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Hussain A, Ramsey D, Lee M, Mahtta D, Khan MS, Nambi V, Ballantyne CM, Petersen LA, Walker AD, Kayani WT, Butler J, Slipczuk L, Rogers JG, Bozkurt B, Navaneethan SD, Virani SS. Utilization Rates of SGLT2 Inhibitors Among Patients With Type 2 Diabetes, Heart Failure, and Atherosclerotic Cardiovascular Disease: Insights From the Department of Veterans Affairs. JACC. HEART FAILURE 2023; 11:933-942. [PMID: 37204363 DOI: 10.1016/j.jchf.2023.03.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 03/20/2023] [Accepted: 03/31/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Multiple clinical trials have demonstrated significant cardiovascular benefit with use of sodium-glucose cotransporter-2 (SGLT2) inhibitors in patients with type 2 diabetes (T2DM) and heart failure (HF) irrespective of ejection fraction. There are limited data evaluating real-world prescription and practice patterns of SGLT2 inhibitors. OBJECTIVES The authors sought to assess utilization rates and facility-level variation in the use among patients with established atherosclerotic cardiovascular disease (ASCVD), HF, and T2DM using data from the nationwide Veterans Affairs health care system. METHODS The authors included patients with established ASCVD, HF, and T2DM seen by a primary care provider between January 1, 2020, and December 31, 2020. They assessed the use of SGLT2 inhibitors and the facility-level variation in their use. Facility-level variation was computed using median rate ratios, a measure of likelihood that 2 random facilities differ in use of SGLT2 inhibitors. RESULTS Among 105,799 patients with ASCVD, HF, and T2DM across 130 Veterans Affairs facilities, 14.6% received SGLT2 inhibitors. Patients receiving SGLT2 inhibitors were younger men with higher hemoglobin A1c and estimated glomerular filtration rate and were more likely to have HF with reduced ejection fraction and ischemic heart disease. There was significant facility-level variation of SGLT2 inhibitor use, with an adjusted median rate ratio of 1.55 (95% CI: 1.46-1.64), indicating a 55% residual difference in SGLT2 inhibitor use among similar patients with ASCVD, HF, and T2DM receiving care at 2 random facilities. CONCLUSIONS Utilization rates of SGLT2 inhibitors are low in patients with ASCVD, HF, and T2DM, with high residual facility-level variation. These findings suggest opportunities to optimize SGLT2 inhibitor use to prevent future adverse cardiovascular events.
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Affiliation(s)
- Aliza Hussain
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - David Ramsey
- Health Policy, Quality and Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA; Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Michelle Lee
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Dhruv Mahtta
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Vijay Nambi
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Christie M Ballantyne
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Laura A Petersen
- Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
| | - Adrienne D Walker
- Baylor Scott and White Research Institute, Baylor Scott and White, Dallas, Texas, USA
| | - Waleed T Kayani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Baylor Scott and White, Dallas, Texas, USA; Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, USA
| | - Leandro Slipczuk
- Cardiology Division, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Joseph G Rogers
- Department of Cardiology, Texas Heart Institute, Houston, Texas, USA
| | - Biykem Bozkurt
- Department of Medicine, Cardiology Section, Winters Center for Heart Failure Research, Cardiovascular Research Institute, Baylor College of Medicine, DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Sankar D Navaneethan
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA; Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA; Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, Texas, USA
| | - Salim S Virani
- The Aga Khan University, Karachi, Pakistan; Michael E. DeBakey Veterans Affairs Medical Center, Texas Heart Institute, and Baylor College of Medicine, Houston, Texas.
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Mahtta D, Ramsey DJ, Lee MT, Chen L, Al Rifai M, Akeroyd JM, Vaughan EM, Matheny ME, Santo KRDE, Navaneethan SD, Lavie CJ, Birnbaum Y, Ballantyne CM, Petersen LA, Virani SS. Utilization Rates of SGLT2 Inhibitors and GLP-1 Receptor Agonists and Their Facility-Level Variation Among Patients With Atherosclerotic Cardiovascular Disease and Type 2 Diabetes: Insights From the Department of Veterans Affairs. Diabetes Care 2022; 45:372-380. [PMID: 35015080 PMCID: PMC8914426 DOI: 10.2337/dc21-1815] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 11/17/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE There is mounting evidence regarding the cardiovascular benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RA) among patients with atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes mellitus (T2DM). There is paucity of data assessing real-world practice patterns for these drug classes. We aimed to assess utilization rates of these drug classes and facility-level variation in their use. RESEARCH DESIGN AND METHODS We used the nationwide Veterans Affairs (VA) health care system data set from 1 January 2020 to 31 December 2020 and included patients with established ASCVD and T2DM. Among these patients, we assessed the use of SGLT2i and GLP-1 RA and the facility-level variation in their use. Facility-level variation was computed using median rate ratios (MRR), a measure of likelihood that two random facilities differ in use of SGLT2i and GLP-1 RA in patients with ASCVD and T2DM. RESULTS Among 537,980 patients with ASCVD and T2DM across 130 VA facilities, 11.2% of patients received an SGLT2i while 8.0% of patients received a GLP-1 RA. Patients receiving these cardioprotective glucose-lowering drug classes were on average younger and had a higher proportion of non-Hispanic Whites. Overall, median (10th-90th percentile) facility-level rates were 14.92% (9.31-22.50) for SGLT2i and 10.88% (4.44-17.07) for GLP-1 RA. There was significant facility-level variation among SGLT2i use-MRRunadjusted: 1.41 (95% CI 1.35-1.47) and MRRadjusted: 1.55 (95% CI 1.46 -1.63). Similar facility-level variation was observed for use of GLP-1 RA-MRRunadjusted: 1.34 (95% CI 1.29-1.38) and MRRadjusted: 1.78 (95% CI 1.65-1.90). CONCLUSIONS Overall utilization rates of SGLT2i and GLP-1 RA among eligible patients are low, with significantly higher residual facility-level variation in the use of these drug classes. Our results suggest opportunities to optimize their use to prevent future adverse cardiovascular events among these patients.
