Understanding Statin Use in America and Gaps in Patient Education (USAGE): An internet-based survey of 10,138 current and former statin users


      Statins substantially reduce the risk of cardiovascular disease and are generally well-tolerated. Despite this, many patients discontinue therapy. A better understanding of the characteristics of current and former statin users may be helpful for formulating strategies to improve long-term adherence.


      The Understanding Statin Use in America and Gaps in Education (USAGE) survey assessed the attitudes, beliefs, practices, and behavior of current and former statin users.


      Individuals 18 years or older who reported a history of high cholesterol and current or former statin use were identified within a registered consumer panel cohort in the United States and invited to participate in an Internet survey.


      Of the 10,138 respondents, 8918 (88%) were current statin users and 1220 (12%) were former users. Participants (mean age 61 years) were predominantly white (92%), female (61%), of middle income (median $44,504/yr), and had health insurance (93%). Among current users, 95% took a statin alone, and 70% had not missed a dose in the past month. Although ∼70% reported that their physicians had explained the importance of cholesterol levels for their heart health former users were less satisfied with the discussions (65% vs. 83%, P < .05). Muscle-related side effects were reported by 60% and 25% of former and current users, respectively (P < .05). Nearly half of all respondents switched statins at least once. The primary reason for switching by current users was cost (32%) and the primary reason for discontinuation was side effects (62%).


      This survey provides important insights into behavior and attitudes among current and former statin users and the results suggest that more effective dialogue between healthcare providers and patients may increase persistence of statin use, particularly when the patient has concerns about side effects and drug costs.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Clinical Lipidology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Cheung B.M.
        • Lauder I.J.
        • Lau C.P.
        • Kumana C.R.
        Meta-analysis of large randomized controlled trials to evaluate the impact of statins on cardiovascular outcomes.
        Br J Clin Pharmacol. 2004; 57: 640-651
        • Baigent C.
        • Keech A.
        • Kearney P.M.
        • et al.
        • Cholesterol Treatment Trialists' (CTT) Collaborators
        Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins.
        Lancet. 2005; 366: 1267-1278
        • Thavendiranathan P.
        • Bagai A.
        • Brookhart M.A.
        • Choudhry N.K.
        Primary prevention of cardiovascular diseases with statin therapy: a meta-analysis of randomized controlled trials.
        Arch Intern Med. 2006; 166: 2307-2313
        • Delahoy P.J.
        • Magliano D.J.
        • Webb K.
        • Grobler M.
        • Liew D.
        The relationship between reduction in low-density lipoprotein cholesterol by statins and reduction in risk of cardiovascular outcomes: an updated meta-analysis.
        Clin Ther. 2009; 31: 236-244
        • Shalev V.
        • Chodick G.
        • Silber H.
        • Kokia E.
        • Jan J.
        • Heymann A.D.
        Continuation of statin treatment and all-cause mortality. A population-based cohort study.
        Arch Intern Med. 2009; 169: 260-268
        • Srinivasa Rao K.
        • Prasad T.
        • Mohanta G.P.
        • Manna P.K.
        An overview of statins as hypolipidemic drugs. I.
        Int J Pharm Sci Drug Res. 2011; 3: 178-183
      1. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults: Third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report.
        Circulation. 2002; 106: 3143-3421
        • Endo A.
        The origin of the statins. 2004.
        Atheroscler Suppl. 2004; 5: 125-130
      2. Centers for Disease Control and Prevention. Health, United States, 2010: In Brief. Available at: Accessed February 9, 2012.

