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Darricarrere C, Jacquot E, Bricout S, Louis C, Bénard M, Poulter NR. Uncontrolled blood pressure and therapeutic inertia in treated hypertensive patients: A retrospective cohort study using a UK general practice database. J Clin Hypertens (Greenwich) 2023; 25:895-904. [PMID: 37740433 PMCID: PMC10560967 DOI: 10.1111/jch.14699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 06/02/2023] [Accepted: 07/01/2023] [Indexed: 09/24/2023]
Abstract
Uncontrolled blood pressure (BP) and therapeutic inertia pose significant challenges in effectively managing hypertension. This study objective was to quantify levels of uncontrolled BP and therapeutic inertia among patients treated for hypertension in primary care. This retrospective cohort study used data recorded by general practitioners from the UK Clinical Practice Research Datalink database. Adults with primary hypertension who received a recorded prescription for any antihypertensive drug between January 2015 and June 2017 (index date) were included, with a follow-up of 18 months. Primary outcomes included the percentage of patients with uncontrolled BP (defined as systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg) and of apparent therapeutic inertia (defined as two consecutive uncontrolled BP records without treatment change) during follow-up. Finally, of 581 260 patients receiving antihypertensive drug(s), 37.2% (n = 216 014) had uncontrolled BP at the index date and 30.3% (n = 175 955) had no record of BP at this date. During follow-up, 59.2% had ≥1 record of uncontrolled BP, in 22% all records showed uncontrolled BP, and 12.8% had no record of BP. Among those with uncontrolled BP at the index date, 72.9% had ≥1 record of uncontrolled BP during follow-up, and in 28.3% all records showed uncontrolled BP. Therapeutic inertia was observed in 33.1% of patients overall, and in 55.7% of those with uncontrolled BP at the index date. In conclusion, BP recording was infrequent, possibly reflecting both a low frequency of measurement and potential under-recording. Uncontrolled BP and therapeutic inertia appear to be widespread in UK general practice.
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Affiliation(s)
- Céline Darricarrere
- Pharmacoepidemiology and Real World Evidence DepartmentServier LaboratoriesSuresnesFrance
| | - Emmanuelle Jacquot
- Pharmacoepidemiology and Real World Evidence DepartmentServier LaboratoriesSuresnesFrance
| | - Stéphanie Bricout
- Cardiovascular & Metabolic Diseases Therapeutic Area & Life Cycle ManagementServier LaboratoriesSuresnesFrance
| | - Caroline Louis
- Cardiovascular & Metabolic Diseases Therapeutic Area & Life Cycle ManagementServier LaboratoriesSuresnesFrance
| | | | - Neil R. Poulter
- Imperial Clinical Trials UnitImperial College LondonLondonUK
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2
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Madar H, Lalanne-Mistrih ML, Lebbar M, Wu Z, Robitaille Y, Pelletier J, Grou C, Brazeau AS, Rabasa-Lhoret R. Cardiovascular Risk Factors and Adherence to Cardiovascular Protection Practice Guidelines in Adults With Type 1 Diabetes: A BETTER Registry Cross-sectional Analysis. Can J Diabetes 2023; 47:473-481.e1. [PMID: 37059389 DOI: 10.1016/j.jcjd.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 02/12/2023] [Accepted: 04/05/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVES Cardiovascular disease (CVD) is a major cause of morbidity and mortality in people with type 1 diabetes (PWT1D). We assessed cardiovascular risk factors and pharmacologic treatment in a large Canadian cohort of PWT1D. METHODS This cross-sectional study used data from adult PWT1D in the BETTER registry (n=974). CVD risk factor status, diabetes complications, and treatments (used as proxy for blood pressure and dyslipidemia) were self-reported through online questionnaires. Objective data were available for a subgroup of PWT1D (23%, n=224). RESULTS Participants were adults (43.9±14.8 years) with a diabetes duration of 23.3±15.2 years; 34.8% reported glycated hemoglobin (A1C) levels of ≤7%, 67.2% reported a very high cardiovascular risk, and 27.2% reported at least 3 CVD risk factors. Most participants received care for CVD in accordance with the Diabetes Canada Clinical Practice Guidelines (DC-CPG), with a median recommended pharmacologic treatment score of 75.0%. However, 3 subgroups of participants with lower adherence (<70%) to DC-CPG were identified: 1) those with microvascular complications and receiving a statin (60.8%, 208 of 342) or renin-angiotensin axis nephroprotective therapy (52.6%, 180 of 342); 2) those aged ≥40 years and receiving statin therapy (67.1%, 369 of 550); and 3) those aged ≥30 years with a diabetes duration of ≥15 years and receiving statin therapy (58.9%, 344 of 584). Among a subgroup of participants with recent laboratory results, only 24.5% of PWT1D (26 of 106) achieved both A1C and low-density lipoprotein cholesterol targets. CONCLUSIONS Most PWT1D received recommended pharmacologic cardiovascular protection, but specific subgroups required special attention. Target achievement for key risk factors remains suboptimal.
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Affiliation(s)
- Houssein Madar
- Montreal Clinical Research Institute, Montréal, Québec, Canada
| | - Marie-Laure Lalanne-Mistrih
- Montreal Clinical Research Institute, Montréal, Québec, Canada; Department of Nutrition, University Hospital, Abymes, Guadeloupe, France; UFR Medicine, French West Indies University, Abymes, Guadeloupe, France
| | - Maha Lebbar
- Montreal Clinical Research Institute, Montréal, Québec, Canada; Department of Nutrition, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Zekai Wu
- Montreal Clinical Research Institute, Montréal, Québec, Canada; Department of Medicine, Division of Experimental Medicine, McGill University, Montréal, Québec, Canada
| | - Yves Robitaille
- Centre de Médecine Métabolique de Lanaudière, Terrebone, Québec, Canada
| | | | - Caroline Grou
- Montreal Clinical Research Institute, Montréal, Québec, Canada
| | - Anne-Sophie Brazeau
- Montreal Clinical Research Institute, Montréal, Québec, Canada; School of Human Nutrition, McGill University, Sainte-Anne-de-Bellevue, Québec, Canada; Montréal Diabetes Research Center, Montréal, Québec, Canada
| | - Rémi Rabasa-Lhoret
- Montreal Clinical Research Institute, Montréal, Québec, Canada; Department of Nutrition, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada; Department of Medicine, Division of Experimental Medicine, McGill University, Montréal, Québec, Canada; Montréal Diabetes Research Center, Montréal, Québec, Canada; Centre Hospitalier de l'Université de Montréal Endocrinology Division and CHUM Research Center, Montréal, Québec, Canada.
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3
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Burnier M, Redon J, Volpe M. Single-Pill Combination with Three Antihypertensive Agents to Improve Blood Pressure Control in Hypertension: Focus on Olmesartan-Based Combinations. High Blood Press Cardiovasc Prev 2023; 30:109-121. [PMID: 36696054 PMCID: PMC10090015 DOI: 10.1007/s40292-023-00563-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023] Open
Abstract
Blood pressure control remains an unmet clinical need. Only about half of patients achieve their blood pressure (BP) targets and of these, the majority require combination and double or triple therapies. International guidelines recommend the association of drugs with complementary mechanisms of action and, in particular, the combination of renin-angiotensin system (RAS) inhibitors, calcium channel blockers (CCBs), and diuretics. Among the various angiotensin receptor blockers, olmesartan (OM) is available as a monotherapy and in dual and triple single-pill combinations (SPCs) with amlodipine (AML) and/or hydrochlorothiazide (HCTZ). Several phase III and IV studies, together with real-world studies, have demonstrated the additional benefits of combining OM either with AML or with HCTZ in terms of BP control and target BP achievements both in the general population and in special subgroups of hypertensive patients, such as the elderly, diabetic, chronic kidney disease or obese patients. Ambulatory BP monitoring studies assessing 24h BP have also demonstrated that dual, as well as triple, OM-based SPCs induce a more sustained and smoother BP reduction than placebo and monotherapy. Furthermore, triple OM-based SPC has been shown to improve therapeutic adherence in hypertensive patients compared to free combinations. The availability of OM combined with HCTZ, AML or both at different dosages makes it a valuable option to customize therapy based on the levels of BP and the clinical characteristics of hypertensive patients.
