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Jitraknatee J, Ruengorn C, Nochaiwong S. Prevalence and Risk Factors of Chronic Kidney Disease among Type 2 Diabetes Patients: A Cross-Sectional Study in Primary Care Practice. Sci Rep 2020; 10:6205. [PMID: 32277150 PMCID: PMC7148316 DOI: 10.1038/s41598-020-63443-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 03/31/2020] [Indexed: 12/11/2022] Open
Abstract
This cross-sectional study aimed to investigate the prevalence and risk factors of chronic kidney disease (CKD) among 1,096 primary care type 2 diabetes (T2DM) patients in northern Thailand between October 2016 and September 2017. CKD was defined as estimated glomerular rate filtration values of <60 mL/min/1.73 m2. Prevalence with confidence intervals across CKD advanced stages 3–5 were estimated. Factors associated with CKD were evaluated by multivariate logistic regression. The overall prevalence of CKD was 24.4% (21.9–27.0), with severities of 11.4% (9.7–13.4), 6.8% (5.5–8.5), 4.6% (3.5–6.0), and 1.6% (1.0–2.5) for stages 3 A, 3B, 4, and 5, respectively. Regarding age and glycaemic control, individuals older than 75 years and those with a haemoglobin A1c ≥ 8% had the highest prevalence of 61.3% (51.7–70.1) and 38.6% (34.3–43.2), respectively. The multivariable logistic regression model explained 87.3% of the probability of CKD. The six independent significant risk factors of CKD were older age, retinopathy, albuminuria, haemoglobin A1c ≥ 7%, anaemia, and uric acid>7.5 mg/dL. A relatively high prevalence of CKD, especially in older patients and those with diabetic complications-related to poor glycaemic control, was encountered in this primary care practice. Early identification may help to target optimise care and prevention programs for CKD among T2DM patients.
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Affiliation(s)
| | - Chidchanok Ruengorn
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand.,Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Surapon Nochaiwong
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand. .,Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand.
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Mayyas F, Bataineh W, Jarab A. EVALUATING THE PRESCRIPTION OF ANGIOTENSIN-CONVERTING ENZYME INHIBITORS OR RECEPTOR BLOCKERS IN PATIENTS WITH DIABETES IN JORDAN. Endocr Pract 2017; 23:1289-1296. [PMID: 28816537 DOI: 10.4158/ep171917.or] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are guideline-recommended agents to prevent development and progression of nephropathy and cardiovascular diseases in diabetes mellitus (DM). The aim of this study was to evaluate the prescription of ACEIs/ARBs in DM patients with guideline indications. METHODS Electronic data files for diabetes patients were retrospectively reviewed at a primary care setting northern Jordan. Patient's characteristics and data on ACEIs/ARBs were collected. The primary outcome measure was ACEI/ARB persistence of prescription in DM patients with guideline indications. RESULTS Data for 859 DM patients were reviewed. The mean age (± SEM) was 60.75 ± 0.41 years. Most of patients (97.4%) had type 2 DM. A total of 780 patients (90.8%) had at least one clinical indication to use ACEIs/ARBs. Hypertension followed by coronary artery disease (CAD) and albuminuria were the most common indications for ACEI/ARB prescriptions. A total of 686 (87.9%) of the eligible patients were on ACEIs/ARBs. As the number of indications increased, ACEI/ARB use has also increased. ACEIs/ARBs were prescribed regularly in about 59% of patients, whereas 40.9% were ex-users. Most of the patients received ACEIs/ARBs after the onset of first indication. By multivariate analysis, hypertension, CAD, and albuminuria were significant independent predictors of ACEI/ARB prescriptions. CONCLUSION Indications for ACEI/ARB use are highly prevalent, and the rate of receipt is relatively high but with significant lack of persistence of prescriptions. Management of DM should enforce healthcare professional/patient interactions and education to improve prescription of medications. ABBREVIATIONS ACEI = angiotensin-converting enzyme inhibitors; ADA = American Diabetes Association; ARB = angiotensin-receptor blocker; CAD = coronary artery disease; Cr = creatinine; CVD = cardiovascular disease; DM = diabetes mellitus; HF = heart failure; HT = hypertension; JNC = Joint National Committee; KAUH = King Abdullah University Hospital; LV = left ventricular; PAD = peripheral artery disease; RAAS = renin-angiotensin-aldosterone system; TIA = transient ischemic attack.
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Chang AR, Evans M, Yule C, Bohn L, Young A, Lewis M, Graboski E, Gerdy B, Ehmann W, Brady J, Lawrence L, Antunes N, Green J, Snyder S, Kirchner HL, Grams M, Perkins R. Using pharmacists to improve risk stratification and management of stage 3A chronic kidney disease: a feasibility study. BMC Nephrol 2016; 17:168. [PMID: 27825313 PMCID: PMC5101703 DOI: 10.1186/s12882-016-0383-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 10/30/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Measurement of albuminuria to stratify risk in chronic kidney disease (CKD) is not done universally in the primary care setting despite recommendation in KDIGO (Kidney Disease Improving Global Outcomes) guidelines. Pharmacist medication therapy management (MTM) may be helpful in improving CKD risk stratification and management. METHODS We conducted a pragmatic, cluster-randomized trial using seven primary care clinic sites in the Geisinger Health System to evaluate the feasibility of pharmacist MTM in patients with estimated glomerular filtration rate (eGFR) 45-59 ml/min/1.73 m2 and uncontrolled blood pressure (≥150/85 mmHg). In the three pharmacist MTM sites, pharmacists were instructed to follow a protocol aimed to improve adherence to KDIGO guidelines on testing for proteinuria and lipids, and statin and blood pressure medical therapy. In the four control clinics, patients received usual care. The primary outcome was proteinuria screening over a follow-up of 1 year. A telephone survey was administered to physicians, pharmacists, and patients in the pharmacist MTM arm at the end of the trial. RESULTS Baseline characteristics were similar between pharmacist MTM (n = 24) and control (n = 23) patients, although pharmacist MTM patients tended to be younger (64 vs. 71 y; p = 0.06) and less likely to have diabetes (17 % vs. 35 %; p = 0.2) or baseline proteinuria screening (41.7 % vs. 60.9 %, p = 0.2). Mean eGFR was 54 ml/min/1.73 m2 in both groups. The pharmacist MTM intervention did not significantly improve total proteinuria screening at the population level (OR 2.6, 95 % CI: 0.5-14.0; p = 0.3). However, it tended to increase screening of previously unscreened patients (78.6 % in the pharmacist MTM group compared to 33.3 % in the control group; OR 7.3, 95 % CI: 0.96-56.3; p = 0.05). In general, the intervention was well-received by patients, pharmacists, and providers, who agreed that pharmacists could play an important role in CKD management. A few patients contacted the research team to express anxiety about having a CKD diagnosis without prior knowledge. CONCLUSIONS Pharmacist MTM may be useful in improving risk stratification and management of CKD in the primary care setting, although implementation requires ongoing education and multidisciplinary collaboration and careful communication regarding CKD diagnosis. Future studies are needed to establish the effectiveness of pharmacist MTM on slowing CKD progression and improvement in cardiovascular outcomes. TRIAL REGISTRATION ClinicalTrials.gov, NCT02208674 Registered August 1, 2014, first patient enrolled September 30, 2014.
