JMIR Publications

ABSTRACT

Background:

Background:

Atherosclerotic cardiovascular disease (ASCVD) remains a major global health burden, with statins recommended for primary and secondary prevention in eligible patients with elevated low-density lipoprotein cholesterol (LDL-C) or CVD risk. Despite guidelines, disparities in statin prescriptions persist, often linked to demographics like race and gender. However, geographic and socioeconomic status (SES) factors, potentially involving systemic barriers beyond patient-level issues, have received limited synthesis.

Objective:

Objective:

To systematically review the evidence on socioeconomic and geographic disparities in statin prescription, adherence, intensity, and access among eligible adults.

Methods:

Methods:

We conducted a systematic review following PRISMA guidelines and the Cochrane Handbook (prospective protocol, not registered). From database inception to 20 January 2025, we searched Ovid MEDLINE, Embase, Global Health, Healthstar, APA PsycInfo, and PubMed. Eligible English-language peer-reviewed studies included adults (≥18 years) newly or previously prescribed common statins, with data on prescription patterns stratified by SES (insurance, income, education, employment) or geography. Three reviewers independently performed title/abstract and full-text screening using Covidence (inter-rater agreement Cohen κ ≥0.95). Narrative synthesis was used owing to clinical and methodological heterogeneity.

Results:

Results:

Of 323 records identified, 58 studies (predominantly observational cohorts from North America and Europe) were included. Lack of insurance was strongly associated with lower statin prescription (pooled OR 0.57, 95% CI 0.44–0.73). Lower education and unemployment showed inconsistent associations, sometimes attenuated by social safety nets. Low-income patients received fewer days of therapy and lower supply despite subsidy programs (e.g., 16–28% reductions under US Medicare Low-Income Subsidy). Geographic variation was marked by higher initial prescription rates but poorer adherence and lower dosages in rural areas (e.g., rural South Korea adherence OR 0.963). Cost, limited access to screening, and clinician bias emerged as key barriers.

Conclusions:

Conclusion: Socioeconomic and geographic disparities in statin use are widespread and driven largely by institutional and societal factors rather than clinical need. Policy efforts should prioritize universal coverage, enhanced subsidies, clinician education on bias, and targeted rural outreach to improve equitable access.