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Affiliation(s)
- Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
| | - Josep Redon
- Cardiovascular and Renal Research Group, INCLIVA Research Institute, University of Valencia, Valencia, Spain
- CIBERObn, ISCIII, Madrid, Spain
| | - Massimo Volpe
- Department of Clinical and Molecular Medicine, University of Rome Sapienza, Rome, Italy
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Okyere P, Okyere I, Essuman G, Attakora J, Serwaa D, Donkoh IE, Ephraim RK. Conservative therapy is associated with worse clinical features and biochemical derangements than renal replacement therapy: a retrospective study in Kumasi, Ghana. BMC Nephrol 2022; 23:343. [PMID: 36289495 PMCID: PMC9608926 DOI: 10.1186/s12882-022-02951-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 09/12/2022] [Indexed: 11/12/2022] Open
Abstract
Background The incidence of end stage kidney disease (ESKD) is increasing in Ghana as with the rest of the world. This study compared the sociodemographic, diagnostic characteristics (clinical, biochemical and imaging) and clinical outcomes of ESKD patients who chose either renal replacement therapy (RRT) or conservative therapy as well as the factors that influenced their choice. Methods We retrospectively reviewed the records of 382 ESKD patient from 2006 to 2018. The data was collected from the Nephrology Clinic at the Komfo Anokye Teaching Hospital (KATH). Sociodemographic, diagnostic (clinical, biochemical and imaging) and therapeutic data were obtained, organized and analyzed with Statistical Package for the Social Sciences (SPSS). Results Of the 382 patients, 321 had conservative therapy whiles 61 had renal replacement therapy. The mean age of participants was 47.71 ± 16.10 years. Bipedal swelling (16.8%), fatigue (10.4%) and facial swelling (9.2%) were the major clinical features. Chronic glomerulonephritis (31.4%), hypertension (30.3%) and diabetes mellitus nephropathy (28.2%) were the most frequent predisposing conditions. Nifedipine (82.0%), bisoprolol (32.8%), aspirin (19.7%), ranitidine (26.2%), metformin (13.1%) and lasix (78.7%) were commonly used by the RRT patients than their conservative therapy counterparts. Compared to their RRT counterparts, patients on conservative therapy were more on irbesartan/lisinopril (57.9%) and sodium hydro carbonate (NaHCO3) (52.0%). Diastolic blood pressure (DBP) (p = 0.047), uremic gastritis (p = 0.007), anaemia, uraemia, haematuria and hyperkalaemia (p < 0.001) were more common in conservative therapy patients than RRT patients with RRT patients showing better corticomedullary differentiation (38.1% vs. 27.7%, p < 0.001) and normal echotexture (15.0% vs. 11.6%, p = 0.005). Age, gender, occupation and duration of illness were significantly associated with the decision to opt for conservative therapy. Conclusion Patients on conservative therapy have worse clinical outcomes than their RRT counterparts. Early referrals to nephrologist as well as subsidized RRT should be targeted.
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Affiliation(s)
- Perditer Okyere
- grid.9829.a0000000109466120Department of Medicine, School of Medicine and Dentistry, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Isaac Okyere
- grid.9829.a0000000109466120Department of Surgery, School of Medicine and Dentistry, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Grace Essuman
- grid.413081.f0000 0001 2322 8567Department of Medical Laboratory Science, School of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana ,Kidney Research Initiative, Cape Coast, Ghana
| | - Joseph Attakora
- grid.9829.a0000000109466120Department of Medicine, School of Medicine and Dentistry, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Dorcas Serwaa
- grid.9582.60000 0004 1794 5983Department of Obstetrics and Gynecology, College of Medicine, Institute of Life and Earth Sciences, Pan African University, University of Ibadan, Ibadan, Nigeria
| | - Irene Esi Donkoh
- grid.413081.f0000 0001 2322 8567Department of Medical Laboratory Science, School of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana ,Kidney Research Initiative, Cape Coast, Ghana
| | - Richard K.D. Ephraim
- grid.413081.f0000 0001 2322 8567Department of Medical Laboratory Science, School of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana ,Kidney Research Initiative, Cape Coast, Ghana
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Raveendran AV, Ravindran V. Clinical inertia in rheumatology practice. J R Coll Physicians Edinb 2021; 51:402-406. [PMID: 34882145 DOI: 10.4997/jrcpe.2021.420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Several professional medical learned societies and organisations have recommended guidelines for management of various chronic diseases geared to achieve optimal control over the diseases and improve the quality of care. However, the data from around the world suggest that a majority of patients are not achieving those treatment targets. This has been well documented in diseases such as diabetes, hypertension, dyslipidaemia and rheumatoid arthritis, and clinical inertia is thought to be a major factor responsible. In this article, we have discussed clinical inertia in rheumatology practice, which has relevance to several other chronic non-communicable diseases as well.
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Reid HW, Lin OM, Fabbro RL, Johnson KS, Svetkey LP, Olsen MK, Matsouaka RA, Chung ST, Batch BC. Racial differences in patient perception of interactions with providers are associated with health outcomes in type II diabetes. PATIENT EDUCATION AND COUNSELING 2021; 104:1993-2003. [PMID: 33579569 PMCID: PMC8217118 DOI: 10.1016/j.pec.2021.01.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Examine the association of patient perceptions of care with hemoglobin A1c (HbA1c), medication adherence, and missed appointments in non-Hispanic Black (NHB) and White (NHW) patients with type 2 diabetes (T2DM). METHODS We used linear and logistic regression models to analyze the association of the Interpersonal Processes of Care survey (IPC) with HbA1c, medication adherence, and missed appointments. We then examined how these associations differed by race. RESULTS There was no overall association between IPC subdomains and HbA1c in our sample (N = 221). NHB patients perceiving their provider always explained results and medications had a HbA1c on average 0.59 (-1.13, -0.04; p = 0.04) points lower than those perceiving their provider sometimes explained results and medications. No effect was observed in NHWs. Never perceiving disrespect from office staff was associated with an average 0.67 (-1.1, -0.24; p = 0.002) point improvement in medication adherence for all patients. Never perceiving discrimination from providers was associated with a 0.44 (-0.63, -0.25; p < 0.0001) decrease in the probability of missing an appointment for NHB patients. CONCLUSIONS These results demonstrate that particular aspects of communication in the patient-provider interaction may contribute to racial disparities in T2DM. PRACTICE IMPLICATIONS Communication training for both providers and staff may reduce disparities in T2DM.
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Affiliation(s)
| | | | | | - Kimberly S Johnson
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Center for Aging and Human Development, Duke University School of Medicine, Geriatrics Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, USA
| | - Laura P Svetkey
- Department of Medicine, Division of Nephrology, Duke University School of Medicine, Durham, USA
| | - Maren K Olsen
- Duke University Department of Biostatistics and Bioinformatics, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, USA
| | - Roland A Matsouaka
- Duke University Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University, Durham, USA
| | | | - Bryan C Batch
- Department of Medicine, Division of Endocrinology, Duke University School of Medicine, Durham, USA
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7
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Hsueh L, Hirsh AT, Zapolski T, de Groot M, Mather KJ, Stewart JC. Influence of patient immigrant status on physician trainee diabetes treatment decisions: a virtual patient experimental study. J Behav Med 2021; 44:662-672. [PMID: 33860913 DOI: 10.1007/s10865-021-00224-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 04/08/2021] [Indexed: 10/21/2022]
Abstract
To determine the effect of patient immigrant status on physician trainees' diabetes treatment decisions. Participants were 140 physician trainees ('providers'). Providers viewed videos and vignettes of virtual patients differing in immigrant status (born in Mexico or U.S.; other characteristics held constant). Analyses were completed at the group and individual levels. Providers were less likely to refer foreign-born (vs. U.S.-born) patients to endocrinology. Individual-level results showed an almost even split between treatment ratings for foreign-born vs. U.S.-born patients for three decisions (take no action, add oral hypoglycemic agent, add/switch to insulin), explaining why group-level differences for these ratings did not emerge (i.e., they were cancelled out). Physician trainees are less likely to refer foreign-born patients to endocrinology. Half of individual-level decisions were influenced by patient immigrant status, but group-level analyses mask these differences. Systematic treatment differences based on non-relevant factors could lead to adverse outcomes for immigrants.
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Affiliation(s)
- Loretta Hsueh
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.,Department of Psychology, Indiana University-Purdue University Indianapolis (IUPUI), 402 North Blackford Street, LD100E, Indianapolis, IN, 46202, USA
| | - Adam T Hirsh
- Department of Psychology, Indiana University-Purdue University Indianapolis (IUPUI), 402 North Blackford Street, LD100E, Indianapolis, IN, 46202, USA
| | - Tamika Zapolski
- Department of Psychology, Indiana University-Purdue University Indianapolis (IUPUI), 402 North Blackford Street, LD100E, Indianapolis, IN, 46202, USA
| | - Mary de Groot
- Department of Medicine, Indiana University School of Medicine, 410 W. 10th St., Suite 3100, HS 1140, Indianapolis, IN, 46202, USA
| | - Kieren J Mather
- Department of Medicine, Indiana University School of Medicine, 410 W. 10th St., Suite 3100, HS 1140, Indianapolis, IN, 46202, USA
| | - Jesse C Stewart
- Department of Psychology, Indiana University-Purdue University Indianapolis (IUPUI), 402 North Blackford Street, LD100E, Indianapolis, IN, 46202, USA.