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Affiliation(s)
- Dhruv Mahtta
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX.,Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX
| | - David J Ramsey
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX
| | - Michelle T Lee
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX.,Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX
| | - Liang Chen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX
| | - Mahmoud Al Rifai
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Julia M Akeroyd
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX
| | - Elizabeth M Vaughan
- Division of General Internal Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX.,Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Michael E Matheny
- Geriatrics Research Education and Clinical Care, Tennessee Valley Healthcare System VA, Nashville, TN.,Departments of Biomedical Informatics, Biostatistics, and Medicine, Vanderbilt University Medical Center, Nashville, TN
| | | | - Sankar D Navaneethan
- Section of Nephrology and Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, TX.,Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Carl J Lavie
- 10Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA
| | - Yochai Birnbaum
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Christie M Ballantyne
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX.,Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Laura A Petersen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX.,11Section of Health Services Research, Baylor College of Medicine, Houston, TX
| | - Salim S Virani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX.,Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX.,Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX.,10Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA.,12Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
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Mahtta D, Ramsey D, Krittanawong C, Al Rifai M, Khurram N, Samad Z, Jneid H, Ballantyne C, Petersen LA, Virani SS. Recreational substance use among patients with premature atherosclerotic cardiovascular disease. Heart 2021; 107:650-656. [PMID: 33589427 DOI: 10.1136/heartjnl-2020-318119] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Despite an upsurge in the incidence of atherosclerotic cardiovascular diseases (ASCVD) among young adults, the attributable risk of recreational substance use among young patients has been incompletely evaluated. We evaluated the association of all recreational substances with premature and extremely premature ASCVD. METHODS In a cross-sectional analysis using the 2014-2015 nationwide Veterans Affairs Healthcare database and the Veterans wIth premaTure AtheroscLerosis (VITAL) registry, patients were categorised as having premature, extremely premature or non-premature ASCVD. Premature ASCVD was defined as having first ASCVD event at age <55 years for men and <65 years for women. Extremely premature was defined as having first ASCVD event at age <40 years while non-premature ASCVD was defined as having first ASCVD event at age ≥55 years for men and ≥65 years for women. Patients with premature ASCVD (n=135 703) and those with extremely premature ASCVD (n=7716) were compared against patients with non-premature ASCVD (n=1 112 455). Multivariable logistic regression models were used to study the independent association of all recreational substances with premature and extremely premature ASCVD. RESULTS Compared with patients with non-premature ASCVD, patients with premature ASCVD had a higher use of tobacco (62.9% vs 40.6%), alcohol (31.8% vs 14.8%), cocaine (12.9% vs 2.5%), amphetamine (2.9% vs 0.5%) and cannabis (12.5% vs 2.7%) (p<0.01 for all comparisons). In adjusted models, the use of tobacco (OR 1.97, 95% CI 1.94 to 2.00), alcohol (OR 1.50, 95% CI 1.47 to 1.52), cocaine (OR 2.44, 95% CI 2.38 to 2.50), amphetamine (OR 2.74, 95% CI 2.62 to 2.87), cannabis (OR 2.65, 95% CI 2.59 to 2.71) and other drugs (OR 2.53, 95% CI 2.47 to 2.59) was independently associated with premature ASCVD. Patients with polysubstance use had a graded response with the highest risk (~9-fold) of premature ASCVD among patients with use of ≥4 recreational substances. Similar trends were observed among patients with extremely premature ASCVD. Gender interactions with substance use were significant (p-interaction <0.05), with recreational substance use and premature ASCVD showing stronger associations among women than in men with premature ASCVD. CONCLUSIONS All subgroups of recreational substances were independently associated with a higher likelihood of premature and extremely premature ASCVD. Recreational substance use confers a greater magnitude of risk for premature ASCVD among women. A graded response relationship exists between increasing number of recreational substances used and higher likelihood of early-onset ASCVD.
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Affiliation(s)
- Dhruv Mahtta
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA.,Section of Cardiology, Department of Medicine, -Baylor College of Medicine, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - David Ramsey
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA
| | - Chayakrit Krittanawong
- Section of Cardiology, Department of Medicine, -Baylor College of Medicine, Houston, Texas, USA
| | - Mahmoud Al Rifai
- Section of Cardiology, Department of Medicine, -Baylor College of Medicine, Houston, Texas, USA
| | - Nasir Khurram
- Division of Cardiovascular Medicine, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Zainab Samad
- Department of Medicine, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Hani Jneid
- Section of Cardiology, Department of Medicine, -Baylor College of Medicine, Houston, Texas, USA.,Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Christie Ballantyne
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Laura A Petersen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA .,Section of Cardiology, Department of Medicine, -Baylor College of Medicine, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Significant Facility-Level Variation in Utilization of and Adherence with Secondary Prevention Therapies Among Patients with Premature Atherosclerotic Cardiovascular Disease: Insights from the VITAL (Veterans wIth premaTure AtheroscLerosis) Registry7. Cardiovasc Drugs Ther 2021; 36:93-102. [PMID: 33400053 DOI: 10.1007/s10557-020-07125-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE We investigated facility-level variation in the use and adherence with antiplatelets and statins among patients with premature and extremely premature ASCVD. METHODS Using the 2014-2015 nationwide Veterans wIth premaTure AtheroscLerosis (VITAL) registry, we assessed patients with premature (age at first ASCVD event: males < 55 years, females < 65 years) and extremely premature ASCVD (< 40 years). We examined frequency and facility-level variation in any statin, high-intensity statin (HIS), antiplatelet use (aspirin, clopidogrel, ticagrelor, prasugrel, and ticlopidine), and statin adherence (proportion of days covered ≥ 0.8) across 130 nationwide VA healthcare facilities. Facility-level variation was computed using median rate ratios (MRR), a measure of likelihood that two random facilities differ in use of statins or antiplatelets and statin adherence. RESULTS Our analysis included 135,703 and 7716 patients with premature and extremely premature ASCVD, respectively. Across all facilities, the median (IQR) prescription rate of any statin therapy, HIS therapy, and antiplatelets among patients with premature ASCVD was 0.73 (0.70-0.75), 0.36 (0.32-0.41), and 0.77 (0.73-0.81), respectively. MRR (95% CI) for any statin use, HIS use, and antiplatelet use were 1.53 (1.44-1.60), 1.58 (1.49-1.66), and 1.49 (1.42-1.56), respectively, showing 53, 58, and 49% facility-level variation. The median (IQR) facility-level rate of statin adherence was 0.58 (0.55-0.62) and MRR for statin adherence was 1.13 (1.10-1.15), showing 13% facility-level variation. Similar median facility-level rates and variation were observed among patients with extremely premature ASCVD. CONCLUSIONS There is suboptimal use and significant facility-level variation in the use of statin and antiplatelet therapy among patients with premature and extremely premature ASCVD. Interventions are needed to optimize care and minimize variation among young ASCVD patients.
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Blosnich JR, Montgomery AE, Taylor LD, Dichter ME. Adverse social factors and all-cause mortality among male and female patients receiving care in the Veterans Health Administration. Prev Med 2020; 141:106272. [PMID: 33022319 DOI: 10.1016/j.ypmed.2020.106272] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 09/23/2020] [Accepted: 09/27/2020] [Indexed: 10/23/2022]
Abstract
Social factors account more for health outcomes than medical care, yet health services research in this area is limited due to the lack of social factors data contained within electronic health records (EHR) systems. Few investigations have examined how cumulative burdens of co-occurring adverse social factors impact health outcomes. From 293,872 patients in one region of the Veterans Health Administration (VHA), we examined how increasing numbers of adverse social factors extracted from the EHR were associated with mortality across a one-year period for male and female patients. Adverse social factors were identified using four sources in the EHR: responses to universal VHA screens, International Classification of Disease (ICD) diagnostic codes that indicate social factors, receipt of VHA services related to social factors, and templated social work referrals. Seven types of adverse social factors were coded: violence, housing instability, employment or financial problems, legal issues, social or familial problems, lack of access to care or transportation, and nonspecific psychosocial needs. Overall, each increase in an adverse social factor was associated with 27% increased odds of mortality, after accounting for demographics, medical comorbidity, and military service-related disability. Non-specific psychosocial factors were most strongly associated with mortality, followed by social or familial problems. Although women were more likely than men to have multiple adverse social factors, social factors were not associated with mortality among women as they were among men. By incorporating social factors data, health care systems can better understand patient all-cause mortality and identify potential prevention efforts built around social determinants.
