Prevalent but moderate variation across small geographic regions in patient nonadherence to evidence-based preventive therapies in older adults after acute myocardial infarction

Geographic Variation of Statin Use Among US Nursing Home Residents With Life-limiting Illness

BACKGROUND

Medically compromised nursing home residents continue to be prescribed statins, despite questionable benefits.

OBJECTIVE

To describe regional variation in statin use among residents with life-limiting illness.

RESEARCH DESIGN

Cross-sectional study using 2016 Minimum Data Set 3.0 assessments linked to Medicare administrative data and health service utilization area resource files.

SETTING

Nursing homes (n=14,147) within hospital referral regions (n=306) across the United States.

SUBJECTS

Long-stay residents (aged 65 y and older) with life-limiting illness (eg, serious illness, palliative care, or prognosis <6 mo to live) (n=361,170).

MEASURES

Prevalent statin use was determined by Medicare Part D claims. Stratified by age (65-75, 76 y or older), multilevel logistic models provided odds ratios with 95% confidence intervals.

RESULTS

Statin use was prevalent (age 65-75 y: 46.0%, 76 y or more: 31.6%). For both age groups, nearly all resident-level variables evaluated were associated with any and high-intensity statin use and 3 facility-level variables (ie, higher proportions of Black residents, skilled nursing care provided, and average number of medications per resident) were associated with increased odds of statin use. Although in residents aged 65-75 years, no associations were observed, residents aged 76 years or older located in hospital referral regions (HRRs) with the highest health care utilization had higher odds of statin use than those in nursing homes in HRRs with the lowest health care utilization.

CONCLUSIONS

Our findings suggest extensive geographic variation in US statin prescribing across HRRs, especially for those aged 76 years or older. This variation may reflect clinical uncertainty given the largely absent guidelines for statin use in nursing home residents.

Medication Adherence After Acute Coronary Syndrome in Women Compared With Men: A Systematic Review and Meta-Analysis

Introduction: Pharmacological treatment is an important component of secondary prevention in acute coronary syndrome (ACS) survivors. However, adherence to medication regimens is often suboptimal, reducing the effectiveness of treatment. It has been suggested that sex influences adherence to cardiovascular medication, but results differ across studies, and a systematic overview is lacking. Methods: We performed a systematic search of PubMed and EMBASE on 16 October 2019. Studies that reported sex-specific adherence for one or more specific medication classes for ACS patients were included. Odds ratios, or equivalent, were extracted per medication class and combined using a random effects model. Results: In total, we included 28 studies of which some had adherence data for more than one medication group. There were 7 studies for angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) (n = 100,909, 37% women), 8 studies for antiplatelet medication (n = 37,804, 27% women), 11 studies for beta-blockers (n = 191,339, 38% women), and 17 studies for lipid-lowering medication (n = 318,837, 35% women). Women were less adherent to lipid-lowering medication than men (OR = 0.87, 95% CI 0.82-0.92), but this sex difference was not observed for antiplatelet medication (OR = 0.95, 95% CI 0.83-1.09), ACEIs/ARBs (OR = 0.95, 95% CI 0.78-1.17), or beta-blockers (OR = 0.97, 95% CI 0.86-1.11). Conclusion: Women with ACS have poorer adherence to lipid-lowering medication than men with the same condition. There are no differences in adherence to antiplatelet medication, ACEIs/ARBs, and beta-blockers between women and men with ACS.

Comparison of a new 3-item self-reported measure of adherence to medication with pharmacy claims data in patients with cardiometabolic disease

BACKGROUND

Less than half of patients with cardiometabolic disease consistently take prescribed medications. While health insurers and some delivery organizations use claims to measure adherence, most clinicians do not have access during routine interactions. Self-reported scales exist, but their practical utility is often limited by length or cost. By contrast, the accuracy of a new 3-item self-reported measure has been demonstrated in individuals with HIV. We evaluated its concordance with claims-based adherence measures in cardiometabolic disease.