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Kim BJ, Cho YJ, Hong KS, Lee J, Kim JT, Choi KH, Park TH, Park SS, Park JM, Kang K, Lee SJ, Kim JG, Cha JK, Kim DH, Lee BC, Yu KH, Oh MS, Kim DE, Ryu WS, Choi JC, Kim WJ, Shin DI, Sohn SI, Hong JH, Lee JS, Lee J, Han MK, Gorelick PB, Bae HJ. Treatment Intensification for Elevated Blood Pressure and Risk of Recurrent Stroke. J Am Heart Assoc 2021; 10:e019457. [PMID: 33787300 PMCID: PMC8174371 DOI: 10.1161/jaha.120.019457] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background It remains unclear whether physicians' attitudes toward timely management of elevated blood pressure affect the risk of stroke recurrence. Methods and Results From a multicenter stroke registry database, we identified 2933 patients with acute ischemic stroke who were admitted to participating centers in 2011, survived at the 1‐year follow‐up period, and returned to outpatient clinics ≥2 times after discharge. As a surrogate measure of physicians' attitude, individual treatment intensification (TI) scores were calculated by dividing the difference between the frequencies of observed and expected medication changes by the frequency of clinic visits and categorizing them into 5 groups. The association between TI groups and the recurrence of stroke within 1 year was analyzed using hierarchical frailty models, with adjustment for clustering within each hospital and relevant covariates. Mean±SD of the TI score was −0.13±0.28. The TI score groups were significantly associated with increased risk of recurrent stroke compared with Group 3 (TI score range, −0.25 to 0); Group 1 (range, −1 to −0.5), adjusted hazard ratio (HR) 13.43 (95% CI, 5.95–30.35); Group 2 (range, −0.5 to −0.25), adjusted HR 4.59 (95% CI, 2.01–10.46); and Group 4 (TI score 0), adjusted HR 6.60 (95% CI, 3.02–14.45); but not with Group 5 (range, 0–1), adjusted HR 1.68 (95% CI, 0.62–4.56). This elevated risk in the lowest TI score groups persisted when confining analysis to those with hypertension, history of blood pressure‐lowering medication, no atrial fibrillation, and regular clinic visits and stratifying the subjects by functional capacity at discharge. Conclusions A low TI score, which implies physicians' therapeutic inertia in blood pressure management, was associated with a higher risk of recurrent stroke. The TI score may be a useful performance indicator in the outpatient clinic setting to prevent recurrent stroke.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology and Cerebrovascular Center Seoul National University Bundang HospitalSeoul National University College of Medicine Seongnam Republic of Korea
| | - Yong-Jin Cho
- Department of Neurology Ilsan Paik HospitalInje University Goyang Republic of Korea
| | - Keun-Sik Hong
- Department of Neurology Ilsan Paik HospitalInje University Goyang Republic of Korea
| | - Jun Lee
- Department of Neurology Yeungnam University Hospital Daegu Republic of Korea
| | - Joon-Tae Kim
- Department of Neurology Chonnam National University Medical School and Hospital Gwangju Republic of Korea
| | - Kang Ho Choi
- Department of Neurology Chonnam National University Medical School and Hospital Gwangju Republic of Korea
| | - Tai Hwan Park
- Department of Neurology Seoul Medical Center Seoul Republic of Korea
| | - Sang-Soon Park
- Department of Neurology Seoul Medical Center Seoul Republic of Korea
| | - Jong-Moo Park
- Department of Neurology Eulji General Hospital Eulji University Seoul Republic of Korea
| | - Kyusik Kang
- Department of Neurology Eulji General Hospital Eulji University Seoul Republic of Korea
| | - Soo Joo Lee
- Department of Neurology Eulji University HospitalEulji University Daejeon Republic of Korea
| | - Jae Guk Kim
- Department of Neurology Eulji University HospitalEulji University Daejeon Republic of Korea
| | - Jae-Kwan Cha
- Department of Neurology Dong-A University College of Medicine Busan Republic of Korea
| | - Dae-Hyun Kim
- Department of Neurology Dong-A University College of Medicine Busan Republic of Korea
| | - Byung-Chul Lee
- Department of Neurology Hallym University Sacred Heart Hospital Anyang Republic of Korea
| | - Kyung-Ho Yu
- Department of Neurology Hallym University Sacred Heart Hospital Anyang Republic of Korea
| | - Mi-Sun Oh
- Department of Neurology Hallym University Sacred Heart Hospital Anyang Republic of Korea
| | - Dong-Eog Kim
- Department of Neurology Dongguk University Ilsan Hospital Goyang Republic of Korea
| | - Wi-Sun Ryu
- Department of Neurology Dongguk University Ilsan Hospital Goyang Republic of Korea
| | - Jay Chol Choi
- Department of Neurology Jeju National University Jeju Republic of Korea
| | - Wook-Joo Kim
- Department of Neurology Ulsan University HospitalUniversity of Ulsan College of Medicine Ulsan Republic of Korea
| | - Dong-Ick Shin
- Department of Neurology Chungbuk National University Hospital Cheongju Republic of Korea
| | - Sung Il Sohn
- Department of Neurology Keimyung University Dongsan Medical Center Daegu Republic of Korea
| | - Jeong-Ho Hong
- Department of Neurology Keimyung University Dongsan Medical Center Daegu Republic of Korea
| | - Ji Sung Lee
- Clinical Research Center Asan Medical Center Seoul Republic of Korea
| | - Juneyoung Lee
- Department of Biostatistics College of Medicine Korea University Seoul Republic of Korea
| | - Moon-Ku Han
- Department of Neurology and Cerebrovascular Center Seoul National University Bundang HospitalSeoul National University College of Medicine Seongnam Republic of Korea
| | - Philip B Gorelick
- Davee Department of Neurology Northwestern University Feinberg School of Medicine Chicago IL
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center Seoul National University Bundang HospitalSeoul National University College of Medicine Seongnam Republic of Korea
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Bosworth HB. The Importance of Considering Clinical Inertia and Implementation Science When Addressing Medication Adherence. JAMA Netw Open 2020; 3:e2020233. [PMID: 33034636 DOI: 10.1001/jamanetworkopen.2020.20233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Hayden B Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation Durham Veterans, Affairs Medical Center, Durham, North Carolina
- Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina
- Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
- School of Nursing, Duke University Medical Center, Durham, North Carolina
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10
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Javanmardifard S, Heidari S, Sanjari M, Yazdanmehr M, Shirazi F. The relationship between spiritual well-being and hope, and adherence to treatment regimen in patients with diabetes. J Diabetes Metab Disord 2020; 19:941-950. [PMID: 33520814 DOI: 10.1007/s40200-020-00586-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 07/09/2020] [Indexed: 12/16/2022]
Abstract
Background Adherence to treatment regimen is one of the behaviors related to diabetes, which has predicted successful control of the disease and reduced its intensity as well as negative consequences. This study aimed to determine the relationship between spiritual well-being and hope, and adherence to treatment regimen in patients with type II diabetes referred to diabetes clinics. Methods In this descriptive-correlational study, 227 diabetic patients referred to healthcare centers and diabetes clinics affiliated to Shiraz University of Medical Sciences were selected via cluster sampling (clinics) followed by convenience sampling (patients). The study data were collected using a demographic information form, spiritual well-being scale developed by Ellison and Paloutzian, Herth hope scale, and adherence to treatment regimen questionnaire. Then, the data were entered into the statistical software and were analyzed using descriptive and inferential statistics. Results The results indicated that most participants had moderate spiritual well-being, high hope, and low adherence to treatment regimen. Additionally, spiritual well-being was directly associated with hope and reversely related to adherence to treatment. A significant reverse correlation was also observed between hope and adherence to treatment. Conclusion Considering the fact that spiritual well-being and hope were reversely associated with adherence to treatment regimen, further studies should be done in this field. Also patients' image of God and their interpretations of being sick might not be appropriate and need correction.