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Affiliation(s)
- Alex R Chang
- Division of Nephrology, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17821, USA. .,Kidney Health Research Institute, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17821, USA.
| | - Michael Evans
- Geisinger Health System, Enterprise Pharmacy, Danville, PA, USA
| | - Christina Yule
- Kidney Health Research Institute, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17821, USA
| | - Larissa Bohn
- Kidney Health Research Institute, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17821, USA
| | - Amanda Young
- Kidney Health Research Institute, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17821, USA
| | - Meredith Lewis
- Geisinger Health System, Health Economics Research and Evaluation, Danville, PA, USA
| | - Elisabeth Graboski
- Kidney Health Research Institute, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17821, USA
| | - Bethany Gerdy
- Geisinger Health System, Enterprise Pharmacy, Danville, PA, USA
| | - William Ehmann
- Geisinger Health System, Enterprise Pharmacy, Danville, PA, USA
| | - Jonathan Brady
- Geisinger Health System, Enterprise Pharmacy, Danville, PA, USA
| | - Leah Lawrence
- Geisinger Health System, Enterprise Pharmacy, Danville, PA, USA
| | - Natacha Antunes
- Geisinger Health System, Center for Health Research, Danville, PA, USA
| | - Jamie Green
- Division of Nephrology, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17821, USA.,Kidney Health Research Institute, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17821, USA
| | - Susan Snyder
- Geisinger Health System, Health Economics Research and Evaluation, Danville, PA, USA
| | - H Lester Kirchner
- Geisinger Health System, Biomedical and Translational Informatics, Danville, PA, USA
| | - Morgan Grams
- Johns Hopkins University, Welch Center for Prevention, Epidemiology and Clinical, Baltimore, MD, USA
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Perez A, Levin A, Alam N. A Comparison of the Use of Clinical-Guideline-Recommended Antihypertensive Regimens in Mexican American, Non-Hispanic Black, and Non-Hispanic White Adults With Type 2 Diabetes and Hypertension in the United States: NHANES 2003-2012. DIABETES EDUCATOR 2016; 42:739-747. [PMID: 27621092 DOI: 10.1177/0145721716666680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The purpose of this study was to determine the use of clinical-guideline-recommended antihypertensive regimens among Mexican Americans (MAs) and non-Hispanic blacks and whites with type 2 diabetes and hypertension. METHODS A secondary data analysis based on National Health and Nutrition Examination Survey 2003-2012 cohort data included 1857 noninstitutionalized civilian MA, black, and white adults with type 2 diabetes and hypertension. Unadjusted and adjusted 2-way analysis of variance models evaluated whether there was a difference in the use of recommended antihypertensive regimens across race/ethnic group. RESULTS There was no difference in the use of recommended regimens across race/ethnic group (MAs, 79.1%; blacks, 81.7%; whites, 82.3%). Similarly, there was no difference between blood pressure goal levels and the use of recommended therapies across race/ethnicity (P = .632). Mexican Americans were least likely and blacks most likely to be on 3 or more antihypertensive drug classes (16.8% vs 28%). Furthermore, MAs were least likely to be on recommended add-on therapies such as calcium channel blockers and diuretics. CONCLUSION Racial/ethnic medication use disparities were observed when looking at the number of antihypertensive drug classes per patient regimen, and add-on therapy use was evaluated. Along with lifestyle modifications, frequent antihypertensive regimen reassessment is necessary.
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Affiliation(s)
- Alexandra Perez
- Sociobehavioral and Administrative Pharmacy Department, Nova Southeastern University College of Pharmacy, Davie, Florida (Dr Perez)
| | - Andrea Levin
- Pharmacy Practice Department, Nova Southeastern University College of Pharmacy, Davie, Florida (Dr Levin)
| | - Nowrin Alam
- Nova Southeastern University College of Pharmacy, Davie, Florida (Dr Alam)
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Syed ST, Sharp LK, Kim Y, Jentleson A, Lora CM, Touchette DR, Berbaum ML, Suda KJ, Gerber BS. Relationship Between Medication Adherence and Distance to Dispensing Pharmacies and Prescribers Among an Urban Medicaid Population with Diabetes Mellitus. Pharmacotherapy 2016; 36:590-7. [PMID: 27087250 PMCID: PMC4919160 DOI: 10.1002/phar.1757] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVE To determine whether a relationship exists between medication adherence to angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) and distance to dispensing pharmacies and prescribers among an urban public aid population with diabetes mellitus. DESIGN Retrospective cohort study using claims data. DATA SOURCE Illinois Department of Healthcare and Family Services database. PATIENTS A total of 6532 patients aged 18-64 years with diabetes who had at least one prescription fill for an ACEI or ARB and had continuous Medicaid coverage in the greater Chicago area in 2009. MEASUREMENTS AND MAIN RESULTS We assessed medication adherence, defined as proportion of days covered (PDC) of 0.8 or higher, to ACEIs and ARBs and its association with distances between patients and their pharmacies and prescribers. Of the 6532 patients included in the analyses, 2930 (45%) had PDC levels of 0.8 or higher. No significant differences were observed between patients who were adherent versus those who were nonadherent in distance to pharmacy (median 1.39 vs 1.35 miles, p=0.15) or distance to prescriber (median 4.39 vs 4.48 miles, p=0.80). In a multivariate regression model including age, sex, race/ethnicity, number of pharmacies, number of prescribers, distance to pharmacy, and distance to prescriber, a greater number of prescribers was associated with higher adherence (two prescribers vs one prescriber: odds ratio [OR] 1.396, 95% confidence interval [CI] 1.233-1.580; three or more prescribers vs one prescriber: OR 2.208, 95% CI 1.787-2.727). CONCLUSION ACEI or ARB adherence was not associated with distances to pharmacies and prescribers.