METHODS

We used data from a recently-completed pragmatic trial of patients with cardiometabolic conditions. After 12 months of follow-up, intervention subjects were mailed a survey with the 3-item measure that queries about medication use in the prior 30 days. Responses were linearly transformed and averaged. Adherence was also measured in claims in month 12 and months 1-12 of the trial using proportion of days covered (PDC) metrics. We compared validation metrics for non-adherence for self-report (average <0.80) compared with claims (PDC <0.80).

RESULTS

Of 459 patients returning the survey (response rate: 43.5%), 50.1% were non-adherent in claims in month 12 while 20.9% were non-adherent based on the survey. Specificity of the 3-item metric for non-adherence was high (month 12: 0.83). Sensitivity was relatively poor (month 12: 0.25). Month 12 positive and negative predictive values were 0.59 and 0.52, respectively.

CONCLUSIONS

A 3-item self-reported measure has high specificity but poor sensitivity for non-adherence versus claims in cardiometabolic disease. Despite this, the tool could help target those needing adherence support, particularly in the absence of claims data.

Association of Region and Hospital and Patient Characteristics With Use of High-Intensity Statins After Myocardial Infarction Among Medicare Beneficiaries

Importance

High-intensity statin use after myocardial infarction (MI) varies by patient characteristics, but little is known about differences in use by hospital or region.

Objective

To explore the relative strength of associations of region and hospital and patient characteristics with high-intensity statin use after MI.

Design, Setting, and Participants

This retrospective cohort analysis used Medicare administrative claims and enrollment data to evaluate fee-for-service Medicare beneficiaries 66 years or older who were hospitalized for MI from January 1, 2011, through June 30, 2015, with a statin prescription claim within 30 days of discharge. Data were analyzed from January 4, 2017, through May 12, 2019.

Exposures

Beneficiary characteristics were abstracted from Medicare data. Hospital characteristics were obtained from the 2014 American Hospital Association Survey and Hospital Compare quality metrics. Nine regions were defined according to the US Census.

Main Outcomes and Measures

Intensity of the first statin claim after discharge characterized as high (atorvastatin calcium, 40-80 mg, or rosuvastatin calcium, 20-40 mg/d) vs low to moderate (all other statin types and doses). Trends in high-intensity statins were examined from 2011 through 2015. Associations of region and beneficiary and hospital characteristics with high-intensity statin use from January 1, 2014, to June 15, 2015, were examined using Poisson distribution mixed models.

Results

Among the 139 643 fee-for-service beneficiaries included (69 968 men [50.1%] and 69 675 women [49.9%]; mean [SD] age, 76.7 [7.5] years), high-intensity statin use overall increased from 23.4% in 2011 to 55.6% in 2015, but treatment gaps persisted across regions. In models considering region and beneficiary and hospital characteristics, region was the strongest correlate of high-intensity statin use, with 66% higher use in New England than in the West South Central region (risk ratio [RR], 1.66; 95% CI, 1.47-1.87). Hospital size of at least 500 beds (RR, 1.15; 95% CI, 1.07-1.23), medical school affiliation (RR, 1.11; 95% CI, 1.05-1.17), male sex (RR, 1.10; 95% CI, 1.07-1.13), and patient receipt of a stent (RR, 1.35; 95% CI, 1.31-1.39) were associated with greater high-intensity statin use. For-profit hospital ownership, patient age older than 75 years, prior coronary disease, and other comorbidities were associated with lower use.

Conclusions and Relevance

This study's findings suggest that geographic region is the strongest correlate of high-intensity statin use after MI, leading to large treatment disparities.

A Systematic Review and Meta-analysis of the Factors Associated With Nonadherence and Discontinuation of Statins Among People Aged ≥65 Years

Background

Older individuals (aged ≥65 years) are commonly prescribed statins but may experience a range of barriers in adhering to therapy. The factors associated with poor statin adherence and/or discontinuation among this population have not been comprehensively reviewed.