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Affiliation(s)
- Sorur Javanmardifard
- Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shiva Heidari
- Department of Nursing, Urmia branch, Islamic Azad University, Urmia, Iran
| | - Mahnaz Sanjari
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Yazdanmehr
- Department of Ophthalmology, Shahid Motahari Specialty and Sub-specialty Complex, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Shirazi
- Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
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Tahkola A, Korhonen P, Kautiainen H, Niiranen T, Mäntyselkä P. Lifetime risk assessment in cholesterol management among hypertensive patients: observational cross-sectional study based on electronic health record data. BMC FAMILY PRACTICE 2020; 21:62. [PMID: 32290820 PMCID: PMC7155316 DOI: 10.1186/s12875-020-01138-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 04/06/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND In hypertensive patients, reducing plasma low-density lipoprotein cholesterol level (LDL-C) is one of the main interventions for preventing chronic cardiovascular diseases (CVD). However, LDL-C control remains generally insufficient, also in patients with hypertension. We analyzed Electronic Health Record (EHR) data of 7117 hypertensive patients to find the most potential age and sex subgroups in greatest need for improvement in real life dyslipidemia treatment. Taking into account the current discussion on lifetime CVD risk, we focused on the age dependence in LDL-C control. METHODS In this observational cross-sectional study, based on routine electronic health record (EHR) data, we investigated LDL-C control of hypertensive, non-diabetic patients without renal dysfunction or CVD, aged 30 years or more in Finnish primary care setting. RESULTS More than half (54% of women and 53% of men) of untreated patients did not meet the LDL-C target of < 3 mmol/l and one third (35% of women and 33% of men) of patients did not reach the target even with the lipid-lowering medication (LLM). Furthermore, higher age was strongly associated with better LDL-C control (p < 0.001) and lower LDL-C level (p < 0.001) in individuals with and without LLM. Higher age was also strongly associated with LLM prescription (p < 0.001). In total, about half of the patients were on LLM (53% of women and 51% of men). CONCLUSIONS Our findings indicate that dyslipidemia treatment among Finnish primary care hypertensive patients is generally insufficient, particularly in younger age groups who might benefit the most from CVD risk reduction over time. Clinicians should probably rely more on the lifetime risk of CVD, especially when treating working age hypertensive patients.
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Affiliation(s)
- Aapo Tahkola
- University of Eastern Finland, Institute of Public Health and Clinical Nutrition, Kuopio, Finland
- Health Centre of Jyväskylä Cooperation Area, Jyväskylä, Finland
| | | | | | - Teemu Niiranen
- National Institute for Health and Welfare, Helsinki, Finland
- Department of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Pekka Mäntyselkä
- University of Eastern Finland, Institute of Public Health and Clinical Nutrition, Kuopio, Finland
- Primary Health Care Unit, Kuopio University Hospital, Kuopio, Finland
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12
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Karam SL, Dendy J, Polu S, Blonde L. Overview of Therapeutic Inertia in Diabetes: Prevalence, Causes, and Consequences. Diabetes Spectr 2020; 33:8-15. [PMID: 32116448 PMCID: PMC7026754 DOI: 10.2337/ds19-0029] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Many people with diabetes do not achieve individualized treatment targets. Therapeutic inertia, the underuse of effective therapies in preventing serious clinical end points, is a frequent, important contributor to this failure. Clinicians, patients, health systems, payors, and producers of medications, devices, and other products for those with diabetes all play a role in the development of therapeutic inertia and can all help to reduce it.
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Affiliation(s)
- Susan L Karam
- Frank Riddick Diabetes Institute, Department of Endocrinology, Ochsner Medical Center, New Orleans, LA
| | - Jared Dendy
- Frank Riddick Diabetes Institute, Department of Endocrinology, Ochsner Medical Center, New Orleans, LA
| | - Shruti Polu
- Frank Riddick Diabetes Institute, Department of Endocrinology, Ochsner Medical Center, New Orleans, LA
| | - Lawrence Blonde
- Frank Riddick Diabetes Institute, Department of Endocrinology, Ochsner Medical Center, New Orleans, LA
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13
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Nelson-Piercy C, Vlaev I, Harris K, Fischer-Betz R. What factors could influence physicians' management of women of childbearing age with chronic inflammatory disease? A systematic review of behavioural determinants of clinical inertia. BMC Health Serv Res 2019; 19:863. [PMID: 31752837 PMCID: PMC6868709 DOI: 10.1186/s12913-019-4693-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 10/29/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Pregnancy represents a complex challenge to clinicians treating women with chronic inflammatory disease. Many clinicians face a situation of heightened sensitivity to the potential risks and uncertainties associated with the effect of pharmacological treatment on pregnancy outcomes. This may create an environment vulnerable to clinical inertia, whereby behavioural factors such as cognitive heuristics and biases, and other factors such as attitudes to risk and emotion can contribute. This systematic review was undertaken to assess if clinical inertia has been investigated/identified in this setting and took a behavioural science approach to identify and understand the potential determinants of clinical inertia in this treatment setting. METHODS A systematic literature search was conducted to identify publications which investigated or described clinical inertia or its determinants (e.g. heuristics, biases etc.). Results were coded for thematic analysis using two inter-related behavioural models: the COM-B model and the Theoretical Domains Framework. RESULTS Whilst studies investigating or describing clinical inertia in this treatment setting were not identified, the behavioural analysis revealed a number of barriers to the pharmacological management of women of fertile age affected by chronic inflammatory disease. Factors which may be influencing clinician's behaviour were identified in all domains of the COM-B model. The primary factors identified were a lack of knowledge of treatment guidelines and fears concerning the safety of medications for mother and fetus. Lack of experience of treating pregnant patients was also identified as a contributing factor to undertreatment. CONCLUSION Using a behavioural approach, it was possible to identify potential factors which may be negatively influencing clinician's behaviour in this treatment setting, although specific research was limited.
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Affiliation(s)
| | - Ivo Vlaev
- Warwick Business School, University of Warwick, Coventry, England
| | - Katie Harris
- Ogilvy Health, Alphabeta Building, London, England
| | - Rebecca Fischer-Betz
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany.
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14
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Carter BL, Levy B, Gryzlak B, Xu Y, Chrischilles E, Dawson J, Vander Weg M, Christensen A, James P, Polgreen L. Cluster-Randomized Trial to Evaluate a Centralized Clinical Pharmacy Service in Private Family Medicine Offices. Circ Cardiovasc Qual Outcomes 2019; 11:e004188. [PMID: 29884657 DOI: 10.1161/circoutcomes.117.004188] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 04/20/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of clinical pharmacists in primary care has improved the control of several chronic cardiovascular conditions. However, many private physician practices lack the resources to implement team-based care with pharmacists. The purpose of this study was to evaluate whether a centralized, remote, clinical pharmacy service could improve guideline adherence and secondary measures of cardiovascular risk in primary care offices in rural and small communities. METHODS AND RESULTS This study was a prospective trial in 12 family medicine offices cluster randomized to either the intervention or usual care. The intervention was delivered for 12 months, and subjects had research visits at baseline and 12 months. The primary outcome was adherence to guidelines, and secondary outcomes included changes in key cardiovascular risk factors and preventative health measures. We enrolled 302 subjects. There was no improvement in the Guideline Advantage score from baseline to 12 months in the control group (64.7% versus 63.1%, respectively; P=0.21). There was a statistically significant improvement in the intervention group from 63.3% at baseline to 67.8% at 12 months (P=0.02). The estimated benefit of the intervention was 5.0%±2.4% (95% confidence interval=-0.5% to 10.4%; P=0.07). Several criteria were significantly better for intervention subjects, including appropriate statin therapy (P<0.001), body mass index, screening (P<0.001), and alcohol screening (P<0.001). Only 13.7% of subjects with diabetes mellitus had hemoglobin A1c at goal at baseline, and this increased to 30.8% and 21.0% in the intervention and control group, respectively, at 12 months (P=0.10). CONCLUSIONS The centralized, remote pharmacist intervention was successfully implemented. The improvements in outcomes were modest, in part because of higher than expected baseline guideline adherence. Future studies of this model should focus on patients with uncontrolled conditions at high risk for cardiovascular events. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT 01983813.
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Affiliation(s)
- Barry L Carter
- Department of Pharmacy Practice and Science, College of Pharmacy (B.L.C., B.G., L.P.) .,Department of Family Medicine, Roy J. and Lucille A. Carver College of Medicine (B.L.C., B.L., Y.X.)
| | - Barcey Levy
- Department of Family Medicine, Roy J. and Lucille A. Carver College of Medicine (B.L.C., B.L., Y.X.).,Department of Epidemiology, College of Public Health (B.L., B.G., E.C.)
| | - Brian Gryzlak
- Department of Pharmacy Practice and Science, College of Pharmacy (B.L.C., B.G., L.P.).,Department of Epidemiology, College of Public Health (B.L., B.G., E.C.)
| | - Yinghui Xu
- Department of Family Medicine, Roy J. and Lucille A. Carver College of Medicine (B.L.C., B.L., Y.X.)
| | | | - Jeffrey Dawson
- Department of Biostatistics, College of Public Health (J.D.)
| | - Mark Vander Weg
- Department of Internal Medicine, Carver College of Medicine (M.V.W., A.C.).,Department of Psychological and Brain Sciences, College of Liberal Arts and Sciences (M.V.W., A.C.).,University of Iowa. Iowa City Veterans Administration Health Care System (M.V.W.)
| | - Alan Christensen
- Department of Internal Medicine, Carver College of Medicine (M.V.W., A.C.).,Department of Psychological and Brain Sciences, College of Liberal Arts and Sciences (M.V.W., A.C.)
| | - Paul James
- Department of Family Medicine, University of Washington, Seattle (P.J.)
| | - Linnea Polgreen
- Department of Pharmacy Practice and Science, College of Pharmacy (B.L.C., B.G., L.P.)