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Affiliation(s)
- Samina T. Syed
- Department of Medicine, University of Illinois at Chicago
| | - Lisa K. Sharp
- Department of Medicine, University of Illinois at Chicago
- Institute for Health Research and Policy, University of Illinois at Chicago
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago
| | - Yoonsang Kim
- Institute for Health Research and Policy, University of Illinois at Chicago
| | - Adam Jentleson
- Institute for Health Research and Policy, University of Illinois at Chicago
| | | | - Daniel R. Touchette
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago
| | - Michael L. Berbaum
- Institute for Health Research and Policy, University of Illinois at Chicago
| | - Katie J. Suda
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago
- Center of Innovation for Complex Chronic Healthcare, Hines VA Medical Center
| | - Ben S. Gerber
- Department of Medicine, University of Illinois at Chicago
- Institute for Health Research and Policy, University of Illinois at Chicago
- Center of Innovation for Complex Chronic Healthcare, Jesse Brown VA Medical Center
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Ibrahim SL, Jiroutek MR, Holland MA, Sutton BS. Utilization of angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) in patients diagnosed with diabetes: Analysis from the National Ambulatory Medical Care Survey. Prev Med Rep 2016; 3:166-70. [PMID: 27419010 PMCID: PMC4929215 DOI: 10.1016/j.pmedr.2016.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Objective The objective of this study was to determine if a difference exists in the proportion of visits for the prescribing of angiotensin converting enzyme inhibitors (ACEI), or angiotensin receptor blockers (ARBs) in diabetic patients during 2007–2010. Methods This retrospective, cross-sectional, observational study included adults diagnosed with diabetes mellitus from the National Ambulatory Medical Care Survey (NAMCS) during 2007–2010. Weighted chi-square tests and a multivariable logistic regression model were used to analyze associations between ACEI/ARB prescriptions and predictors of interest. Odds ratios and 95% confidence intervals were reported. Results An unweighted total of 13,590 outpatient ambulatory care visits were identified for adult patients with diabetes without contraindications to ACEIs or ARBs in the NAMCS for the years studied. No statistically significant increase in the proportion of visits with an ACEI/ARB prescription was identified for years 2007–2010 (28.1% in 2007 to 32.2% in 2010). Females (OR 0.78, 95% CI 0.69- 0.89), patients 18–39 years old (OR 0.56, 95% CI 0.43- 0.75), and Medicare users (OR 0.81, 95% CI 0.70- 0.94) were significantly less likely to receive an ACEI/ARB prescription. Patients with hypertension (OR 2.80, 95% CI 2.39-3.29), hyperlipidemia (OR 1.42, 95% CI 1.22-1.65), and ischemic heart disease (OR 1.36, 95% CI 1.10-1.70) were significantly more likely to receive an ACEI/ARB prescription. Conclusions Despite extensive evidence showing the benefits of ACEI/ARB medications in diabetic patients, disparities of treatment remain evident. Assessed ACEI/ARB prescriptions in diabetic patients for ADA guideline adherence A low percentage of patients prescribed an ACEI/ARB (28.1% in 2007–32.2% in 2010) Females, age 18–39, and Medicare users less likely to receive ACEI/ARB prescription Hypertension, hyperlipidemia and IHD: more likely to receive ACEI/ARB prescription Disparities in ACEI/ARB prescriptions remain evident
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Xie Q, Hao CM, Ji L, Hu D, Zhu T, Li X, Qin D, Zhang D. ACEI/ARB underused in patients with type 2 diabetes in Chinese population (CCMR-3B study). PLoS One 2015; 10:e0116970. [PMID: 25675409 PMCID: PMC4326276 DOI: 10.1371/journal.pone.0116970] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 12/16/2014] [Indexed: 01/13/2023] Open
Abstract
Objective In patients with diabetic kidney disease, it is well documented that RAS blockade is associated with an improved outcome. This observational, multicenter study examined the “real-world” use of ACEI/ARB in patients with type 2 diabetes (T2DM) in China. Method Data from the China Cardiometabolic Registries on blood pressure, blood lipid and blood glucose in Chinese T2DM patients (CCMR-3B) were used for the present study. Consecutive outpatients with T2DM for more than 6 months were recruited to this non-interventional, observational, cross-sectional study. Albuminuria was defined as urine albumin creatinine ratio (ACR) ≥ 30mg/g. Results A total of 25,454 outpatients with T2DM from 6 regions in China were enrolled, 47.0% were male, and 59.8% had hypertension. ACR was measured in 6,383 of these patients and 3,231 of them ≥ 30mg/L. Among patients with hypertension, 73.0% were on antihypertensives, and 39.7% used ACEI/ARB. Of the 2,157 patients with hypertension and albuminuria, only 48.3% used ACEI/ARB. Among the non-hypertensive patients with albuminuria, ACEI/ARB usage was < 1%. Multivariate analysis revealed that comorbidities, region, hospital tier, physician specialty and patient’s educational level were associated with ACEI/ARB use. Conclusion In T2DM with hypertension and albuminuria in China, more than half of them were not treated with ACEI/ARB. This real world evidence suggests that the current treatment for patients with diabetes coexisting with hypertension and albuminuria in China is sub-optimal.