Methods

We conducted a systematic review to identify English articles published through December 12, 2016 that reported factors associated with nonadherence and/or discontinuation of statins among older persons. Data were pooled via random-effects meta-analysis techniques.

Results

Forty-five articles reporting data from more than 1.8 million older statin users from 13 countries were included. The factors associated with increased statin nonadherence were black/non-white race (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.39-1.98), female gender (OR 1.08, 95% CI 1.03-1.13), current smoker (OR 1.12, 95% CI 1.03-1.21), higher copayments (OR 1.38, 95% CI 1.25-1.52), new user (OR 1.58, 95% CI 1.21-2.07), lower number of concurrent cardiovascular medications (OR 1.08, 95% CI 1.06-1.09), primary prevention (OR 1.49, 95% CI 1.40-1.59), having respiratory disorders (OR 1.17, 95% CI 1.12-1.23) or depression (OR 1.11, 95% CI 1.06-1.16), and not having renal disease (OR 1.09, 95% CI 1.04-1.14). The factors associated with increased statin discontinuation were lower income status (OR 1.20, 95% CI 1.06-1.36), current smoker (OR 1.14, 95% CI 1.06-1.23), higher copayment (OR 1.61, 95% CI 1.53-1.70), higher number of medications (OR 1.04, 95% CI 1.01-1.06), presence of dementia (OR 1.18, 95% CI 1.02-1.36), cancer (OR 1.22, 95% CI 1.11-1.33) or respiratory disorders (OR 1.19, 95% CI 1.05-1.34), primary prevention (OR 1.66, 95% CI 1.24-2.22), and not having hypertension (OR 1.13, 95% CI 1.07-1.20) or diabetes (OR 1.09, 95% CI 1.04-1.15).

Conclusion

Interventions that target potentially modifiable factors including financial and social barriers, patients' perceptions about disease risk as well as polypharmacy may improve statin use in the older population.

Secondary Prevention Medication Use After Myocardial Infarction in U.S. Nursing Home Residents

BACKGROUND/OBJECTIVES

Secondary prevention medications are recommended for older adults after acute myocardial infarction (AMI), but little is known about whether nursing home (NH) residents receive these medications. The objective was to evaluate new use of secondary prevention medications after AMI in NH residents who were previously nonusers and to evaluate what factors were associated with use.

DESIGN

Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims.

SETTING

U.S. NHs.

PARTICIPANTS

National cohort of 11,192 NH residents aged 65 and older who were hospitalized for an AMI between May 2007 and March 2010, had no beta-blocker or statin use for 4 months or longer before the hospitalization, and survived 14 days or more after NH readmission.

MEASUREMENTS

The outcome was the number of secondary prevention medications initiated within 30 days of NH readmission.

RESULTS

Thirty-seven percent of residents had no secondary prevention medications initiated after AMI, 41% had 1 initiated, and 22% had 2 initiated. After covariate adjustment, fewer secondary prevention medications were used in older residents (proportional odds ratio (POR) = 0.48, 95% confidence interval (CI)  = 0.40-0.57 for ≥95 vs 65-74); women (POR = 0.88, 95% CI = 0.80-0.96);and those with a do-not-resuscitate (DNR) order (POR = 0.90, 95% CI = 0.83-0.98), functional impairment (dependent or totally dependent vs independent to limited assistance, POR = 0.77, 95% CI = 0.69-0.86), and cognitive impairment (moderate to severe vs no impairment, POR = 0.79, 95% CI = 0.70-0.89).

CONCLUSION

More than one-third of older NH residents in the United States do not have any secondary prevention medications initiated after AMI, with fewer medications initiated in older residents; women; and those with, DNR orders, poor physical function, and cognitive impairment. A lack of evidence about the safety and effectiveness of secondary preventions medications in the NH population and unmeasured person-centered goals of care are plausible explanations for these findings.