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15
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Factors Promoting Clinical Inertia in Caring for Patients with Dyslipidemia: A Consensual Study Among Clinicians who Provide Healthcare to Patients with Dyslipidemia. J Natl Med Assoc 2019; 111:18-27. [DOI: 10.1016/j.jnma.2018.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 03/30/2018] [Accepted: 04/08/2018] [Indexed: 11/23/2022]
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16
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Horowitz CR, Ferryman K, Negron R, Sabin T, Rodriguez M, Zinberg RF, Böttinger E, Robinson M. Race, Genomics and Chronic Disease: What Patients with African Ancestry Have to Say. J Health Care Poor Underserved 2018; 28:248-260. [PMID: 28238999 DOI: 10.1353/hpu.2017.0020] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Variants of the APOL1 gene increase risk for kidney failure 10-fold, and are nearly exclusively found in people with African ancestry. To translate genomic discoveries into practice, we gathered information about effects and challenges incorporating genetic risk in clinical care. METHODS An academic-community-clinical team tested 26 adults with self-reported African ancestry for APOL1 variants, conducting in-depth interviews about patients' beliefs and attitudes toward genetic testing- before, immediately, and 30 days after receiving test results. We used constant comparative analysis of interview transcripts to identify themes. RESULTS Themes included: Knowledge of genetic risk for kidney failure may motivate providers and patients to take hypertension more seriously, rather than inspiring fatalism or anxiety. Having genetic risk for a disease may counter stereotypes of Blacks as non-adherent or low-literate, rather than exacerbate stereotypes. CONCLUSION Populations most likely to benefit from genomic research can inform strategies for genetic testing and future research.
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17
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Mahabaleshwarkar R, Templin M, Gohs F, Mulder H, DeSantis A, Ejzykowicz F, Rajpathak S, Wilkins N. Impact of Timely Treatment Intensification on Glycemic Goal Achievement in Patients With Type 2 Diabetes Failing Metformin Monotherapy. DIABETES EDUCATOR 2017; 43:495-505. [PMID: 28828933 DOI: 10.1177/0145721717726508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Purpose The purpose of the study was to examine the association between timely treatment intensification (TTI) and glycemic goal achievement in patients with type 2 diabetes (T2D) failing metformin monotherapy (MM). Methods This study was set at a large integrated health care system in the United States. The study cohort included T2D patients aged 18 to 85 years who were on MM between January 2009 and September 2013 and had an uncontrolled glycated hemoglobin (A1C) reading (≥8%) after at least 3 months of MM (corresponding date was index date). Secondary analyses were performed using A1C <7% as T2D control. TTI was defined as receipt of an add-on therapy within 180 days after the index date. Impact of TTI on glycemic goal achievement was determined using multivariate Cox proportional hazards regression. Patients were censored at their last A1C reading or health care visit during 2 years after the index date. Results The study cohort consisted of 996 patients, ~58% male and ~59% Caucasian, with a mean age of ~54 (±12) years. TTI was observed in 50.2% of the patients. The rate of glycemic goal achievement was higher in patients with TTI compared with patients without TTI (hazards ratio = 1.632, 95% confidence interval = 1.328-2.006). The results for the secondary analyses were largely consistent with the primary findings. Conclusions TTI positively affected glycemic goal achievement among T2D patients failing MM and could be a useful strategy to increase the currently low proportion of patients with their T2D controlled in the United States.
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Affiliation(s)
- Rohan Mahabaleshwarkar
- Center for Outcomes Research and Evaluation, Carolinas HealthCare System, Charlotte, North Carolina (Dr Mahabaleshwarkar, Ms Templin, Mr Gohs, Ms Mulder)
| | - Megan Templin
- Center for Outcomes Research and Evaluation, Carolinas HealthCare System, Charlotte, North Carolina (Dr Mahabaleshwarkar, Ms Templin, Mr Gohs, Ms Mulder)
| | - Frank Gohs
- Center for Outcomes Research and Evaluation, Carolinas HealthCare System, Charlotte, North Carolina (Dr Mahabaleshwarkar, Ms Templin, Mr Gohs, Ms Mulder)
| | - Holly Mulder
- Center for Outcomes Research and Evaluation, Carolinas HealthCare System, Charlotte, North Carolina (Dr Mahabaleshwarkar, Ms Templin, Mr Gohs, Ms Mulder)
| | - Andrea DeSantis
- Department of Family Practice, Carolinas HealthCare System, Charlotte, North Carolina (Dr DeSantis)
| | - Flavia Ejzykowicz
- Outcomes Research, Merck & Co, Inc, Kenilworth, New Jersey (Dr Ejzykowicz, Dr Rajpathak)
| | - Swapnil Rajpathak
- Outcomes Research, Merck & Co, Inc, Kenilworth, New Jersey (Dr Ejzykowicz, Dr Rajpathak)
| | - Nick Wilkins
- AmCare Clinical Pharmacy Services, Carolinas HealthCare System, Concord, North Carolina (Dr Wilkins)
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18
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Reach G, Pechtner V, Gentilella R, Corcos A, Ceriello A. Clinical inertia and its impact on treatment intensification in people with type 2 diabetes mellitus. DIABETES & METABOLISM 2017; 43:501-511. [PMID: 28754263 DOI: 10.1016/j.diabet.2017.06.003] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/24/2017] [Accepted: 06/14/2017] [Indexed: 12/13/2022]
Abstract
Many people with type 2 diabetes mellitus (T2DM) fail to achieve glycaemic control promptly after diagnosis and do not receive timely treatment intensification. This may be in part due to 'clinical inertia', defined as the failure of healthcare providers to initiate or intensify therapy when indicated. Physician-, patient- and healthcare-system-related factors all contribute to clinical inertia. However, decisions that appear to be clinical inertia may, in fact, be only 'apparent' clinical inertia and may reflect good clinical practice on behalf of the physician for a specific patient. Delay in treatment intensification can happen at all stages of treatment for people with T2DM, including prescription of lifestyle changes after diagnosis, introduction of pharmacological therapy, use of combination therapy where needed and initiation of insulin. Clinical inertia may contribute to people with T2DM living with suboptimal glycaemic control for many years, with dramatic consequences for the patient in terms of quality of life, morbidity and mortality, and for public health because of the huge costs associated with uncontrolled T2DM. Because multiple factors can lead to clinical inertia, potential solutions most likely require a combination of approaches involving fundamental changes in medical care. These could include the adoption of a person-centred model of care to account for the complex considerations influencing treatment decisions by patients and physicians. Better patient education about the progressive nature of T2DM and the risks inherent in long-term poor glycaemic control may also reinforce the need for regular treatment reviews, with intensification when required.
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Affiliation(s)
- G Reach
- Department of Endocrinology, Diabetes and Metabolic Diseases, Avicenne Hospital APHP and EA 3412, CRNH-IdF, Paris 13 University, 93017 Bobigny, France.
| | - V Pechtner
- Lilly Diabetes, Eli Lilly & Company, 92521 Neuilly-sur-Seine, France
| | - R Gentilella
- Eli Lilly Italia, Sesto Fiorentino, 50019 Florence, Italy
| | - A Corcos
- Eli Lilly Italia, Sesto Fiorentino, 50019 Florence, Italy
| | - A Ceriello
- U.O. Diabetologia e Malattie Metaboliche, Multimedica IRCCS Sesto San Giovanni, 20099 Milan, Italy
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19
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Smits KPJ, Sidorenkov G, Kleefstra N, Bouma M, Meulepas M, Voorham J, Navis G, Bilo HJG, Denig P. Development and validation of prescribing quality indicators for patients with type 2 diabetes. Int J Clin Pract 2017; 71. [PMID: 27981681 DOI: 10.1111/ijcp.12922] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 11/19/2016] [Indexed: 11/30/2022] Open
Abstract
AIM Quality indicators are used to measure whether healthcare professionals act according to guidelines, but few indicators focus on the quality of pharmacotherapy for diabetes. The aim of this study was to develop and validate a set of prescribing quality indicators (PQIs) for type 2 diabetes in primary care, and to apply this set in practice. To take into account the stepwise treatment of chronic disease, clinical action indicators were specifically considered. METHODS Potential PQIs were derived from clinical practice guidelines and evaluated using the RAND/UCLA Appropriateness Method, a modified Delphi panel. Thereafter, the feasibility of calculating the PQIs was tested in two large Dutch primary care databases including >80 000 diabetes patients in 2012. RESULTS 32 PQIs focusing on treatment with glucose, lipid, blood pressure and albuminuria lowering drugs, and on vaccination, medication safety and adherence were assessed by ten experts. After the Delphi panel, the final list of twenty PQIs was tested for feasibility. All PQIs definitions were feasible for measuring the quality of medication treatment using these databases. Indicator scores ranged from 18.8% to 90.8% for PQIs focusing on current medication use, clinical action and medication choice, and from 2.1% to 37.2% for PQIs focusing on medication safety. DISCUSSION AND CONCLUSIONS Twenty PQIs focusing on treatment with glucose, lipid, blood pressure and albuminuria lowering drugs, and on medication safety in type 2 diabetes were developed, considered valid and operationally feasible. Results showed room for improvement, especially in initiation and intensification of treatment as measured with clinical action indicators.