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Affiliation(s)
- Qionghong Xie
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chuan-Ming Hao
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Dayi Hu
- Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Tongying Zhu
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xuehai Li
- VitalStrategic Research Institute, Berwyn, PA, United States of America
| | - Dandan Qin
- VitalStrategic Research Institute, Berwyn, PA, United States of America
| | - Danyi Zhang
- VitalStrategic Research Institute, Berwyn, PA, United States of America
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Guénette L, Breton MC, Hamdi H, Grégoire JP, Moisan J. Important treatment gaps in vascular protection for the elderly after type 2 diabetes therapy initiation. Can J Cardiol 2013; 29:1593-8. [PMID: 24183301 DOI: 10.1016/j.cjca.2013.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 09/03/2013] [Accepted: 09/03/2013] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Canadian practice guidelines recommend the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) for vascular protection in individuals with diabetes who are at high risk of cardiovascular events, including those ≥ 65 years. We estimated the proportion of elderly persons who initiated an ACEI or an ARB in the year after beginning oral antidiabetes (OAD) treatment, and we identified factors associated with this initiation. METHODS Using the Quebec Health Insurance Board (RAMQ) databases, we conducted a population-based cohort study of individuals ≥ 65 years recently prescribed an OAD. We excluded those who were already taking an ACEI or ARB. Factors associated with ACEI or ARB initiation were identified using multivariate logistic regression. RESULTS Among 43,700 individuals, 13,621 (31.2%) initiated an ACEI or ARB in the year after beginning OAD. Individuals were more likely to begin an ACEI or an ARB if they initially received both metformin and a sulfonylurea, lived in a rural region, began OAD treatment between 2001 and 2006, were hospitalized, or had ≥ 22 medical visits in the year before OAD initiation. Individuals ≥ 75 years, those who were prescribed an OAD by a general practitioner, initially received a sulfonylurea, or received ≥ 4 different medications in the year before OAD initiation were less likely to begin an ACEI or ARB. CONCLUSIONS In the elderly not already taking ACEIs or ARBs, a low proportion of those undertaking OAD treatment are prescribed the recommended cardioprotection of an ACEI or ARB in the following year. Interventions are needed to close this treatment gap.
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Affiliation(s)
- Line Guénette
- Faculty of Pharmacy, Université Laval, Québec City, Québec, Canada; Chair on Adherence to Treatments, Université Laval, Québec City, Québec, Canada; Centre de recherche du CHU de Québec, Hôpital du Saint-Sacrement, Québec City, Québec, Canada.
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Worswick J, Wayne SC, Bennett R, Fiander M, Mayhew A, Weir MC, Sullivan KJ, Grimshaw JM. Improving quality of care for persons with diabetes: an overview of systematic reviews - what does the evidence tell us? Syst Rev 2013; 2:26. [PMID: 23647654 PMCID: PMC3667096 DOI: 10.1186/2046-4053-2-26] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 04/15/2013] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Ensuring high quality care for persons with diabetes remains a challenge for healthcare systems globally with consistent evidence of suboptimal care and outcomes. There is increasing interest in quality improvement strategies to improve diabetes management as reflected by a growing number of systematic reviews. These reviews are of varying quality and dispersed across many sources. In this paper, we present an overview of systematic reviews evaluating the impact of interventions to improve the quality of diabetes care. METHODS We searched for systematic reviews evaluating the effectiveness of any intervention intended to improve intermediate patient outcomes and process of care measures for patients with any type of diabetes. Two reviewers independently screened search results, appraised each systematic review using AMSTAR and extracted data from high quality reviews (AMSTAR score ≥ 5). Within reviews, we used vote counting by direction of effect to report the number of studies favouring an intervention for each outcome. We produced summaries of results for each intervention category. RESULTS We identified 125 reviews of varying methodological quality and summarised key findings from 50 high quality reviews. We categorised reviews by quality improvement intervention. Eight reviews were broad based (involving a variety of strategies). Other reviews considered: patient education and support (n = 21), telemedicine (n = 10), provider role changes (n = 7), and organisational changes (n = 4). Reviews reported intermediate patient outcomes (e.g. glycaemic control) (n = 49) and process of care outcomes (n = 9). There was evidence of considerable overlap of included studies between reviews. CONCLUSIONS There is consistent evidence from high quality systematic reviews that patient education and support, provider role changes, and telemedicine are associated with improvements in glycaemic and vascular risk factor control in patients. There is less evidence about the impact of quality improvement interventions on other key process measures such as screening patients for diabetic complications. This paper provides decision makers with a comprehensive overview of evidence from high quality systematic reviews about the effects of quality improvement interventions on improving diabetes care.
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Affiliation(s)
- Julia Worswick
- Cochrane Effective Practice and Organisation of Care Group, Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital – General Campus, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8M5, Canada
| | - S Carolyn Wayne
- Cochrane Effective Practice and Organisation of Care Group, Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital – General Campus, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8M5, Canada
| | - Rachel Bennett
- Cochrane Effective Practice and Organisation of Care Group, Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital – General Campus, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8M5, Canada
| | - Michelle Fiander
- Cochrane Effective Practice and Organisation of Care Group, Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital – General Campus, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8M5, Canada
| | - Alain Mayhew
- Cochrane Effective Practice and Organisation of Care Group, Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital – General Campus, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8M5, Canada
| | - Michelle C Weir
- Cochrane Effective Practice and Organisation of Care Group, Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital – General Campus, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8M5, Canada
| | - Katrina J Sullivan
- Cochrane Effective Practice and Organisation of Care Group, Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital – General Campus, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8M5, Canada
| | - Jeremy M Grimshaw
- Cochrane Effective Practice and Organisation of Care Group, Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital – General Campus, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8M5, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Road, Box 711, Ottawa, Ontario K1H 8M5, Canada
- Department of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada
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Navarro-Vidal B, Banegas JR, León-Muñoz LM, Rodríguez-Artalejo F, Graciani A. Achievement of cardiometabolic goals among diabetic patients in Spain. A nationwide population-based study. PLoS One 2013; 8:e61549. [PMID: 23637851 PMCID: PMC3630125 DOI: 10.1371/journal.pone.0061549] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 03/11/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND No previous study has reported a comprehensive assessment of the attainment of cardiometabolic goals in the diabetic population of a European country. We examined the achievement of cardiometabolic goals among diabetics in Spain. METHODS AND FINDINGS A cross-sectional survey was performed in 2008-2010 among 12,077 individuals representative of the Spanish population aged ≥18 years. Information on cardiometabolic characteristics was collected at the participants' homes through structured questionnaires, physical examination, and fasting blood samples. Attainment of cardiometabolic goals was evaluated according to the most well-known guidelines. A total of 834 individuals had diabetes (fasting serum glucose ≥126 mg/dl, or glycosylated hemoglobin ≥6.5%,) or were being treated with oral antidiabetic drugs or insulin). Among diabetic patients, 661 (79.2%) were aware of their condition. Among the aware diabetic patients, only 11.4% had neither general (body mass index <25 kg/m(2)) nor abdominal obesity (waist circumference ≤102 cm in men and ≤88 cm in women), 8.6% consumed <7% of calories daily from saturated fats, and 41.1% achieved the recommendation on weekly physical activity. About 71% had glycosylated hemoglobin <7%, 22% had blood pressure <130/80 mmHg, and 36% reached the LDL-cholesterol goal of <100 mg/dl. Although a large proportion of aware diabetic individuals received lifestyle medical advice, only 38% of overweight individuals and 20% of daily smokers were offered a specific strategy for weight loss or quitting smoking, respectively. CONCLUSIONS In a European country with universal healthcare coverage, achievement of many cardiometabolic goals, in particular lifestyle, among aware diabetic individuals is poor. This suggests a need for improvement in both clinical guidelines' implementation and patients' adherence.