Evidence for underuse of effective medical services around the world

Underuse-the failure to use effective and affordable medical interventions-is common and responsible for substantial suffering, disability, and loss of life worldwide. Underuse occurs at every point along the treatment continuum, from populations lacking access to health care to inadequate supply of medical resources and labour, slow or partial uptake of innovations, and patients not accessing or declining them. The extent of underuse for different interventions varies by country, and is documented in countries of high, middle, and low-income, and across different types of health-care systems, payment models, and health services. Most research into underuse has focused on measuring solutions to the problem, with considerably less attention paid to its global prevalence or its consequences for patients and populations. Although focused effort and resources can overcome specific underuse problems, comparatively little is spent on work to better understand and overcome the barriers to improved uptake of effective interventions, and methods to make them affordable.

Medication Adherence in Older Patients With Dementia: A Systematic Literature Review

Background:

Older patients with dementia are often unable to take their medications as prescribed due to cognitive and physical impairment.

Objectives:

To review the evidence on medication adherence in older patients with dementia in terms of the level of adherence, outcomes, contributing factors, and available interventions.

Methods:

A systematic literature review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searched databases included CINAHL, Cochrane Library, DARE, MEDLINE, and PubMed.

Results:

Eighteen studies reported levels of medication adherence or discontinuation and related factors. Medication adherence ranged from 17% to 42%, and medication discontinuation before the end of treatment ranged from 37% to 80%. Nonadherence was associated with an increased risk of hospitalization or death, while increasing age, choice of medication, use of concomitant medications, and medicines’ costs were reported to decrease medication adherence. Telehealth home monitoring and treatment modification were the only interventions reported in the literature to improve medication adherence in this population.

Conclusion:

Older patients with dementia have a low level of medication adherence. Future research should focus on the development and implementation of interventions to help older patients with dementia and their caregivers make better use of medications.

Using big data from health records from four countries to evaluate chronic disease outcomes: a study in 114 364 survivors of myocardial infarction

AIMS

To assess the international validity of using hospital record data to compare long-term outcomes in heart attack survivors.

METHODS AND RESULTS

We used samples of national, ongoing, unselected record sources to assess three outcomes: cause death; a composite of myocardial infarction (MI), stroke, and all-cause death; and hospitalized bleeding. Patients aged 65 years and older entered the study 1 year following the most recent discharge for acute MI in 2002-11 [n = 54 841 (Sweden), 53 909 (USA), 4653 (England), and 961 (France)]. Across each of the four countries, we found consistent associations with 12 baseline prognostic factors and each of the three outcomes. In each country, we observed high 3-year crude cumulative risks of all-cause death (from 19.6% [England] to 30.2% [USA]); the composite of MI, stroke, or death [from 26.0% (France) to 36.2% (USA)]; and hospitalized bleeding [from 3.1% (France) to 5.3% (USA)]. After adjustments for baseline risk factors, risks were similar across all countries [relative risks (RRs) compared with Sweden not statistically significant], but higher in the USA for all-cause death [RR USA vs. Sweden, 1.14 (95% confidence interval 1.04-1.26)] and hospitalized bleeding [RR USA vs. Sweden, 1.54 (1.21-1.96)].

CONCLUSION

The validity of using hospital record data is supported by the consistency of estimates across four countries of a high adjusted risk of death, further MI, and stroke in the chronic phase after MI. The possibility that adjusted risks of mortality and bleeding are higher in the USA warrants further study.

Impact of Hospitalization for Acute Myocardial Infarction on Adherence to Statins Among Older Adults

BACKGROUND

Little is known about the impact of hospitalization for an acute myocardial infarction (AMI) on subsequent adherence to statins.