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Affiliation(s)
- Kirsten P J Smits
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Grigory Sidorenkov
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Nanno Kleefstra
- Langerhans Medical Research Group, Zwolle, The Netherlands
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Margriet Bouma
- Dutch College of General Practitioners (NHG), Utrecht, The Netherlands
| | - Marianne Meulepas
- Dutch Institute for Rational Use of Medicine (IVM), Utrecht, The Netherlands
| | - Jaco Voorham
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gerjan Navis
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Henk J G Bilo
- Diabetes Centre, Isala Clinics, Zwolle, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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20
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Ajmera M, Raval A, Zhou S, Wei W, Bhattacharya R, Pan C, Sambamoorthi U. A Real-World Observational Study of Time to Treatment Intensification Among Elderly Patients with Inadequately Controlled Type 2 Diabetes Mellitus. J Manag Care Spec Pharm 2016; 21:1184-93. [PMID: 26679967 DOI: 10.18553/jmcp.2015.21.12.1184] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Among elderly patients, the management of type 2 diabetes mellitus (T2DM) is complicated by population heterogeneity and elderly-specific complexities. Few studies have been done to understand treatment intensification among elderly patients failing multiple oral antidiabetic drugs (OADs). OBJECTIVE To examine the association between time to treatment intensification of T2DM and elderly-specific patient complexities. METHODS In this observational, retrospective cohort study, elderly (aged ≥ 65 years) Medicare beneficiaries (n = 16,653) with inadequately controlled T2DM (hemoglobin A1c ≥ 8.0% despite 2 OADs) were included. Based on the consensus statement for diabetes care in elderly patients published by the American Diabetes Association and the American Geriatric Society, elderly-specific patient complexities were defined as the presence or absence of 5 geriatric syndromes: cognitive impairment; depression; falls and fall risk; polypharmacy; and urinary incontinence. RESULTS Overall, 48.7% of patients received intensified treatment during follow-up, with median time to intensification 18.5 months (95% CI = 17.7-19.3). Median time to treatment intensification was shorter for elderly patients with T2DM with polypharmacy (16.5 months) and falls and fall risk (12.7 months) versus those without polypharmacy (20.4 months) and no fall risk (18.6 months). Elderly patients with urinary incontinence had a longer median time to treatment intensification (18.6 months) versus those without urinary incontinence (14.6 months). The median time to treatment intensification did not significantly differ by the elderly-specific patient complexities that included cognitive impairment and depression. However, after adjusting for demographic, insurance, clinical characteristics, and health care utilization, we found that only polypharmacy was associated with time to treatment intensification (adjusted hazard ratio, 1.10; 95% CI = 1.04-1.15; P = 0.001). CONCLUSIONS Less than half of elderly patients with inadequately controlled T2DM received treatment intensification. Elderly-specific patient complexities were not associated with time to treatment intensification, emphasizing a positive effect of the integrated health care delivery model. Emerging health care delivery models that target integrated care may be crucial in providing appropriate treatment for elderly T2DM patients with complex conditions.
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Affiliation(s)
- Mayank Ajmera
- RTI Health Solutions, 300 Park Offices Dr., Research Triangle Park, NC 27709.
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21
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Lavoie KL, Rash JA, Campbell TS. Changing Provider Behavior in the Context of Chronic Disease Management: Focus on Clinical Inertia. Annu Rev Pharmacol Toxicol 2016; 57:263-283. [PMID: 27618738 DOI: 10.1146/annurev-pharmtox-010716-104952] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Widespread acceptance of evidence-based medicine has led to the proliferation of clinical practice guidelines as the primary mode of communicating current best practices across a range of chronic diseases. Despite overwhelming evidence supporting the benefits of their use, there is a long history of poor uptake by providers. Nonadherence to clinical practice guidelines is referred to as clinical inertia and represents provider failure to initiate or intensify treatment despite a clear indication to do so. Here we review evidence for the ubiquity of clinical inertia across a variety of chronic health conditions, as well as the organizational and system, patient, and provider factors that serve to maintain it. Limitations are highlighted in the emerging literature examining interventions to reduce clinical inertia. An evidence-based framework to address these limitations is proposed that uses behavior change theory and advocates for shared decision making and enhanced guideline development and dissemination.
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Affiliation(s)
- Kim L Lavoie
- Department of Psychology, University of Quebec at Montreal (UQAM), Montreal, Quebec H3C 3P8, Canada.,Montreal Behavioural Medicine Centre (MBMC), Research Centre, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec H2J 1C5, Canada
| | - Joshua A Rash
- Department of Psychology, University of Calgary, Calgary, Alberta T2N 1N4, Canada;
| | - Tavis S Campbell
- Department of Psychology, University of Calgary, Calgary, Alberta T2N 1N4, Canada;
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22
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Watson L, Das R, Farquhar R, Langerman H, Barnett AH. Consequences of delaying treatment intensification in type 2 diabetes: evidence from a UK database. Curr Med Res Opin 2016; 32:1465-75. [PMID: 26907851 DOI: 10.1185/03007995.2016.1157462] [Citation(s) in RCA: 21] [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] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Type 2 diabetes mellitus (TD2M) treatment focuses on achieving glycemic control, with HbA1c targeted at 6.5-7.5%. Clinicians commonly delay treatment intensification despite patients failing glycemic targets. This study evaluated longitudinal clinical and cost outcomes in patients failing metformin monotherapy using electronic medical records. RESEARCH DESIGN AND METHODS Adults with incident T2DM were identified in the UK Clinical Practice Research Datalink (CPRD) from 1 January 2000 to 31 March 2014. Patients were initiated on metformin monotherapy but had not reached target (HbA1c <7%). Patients were grouped by time to intensification of second-line therapy from first recorded HbA1c ≥7%: Group A, rapid intensification within 365 days; Group B, delayed intensification days 366-1824; Group C, never intensified. Patients were followed from day 366 for 5 years until end of study, switch to insulin, migration or death. MAIN OUTCOME MEASURES The study evaluated baseline clinical and medication characteristics which were re-evaluated each year, including HbA1c, weight, cholesterol and concomitant prescribing. RESULTS A total of 6710 patients were included (Group A 2647, Group B 2452, Group C 1611). Group A achieved a significant decline in HbA1c at 1 year post-index date compared to Groups B and C (-1.13% Group A; +0.26% Group B, +0.16% Group C). A significantly higher proportion of patients achieved HbA1c target < 7% in Group A (Group A [45.8%]; Group B [19.1%], p < 0.0001). Using an adjusted hazard model, Group A was found to achieve the HbA1c target from the index date significantly faster than Group B (hazard ratio 3.25 [95% CI 2.87-3.69]). The most commonly prescribed second-line medications were sulfonylureas in Groups A and B throughout observation and were associated with significant weight gain (+1.3 kg per patient) in the adjusted models. CONCLUSIONS Patients who were rapidly intensified achieved a maintained reduction in HbA1c faster than those with delayed intensification or no second-line therapy, despite a higher baseline HbA1c.
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Affiliation(s)
| | | | | | | | - Anthony H Barnett
- c Diabetes and Endocrine Centre , Heart of England NHS Foundation Trust and University of Birmingham , UK
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23
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Hussey PS, Friedberg MW, Anhang Price R, Lovejoy SL, Damberg CL. Episode-Based Approaches to Measuring Health Care Quality. Med Care Res Rev 2016; 74:127-147. [PMID: 26896470 DOI: 10.1177/1077558716630173] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Most currently available quality measures reflect point-in-time provider tasks, providing a limited and fragmented assessment of care. The concept of episodes of care could be used to develop quality measurement approaches that reflect longer periods of care. With input from clinical experts, we constructed episode-of-care frameworks for six illustrative conditions and identified potential gaps and measure development priority areas. Episode-based measures could assess changes in health outcomes ("delta measures"), the amount of time during an episode in which a patient has suboptimal health status ("integral measures"), quality contingent upon events occurring previously ("contingent measures"), and composites of measures throughout the episode. This article identifies a number of challenges that will need to be addressed to advance operationalization of episode-based quality measurement.