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Affiliation(s)
- John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, United States of America; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America.
| | - Ann Elizabeth Montgomery
- U.S. Department of Veterans Affairs (VA), National Center on Homelessness Among Veterans, Tampa, FL, United States of America; Birmingham VA Medical Center, Birmingham, AL, United States of America; Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Laura D Taylor
- U.S. Department of Veterans Affairs (VA), National Social Work Program Office, Washington, DC, United States of America
| | - Melissa E Dichter
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States of America; School of Social Work, College of Public Health, Temple University, Philadelphia, PA, United States of America
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Mahtta D, Gupta A, Ramsey DJ, Rifai MA, Mehta A, Krittanawong C, Lee MT, Nasir K, Samad Z, Blumenthal RS, Jneid H, Ballantyne CM, Petersen LA, Virani SS. Autoimmune Rheumatic Diseases and Premature Atherosclerotic Cardiovascular Disease: An Analysis From the VITAL Registry. Am J Med 2020; 133:1424-1432.e1. [PMID: 32598903 DOI: 10.1016/j.amjmed.2020.05.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Although the association between autoimmune rheumatic diseases and atherosclerotic cardiovascular disease is well-known, there is a lack of data regarding the role of such disorders in patients with premature and extremely premature atherosclerotic cardiovascular disease. METHODS The Veterans With Premature Atherosclerosis (VITAL) registry, including patients with premature (males <55 years, females <65 years) and extremely premature atherosclerotic cardiovascular disease (<40 years), was created from the 2014-2015 nationwide Veterans Affairs (VA) health care system database. We assessed age at the time of first cardiovascular event to compare patients with premature (n = 135,703) and those with extremely premature atherosclerotic cardiovascular disease (n = 7716) with age-matched patients without atherosclerotic cardiovascular disease (nyoung = 1,153,535, nextremely young = 441,836). We assessed whether systemic lupus erythematosus, rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis were independently associated with premature and extremely premature atherosclerotic cardiovascular disease. RESULTS Patients with premature and extremely premature atherosclerotic cardiovascular disease had a higher prevalence of all rheumatic diseases as compared with age-matched patients without atherosclerotic cardiovascular disease. In fully adjusted models, systemic lupus erythematosus (odds ratio [OR]: 1.69, 95% confidence interval [CI]: 1.56-1.83) and rheumatoid arthritis (OR: 1.72, 95% CI: 1.63-1.81) were associated with increased odds of premature atherosclerotic cardiovascular disease. Patients with systemic lupus erythematosus (OR: 3.06, 95% CI: 2.38-3.93) and rheumatoid arthritis (OR: 2.39, 95% CI: 1.85-3.08) also had a higher likelihood of extremely premature atherosclerotic cardiovascular disease. CONCLUSION Patients with systemic lupus erythematosus and rheumatoid arthritis carry higher odds of both premature and extremely premature atherosclerotic cardiovascular disease. Future studies are needed to understand the rheumatic disease-specific factors behind the development and progression of clinical atherosclerotic cardiovascular disease in these young patients.
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Affiliation(s)
- Dhruv Mahtta
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Houston, Tex; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Tex
| | - Angela Gupta
- Department of Medicine, University Hospitals Cleveland Medical Center, and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - David J Ramsey
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Houston, Tex
| | - Mahmoud Al Rifai
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Tex
| | - Anurag Mehta
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Ga
| | | | - Michelle T Lee
- Department of Medicine, University of Texas Health Science Center, Houston
| | - Khurram Nasir
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Tex
| | - Zainab Samad
- Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Hani Jneid
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Tex; Section of Cardiology, Michael E. DeBakey VA Medical Center, Houston, Tex
| | - Christie M Ballantyne
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Tex; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Tex
| | - Laura A Petersen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Houston, Tex; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Tex
| | - Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Houston, Tex; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Tex; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Tex; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Tex.
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Mahtta D, Ramsey DJ, Al Rifai M, Nasir K, Samad Z, Aguilar D, Jneid H, Ballantyne CM, Petersen LA, Virani SS. Evaluation of Aspirin and Statin Therapy Use and Adherence in Patients With Premature Atherosclerotic Cardiovascular Disease. JAMA Netw Open 2020; 3:e2011051. [PMID: 32816031 PMCID: PMC7441361 DOI: 10.1001/jamanetworkopen.2020.11051] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Studies on the use of and adherence to secondary prevention therapies in patients with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD) are lacking. OBJECTIVE To evaluate and compare aspirin use, any statin use, high-intensity statin use, and statin adherence among patients with premature or extremely premature ASCVD compared with patients with nonpremature ASCVD. DESIGN, SETTING, AND PARTICIPANTS This multicenter cross-sectional study used the clinical and administrative data sets of the US Department of Veterans Affairs (VA) to identify adult patients with at least 1 primary care visit in the VA health care system between October 1, 2014, and September 30, 2015. The study cohort comprised patients with ASCVD (ischemic heart disease, peripheral arterial disease, or ischemic cerebrovascular disease) who were enrolled in the Veterans With Premature Atherosclerosis (VITAL) registry. Patients with missing data for date of birth or sex and those with limited life expectancy were excluded. Data were analyzed from November 1, 2019, to January 1, 2020. EXPOSURES Premature (the first ASCVD event occurred at age <55 years for men and age <65 years for women) vs nonpremature (the first ASCVD event occurred at age ≥55 years for men or age ≥65 years for women) ASCVD and extremely premature (the first ASCVD event occurred at age <40 years) vs nonpremature ASCVD. MAIN OUTCOMES AND MEASURES The primary outcomes were aspirin use, any statin use, high-intensity statin use, and statin adherence (measured by proportion of days covered [PDC] ≥0.8). RESULTS Of the 1 248 158 patients identified, 135 703 (10.9%) had premature ASCVD (mean [SD] age, 49.6 [5.8] years; 116 739 men [86.0%]), 1 112 455 (89.1%) had nonpremature ASCVD (mean [SD] age, 69.6 [8.9] years; 1 104 318 men [99.3%]), and 7716 (0.6%) had extremely premature ASCVD (mean [SD] age, 34.2 [4.3] years; 6576 men [85.2%]). Patients with premature ASCVD vs those with nonpremature ASCVD had lower rates of aspirin use (96 468 [71.1%] vs 860 726 [77.4%]; P < .001) and any statin use (98 908 [72.9%] vs 894 931 [80.5%]; P < .001); had a statin PDC of 0.8 or higher (57 306 [57.9%] vs 644 357 [72.0%]; P < .001); and a higher rate of high-intensity statin use (49 354 [36.4%] vs 332 820 [29.9%]; P < .001). Similarly, patients with extremely premature ASCVD were less likely to use aspirin (odds ratio [OR], 0.27; 95% CI, 0.26-0.29), any statin (OR, 0.25; 95% CI, 0.24-0.27), or high-intensity statin (OR, 0.78; 95% CI, 0.74-0.82) and to be statin adherent (OR, 0.44; 95% CI, 0.41-0.47). CONCLUSIONS AND RELEVANCE In this study, patients with premature or extremely premature ASCVD appeared to be less likely to use aspirin or statins and to adhere to statin therapy. This finding warrants further investigation into premature ASCVD and initiatives, including clinician and patient education, to better understand and mitigate the disparities in medication use and adherence.
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Affiliation(s)
- Dhruv Mahtta
- Health Policy, Quality and Informatics Program, Health Services Research and Development, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - David J. Ramsey
- Health Policy, Quality and Informatics Program, Health Services Research and Development, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Mahmoud Al Rifai
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Khurram Nasir
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Zainab Samad
- Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - David Aguilar
- Division of Cardiology, University of Texas Health Science Center McGovern Medical School, Houston
| | - Hani Jneid
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Christie M. Ballantyne
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Laura A. Petersen
- Health Policy, Quality and Informatics Program, Health Services Research and Development, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Salim S. Virani
- Health Policy, Quality and Informatics Program, Health Services Research and Development, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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8
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Griffith KN, Prentice JC, Mohr DC, Conlin PR. Predicting 5- and 10-Year Mortality Risk in Older Adults With Diabetes. Diabetes Care 2020; 43:1724-1731. [PMID: 32669409 PMCID: PMC7372062 DOI: 10.2337/dc19-1870] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 05/08/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Several diabetes clinical practice guidelines suggest that treatment goals may be modified in older adults on the basis of comorbidities, complications, and life expectancy. The long-term benefits of treatment intensification may not outweigh short-term risks for patients with limited life expectancy. Because of the uncertainty of determining life expectancy for individual patients, we sought to develop and validate prognostic indices for mortality in older adults with diabetes. RESEARCH DESIGN AND METHODS We used a prevalence sample of veterans with diabetes who were aged ≥65 years on 1 January 2006 (N = 275,190). Administrative data were queried for potential predictors that included patient demographics, comorbidities, procedure codes, laboratory values and anthropomorphic measurements, medication history, and previous health service utilization. Logistic least absolute shrinkage and selection operator regressions were used to identify variables independently associated with mortality. The resulting odds ratios were then weighted to create prognostic indices of mortality over 5 and 10 years. RESULTS Thirty-seven predictors of mortality were identified: 4 demographic variables, prescriptions for insulin or sulfonylureas or blood pressure medications, 6 biomarkers, previous outpatient and inpatient utilization, and 22 comorbidities/procedures. The prognostic indices showed good discrimination, with C-statistics of 0.74 and 0.76 for 5- and 10-year mortality, respectively. The indices also demonstrated excellent agreement between observed outcome and predictions, with calibration slopes of 1.01 for both 5- and 10-year mortality. CONCLUSIONS Prognostic indices obtained from administrative data can predict 5- and 10-year mortality in older adults with diabetes. Such a tool may enable clinicians and patients to develop individualized treatment goals that balance risks and benefits of treatment intensification.