METHODS AND RESULTS

Using administrative claims from a 5% random sample of Medicare beneficiaries, we identified a cohort of Medicare patients aged ≥65 years, hospitalized from 2007 to 2011, taking statins in the year before AMI hospitalization (n=6618). We then determined the proportion of patients nonadherent to statins (proportion of days covered <80%) in the year before AMI hospitalization who became statin adherent (proportion of days covered ≥80%) in the year after AMI hospitalization. The proportion of statin-adherent patients who became nonadherent was also studied. These proportions were compared with patients hospitalized for pneumonia (n=11 471) and patients not hospitalized (n=158 099) in 2010 and 2011. Among patients nonadherent to statins before AMI hospitalization, 37.7% became adherent after discharge. Patients hospitalized for AMI were more likely to become adherent than patients hospitalized for pneumonia (adjusted relative risk: 1.70; 95% confidence interval, 1.57-1.84) or patients not hospitalized (adjusted relative risk: 1.79; 95% confidence interval, 1.68-1.90). Among patients adherent to statins before AMI hospitalization, 32.6% became nonadherent after discharge. Those hospitalized for AMI were less likely to become nonadherent than those hospitalized for pneumonia (adjusted relative risk: 0.93; 95% confidence interval 0.88-0.98) but more likely to become nonadherent than patients without hospitalizations (adjusted relative risk: 1.41; 95% confidence interval, 1.35-1.48).

CONCLUSIONS

Among nonadherent patients, hospitalization for AMI was associated with increased likelihood of becoming adherent to statins compared with hospitalization for pneumonia or no hospitalizations. Among adherent patients, hospitalization for AMI was associated with increased likelihood of becoming nonadherent to statins compared with no hospitalizations.

Comparative impact of implementing the 2013 or 2014 cholesterol guideline on vascular events in a quality improvement network

OBJECTIVES

The Quality and Care Model Committee for a clinically integrated network requested a comparative analysis on the projected cardiovascular benefits of implementing either the 2013 and 2014 cholesterol guideline in a South Carolina patient population. A secondary request was to assess the relative risk of the two guidelines based on the literature.

METHODS

Electronic health data were obtained on 1,580,860 adults aged 21-80 years who had had one or more visits from January 2013 to June 2015; 566,688 had data to calculate 10-year atherosclerotic cardiovascular disease (ASCVD10) risk. Adults with end-stage renal disease (n = 7852), congestive heart failure (n = 19,818), alcohol or drug abuse (n = 68,547), or currently on statins (n = 154,964) were excluded leaving 315,508 for analysis. Estimated reduction in ASCVD10 assumed that: (a) moderate-intensity statins lowered low-density lipoprotein cholesterol (LDL-C) by 35% and high-intensity statins by 50%; (b) ASCVD events declined 22% for each 1 mmol/l fall in LDL-C.

RESULTS

Among the 315,508 adults in the analysis, 131,289 (41.6%) were eligible for statins according to the 2013 guideline and 137,375 (43.5%) to the 2014 guideline. The 2013 and 2014 guidelines were estimated to prevent 6780 and 5915 ASCVD events over 10 years with: (a) relative risk reductions of 29.0% and 21.8%; (b) absolute risk reductions of 5.2% and 4.3%; (c) number needed-to-treat (NNT) of 19 and 23, respectively. The greater projected cardiovascular protection with the 2013 guideline was largely related to greater use of high-dose statins, which carry a greater risk for adverse events. The literature indicates that the NNT for benefit with high-intensity versus moderate-intensity statins is 31 in high-risk patients with a number needed-to-harm of 47.

CONCLUSIONS

The 2013 guideline is projected to prevent more clinical ASCVD events and with lower NNTs than the 2014 guideline, yet both have substantial benefit. The 2013 guideline is also expected to generate more adverse events, but the risk-benefit profile appears favor .

Association Between Preadmission Functional Status and Use and Effectiveness of Secondary Prevention Medications in Elderly Survivors of Acute Myocardial Infarction

OBJECTIVES

To determine whether function-related indicators (FRIs), derived from preadmission claims data, help explain the frequent practice of forgoing secondary prevention medications observed in Medicare.

DESIGN

Retrospective cohort.

SETTING

National Medicare data.

PARTICIPANTS

Elderly Medicare beneficiaries discharged alive from an acute myocardial infarction (AMI) hospitalization in 2007-2008 (N = 184,156).