        • Mann D.
        • Reynolds K.
        • Smith D.
        • Muntner P.
        Trends in statin use and low-density lipoprotein cholesterol levels among US adults: impact of the 2001 National Cholesterol Education Program guidelines.
        Ann Pharmacother. 2008; 42: 1208-1215
        • Davidson M.H.
        • Maki K.C.
        • Pearson T.A.
        • et al.
        Results of the National Cholesterol Education (NCEP) Program Evaluation Project Utilizing Novel E-Technology (NEPTUNE) II survey and implications for treatment under the recent NCEP Writing Group recommendations.
        Am J Cardiol. 2005; 96: 556-563
        • Keevil J.G.
        • Cullen M.W.
        • Gangnon R.
        • McBride P.E.
        • Stein J.H.
        Implications of cardiac risk and low-density lipoprotein cholesterol distributions in the United States for the diagnosis and treatment of dyslipidemia: Data from National Health and Nutrition Examination Survey 1999 to 2002.
        Circulation. 2007; 115: 1363-1370
        • Waters D.D.
        • Brotons C.
        • Chiang C.W.
        • et al.
        • Lipid Treatment Assessment Project 2 Investigators
        Lipid Treatment Assessment Project 2: A multinational survey to evaluate the proportion of patients achieving low-density lipoprotein goals.
        Circulation. 2009; 120: 28-34
        • Centers for Disease Control and Prevention
        Vital signs: prevalence, treatment, and control of high levels of low-density lipoprotein cholesterol—United States, 1999–2002 and 2005–2008.
        MMWR Morb Mortal Wkly Rep. 2011; 60: 109-114
        • Cohen J.D.
        • Cziraky M.J.
        • Cai Q.
        • et al.
        30-year trends in serum lipids among United States adults: Result from the National Health and Nutrition Examination Surveys II, III, and 1999–2006.
        Am J Cardiol. 2010; 106: 969-975
        • Vermeire E.
        • Hearnshaw H.
        • Van Royen P.
        • Denekens J.
        Patient adherence to treatment: three decades of research. A comprehensive review.
        J Clin Pharm Ther. 2001; 26: 331-342
        • Lardizabal J.A.
        • Deedwania P.C.
        Benefits of statin therapy and compliance in high risk cardiovascular patients.
        Vasc Health Risk Manag. 2010; 6: 843-853
        • Unni E.
        • Farris K.B.
        Determinants of different types of medication non-adherence in cholesterol lowering and asthma maintenance medications: a theoretical approach.
        Patient Educ Couns. 2011; 83: 382-390
        • Mann D.M.
        • Woodward M.
        • Muntner P.
        • Falzon L.
        • Kronish I.
        Predictors of nonadherence to statins: a systematic review and meta-analysis.
        Ann Pharmacother. 2010; 44: 1410-1421
        • Helin-Salmivaara A.
        • Lavikainen P.T.
        • Korhonen M.J.
        • et al.
        Pattern of statin use among 10 cohorts of new users from 1995 to 2004: a register-based nationwide study.
        Am J Manag Care. 2010; 16: 116-122
        • Rublee D.A.
        • Chen S.Y.
        • Mardekian J.
        • et al.
        Evaluation of cardiovascular morbidity associated with adherence to atorvastatin therapy.
        Am J Ther. 2012; 19: 24-32
        • McGinnis B.D.
        • Olson K.L.
        • Delate T.M.
        • Stolcpart R.S.
        Statin adherence and mortality in patients enrolled in a secondary prevention program.
        Am J Manag Care. 2009; 15: 689-695
        • The West of Scotland Coronary Prevention Study Group
        Compliance and adverse event withdrawal: Their impact on the West of Scotland Coronary Prevention Study.
        Eur Heart J. 1997; 18: 1718-1724
        • Simpson Jr., R.J.
        • Mendys P.
        The effects of adherence and persistence on clinical outcomes in patients treated with statins: a systematic review.
        J Clin Lipidol. 2010; 4: 462-471
        • Pollack M.F.
        • Purayidathil F.W.
        • Bolge S.C.
        • Williams S.A.
        Patient-reported tolerability issues with oral antidiabetic agents: associations with adherence; treatment satisfaction and health-related quality of life.
        Diabetes Res Clin Pract. 2010; 87: 204-210
        • Williams S.A.
        • Pollack M.F.
        • Dibonaventura M.
        Effects of hypoglycemia on health-related quality of life, treatment satisfaction and healthcare resource utilization in patients with type 2 diabetes mellitus.
        Diabetes Res Clin Pract. 2011; 91: 363-370
        • Osterberg L.
        • Blaschke T.
        Adherence to medication.
        N Engl J Med. 2005; 353: 487-497
      3. Barnes PM, Schoenborn CA. Trends in adults receiving a recommendation for exercise or other physical activity from a physician or other health professional. National Center for Health Statistics Data Brief. No. 86. February 2012. Available at: Accessed February 10, 2010.