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Affiliation(s)
- Kevin N Griffith
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, MA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA
| | - Julia C Prentice
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA
| | - David C Mohr
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
| | - Paul R Conlin
- VA Boston Healthcare System, Boston, MA
- Harvard Medical School, Boston, MA
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Jia X, Ramsey DJ, Rifai MA, Ahmed ST, Akeroyd JM, Dixon DL, Gluckman TJ, Nambi V, Ballantyne CM, Petersen LA, Stone NJ, Virani SS. Impact of Lipid Monitoring on Treatment Intensification of Cholesterol Lowering Therapies (from the Veterans Affairs Healthcare System). Am J Cardiol 2020; 125:874-879. [PMID: 31952841 DOI: 10.1016/j.amjcard.2019.12.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/08/2019] [Accepted: 12/13/2019] [Indexed: 01/09/2023]
Abstract
Treatment guidelines recommend monitoring of lipids to assess efficacy and adherence to lipid lowering therapy. We assessed whether lipid profile monitoring is associated with intensification of cholesterol lowering therapy. Patients from the Veterans Affairs (VA) healthcare system with atherosclerotic cardiovascular disease and at least one primary care visit between October 2013 and September 2014 were included (n = 1,061,753). Treatment intensification was defined as the initiation of a statin, an increase in the intensity or dose of statin therapy and/or the addition of ezetimibe. An association between the number of lipid panels and treatment intensification was assessed with adjusted regression models. During the study period, 87.1% of included patients had ≥1 lipid panel. Patients with ≥1 lipid panel were more likely to undergo treatment intensification compared with individuals with 0 lipid panels (9.3% vs 5.4%, respectively, p <0.001). Among individuals not on statin therapy at the index date (n = 287,636), those with ≥1 lipid panel were more likely to have a statin initiated compared those who without a lipid panel (21.5% vs 8.7%, p <0.001). On regression analysis (odds ratio [OR] [95% confidence interval {CI}]), patients with 1 lipid panel (1.55 [1.50 to 1.59]), 2 to 3 lipid panels (1.76 [1.71 to 1.81]) and >3 lipid panels (3.02 [2.90 to 3.14]) showed greater odds of treatment intensification compared with individuals without a lipid panel. In conclusion, lipid monitoring is associated with higher rates of treatment intensification in patients with atherosclerotic cardiovascular disease. This has important clinical implications as higher intensity regimens with statins and in combination with select nonstatin therapies is associated with improved cardiovascular outcomes.
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10
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Ahmed ST, Mahtta D, Rehman H, Akeroyd J, Al Rifai M, Rodriguez F, Jneid H, Nasir K, Samad Z, Alam M, Petersen LA, Virani SS. Association between frequency of primary care provider visits and evidence-based statin prescribing and statin adherence: Findings from the Veterans Affairs system. Am Heart J 2020; 221:9-18. [PMID: 31896038 DOI: 10.1016/j.ahj.2019.11.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/30/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Statin use remains suboptimal in patients with atherosclerotic cardiovascular disease (ASCVD). We assessed if the frequency of visits with primary care providers (PCPs) is associated with higher use of evidence-based statin prescriptions and adherence among patients with ASCVD. METHODS We identified patients with ASCVD aged ≥18 years receiving care in 130 facilities and associated community-based outpatient clinics in the entire Veterans Affairs Health Care System between October 1, 2013 and September 30, 2014. Patients were divided into frequent PCP visitors (annual PCP visits ≥ median number of PCP visits for the entire cohort) and infrequent PCP visitors (annual PCP visits < median number of patient visits). We assessed any- and high-intensity statin prescription as well as statin adherence which was defined by proportion of days covered (PDC). RESULTS We included 1,249,061 patients with ASCVD (mean age was 71.9 years; 98.0% male). Median number of annual PCP visits was 3. Approximately 80.1% patients were on statins with 23.8% on high-intensity statins. Mean PDC was 0.715 ± 0.336 with 58.3% patients with PDC ≥0.8. Frequent PCP visitors had higher frequency of statin use (82.2% vs 77.4%), high-intensity statin use (26.4% vs 20.3%), and statin adherence (mean PDC 0.73 vs 0.68; P < .01) compared to infrequent PCP visitors. After adjusting for covariates, frequent PCP visits was associated with greater odds of being on any statin, high intensity statin, and higher statin adherence. CONCLUSION Frequent visits with PCPs is associated with a higher likelihood of any statin use, high intensity statin use, and statin adherence. Further research endeavors are needed to understand the reasons behind these associations.
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11
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Woodard L, Kamdar N, Hundt N, Gordon HS, Hertz B, Amspoker AB, Kiefer L, Mehta P, Odom E, Rajan S, Stone E, Jones L, Naik AD. Empowering patients in chronic care to improve diabetes distress and glycaemic control: Protocol for a hybrid implementation-effectiveness clinical trial. Endocrinol Diabetes Metab 2020; 3:e00099. [PMID: 31922026 PMCID: PMC6947690 DOI: 10.1002/edm2.99] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/23/2019] [Accepted: 10/07/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To evaluate the effectiveness of a collaborative goal-setting intervention (Empowering Patients in Chronic Care [EPIC]) to improve glycaemic control and diabetesrelated distress, and implementation into routine care across multiple primary care clinics. DESIGN Randomized controlled trial comparing the effectiveness of the EPIC intervention with enhanced usual care (EUC) at five clinic sites located in the greater Chicago and Houston areas. We will measure differences in haemoglobin A1c (HbA1c) and diabetes distress scale scores among study arms at post-intervention and maintenance (6 months post-intervention). We will evaluate implementation of the intervention across sites using the RE-AIM framework. We will evaluate reach by comparing the per cent and characteristics of enrolled study participants among all potentially eligible participants in the given clinic population. Adoption is reflected by the characteristics of the involved providers and the number of intervention sessions conducted. Implementation of EPIC will be evaluated by number of sessions delivered, participants' evaluation of group sessions, and evaluation of quality of goal-setting. PATIENTS We randomized 280 participants with equal allocation to EPIC and enhanced usual care (EUC). RESULTS At baseline, the groups were similar with the exception that EUC participants were more likely to have prior diabetes education. At baseline, participants were predominately older men who have poorly controlled diabetes (mean HbA1c = 76 mmol/mol [9.1%]) and moderate levels of diabetes distress (mean DDS = 2.43). CONCLUSIONS This hybrid effectiveness-implementation protocol is designed to accelerate the translation of a patient-centred diabetes care intervention from research to clinical practice.