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Affiliation(s)
- Beatriz Navarro-Vidal
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPAZ; CIBERESP, Madrid, Spain
| | - José R. Banegas
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPAZ; CIBERESP, Madrid, Spain
| | - Luz M. León-Muñoz
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPAZ; CIBERESP, Madrid, Spain
| | - Fernando Rodríguez-Artalejo
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPAZ; CIBERESP, Madrid, Spain
| | - Auxiliadora Graciani
- Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid/IdiPAZ; CIBERESP, Madrid, Spain
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Impact of Part D low-income subsidies on medication patterns for Medicare beneficiaries with diabetes. Med Care 2013; 50:913-9. [PMID: 23047779 DOI: 10.1097/mlr.0b013e31826c85f9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND It is not known whether low-income subsidies (LIS) under Medicare Part D help beneficiaries overcome impediments to medication use associated with poor socioeconomic status and high disease burden. OBJECTIVES To compare Medicare beneficiaries with LIS and Medicaid (duals), LIS without dual eligibility, and non-LIS recipients on use of medications recommended in diabetes treatment. RESEARCH DESIGN Fixed-effect comparisons among beneficiaries in the same Part D plans in 2006-2007. SUBJECTS Nationally representative sample of enrollees in Part D prescription drug plans. A total of 109,292 beneficiaries were in 204 prescription drug plans; 47.5% non-LIS, 44.4% duals, and 8.1% nondual LIS recipients. MEASURES Medications included antidiabetic agents, renin-angiotensin-aldosterone system inhibitors, and antihyperlipidemics. Drug use was measured by exposure, duration of therapy, and medication possession ratio. RESULTS The LIS dual cohort had significantly higher comorbidity compared with non-LIS comparisons, LIS nonduals were significantly more likely to take medications in all 3 drug classes compared with non-LIS recipients, but differences were small (between 2% and 4%; P<0.05). Non-LIS recipients and duals had equivalent exposure to any antidiabetic drug and antihyperlipidemics, but duals were 3% less likely to receive renin-angiotensin-aldosterone system inhibitors compared with non-LIS recipients (P<0.05). Small differences in adjusted values for duration of therapy and medication possession ratio among the 3 cohorts were also observed, none of which were clinically meaningful. CONCLUSIONS Similarities in medication utilization among Part D enrollees with and without LIS coverage supports the program objective of providing enhanced access to needed medications for diverse groups of Medicare beneficiaries.
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Lora CM, Sokolovsky AW, Touchette DR, Jin J, Hu X, Gao W, Gerber BS. ACE inhibitor and ARB medication use among Medicaid enrollees with diabetes. Ethn Dis 2013; 23:189-195. [PMID: 23530300 PMCID: PMC3711220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVE To examine ace-inhibitor (ACEI) and angiotensin receptor blockers (ARB) prescription and adherence patterns by race in diabetic public aid recipients. DESIGN, PARTICIPANTS, AND MEASURES We analyzed prescription records of 27,529 adults aged 18-64 with diabetes who had at least one clinical indication for receiving an ACEI/ ARB prescription and were enrolled in the State of Illinois public aid program during 2007. We calculated proportion of days covered (PDC) to assess adherence. Multivariate models adjusted for age, sex, ACEI/ARB indication, and any significant interaction terms. RESULTS Only 47.4% of individuals with at least one indication for ACEI/ARB had filled an ACEI/ARB prescription. African American men were more likely than Caucasian men to ever fill an ACEI/ARB prescription (adjusted odds ratio, [AOR] [95% CI] 1.69 [1.55-1.83]). Hispanic English and Spanish speaking men were also more likely than Caucasian men to ever fill an ACEI/ARB prescription (AOR [95% CI] 1.37 [1.16-1.62] and 1.27 [1.05-1.53], respectively). Similarly, African American and Hispanic English and Spanish speaking women were more likely than Caucasian women to ever fill an ACEI/ARB prescription (AOR [95% CI] 1.70 [1.59-1.81], 1.55 (1.36-1.76), and 1.98 (1.73-2.28), respectively. However, African Americans and Hispanics were less likely than Caucasians to achieve a PDC> or =80%. Compared to Caucasians, Hispanic Spanish speakers were the least likely to be adherent (AOR [95% CI] .49 [.41-.58]). Furthermore, older individuals were more likely to achieve a PDC> or =80% than younger individuals. CONCLUSION African Americans and Hispanics with diabetes receiving public aid in Illinois were more likely than Caucasians to have filled at least one ACEI/ARB prescription. However, they were less adherent with these medications. Future studies should assess barriers to medication adherence in this population.