MEASUREMENTS

Study outcomes were number of guideline-recommended secondary prevention medications (statins, beta-blockers, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) used after discharge and 12-month survival. Preadmission data (FRIs, cardiovascular conditions, comorbid conditions), type of AMI (non-ST-elevation myocardial infarction, anterior, other), and procedures and complications during the hospitalization were from claims data.

RESULTS

Function-related indicators (FRIs) were common before admission; 50% of individuals had at least one (range 0-11). After discharge, 85.8% used at least one class of guideline medication, and 30.2% used all three; 19.6% died within 12 months. Each additional FRI reduced the likelihood of receiving all three medication classes by 5% (adjusted odds ratio = 0.95, 95% confidence interval (CI) = 0.94-0.96) and increased 12-month mortality by 20% (adjusted hazard ratio (aHR) = 1.20, 95% CI = 1.19-1.21). Individuals taking all three classes of medication were 30% less likely to die within 12 months than those not taking guideline medications (aHR = 0.70, 95% CI = 0.67-0.73). Similar survival benefit was observed in individuals with and without functional impairments.

CONCLUSION

Greater impairment in preadmission functional status, using a measure derived from claims data, was associated with less use of secondary prevention medications after AMI. Survival benefits of taking these medications were consistent across functional impairment levels.

Impact of Implementing the 2013 ACC/AHA Cholesterol Guidelines on Vascular Events in a Statewide Community-Based Practice Registry

Electronic health record data were analyzed to estimate the number of statin-eligible adults with the 2013 American College of Cardiology/American Heart Association cholesterol guidelines not taking statin therapy and the impact of recommended statin therapy on 10-year atherosclerotic cardiovascular disease (ASCVD10 ) events. Adults aged 21 to 80 years in an outpatient network with ≥1 clinic visit(s) from January 2011 to June 2014 with data to calculate ASCVD10 were eligible. Moderate-intensity statin therapy was assumed to lower low-density lipoprotein cholesterol by 30% and high-intensity therapy was assumed to reduce low-density lipoprotein cholesterol by 50%. ASCVD events were assumed to decline 22% for each 39 mg/dL decline in low-density lipoprotein cholesterol. Among 411,768 adults, 260,434 (63.2%) were not taking statins and 103,478 (39.7%) were eligible for a statin, including 79,069 (76.4%) patients with hypertension. Estimated ASCVD10 events were 18,781 without and 13,328 with statin therapy, a 29.0% relative and 5.3% absolute risk reduction with a number needed to treat of 19. The 2013 cholesterol guidelines are a relatively efficient approach to reducing ASCVD in untreated, statin-eligible adults who often have concomitant hypertension.

Quality of medical care for persons with serious mental illness: A comprehensive review

OBJECTIVES

Prior studies suggest variation in the quality of medical care for somatic conditions such as cardiovascular disease and diabetes provided to persons with SMI, but to date no comprehensive review of the literature has been conducted. The goals of this review were to summarize the prior research on quality of medical care for the United States population with SMI; identify potential sources of variation in quality of care; and identify priorities for future research.

METHODS

Peer-reviewed studies were identified by searching four major research databases and subsequent reference searches of retrieved articles. All studies assessing quality of care for cardiovascular disease, diabetes, dyslipidemia, and HIV/AIDs among persons with schizophrenia and bipolar disorder published between January 2000 and December 2013 were included. Quality indicators and information about the study population and setting were abstracted by two trained reviewers.

RESULTS

Quality of medical care in the population with SMI varied by study population, time period, and setting. Rates of guideline-concordant care tended to be higher among veterans and lower among Medicaid beneficiaries. In many study samples with SMI, rates of guideline adherence were considerably lower than estimated rates for the overall US population.

CONCLUSIONS

Future research should identify and address modifiable provider, insurer, and delivery system factors that contribute to poor quality of medical care among persons with SMI and examine whether adherence to clinical guidelines leads to improved health and disability outcomes in this vulnerable group.