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Affiliation(s)
- LeChauncy Woodard
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
- Department of MedicineBaylor College of MedicineHoustonTexas
| | - Nipa Kamdar
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
| | - Natalie Hundt
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
- Department of Psychiatry and Behavioral SciencesBaylor College of MedicineHoustonTexas
| | - Howard S. Gordon
- Jesse Brown Veterans Affairs Medical Center and VA Center of Innovation for Complex Chronic HealthcareChicagoIllinois
- Section of Academic Internal MedicineDepartment of MedicineUniversity of Illinois at ChicagoChicagoIllinois
- Institute for Health Research and PolicyUniversity of Illinois at ChicagoChicagoIllinois
| | - Brian Hertz
- Department of Internal MedicineLoyola University ChicagoIllinois
- U.S. Department of Veterans AffairsEdward Hines Jr. VA HospitalHinesIllinois
| | - Amber B. Amspoker
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
- Department of MedicineBaylor College of MedicineHoustonTexas
| | - Lea Kiefer
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
| | - Praveen Mehta
- Jesse Brown Veterans Affairs Medical Center and VA Center of Innovation for Complex Chronic HealthcareChicagoIllinois
| | - Edward Odom
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
| | - Suja Rajan
- University of Texas, School of Public HealthHoustonTexas
| | - Elizabeth Stone
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
- School of Social SciencesBrown CollegeRice UniversityHoustonTexas
| | - Lindsey Jones
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
- U.S. Department of Veterans AffairsEdward Hines Jr. VA HospitalHinesIllinois
- U.S. Department of Veterans AffairsVA Information Resource Center (VIReC)Edward Hines Jr. VA HospitalHinesIllinois
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness, and SafetyMichael E. DeBakey VAMCHoustonTexas
- Department of MedicineBaylor College of MedicineHoustonTexas
- Department of Psychiatry and Behavioral SciencesBaylor College of MedicineHoustonTexas
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12
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Rehman H, Ahmed ST, Akeroyd J, Mahtta D, Jia X, Rifai MA, Nasir K, Jneid H, Khalid MU, Alam M, Toth PP, Virani SS. Relation Between Cardiology Follow-Up Visits, Evidence-Based Statin Prescribing, and Statin Adherence (from the Veterans Affairs Health Care System). Am J Cardiol 2019; 124:1165-1170. [PMID: 31405545 DOI: 10.1016/j.amjcard.2019.07.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 07/07/2019] [Accepted: 07/11/2019] [Indexed: 11/30/2022]
Abstract
Statin use remains suboptimal in patients with atherosclerotic cardiovascular disease (ASCVD). We assessed whether outpatient care with a cardiology provider is associated with evidence-based statin prescription and statin adherence. We identified patients with ASCVD aged ≥18 years receiving primary care in 130 facilities and associated community-based outpatient clinics in the entire Veterans Affairs Health Care System between October 1, 2013 and September 30, 2014. Patients were divided into: (1) patients with at least 1 outpatient cardiology visit and (2) patients with no outpatient cardiology visits in the year before the index primary care visit. We assessed any- and high-intensity statin prescription adjusting for several patient- and facility-level covariates, and statin adherence using proportion of days covered (PDC). We included 1,249,061 patients with ASCVD (mean age: 71.9 years; 98.0% male). After adjusting for covariates, patients who visited a cardiology provider had greater odds of being on a statin (87.4% vs 78.4%; Odds ratio [OR] 1.25, 95% Confidence interval [CI] 1.24 to 1.26), high-intensity statin (34.5% vs 21.2%; OR: 1.21, 95% CI 1.21 to 1.22), and higher statin adherence (mean PDC 0.76 ± 0.29 vs 0.70 ± 0.34, PDC ≥0.8: 62.0% vs 57.3%; OR 1.09, 95% CI 1.09 to 1.11). A dose response relation was seen with a higher number of cardiology visits associated with a higher statin use and statin adherence. In conclusion, compared with outpatient care delivered by primary care providers alone, care delivered by a cardiology provider for patients with ASCVD is associated with a higher likelihood of guideline-based statin use and statin adherence.
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Affiliation(s)
- Hasan Rehman
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Sarah T Ahmed
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Julia Akeroyd
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Dhruv Mahtta
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Xiaoming Jia
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Mahmoud Al Rifai
- Department of Medicine, University of Kansas School of Medicine, Wichita, Kankas
| | - Khurram Nasir
- Division of Cardiovascular Medicine, Center for Outcomes & Research Evaluation (CORE), Yale University School of Medicine & Yale New Haven Health, New Haven, Connecticut
| | - Hani Jneid
- Department of Medicine, Division of Cardiology, Baylor College of Medicine Houston, Texas
| | - Mirza U Khalid
- Department of Medicine, Division of Cardiology, Baylor College of Medicine Houston, Texas
| | - Mahboob Alam
- Department of Medicine, Division of Cardiology, Baylor College of Medicine Houston, Texas
| | - Peter P Toth
- Clinical Family and Community Medicine, University of Illinois College of Medicine, Peoria, Illinois; Department of Medicine, Michigan State University College of Osteopathic Medicine, East Lansing, Michigan
| | - Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
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13
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Jia X, Al Rifai M, Ramsey DJ, Ahmed ST, Akeroyd JM, Nambi V, Ballantyne CM, Petersen LA, Stone NJ, Virani SS. Association Between Lipid Testing and Statin Adherence in the Veterans Affairs Health System. Am J Med 2019; 132:e693-e700. [PMID: 31103643 DOI: 10.1016/j.amjmed.2019.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Measurement with a lipid panel after statin initiation and in long-term follow-up is recommended in both 2013 and 2018 cholesterol guidelines to assess statin efficacy and adherence. We assessed whether routine laboratory evaluation with lipid panels is associated with greater statin adherence. METHODS We identified patients with atherosclerotic cardiovascular disease within the entire Veterans Affairs (VA) health care system with at least one primary care visit between October 2013 and September 2014, who were on statin therapy (n = 813,887; n = 52,583 for new statin users). Statin adherence was determined using medication refill data and assessed by proportion of days covered (PDC). Association between number of lipid panels completed and PDC was assessed with adjusted regression models. RESULTS Within the study period, the mean number of lipid panels that were completed per patient was 1.5 ± 1.0. In the overall cohort, percentage of statin users with PDC ≥80% was 66.0% for patients with ≥1 lipid panel and 61.2% for patients with 0 lipid panels (P < .0001). Among new statin users, PDC ≥80% was 68.0% for patients with lipid panels completed within 4-12 weeks of therapy initiation and 59.3% for those without lipid panels completed within the timeframe (P < .0001). In adjusted analysis, number of lipid panels completed was associated with a modest but significant increase in PDC, when PDC was evaluated as a continuous (beta-coefficient 0.0054, P < .001) or categorical (PDC ≥80% [odds ratio (OR) 1.01; 95% confidence interval (CI), 1.00-1.01]) measure of statin adherence. The significant association was also observed in new users (beta-coefficient 0.0058, P < .001; OR 1.02; 95% CI, 1.00-1.03). CONCLUSION Routine, guideline-directed completion of lipid panels in atherosclerotic cardiovascular disease patients on statins overall and among new statin users is associated with a modes6t but significant increase in statin adherence.
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Affiliation(s)
- Xiaoming Jia
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Mahmoud Al Rifai
- Department of Medicine, University of Kansas School of Medicine, Wichita; Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Md
| | - David J Ramsey
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, Texas
| | - Sarah T Ahmed
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, Texas
| | - Julia M Akeroyd
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, Texas
| | - Vijay Nambi
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Christie M Ballantyne
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Laura A Petersen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, Texas
| | - Neil J Stone
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Ill
| | - Salim S Virani
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, Texas; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas.