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Affiliation(s)
- Claudia M Lora
- Department of Medicine, Section of Nephrology, 820 S. Wood Street M/C 793, Chicago, IL 60612, USA.
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The impact of renin-angiotensin-aldosterone system inhibitors on Type 1 and Type 2 diabetic patients with and without early diabetic nephropathy. Kidney Int 2011; 81:674-83. [PMID: 22189841 DOI: 10.1038/ki.2011.413] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Renin-angiotensin-aldosterone system inhibitors prevent the progression of kidney disease in patients with diabetic nephropathy, and we studied how that benefit varies by the type of diabetes and baseline urinary albumin. We pooled data from 49 randomized controlled trials in a meta-analysis using the ratio of endpoint urinary albumin levels in those treated compared to those untreated with renin-angiotensin-aldosterone system inhibitors in both fixed- and random-effects models. The urinary albumin excretion for treated microalbuminuric patients with Type 1 diabetes was on average 60% lower at the end of the trial compared with patients not treated with renin-angiotensin-aldosterone system inhibitors using the fixed-effects model and 67% lower using the random-effects model. There was no significant effect of treatment in patients with normal albumin excretion. For normoalbuminuric patients with Type 2 diabetes, urinary albumin excretion was on average 12% lower after treatment using the fixed-effects model compared to 21% lower using the random-effects model. For microalbuminuric patients, urinary albumin excretion was on average 23% lower using the fixed-effects model and 27% lower using the random-effects model. Thus, renin-angiotensin-aldosterone system inhibition reduced urinary albumin excretion for Type 1 diabetic patients with micro-, but not those with normoalbuminuria. Treatment reduced urinary albumin excretion for Type 2 diabetic patients with and without microalbuminuria.
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Laflam P, Schmitt KE, Edie CF, Simbartl LA, Thakar CV. Factors affecting conformity to renin-angiotensin system inhibitor usage in chronic kidney disease and diabetes mellitus. J Clin Hypertens (Greenwich) 2011; 13:473-8. [PMID: 21762359 PMCID: PMC8108888 DOI: 10.1111/j.1751-7176.2011.00444.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Revised: 01/20/2011] [Accepted: 01/22/2011] [Indexed: 11/27/2022]
Abstract
Renin-angiotensin system inhibitor (RASi) agents improve renal and cardiovascular outcomes in patients with diabetes mellitus (DM) and chronic kidney disease (CKD). Studies examining conformity to guidelines have relied on pharmacy claims or filled prescriptions rather than provider-based information. The main outcome of RASi use was examined in 2889 patients with CKD and DM for its association with patient characteristics and specialty clinic visits. RASi use was 77% during the 2-year study period, and declined with worsening CKD stages (79%, 59%, and 48% in stages III, IV, and V, respectively; P<.0001). By multivariate analysis, hypertension (odds ratio [OR], 5.49, 95% confidence interval [CI], 4.16-7.25); older age (OR, 0.85; 95% CI, 0.78-0.93), and higher glomerular filtration rate (OR, 1.42; 95% CI, 1.31-1.53) were associated with RASi use. In a model examining the effect of each specialty, RASi use was greater in patients attending cardiology (OR, 3.52; 95% CI, 2.63-4.71), pharmacy (OR, 3.15; 95% CI, 2.49-3.98), endocrine (OR, 3.39; 95% CI, 2.22-5.16), and renal clinic visits (OR, 2.04; 95% CI, 1.54-2.71). Diagnosis of hypertension increases RASi usage, whereas older age and lower glomerular filtration rate reduce that likelihood. Appropriate specialty referrals improve conformity to guidelines in practice.
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Affiliation(s)
- Paul Laflam
- From the Cincinnati Veterans Affairs Medical Center
- the Division of Nephrology and Hypertension, Department of Internal Medicine, University of Cincinnati
| | | | - Christine F. Edie
- From the Cincinnati Veterans Affairs Medical Center
- the Veterans Integrated Service Network‐10, Pharmacy Benefits Management, Cincinnati, OH
| | | | - Charuhas V. Thakar
- From the Cincinnati Veterans Affairs Medical Center
- the Division of Nephrology and Hypertension, Department of Internal Medicine, University of Cincinnati
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Zucker J, Gillen J, Ackrivo J, Schroeder R, Keller S. Hypertension management in a student-run free clinic: meeting national standards? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2011; 86:239-245. [PMID: 21169778 DOI: 10.1097/acm.0b013e31820465e0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
PURPOSE Affecting one in three adults, hypertension is one of the most prevalent disorders in the United States. The purpose of this analysis was to evaluate, using national care guidelines and quality standards, the quality of care provided at the Student Family Health Care Center (SFHCC) of the University of Medicine and Dentistry of New Jersey (Newark). METHOD The authors performed a chart review of all patients seen from June 2008 to June 2009, collecting the following data: age, gender, ethnicity, body mass index, most recent blood pressure measurement, comorbid conditions, number of visits, free medications dispensed, and smoking status. The authors used the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines and Healthy People 2010 quality standards to analyze results. RESULTS Of the 119 SFHCC patients seen during the study period, 60 had a diagnosis of hypertension. Overall, 30 (50%) of these patients were at target blood pressure. Of the 19 patients (32% of 60) with diabetes and hypertension, 5 (26%) were controlled compared with 25 (61% of 41) with hypertension only. Thirty-eight patients (63%) were taking a thiazide, 42 (70%) were on multidrug regimens, and all 19 of the patients with diabetes (100%) were on an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, as per the JNC 7 guidelines. CONCLUSIONS SFHCC patients with hypertension received pharmacotherapy as recommended by JNC 7 guidelines and were at the blood pressure goal set by Healthy People 2010.
