation; 2018.

NICE. Cardiovascular disease: risk assessment vascular disease: risk assessment and reduction, including lipid and reduction, including lipid modification. CG181. London: National Institute for Health and Care Excellence; 2014.

PHE. Using the world leading NHS Health Check programme to prevent CVD. London: Public Health England; 2018.

Why was this study needed?

Cardiovascular disease (CVD) is an umbrella term for conditions affecting the heart and blood vessels. These cause over 150,000 deaths and cost the UK economy about £19 billion each year. Though death rates from CVD are falling, hospital admissions for CVD appear to be rising.

Over half of adults in England have raised cholesterol (>5mmol/l), increasing their risk of CVD. In people with an increased risk, a reduction of 1mmol/l cholesterol by taking statins would decrease their incidence of heart attacks and strokes by 20 to 24%.

As there are clear benefits at a population level, GPs have been incentivised to prescribe statins. But this has created mistrust as the benefits for individuals at moderate risk may be minimal and not outweigh the drawbacks.

This study explores factors affecting people’s decision to take statins as the majority of those eligible are not using them.

What did this study do?

This systematic review reported on the perspectives of 888 adults about taking statins. The 32 qualitative studies were conducted across eight countries, mostly in the UK and US. At least 41% of participants had taken statins. Studies included people who were at risk of developing CVD (primary prevention) and people who were advised to take statins to prevent a further heart attack or stroke (secondary prevention). Most studies used face-to-face interviews.

Many of the studies were not reported comprehensively. Information regarding comorbidities was often unavailable. Nevertheless, the study provides valuable insights into a broad range of opinions that are likely to be representative of the UK general population.

What did it find?

  • Five main themes emerged as barriers to the use of statins: scepticism about clinician’s motivation; side effects and possible toxicity; cost; unclear benefits, and fear of dependence on statins.
  • Two themes drove statin usage: believing statins work and are a positive step to prolonging good quality of life, and convenience of fitting them into the daily routine.
  • Those who took statins reported noticeable improvements in their cholesterol levels from blood tests which encouraged further use.
  • When used for secondary prevention, patients felt that statins were the main reason for improvement in their condition. They were viewed as more effective than behavioural and dietary modification.
  • To enable informed decision making, patients wanted more specific information on the mechanism of action of statins.

What does current guidance say on this issue?

The NICE 2014 guideline on CVD recommends that the decision to start statins should occur after an informed discussion between the patient and clinician. This should explore risks and benefits, patient preference, comorbidities, polypharmacy (taking multiple medications), general frailty and life expectancy. The aim is to reduce total cholesterol to less than 5mmol/l.

The NICE clinical guideline on medicines adherence also recommends that any interventions should be considered on a case˗by˗case basis, addressing the concerns and needs of individual patients.

What are the implications?

The current recommendations in this study are broadly in line with NICE’s recommendations about informed discussion. This paper provides useful conversation points for primary care practitioners to have with their patients. Building trust and a focus on the patient’s specific concerns, priorities and goals will help with shared decision-making on whether or not to take statins.

Citation and Funding

Ju A, Hanson CS, Banks E, et al. Patient beliefs and attitudes to taking statins: systematic review of qualitative studies. Br J Gen Pract. 2018;68(671):e408-19.

This work is supported by a National Health and Medical Research Council Partnership Grant (NHMRC) (1092674) (Australia), including support from the National Heart Foundation of Australia, and an NHMRC Program Grant (1092597). Allison Tong and Emily Banks are supported by NHMRC Fellowships (1106716 and 1042717, respectively).

Bibliography

Bhatnagar P, Wickramasinghe K, Wilkins E, et al. Trends in the epidemiology of cardiovascular disease in the UK. Heart. 2016;102(24):1945-52.

BHF. CVD statistics – BHF UK factsheet. London: British Heart Foundation; 2018.

NICE. Cardiovascular disease: risk assessment vascular disease: risk assessment and reduction, including lipid and reduction, including lipid modification. CG181. London: National Institute for Health and Care Excellence; 2014.

PHE. Using the world leading NHS Health Check programme to prevent CVD. London: Public Health England; 2018.

Patient beliefs and attitudes to taking statins: systematic review of qualitative studies

Published on 23 May 2018

Ju, A.,Hanson, C. S.,Banks, E.,Korda, R.,Craig, J. C.,Usherwood, T.,MacDonald, P.,Tong, A.

Br J Gen Pract , 2018

BACKGROUND: Statins are effective in preventing cardiovascular disease (CVD) events and are recommended for at-risk individuals but estimated adherence rates are low. AIM: To describe patients' perspectives, experiences, and attitudes towards taking statins. DESIGN AND SETTING: Systematic review of qualitative studies reporting perspectives of patients on statins. METHOD: PsycINFO, CINAHL, Embase, MEDLINE, and PhD dissertations from inception to 6 October 2016 were searched for qualitative studies on adult patients' perspectives on statins. All text and participant quotations were extracted from each article and analysed by thematic synthesis. RESULTS: Thirty-two studies involving 888 participants aged 22-93 years across eight countries were included. Seven themes were identified: confidence in prevention (trust in efficacy, minimising long-term catastrophic CVD, taking control, easing anxiety about high cholesterol); routinising into daily life; questioning utility (imperceptible benefits, uncertainties about pharmacological mechanisms); medical distrust (scepticism about overprescribing, pressure to start therapy); threatening health (competing priorities and risks, debilitating side effects, toxicity to body); signifying sickness (fear of perpetual dependence, losing the battle); and financial strain. CONCLUSION: An expectation that statins could prevent CVD and being able to integrate the statin regimen in daily life facilitated acceptance of statins among patients. However, avoiding the 'sick' identity and prolonged dependence on medications, uncertainties about the pharmacological mechanisms, risks to health, side effects, costs, and scepticism about clinicians' motives for prescribing statins were barriers to uptake. Shared decision making that addresses the risks, reasons for prescribing, patient priorities, and implementing strategies to minimise lifestyle intrusion and manage side effects may improve patient satisfaction and continuation of statins.

Expert commentary

This paper provides prescribers who want to help patients make the most of their statins, thereby optimising medicines, with specific issues they can usefully explore. Establishing the patient’s orientation in terms of trust or distrust may be a good starting point. Other motivating factors are primary or secondary prevention, and other medications already being taken.

The paper does not focus on patients’ trajectories but once started, issues such as side effects, the challenges of incorporation into everyday life, and perceived dependence may be more salient. The conversation may need to continue across several consultations.

Nicky Britten, Professor of Applied Health Care Research, University of Exeter Medical School