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15
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Virani SS, Akeroyd JM, Ramsey DJ, Deswal A, Nasir K, Rajan SS, Ballantyne CM, Petersen LA. Health Care Resource Utilization for Outpatient Cardiovascular Disease and Diabetes Care Delivery Among Advanced Practice Providers and Physician Providers in Primary Care. Popul Health Manag 2018; 21:209-216. [DOI: 10.1089/pop.2017.0090] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Salim S. Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Julia M. Akeroyd
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - David J. Ramsey
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Anita Deswal
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Khurram Nasir
- Center for Healthcare Advancement & Outcomes, Baptist Health South Florida, Miami, Florida
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Suja S. Rajan
- Division of Management, Policy and Community Heath, School of Public Health, University of Texas—Health Science Center at Houston, Houston, Texas
| | - Christie M. Ballantyne
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Laura A. Petersen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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16
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Rehman H, Akeroyd JM, Ramsey D, Ahmed ST, Merchant AT, Navaneethan SD, Petersen LA, Virani SS. Facility-level variation in diabetes and blood pressure control in patients with diabetes: Findings from the Veterans Affairs national database. Clin Cardiol 2017; 40:1055-1060. [PMID: 28841246 DOI: 10.1002/clc.22769] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 07/11/2017] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Intensive glycemic and blood pressure (BP) control in diabetic patients is associated with improved cardiovascular outcomes. HYPOTHESIS We hypothesized that there is suboptimal glycemic and BP control with significant facility-level variation in patients with diabetes. METHODS We identified patients with diabetes receiving care in 130 facilities in the Veterans Affairs Health Care System. We assessed facility-level rates of glycemic (hemoglobin [Hb]A1c <7%), BP (BP <140/90 mmHg), and combined glycemic and BP control (HbA1c <7% and BP <140/90 mmHg), and their facility-level variation in using median rate ratios (MRR). RESULTS Among 1 103 302 patients with diabetes, 50.2% participants had an HbA1c <7%, 77.5% had a BP <140/90 mmHg, and 39.8% had both, HbA1c <7% and BP <140/90 mmHg. Median facility-level rates were 50.3% (interquartile range [IQR], 47.9%-52.4%) for glycemic control, 78.4% (IQR, 75.2%-80.0%) for BP control, and 39.9% (IQR, 38.14%-42.34%) for combined glycemic and BP control. Unadjusted MRR for glycemic control was 1.61 (95% confidence interval [CI]: 1.51-1.70) which decreased to 1.16 (95% CI: 1.14-1.19) after adjusting for patient and facility-level variables, indicating a 16% variation in glycemic control between 2 identical patients receiving care at 2 random facilities. Unadjusted MRR for BP control was 1.49 (95% CI: 1.41-1.56), which decreased to 1.25 (95% CI: 1.21-1.28), whereas unadjusted MRR for combined glycemic and BP control was 1.59 (95% CI: 1.50-1.68), which decreased to 1.15 (95% CI: 1.13-1.17) after adjustment. CONCLUSIONS Facility-level rates for BP control and glycemic control remain low with significant facility-level variation. Much of this is explained by patient and facility-level variables although 16%, 25%, and 15% variation in glycemic, BP, and combined glycemic and BP control remains unexplained.
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Affiliation(s)
- Hasan Rehman
- Department of Medicine, Houston Methodist Hospital, Houston, Texas
| | - Julia M Akeroyd
- Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center, Health Services Research and Development Center for Innovations, Houston, Texas; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - David Ramsey
- Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center, Health Services Research and Development Center for Innovations, Houston, Texas; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Sarah T Ahmed
- Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center, Health Services Research and Development Center for Innovations, Houston, Texas; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Anwar T Merchant
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, WJB Dorn VA Medical Center, Columbia, South Carolina
| | - Sankar D Navaneethan
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Laura A Petersen
- Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center, Health Services Research and Development Center for Innovations, Houston, Texas; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Salim S Virani
- Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center, Health Services Research and Development Center for Innovations, Houston, Texas; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; and Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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17
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Virani SS, Akeroyd JM, Ramsey DJ, Chan WJ, Frazier L, Nasir K, S Rajan S, Ballantyne CM, Petersen LA. Comparative effectiveness of outpatient cardiovascular disease and diabetes care delivery between advanced practice providers and physician providers in primary care: Implications for care under the Affordable Care Act. Am Heart J 2016; 181:74-82. [PMID: 27823696 DOI: 10.1016/j.ahj.2016.07.020] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 07/30/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND The objective was to compare quality of diabetes and cardiovascular disease (CVD) care between advanced practice providers (APPs) and physicians in a primary care setting. METHODS We identified diabetes (n=1,022,588) and CVD (n=1,187,035) patients receiving primary care between October 2013 and September 2014 in 130 Veterans Affairs facilities. We compared glycemic control (hemoglobin A1c <7%) in diabetic patients, blood pressure (BP) <140/90 mmHg in diabetic or CVD patients, cholesterol control (low-density lipoprotein cholesterol<100 mg/dL, receiving a statin) in diabetic or CVD patients, and those receiving a β-blocker (with history of myocardial infarction in the last 2 years) among patients receiving care from physicians and APPs. We also compared the proportion meeting composite measure (glycemic, BP, and cholesterol control in diabetic patients; BP, cholesterol control, and receipt of β-blocker among eligible CVD patients). RESULTS Diabetic patients receiving care from APPs were statistically more likely to have glycemic (50% vs 51.4%, odds ratio [OR] 1.06 [1.05-1.08]) and BP control (77.5% vs 78.4%, OR 1.04 [1.03-1.06]), whereas patients receiving care from physicians were more likely to have cholesterol control (receipt of statin 68% vs 66.5%, OR 0.94 [0.93-0.95]) in adjusted models, although these differences are not clinically significant. Similar results were seen in CVD patients. Few patients met the composite measure (27.1% and 27.6% of diabetic and 54.0% and 54.8% of CVD patients receiving care from physicians and APPs, respectively). CONCLUSIONS Diabetes and CVD care quality was comparable between physicians and APPs with clinically insignificant differences. Regardless of provider type, there is a need to improve performance on eligible measures in diabetes or CVD patients.
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Affiliation(s)
- Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX; Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, TX.
| | - Julia M Akeroyd
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - David J Ramsey
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Winston J Chan
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Lorraine Frazier
- The University of Texas Health Science Center at Houston (UTHealth) School of Nursing, Houston, TX
| | - Khurram Nasir
- Center for Healthcare Advancement & Outcomes at Baptist Health South Florida, Miami, FL; The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD
| | - Suja S Rajan
- Division of Management, Policy and Community Heath, School of Public Health, University of Texas - Health Science Center at Houston, Houston, TX
| | - Christie M Ballantyne
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX; Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, TX
| | - Laura A Petersen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
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Hira RS, Cowart JB, Akeroyd JM, Ramsey DJ, Pokharel Y, Nambi V, Jneid H, Deswal A, Denktas A, Taylor A, Nasir K, Ballantyne CM, Petersen LA, Virani SS. Risk Factor Optimization and Guideline-Directed Medical Therapy in US Veterans With Peripheral Arterial and Ischemic Cerebrovascular Disease Compared to Veterans With Coronary Heart Disease. Am J Cardiol 2016; 118:1144-1149. [PMID: 27553104 DOI: 10.1016/j.amjcard.2016.07.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 07/05/2016] [Accepted: 07/05/2016] [Indexed: 01/28/2023]
Abstract
Cardiovascular disease (CVD) is a systemic process involving multiple vascular beds and includes coronary heart disease (CHD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD). All these manifestations are associated with an increased risk of subsequent myocardial infarction, stroke, and death. Guideline-directed medical therapy is recommended for all patients with CVD. In a cohort of US veterans, we identified 1,242,015 patients with CVD receiving care in 130 Veterans Affairs facilities from October 1, 2013 to September 30, 2014. CVD included diagnoses of CHD, PAD, or ICVD. We assessed the frequency of risk factor optimization and the use of guideline-directed medical therapy in patients with CHD, PAD alone, ICVD alone, and PAD + ICVD groups. A composite of 4 measures (blood pressure <140/90 mm Hg, A1c <7% in diabetics, statin use, and antiplatelet use in eligible patients), termed optimal medical therapy (OMT) was compared among groups. Multivariate logistic regression was performed with CHD as the referent category. CHD comprised 989,380 (79.7%), PAD alone 70,404 (5.7%), ICVD alone 163,730 (13.2%), and PAD + ICVD 18,501 (1.5%) of the cohort. Overall, only 36% received OMT with adjusted odds ratios of 0.54 (95% CI 0.53 to 0.55), 0.77 (0.76 to 0.78), and 0.97 (0.94 to 1.00) for patients with PAD alone, ICVD alone, and PAD + ICVD, respectively, compared with patients with CHD. In conclusion, OMT was low in all groups. Patients with PAD alone and ICVD alone were less likely to receive OMT than those with CHD and PAD + ICVD.