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Affiliation(s)
| | - Mark W Friedberg
- 1 RAND Corporation, Boston, MA, USA.,5 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA.,6 Harvard Medical School, Boston, MA
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de Vries FM, Voorham J, Hak E, Denig P. Prescribing patterns, adherence and LDL-cholesterol response of type 2 diabetes patients initiating statin on low-dose versus standard-dose treatment: a descriptive study. Int J Clin Pract 2016; 70:482-92. [PMID: 27125890 DOI: 10.1111/ijcp.12806] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
AIMS The aim of this study was to describe and compare treatment modifications and discontinuation, adherence levels and response to treatment in patients with type 2 diabetes initiating on low-dose vs. standard-dose statin treatment. METHODS A 2-year follow-up cohort study was performed using data from the Groningen Initiative to Analyse Type 2 Diabetes Treatment (GIANTT) database in patients with type 2 diabetes initiating statin treatment between January 2007 and December 2012. First, we determined whether there were differences in treatment modifications and discontinuation after statin initiation between patients starting on a low-dose vs. standard-dose. Second, we looked at differences in adherence and LDL-cholesterol response after 2 years follow-up between these groups. RESULTS Around 22% of patients initiated statin treatment on a dose lower than recommended. More than half of them remained on a low dose during a 2-year follow-up period, whereas less than 15% received a dose increase. Of the patients initiating on standard-dose, also more than half remained on the same treatment during this period, whereas 8% received a dose decrease without subsequent increase. Over 25% of patients starting on low-dose or standard-dose treatment discontinued treatment, often within the first 180 days after initiation or after a first treatment change. Patients on low-dose treatment had lower adherence levels and were less likely to have adequate LDL-cholesterol response compared with patients on standard-dose after 2 years follow-up. CONCLUSIONS Current patterns of statin treatment in patients with type 2 diabetes are suboptimal, with discontinuation, inadequate adherence levels and lack of treatment intensification seen in those who had inadequate LDL-cholesterol response after 2 years of follow-up. Patients starting on low-dose had more treatment modifications, discontinuation and adherence problems as compared with those starting on standard-dose treatment, which calls for a closer look at the rationale of starting patients on low-dose statin treatment.
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Affiliation(s)
- F M de Vries
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Unit of PharmacoEpidemiology & PharmacoEconomics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - J Voorham
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - E Hak
- Unit of PharmacoEpidemiology & PharmacoEconomics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - P Denig
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Lebeau JP, Cadwallader JS, Vaillant-Roussel H, Pouchain D, Yaouanc V, Aubin-Auger I, Mercier A, Rusch E, Remmen R, Vermeire E, Hendrickx K. General practitioners' justifications for therapeutic inertia in cardiovascular prevention: an empirically grounded typology. BMJ Open 2016; 6:e010639. [PMID: 27178974 PMCID: PMC4874143 DOI: 10.1136/bmjopen-2015-010639] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To construct a typology of general practitioners' (GPs) responses regarding their justification of therapeutic inertia in cardiovascular primary prevention for high-risk patients with hypertension. DESIGN Empirically grounded construction of typology. Types were defined by attributes derived from the qualitative analysis of GPs' reported reasons for inaction. PARTICIPANTS 256 GPs randomised in the intervention group of a cluster randomised controlled trial. SETTING GPs members of 23 French Regional Colleges of Teachers in General Practice, included in the EffectS of a multifaceted intervention on CArdiovascular risk factors in high-risk hyPErtensive patients (ESCAPE) trial. DATA COLLECTION AND ANALYSIS The database consisted of 2638 written responses given by the GPs to an open-ended question asking for the reasons why drug treatment was not changed as suggested by the national guidelines. All answers were coded using constant comparison analysis. A matrix analysis of codes per GP allowed the construction of a response typology, where types were defined by codes as attributes. Initial coding and definition of types were performed independently by two teams. RESULTS Initial coding resulted in a list of 69 codes in the final codebook, representing 4764 coded references in the question responses. A typology including seven types was constructed. 100 GPs were allocated to one and only one of these types, while 25 GPs did not provide enough data to allow classification. Types (numbers of GPs allocated) were: 'optimists' (28), 'negotiators' (20), 'checkers' (15), 'contextualisers' (13), 'cautious' (11), 'rounders' (8) and 'scientists' (5). For the 36 GPs that provided 50 or more coded references, analysis of the code evolution over time and across patients showed a consistent belonging to the initial type for any given GP. CONCLUSION This typology could provide GPs with some insight into their general ways of considering changes in the treatment/management of cardiovascular risk factors and guide design of specific physician-centred interventions to reduce inappropriate inaction. TRIAL REGISTRATION NUMBER NCT00348855.
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Affiliation(s)
- Jean-Pierre Lebeau
- Department of General Practice, EES Research Team, University of Tours. Faculté de Médecine, Tours, France
| | | | - Hélène Vaillant-Roussel
- Department of General Practice, University of Auvergne. Faculté de Médecine, Clermont-Ferrand, France
| | - Denis Pouchain
- Department of General Practice, University of Tours. Faculté de Médecine, Tours, France
| | | | - Isabelle Aubin-Auger
- Department of General Practice, REMES Research Team, University Paris Diderot. 16 rue Henri Huchard, Paris, France
| | - Alain Mercier
- Department of General Practice, University Paris 13. UFR SMBH, Bobigny, France
| | - Emmanuel Rusch
- Department of Public Health, EES Research team University of Tours. Faculté de Médecine, Tours, France
| | - Roy Remmen
- Department of Primary and Interdisciplinary Care, University of Antwerp. Campus Drie Eiken, Antwerpen, Belgium
| | - Etienne Vermeire
- Department of Primary and Interdisciplinary Care, University of Antwerp. Campus Drie Eiken, Antwerpen, Belgium
| | - Kristin Hendrickx
- Department of Primary and Interdisciplinary Care, University of Antwerp. Campus Drie Eiken, Antwerpen, Belgium
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Yu S, Schwab P, Bian B, Radican L, Tunceli K. Use of Add-on Treatment to Metformin Monotherapy for Patients with Type 2 Diabetes and Suboptimal Glycemic Control: A U.S. Database Study. J Manag Care Spec Pharm 2016; 22:272-80. [PMID: 27003557 PMCID: PMC10397849 DOI: 10.18553/jmcp.2016.22.3.272] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The American Diabetes Association (ADA) recommends metformin to treat individuals diagnosed with type 2 diabetes and recommends that hemoglobin A1c (HbA1c) be maintained below or around 7%. If the HbA1c target is not achieved or maintained by metformin monotherapy at maximal tolerated dose over 3 to 6 months, treatment modification with addition of a second oral antihyperglycemic agent or by initiating insulin is recommended. Despite the importance of attaining and maintaining HbA1c goals, actual treatment behavior may not follow ADA guidelines to add a second oral agent or to initiate insulin as expected even considering that individual patient's needs are taken into account when treatment decisions are made. OBJECTIVE To evaluate treatment addition for metformin monotherapy users with suboptimal glycemic control and associated factors. METHODS A retrospective health care claims study identified 7,109 subjects aged 18 to 89 years, treated for type 2 diabetes with an HbA1c > 7% following at least 60 days of continuous metformin monotherapy. Subjects were required to have 12 months continuous enrollment with the health plan before and after the index lab date. Pharmacological treatment additions after the HbA1c lab result and time to treatment addition were evaluated. A logistic regression model was used to evaluate the patient characteristics and comorbidities associated with the treatment addition. RESULTS Thirty-eight percent of study subjects had evidence of addition of a second antidiabetic medication to primary metformin monotherapy, 57.5% remained on metformin monotherapy, and 4.5% discontinued metformin altogether. A logistic regression model found age inversely related to treatment addition: age 45-64 versus 18-44 (OR = 0.77, 95% CI = 0.59-0.99) and age 65-89 versus 18-44 (OR = 0.57, 95% CI = 0.43-0.74). HbA1c was positively related to treatment addition: > 8%-9% versus > 7%-8% (OR = 2.31, 95% CI = 2.00-2.67); > 9%-10% versus > 7%-8% (OR = 2.88, 95% CI = 2.32-3.58); and > 10% versus > 7%-8% (OR = 3.54, 95% CI = 2.92-4.28). Evidence of ophthalmic disorder was not related to treatment addition (P = 0.056), but evidence of hypertension (OR = 1.56, 95% CI = 1.28-1.89); hyperlipidemia (OR = 1.28, 95% CI = 1.05-1.55); other cardiovascular diseases (OR = 1.30, 95% CI = 1.16-1.45); obesity (OR = 1.21, 95% CI = 1.08-1.36); and renal disease (OR = 1.35, 95% CI = 1.21-1.51) were associated. CONCLUSIONS The majority of the metformin monotherapy users with suboptimal glycemic control did not initiate add-on therapy as recommended by guidelines, and prolonged time on metformin monotherapy demonstrated clinical inertia in real-world clinical practice. Several factors were associated with this delay including older age, lower index HbA1c, and lack of evidence of certain comorbidities.