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Affiliation(s)
- Jason Zucker
- Internal Medicine and Pediatrics, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey 07103, USA
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Vupputuri S, Nichols GA, Lau H, Joski P, Thorp ML. Risk of progression of nephropathy in a population-based sample with type 2 diabetes. Diabetes Res Clin Pract 2011; 91:246-52. [PMID: 21156326 DOI: 10.1016/j.diabres.2010.11.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 10/14/2010] [Accepted: 11/16/2010] [Indexed: 10/18/2022]
Abstract
AIMS Progression through stages of nephropathy has not been well described in a large, well-characterized, population-based study. Our aims were to describe the progression of nephropathy and identify characteristics associated with progression in a U.S. population-based sample. METHODS We identified 10,290 members of a managed care organization who had hypertension and type 2 diabetes, a urine albumin-to-creatinine ratio (UACR) measurement in 2001-2003, and at least 2 follow-up UACRs. Progression of nephropathy was defined as progression to a higher stage of nephropathy than was present at baseline. RESULTS At baseline, 57% had normoalbuminuria, 31% had microalbuminuria, and 12% had macroalbuminuria. The incidence of nephropathy progression (per 1000 person-years) was 94.7, 35.1, and 6.5 for normo-, micro-, and macro-albuminuria, respectively. ACEi/ARB use ranged from 61-67%, except among patients with macroalbuminuria at follow-up. Age, diabetes duration, and A1C were significant predictors of progression. CONCLUSIONS Our study, one of the first to examine the progression of nephropathy in a U.S. population-based sample, showed that among adults with diabetes and hypertension, the burden of nephropathy and its progression may be greater than previously reported. Further, the use of ACEi/ARBs was not optimal.
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Affiliation(s)
- S Vupputuri
- The Center for Health Research/Southeast, Kaiser Permanente Georgia, Atlanta, GA 30305, United States.
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18
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High-risk diabetic patients in Medicare Part D programs: are they getting the recommended ACEI/ARB therapy? J Gen Intern Med 2010; 25:298-304. [PMID: 20108127 PMCID: PMC2842542 DOI: 10.1007/s11606-009-1242-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Revised: 11/15/2009] [Accepted: 12/22/2009] [Indexed: 01/13/2023]
Abstract
BACKGROUND Diabetes patients with hypertension and/or renal disease are at an increased risk of cardiovascular morbidity and mortality. Clinical evidence suggests that the use of ACEI/ARB for these patients improves patient outcomes. OBJECTIVE To describe ACEI/ARB utilization among high-risk patients with diabetes and to identify patient characteristics that predict suboptimal utilization of ACEI/ARB. DESIGN A retrospective cohort study. PATIENTS Diabetic patients with coexisting hypertension and/or renal disease with continuous Medicare coverage from October 1, 2005 through June 30, 2006 in six states (Alabama, California, Florida, Mississippi, New York, and Ohio). INTERVENTIONS AND MEASUREMENTS Any ACEI/ARB use during the first 6 months of 2006. RESULTS A total of 1,250,466 Medicare Part D enrollees met our inclusion criteria. ACEI/ARB utilization rates were 63%, 58.3%, and 43.1% among diabetic patients with hypertension and renal disease, hypertension without renal disease, and renal involvement without hypertension, respectively. After adjusting for all other characteristics studied, patients in the hypertension only (OR 0.83; 95% CI: 0.82-0.84) and renal disease only (OR: 0.48; 95% CI: 0.46-0.50) risk groups were less likely to use ACEI/ARB compared to diabetes patients with both hypertension and renal disease. Several demographics, including male gender, age older than 65, and white race, were all predictors of suboptimal ACEI/ARB use. Results from state-specific analyses are consistent with those for all six states. CONCLUSION In this cohort, less than 60% of high-risk patients with diabetes were receiving the recommended ACEI/ARB therapy. Several patient demographic and clinical characteristics are strongly associated with suboptimal ACEI/ARB use.
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Sirois C, Moisan J, Poirier P, Couture J, Gregoire JP. Association between age and the initiation of antihypertensive, lipid lowering and antiplateletet medications in elderly individuals newly treated with antidiabetic drugs. Age Ageing 2009; 38:741-5. [PMID: 19759258 DOI: 10.1093/ageing/afp170] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Caroline Sirois
- Universite Laval, Faculte de pharmacie, Centre hospitalier affilie universitaire de Quebec, Unite de recherche en sante des populations, 1050 Chemin Sainte-Foy, Quebec, G1S 4L8, Canada
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20
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21
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Kelly AM, Cronin P, Carlos RC. Introduction to Value-Based Insurance Design. J Am Coll Radiol 2008; 5:1118-24. [DOI: 10.1016/j.jacr.2008.06.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Indexed: 11/27/2022]
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Hypertension management in outpatient visits by diabetic patients. Res Social Adm Pharm 2008; 4:284-91. [PMID: 18794038 DOI: 10.1016/j.sapharm.2007.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Revised: 07/24/2007] [Accepted: 07/25/2007] [Indexed: 01/01/2023]
Abstract
BACKGROUND Hypertension is a common comorbidity among patients with diabetes. Few national studies have examined hypertension management in diabetic patients and even fewer studies have examined prescribing of angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), the recommended first line of treatment in hypertensive diabetic patients. OBJECTIVE This study examined hypertension management, including behavioral therapy and pharmacotherapy, in a nationally representative sample of outpatient visits by diabetic patients. METHODS The 2003--2004 National Ambulatory Medical Care Survey and the outpatient department portion of the 2003--2004 National Hospital Ambulatory Medical Care Survey were used to examine hypertension management in patients with diabetes and hypertension. Descriptive analysis was used to evaluate utilization of behavioral therapy and pharmacotherapy in hypertensive diabetic patients. Multivariate analysis was used to examine prescribing variation in the use of ACE inhibitors and ARBs in hypertensive diabetic patients. RESULTS An estimated 34 million outpatient visits were made by hypertensive diabetic patients in 2003--2004. Blood pressure > 130/80 mmHg was found in 66% of the outpatient visits by hypertensive diabetic patients. Nearly 57% of these visits involved educational and counseling services, with 53% receiving diet and nutrition services. In 71% of these visits antihypertensive agents were used, with 49% involving 2 or more antihypertensive agents. ACE inhibitors and ARBs were prescribed in 36% and 19% of the visits, respectively. Multivariate analysis found that patients with blood pressure > 130/80 mmHg were more likely to receive ACE inhibitors or ARBs and patients of other races, especially American Indians, were less likely to receive ACE inhibitors or ARBs. CONCLUSIONS The study found that although behavioral therapy and pharmacotherapy are often used for hypertension management in diabetic patients, optimal blood pressure was observed in only one third of the visits. Targeted efforts are needed to increase the use of ACE inhibitors or ARBs to improve hypertension management in diabetic patients.