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Affiliation(s)
- Ravi S Hira
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington.
| | - Jennifer B Cowart
- Division of Cardiology, Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Julia M Akeroyd
- Health Policy, Quality and Informatics Program, Michael E. DeBakey Veteran Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, Texas
| | - David J Ramsey
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Yashashwi Pokharel
- Section of Cardiovascular Research, Department of Medicine, Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, Missouri
| | - Vijay Nambi
- Division of Cardiology, Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Cardiovascular Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Hani Jneid
- Division of Cardiology, Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Anita Deswal
- Division of Cardiology, Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Ali Denktas
- Division of Cardiology, Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Addison Taylor
- Division of Cardiology, Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Khurram Nasir
- Center for Healthcare Advancement & Outcomes, Baptist Health South Florida, Miami, Florida
| | - Christie M Ballantyne
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Cardiovascular Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Laura A Petersen
- Division of Cardiology, Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Health Policy, Quality and Informatics Program, Michael E. DeBakey Veteran Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Salim S Virani
- Division of Cardiology, Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Health Policy, Quality and Informatics Program, Michael E. DeBakey Veteran Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Pokharel Y, Akeroyd JM, Ramsey DJ, Hira RS, Nambi V, Shah T, Woodard LD, Winchester DE, Ballantyne CM, Petersen LA, Virani SS. Statin Use and Its Facility-Level Variation in Patients With Diabetes: Insight From the Veterans Affairs National Database. Clin Cardiol 2016; 39:185-91. [PMID: 27059708 DOI: 10.1002/clc.22503] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 11/10/2015] [Indexed: 11/06/2022] Open
Abstract
We sought to determine use of any and at least moderate-intensity statin therapy in a national sample of patients with diabetes mellitus (DM), with the hypothesis that nationwide frequency and facility-level variation in statin therapy are suboptimal. We sampled patients with DM age 40 to 75 years receiving primary care between October 1, 2012, and September 30, 2013, at 130 parent facilities and associated community-based outpatient clinics in the Veterans Affairs Health Care System. We examined frequency and facility-level variation in use of any or at least moderate-intensity statin therapy (mean daily dose associated with ≥30% low-density lipoprotein cholesterol lowering). In 911 444 patients with DM, 68.3% and 58.4% were receiving any and moderate- to high-intensity statin therapy, respectively. Patients receiving statin had higher burden of cardiovascular disease, were more likely to be on nonstatin lipid-lowering therapy and to receive care at a teaching facility, and had more frequent primary-care visits. Median facility-level uses of any and at least moderate-intensity statin therapy were 68.7% (interquartile range, 65.9%-70.8%) and 58.6% (interquartile range, 55.8%-61.4%), respectively. After adjusting for several patient-related and some facility-related characteristics, the median rate ratios for any and moderate- to high-intensity statin therapy were 1.20 (95% confidence interval: 1.18-1.22) and 1.29 (95% confidence interval: 1.24-1.33) respectively, indicating 20% to 29% variation in statin use between 2 identical patients receiving care at 2 random facilities. Statin use was suboptimal in a national sample of patients with DM with modest facility-level variation, likely indicating differences in statin-prescribing patterns.
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Affiliation(s)
- Yashashwi Pokharel
- Saint Luke's Mid-America Heart Institute, University of Missouri-Kansas City, Missouri
| | - Julia M Akeroyd
- Department of Medicine, Baylor College of Medicine, Houston, Texas.,Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, Texas.,Michael E. DeBakey VA Medical Center, Houston, Texas
| | - David J Ramsey
- Department of Medicine, Baylor College of Medicine, Houston, Texas.,Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, Texas.,Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Ravi S Hira
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Vijay Nambi
- Section of Cardiovascular Research, Baylor College of Medicine, Houston, Texas.,Department of Medicine, Baylor College of Medicine, Houston, Texas.,Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas.,Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Tina Shah
- Department of Medicine, Baylor College of Medicine, Houston, Texas.,Michael E. DeBakey VA Medical Center, Houston, Texas
| | - LeChauncy D Woodard
- Department of Medicine, Baylor College of Medicine, Houston, Texas.,Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, Texas.,Michael E. DeBakey VA Medical Center, Houston, Texas
| | - David E Winchester
- Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida.,University of Florida College of Medicine, Gainesville, Florida
| | - Christie M Ballantyne
- Section of Cardiovascular Research, Baylor College of Medicine, Houston, Texas.,Department of Medicine, Baylor College of Medicine, Houston, Texas.,Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Laura A Petersen
- Department of Medicine, Baylor College of Medicine, Houston, Texas.,Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, Texas.,Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Salim S Virani
- Section of Cardiovascular Research, Baylor College of Medicine, Houston, Texas.,Department of Medicine, Baylor College of Medicine, Houston, Texas.,Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas.,Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, Texas.,Michael E. DeBakey VA Medical Center, Houston, Texas
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20
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Virani SS, Woodard LD, Ramsey DJ, Urech TH, Akeroyd JM, Shah T, Deswal A, Bozkurt B, Ballantyne CM, Petersen LA. Gender disparities in evidence-based statin therapy in patients with cardiovascular disease. Am J Cardiol 2015; 115:21-6. [PMID: 25456865 DOI: 10.1016/j.amjcard.2014.09.041] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 09/30/2014] [Accepted: 09/30/2014] [Indexed: 11/27/2022]
Abstract
Studies have shown gender disparities in cholesterol care in patients with cardiovascular disease (CVD), with women less likely than men to have low-density lipoprotein cholesterol levels <100 mg/dl. Whether this is related to a lower evidence-based statin or high-intensity statin use is not known. We used a national cohort of 972,532 patients with CVD (coronary heart disease, peripheral artery disease, and ischemic stroke) receiving care in 130 Veterans Health Administration facilities from October 1, 2010, to September 30, 2011, to identify the proportion of male and female patients with CVD receiving any statin and high-intensity statin. Women with CVD (n = 13,371) were less likely than men to receive statins (57.6% vs 64.8%, p <0.0001) or high-intensity statins (21.1% vs 23.6%, p <0.0001). Mean low-density lipoprotein cholesterol levels (99 vs 85 mg/dl) were higher in women compared with men (p <0.0001). In adjusted models, female gender was independently associated with a lower likelihood of receiving statins (odds ratio 0.68, 95% confidence interval 0.66 to 0.71) or high-intensity statins (odds ratio 0.76, 95% confidence interval 0.73 to 0.80). The median facility-level rate of statin and high-intensity statin use among female patients (57.3% [interquartile range = 8.93%] for statin, 20% [interquartile range = 7.7%] for high-intensity statin use) showed significant variation. In conclusion, women with CVD are less likely to receive evidence-based statin and high-intensity statins compared with men, although, their use remains low in both genders. There is a significant facility-level variation in evidence-based statin or high-intensity statin use in female patients with CVD. With the "statin dose-based approach" proposed by the recent cholesterol guidelines, these results highlight areas for quality improvement.