        • Mann D.M.
        • Allegrante J.P.
        • Natarajan S.
        • Halm E.A.
        • Charlson M.
        Predictors of adherence to statins for primary prevention.
        Cardiovasc Drugs Ther. 2007; 21: 311-316
        • Brown M.T.
        • Bussell J.K.
        Medication adherence: WHO cares?.
        Mayo Clin Proc. 2011; 86: 304-314
        • Kashani A.
        • Phillips C.O.
        • Foody J.M.
        • et al.
        Risks associated with statin therapy: a systematic overview of randomized clinical trials.
        Circulation. 2006; 114: 2788-2797
        • Golomb B.A.
        • Evans M.A.
        Statin adverse effects: a review of the literature and evidence for a mitochondrial mechanism.
        Am J Cardiovasc Drugs. 2008; 8: 373-418
        • Huskamp H.A.
        • Deverka P.A.
        • Epstein A.M.
        • et al.
        The effect of incentive-based formularies on prescription-drug utilization and spending.
        N Engl J Med. 2003; 349: 2224-2232
        • Landsman P.B.
        • Yu W.
        • Liu X.
        • Teutsch S.M.
        • Berger M.L.
        Impact of 3-tier pharmacy benefit design and increased consumer cost-sharing on drug utilization.
        Am J Manag Care. 2005; 11: 621-628
        • Gibson T.B.
        • Mark T.L.
        • McGuigan K.A.
        • Axelsen K.
        • Wang S.
        The effects of prescription drug copayments on statin adherence.
        Am J Manag Care. 2006; 12: 509-517
        • Goldman D.P.
        • Joyce G.F.
        • Karaca-Mandic P.
        Varying pharmacy benefits with clinical status: The case of cholesterol-lowering therapy.
        Am J Manag Care. 2006; 12: 21-28
        • McHorney C.A.
        The Adherence Estimator: a brief, proximal screener for patient propensity to adhere to prescription medications for chronic disease.
        Curr Med Res Opin. 2009; 25: 215-238
        • Kon R.H.
        • Russo M.W.
        • Ory B.
        • Mendys P.
        • Simpson Jr., R.J.
        Misperception among physicians and patients regarding the risks and benefits of statin treatment: the potential role of direct-to-consumer advertising.
        J Clin Lipidol. 2008; 2: 51-57
        • McKenney J.M.
        A symposium: report of the National Lipid Association's Statin Safety Task Force.
        Am J Cardiol. 2006; 97: 1C-3C
        • Elder J.P.
        • Ayala G.X.
        • Harris S.
        Theories and intervention approaches to health behavior change in primary care.
        Am J Prev Med. 1999; 17: 275-284
        • Jackevicius C.A.
        • Mamdani M.
        • Tu J.V.
        Adherence with statin therapy in elderly patients with and without acute coronary syndromes.
        JAMA. 2002; 288: 462-467
        • Benner J.S.
        • Glynn R.J.
        • Mogun H.
        • Neumann P.J.
        • Weinstein M.C.
        • Avorn J.
        Long-term persistence in use of statin therapy in elderly patients.
        JAMA. 2002; 288: 455-461
        • Yang C.C.
        • Jick S.S.
        • Testa M.A.
        Discontinuation and switching of therapy after initiation of lipid-lowering drugs: the effects of comorbidities and patient characteristics.
        Br J Clin Pharmacol. 2003; 56: 84-91
        • Perreault S.
        • Blais L.
        • Lamarre D.
        • et al.
        Persistence and determinants of statin therapy among middle-aged patients for primary and secondary prevention.
        Br J Clin Pharmacol. 2005; 59: 564-573
        • Poluzzi E.
        • Strahinja P.
        • Lanzoni M.
        • et al.
        Adherence to statin therapy and patients' cardiovascular risk: a pharmacoepidemiological study in Italy.
        Eur J Clin Pharmacol. 2008; 64: 425-432
        • Ellis J.J.
        • Erickson S.R.
        • Stevenson J.G.
        • et al.
        Suboptimal statin adherence and discontinuation in primary and secondary prevention populations. Should we target patients with the most to gain?.
        J Gen Intern Med. 2004; 19: 638-645
        • Clark L.T.
        • Maki K.C.
        • Galant R.
        • et al.
        Ethnic difference in achievement of cholesterol treatment goals. Results from the National Cholesterol Education Program Evaluation Project Utilizing Novel E-technology II.
        J Gen Intern Med. 2006; 21: 320-326
      4. U.S. Census Bureau: State and country quickfacts. Available at: Accessed February 9, 2012.

      5. DeNavas-Walt C, Proctor BD, Smith JC. Income, poverty, and health insurance coverage in the United States: 2010. U.S. Census Bureau. Issued September 2011. Available at:–239.pdf. Accessed March 3, 2012.

        • Okura Y.
        • Urban L.H.
        • Mahoney D.W.
        • et al.
        Agreement between self-report questionnaires and medical record data was substantial for diabetes, hypertension, myocardial infarction and stroke but not for heart failure.
        J Clin Epidemiol. 2004; 57: 1096-1103