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Kreyenbuhl J, Medoff DR, Seliger SL, Dixon LB. Use of medications to reduce cardiovascular risk among individuals with psychotic disorders and Type 2 diabetes. Schizophr Res 2008; 101:256-65. [PMID: 18353616 PMCID: PMC3116690 DOI: 10.1016/j.schres.2008.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Revised: 02/05/2008] [Accepted: 02/07/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Cardiovascular disease (CVD) is the leading cause of death in patients with serious mental illness (SMI) and in patients with Type 2 diabetes. Inadequate pharmacologic care for CVD may partially explain poor health outcomes in individuals with both conditions. We sought to identify patients in this group at greatest risk for suboptimal pharmacologic management. METHODS Among individuals with Type 2 diabetes and SMI identified from Maryland Medicaid data, we evaluated patient and service utilization factors associated with the prescription of HMG-CoA reductase inhibitors ("statins") for hyperlipidemia and angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) for chronic kidney disease, congestive heart failure, and hypertension. RESULTS From 2001 to 2003, the annual prevalence of use of statins and ACE-inhibitors/ARBs ranged from 44 to 59%, with rates increasing each year. Being female, having certain cardiovascular conditions, and having a greater number of outpatient visits for diabetes increased the odds of receiving statins and ACE-inhibitors/ARBs. More frequent contact with the mental health system was associated with a lower likelihood of receipt of both medication classes; having a substance use disorder was associated with reduced use of statins. African-Americans were less likely than Caucasians to receive statins, but more likely to receive prescriptions for ACE-inhibitors/ARBs. CONCLUSIONS Although the use of cardioprotective medications in individuals with Type 2 diabetes and SMI increased over the study period, a considerable proportion of patients remained inadequately managed despite their considerable cardiac risk. Further study should focus on observed racial variations and strategies to increase the capacity of mental health contacts to improve prescribing of these agents.
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Affiliation(s)
- Julie Kreyenbuhl
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Deborah R. Medoff
- Division of Services Research, Department of Psychiatry, University of Maryland School of Medicine, 737 W. Lombard Street, 5th floor, Baltimore, MD, 21201, United States, VA Capitol Healthcare Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), 10 N. Greene St. (BT/MIRECC), Baltimore, MD, 21201, United States
| | - Stephen L. Seliger
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, 22 S. Greene St., N3W143, Baltimore, MD, 21201, United States
| | - Lisa B. Dixon
- Division of Services Research, Department of Psychiatry, University of Maryland School of Medicine, 737 W. Lombard Street, 5th floor, Baltimore, MD, 21201, United States, VA Capitol Healthcare Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), 10 N. Greene St. (BT/MIRECC), Baltimore, MD, 21201, United States
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Chen JP. Ileostomy and ramipril-induced acute renal failure and shock. Heart Lung 2007; 36:298-9. [PMID: 17628199 DOI: 10.1016/j.hrtlng.2006.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2006] [Revised: 10/23/2006] [Accepted: 10/31/2006] [Indexed: 11/23/2022]
Affiliation(s)
- Jack P Chen
- Section of Cardiology, Northside Hospital, Atlanta, GA, USA
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Sirois C, Moisan J, Poirier P, Grégoire JP. Suboptimal use of cardioprotective drugs in newly treated elderly individuals with type 2 diabetes. Diabetes Care 2007; 30:1880-2. [PMID: 17384345 DOI: 10.2337/dc06-2257] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Cutler DM, Long G, Berndt ER, Royer J, Fournier AA, Sasser A, Cremieux P. The value of antihypertensive drugs: a perspective on medical innovation. Health Aff (Millwood) 2007; 26:97-110. [PMID: 17211019 DOI: 10.1377/hlthaff.26.1.97] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Using national survey data and risk equations from the Framingham Heart Study, we quantify the impact of antihypertensive therapy changes on blood pressures and the number and cost of heart attacks, strokes, and deaths. Antihypertensive therapy has had a major impact on health. Without it, 1999-2000 average blood pressures (at age 40+) would have been 10-13 percent higher, and 86,000 excess premature deaths from cardiovascular disease would have occurred in 2001. Treatment has generated a benefit-to-cost ratio of at least 6:1, but much more can be achieved. More effective use of antihypertensive medication would have an impact on mortality akin to eliminating all deaths from medical errors or accidents.
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Affiliation(s)
- David M Cutler
- Department of Economics, Harvard University, Cambridge, Massachusetts, USA.
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Long G, Cutler DM, Berndt ER. Antihypertensive drugs: a perspective on the value of improved blood pressure control in the USA. Eur Heart J Suppl 2007. [DOI: 10.1093/eurheartj/sum004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Roughead EE, Pratt N, Gilbert AL. Trends over 5 years in cardiovascular medicine use in Australian veterans with diabetes. Br J Clin Pharmacol 2007; 64:100-4. [PMID: 17298476 PMCID: PMC2000620 DOI: 10.1111/j.1365-2125.2007.02853.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
AIM To determine trends over 5 years in cardiovascular medicine use in the Australian veteran population with diabetes. METHODS An observational study. All veterans dispensed medicines indicative of diabetes between 2000 and 2005 were identified from the Veterans Affairs pharmacy claims dataset. Concurrent dispensings of angiotensin-converting enzyme inhibitor (ACEI), lipid-lowering medicines and antiplatelets were assessed. RESULTS ACEI/angiotensin II receptor blocker use has risen from 46% to 67% in the veteran population dispensed medicines indicative of diabetes. Lipid-lowering medicines have increased from 33% to 58% and antiplatelets from 28% to 50%. CONCLUSION The increasing use of cardiovascular medicines in the diabetes population is suggestive of improved treatment practices over time, consistent with guidelines and quality use of medicines initiatives.
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Affiliation(s)
- Elizabeth E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, Sansom Institute, University of South Australia, Adelaide, Australia.
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