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21
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Virani SS, Woodard LD, Akeroyd JM, Ramsey DJ, Ballantyne CM, Petersen LA. Is high-intensity statin therapy associated with lower statin adherence compared with low- to moderate-intensity statin therapy? Implications of the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guidelines. Clin Cardiol 2014; 37:653-9. [PMID: 25324147 DOI: 10.1002/clc.22343] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 09/11/2014] [Accepted: 09/11/2014] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The recent cholesterol guideline recommends high-intensity statins in cardiovascular disease (CVD) patients. High-intensity statins are associated with more frequent side effects. Therefore, it may be of concern that these recommendations might reduce statin adherence. HYPOTHESIS High-intensity statins are associated with lower adherence compared with low- to moderate-intensity statins. METHODS In a national database of 972,532 CVD patients from the Veterans Health Administration, we identified patients receiving statins between October 1, 2010, and September 30, 2011. We assessed statin adherence by calculating proportion of days covered (PDC) and determined whether high-intensity statin therapy was independently associated with a lower PDC. RESULTS Statins were prescribed in 629,005 (64.7%). Of those, 229,437 (36.5%) received high-intensity statins. Mean PDC (0.87 vs 0.86, P < 0.0001) and patients with PDC ≥ 0.80 (76.3% vs 74.2%, P < 0.0001) were slightly higher for those receiving low- to moderate-intensity compared with high-intensity statins. In adjusted analyses, high-intensity statin use was associated with a significant but modest PDC reduction compared with low- to moderate-intensity statin use, whether PDC was assessed as a continuous (β-coefficient: -0.008, P < 0.0001) or categorical (PDC ≥ 0.80 [odds ratio: 0.94, 95% confidence interval: 0.93-0.96]) measure of statin adherence. CONCLUSIONS An approach of high-intensity statin therapy will lead to a significant practice change, as the majority of CVD patients are not on high-intensity therapy. However, this change may be associated with a very modest reduction in statin adherence compared with low- to moderate-intensity therapy that is unlikely to be of clinical significance.
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Affiliation(s)
- Salim S Virani
- Health Policy, Quality and Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Baylor College of Medicine, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houstona, Texas; Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, Texas
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Woodard LD, Landrum CR, Amspoker AB, Ramsey D, Naik AD. Interaction between functional health literacy, patient activation, and glycemic control. Patient Prefer Adherence 2014; 8:1019-24. [PMID: 25092966 PMCID: PMC4114908 DOI: 10.2147/ppa.s63954] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Functional health literacy (FHL) and patient activation can impact diabetes control through enhanced diabetes self-management. Less is known about the combined effect of these characteristics on diabetes outcomes. Using brief, validated measures, we examined the interaction between FHL and patient activation in predicting glycosylated hemoglobin (HbA1c) control among a cohort of multimorbid diabetic patients. METHODS We administered a survey via mail to 387 diabetic patients with coexisting hypertension and ischemic heart disease who received outpatient care at one regional VA medical center between November 2010 and December 2010. We identified patients with the study conditions using the International Classification of Diseases-Ninth Revision-Clinical Modification (ICD-9-CM) diagnoses codes and Current Procedure Terminology (CPT) procedures codes. Surveys were returned by 195 (50.4%) patients. We determined patient activation levels based on participant responses to the 13-item Patient Activation Measure and FHL levels using the single-item screening question, "How confident are you filling out medical forms by yourself?" We reviewed patient medical records to assess glycemic control. We used multiple logistic regression to examine whether activation and FHL were individually or jointly related to HbA1c control. RESULTS Neither patient activation nor FHL was independently related to glycemic control in the unadjusted main effects model; however, the interaction between the two was significantly associated with glycemic control (odds ratio 1.05 [95% confidence interval 1.01-1.09], P=0.02). Controlling for age, illness burden, and number of primary care visits, the combined effect of these measures on glycemic control remained significant (odds ratio 1.05 [95% confidence interval 1.01-1.09], P=0.02). CONCLUSION The interaction between FHL and patient activation is associated with HbA1c control beyond the independent effects of these parameters alone. A personalized approach to diabetes management incorporating these characteristics may increase patient-centered care and improve outcomes for patients with diabetes.
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Affiliation(s)
- LeChauncy D Woodard
- Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Correspondence: LeChauncy D Woodard, MEDVAMC 152, 2002 Holcombe Blvd, Houston, TX 77030, USA, Tel +1 713 440 4441, Fax +1 713 748 7359, Email
| | - Cassie R Landrum
- Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Amber B Amspoker
- Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - David Ramsey
- Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Aanand D Naik
- Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Giovannetti ER, Dy S, Leff B, Weston C, Adams K, Valuck TB, Pittman AT, Blaum CS, McCann BA, Boyd CM. Performance measurement for people with multiple chronic conditions: conceptual model. THE AMERICAN JOURNAL OF MANAGED CARE 2013; 19:e359-e366. [PMID: 24304183 PMCID: PMC4459786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Improving quality of care for people with multiple chronic conditions (MCCs) requires performance measures reflecting the heterogeneity and scope of their care. Since most existing measures are disease specific, performance measures must be refined and new measures must be developed to address the complexity of care for those with MCCs. OBJECTIVES To describe development of the Performance Measurement for People with Multiple Chronic Conditions (PM-MCC) conceptual model. STUDY DESIGN Framework development and a national stakeholder panel. METHODS We used reviews of existing conceptual frameworks of performance measurement, review of the literature on MCCs, input from experts in the multistakeholder Steering Committee, and public comment. RESULTS The resulting model centers on the patient and family goals and preferences for care in the context of multiple care sites and providers, the type of care they are receiving, and the national priority domains for healthcare quality measurement. CONCLUSIONS This model organizes measures into a comprehensive framework and identifies areas where measures are lacking. In this context, performance measures can be prioritized and implemented at different levels, in the context of patients' overall healthcare needs.
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Affiliation(s)
- Erin R Giovannetti
- Research Scientist, National Committee for Quality Assurance, 1100 13th St NW, Ste 1000, Washington, DC 20005. E-mail:
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Basger BJ, Chen TF, Moles RJ. Validation of prescribing appropriateness criteria for older Australians using the RAND/UCLA appropriateness method. BMJ Open 2012; 2:e001431. [PMID: 22983875 PMCID: PMC3467596 DOI: 10.1136/bmjopen-2012-001431] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 08/20/2012] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To further develop and validate previously published national prescribing appropriateness criteria to assist in identifying drug-related problems (DRPs) for commonly occurring medications and medical conditions in older (≥65 years old) Australians. DESIGN RAND/UCLA appropriateness method. PARTICIPANTS A panel of medication management experts were identified consisting of geriatricians/pharmacologists, clinical pharmacists and disease management advisors to organisations that produce Australian evidence-based therapeutic publications. This resulted in a round-one panel of 15 members, and a round-two panel of 12 members. MAIN OUTCOME MEASURE Agreement on all criteria. RESULTS Forty-eight prescribing criteria were rated. In the first rating round via email, there was disagreement regarding 17 of the criteria according to median panel ratings. During a face-to-face second round meeting, discussion resulted in retention of 25 criteria after amendments, agreement for 14 criteria with no changes required and deletion of 9 criteria. Two new criteria were added, resulting in a final validated list of 41 prescribing appropriateness criteria. Agreement after round two was reached for all 41 criteria, measured by median panel ratings and the amount of dispersion of panel ratings, based on the interpercentile range. CONCLUSIONS A set of 41 Australian prescribing appropriateness criteria were validated by an expert panel. Use of these criteria, together with clinical judgement and other medication review processes such as patient interview, is intended to assist in improving patient care by efficiently detecting potential DRPs related to commonly occurring medicines and medical conditions in older Australians. These criteria may also contribute to the medication management education of healthcare professionals.
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Affiliation(s)
- Sei J. Lee
- Division of Geriatrics, San Francisco VA Medical Center and the University of California San Francisco
| | - Cynthia M. Boyd
- Division of Geriatric Medicine and Gerontology and Department of Health Policy and Management, Johns Hopkins University
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