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Affiliation(s)
- Shengsheng Yu
- Manager, Global Market Access, Abbott Diabetes Care, Alameda, California
| | - Phil Schwab
- Research Lead, Comprehensive Health Insights, Louisville, Kentucky
| | - Boyang Bian
- Metrician, Healthcare Economics, Humana, Louisville, Kentucky
| | - Larry Radican
- Executive Director, Center for Observational and Real-World Evidence, Merck, Kenilworth, New Jersey
| | - Kaan Tunceli
- Executive Director, Center for Observational and Real-World Evidence, Merck, Kenilworth, New Jersey
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Lafata JE, Karter AJ, O'Connor PJ, Morris H, Schmittdiel JA, Ratliff S, Newton KM, Raebel MA, Pathak RD, Thomas A, Butler MG, Reynolds K, Waitzfelder B, Steiner JF. Medication Adherence Does Not Explain Black-White Differences in Cardiometabolic Risk Factor Control among Insured Patients with Diabetes. J Gen Intern Med 2016; 31:188-195. [PMID: 26282954 PMCID: PMC4720651 DOI: 10.1007/s11606-015-3486-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Among patients with diabetes, racial differences in cardiometabolic risk factor control are common. The extent to which differences in medication adherence contribute to such disparities is not known. We examined whether medication adherence, controlling for treatment intensification, could explain differences in risk factor control between black and white patients with diabetes. METHODS We identified three cohorts of black and white patients treated with oral medications and who had poor risk factor control at baseline (2009): those with glycated hemoglobin (HbA1c) >8 % (n = 37,873), low-density lipoprotein cholesterol (LDL-C) >100 mg/dl (n = 27,954), and systolic blood pressure (SBP) >130 mm Hg (n = 63,641). Subjects included insured adults with diabetes who were receiving care in one of nine U.S. integrated health systems comprising the SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) consortium. Baseline and follow-up risk factor control, sociodemographic, and clinical characteristics were obtained from electronic health records. Pharmacy-dispensing data were used to estimate medication adherence (i.e., medication refill adherence [MRA]) and treatment intensification (i.e., dose increase or addition of new medication class) between baseline and follow-up. County-level income and educational attainment were estimated via geocoding. Logistic regression models were used to test the association between race and follow-up risk factor control. Models were specified with and without medication adherence to evaluate its role as a mediator. RESULTS We observed poorer medication adherence among black patients than white patients (p < 0.01): 50.6 % of blacks versus 39.7 % of whites were not highly adherent (i.e., MRA <80 %) to HbA1c oral medication(s); 58.4 % of blacks and 46.7 % of whites were not highly adherent to lipid medication(s); and 33.4 % of blacks and 23.7 % of whites were not highly adherent to BP medication(s). Across all cardiometabolic risk factors, blacks were significantly less likely to achieve control (p < 0.01): 41.5 % of blacks and 45.8 % of whites achieved HbA1c <8 %; 52.6 % of blacks and 60.8 % of whites achieved LDL-C <100; and 45.7 % of blacks and 53.6 % of whites achieved SBP <130. Adjusting for medication adherence/treatment intensification did not alter these patterns or model fit statistics. CONCLUSIONS Medication adherence failed to explain observed racial differences in the achievement of HbA1c, LDL-C, and SBP control among insured patients with diabetes.
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Affiliation(s)
- Jennifer Elston Lafata
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA.
- Henry Ford Health System, Detroit, MI, USA.
- Department of Social and Behavioral Health, Virginia Commonwealth University, PO Box 980149, Richmond, VA, 23298, USA.
| | - Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Patrick J O'Connor
- HealthPartners Institute for Education and Research, Minneapolis, MN, USA
| | | | - Julie A Schmittdiel
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Scott Ratliff
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Marsha A Raebel
- Kaiser Permanente Colorado Institute for Health Research, Denver, CO, USA
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | | | | | - Melissa G Butler
- Kaiser Permanente Georgia Center for Health Research- Southeast, Atlanta, GA, USA
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Los Angeles, CA, USA
| | - Beth Waitzfelder
- Kaiser Permanente Hawaii, Center for Health Research - Hawaii, Honolulu, HI, USA
| | - John F Steiner
- Kaiser Permanente Colorado Institute for Health Research, Denver, CO, USA
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Mugomeri E, Ramathebane MV, Maja L, Chatanga P, Moletsane L. Knowledge of disease condition and medications among hypertension patients in Lesotho. ACTA ACUST UNITED AC 2016; 10:41-6. [PMID: 26775548 DOI: 10.1016/j.jash.2015.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 10/21/2015] [Accepted: 10/23/2015] [Indexed: 10/22/2022]
Abstract
This study evaluated the levels of knowledge of hypertension and the associated medications among hypertension patients in Lesotho and assessed the significance of these indicators on hypertension treatment outcomes. About 81% (n = 212) of the patients had hypertension monocondition while the remaining had multiple chronic conditions. Seventy-six percent of the patients had uncontrolled hypertension. Nearly 36% had inadequate knowledge about hypertension while 44% had inadequate knowledge about their medicines. In total, 52.4% of the patients defaulted appointment dates while 64.6% failed to take their medications as prescribed at least once. Inadequate knowledge of antihypertensive medicines was significantly associated (P = .028) with having uncontrolled hypertension. Inadequate knowledge of antihypertensive medicines is an important determinant of uncontrolled hypertension. Improving the knowledge of hypertension and the associated medications is an important intervention required in this population.
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Affiliation(s)
- Eltony Mugomeri
- Faculty of Health Sciences, Department of Pharmacy, National University of Lesotho, Maseru, Lesotho.
| | - Maseabata V Ramathebane
- Faculty of Health Sciences, Department of Pharmacy, National University of Lesotho, Maseru, Lesotho
| | - Lineo Maja
- Faculty of Health Sciences, Department of Pharmacy, National University of Lesotho, Maseru, Lesotho
| | - Peter Chatanga
- Faculty of Science and Technology, Department of Biology, National University of Lesotho, Maseru, Lesotho
| | - Lipalesa Moletsane
- Faculty of Health Sciences, Department of Pharmacy, National University of Lesotho, Maseru, Lesotho
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Huang LY, Yeh HL, Yang MC, Shau WY, Su S, Lai MS. Therapeutic inertia and intensified treatment in diabetes mellitus prescription patterns: A nationwide population-based study in Taiwan. J Int Med Res 2016; 44:1263-1271. [PMID: 28322095 PMCID: PMC5536765 DOI: 10.1177/0300060516663095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Objective To measure therapeutic inertia by characterizing prescription patterns using secondary data obtained from the nationwide diabetes mellitus pay-for-performance (DM-P4P) programme in Taiwan. Methods Using reimbursement claims from Taiwan’s National Health Insurance Research Database, a nationwide retrospective cohort study was undertaken of patients with diabetes mellitus who participated in the DM-P4P programme from 2006–2008. Glycosylated haemoglobin results were used to evaluate modifications in therapy in response to poor diabetes control. Prescription patterns were used to assign patients to either a therapeutic inertia group or an intensified treatment group. Therapeutic inertia was defined as the failure to act on a known problem. Results The research sample comprised of 168 876 patients with diabetes mellitus who had undergone 899 135 tests. Of these, 37.4% (336 615 visits) of prescriptions were for a combination of two types of drug and 27.7% (248 788 visits) were for a combination of three types of drug. The proportion of patients in the intensified therapy group who were prescribed more than two types of drug was considerably higher than that in the therapeutic inertia group. Conclusion In many cases in the therapeutic inertia group only a single type of hypoglycaemic drug was prescribed or the dosage remained unchanged.
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Affiliation(s)
- Li-Ying Huang
- 1 Division of Health Technology Assessment, Centre for Drug Evaluation, Taipei, Taiwan.,2 Graduate Institute of Health Care Organization Administration, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Hseng-Long Yeh
- 3 School of Public Health, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan.,4 Department of Cardiology, Sijhih Cathay General Hospital, Taipei, Taiwan
| | - Ming-Chin Yang
- 2 Graduate Institute of Health Care Organization Administration, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Wen-Yi Shau
- 1 Division of Health Technology Assessment, Centre for Drug Evaluation, Taipei, Taiwan
| | - Syi Su
- 2 Graduate Institute of Health Care Organization Administration, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Mei-Shu Lai
- 5 Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taiwan
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Schwab P, Saundankar V, Bouchard J, Wintfeld N, Suehs B, Moretz C, Allen E, DeLuzio A. Early treatment revisions by addition or switch for type 2 diabetes: impact on glycemic control, diabetic complications, and healthcare costs. BMJ Open Diabetes Res Care 2016; 4:e000099. [PMID: 26925237 PMCID: PMC4761990 DOI: 10.1136/bmjdrc-2015-000099] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 11/23/2015] [Accepted: 12/25/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The study examined the prevalence of early treatment revisions after glycosylated hemoglobin (HbA1c) ≥9.0% (75 mmol/mol) and estimated the impact of early treatment revisions on glycemic control, diabetic complications, and costs. RESEARCH DESIGN AND METHODS A retrospective cohort study of administrative claims data of plan members with type 2 diabetes and HbA1c ≥9.0% (75 mmol/mol) was completed. Treatment revision was identified as treatment addition or switch. Glycemic control was measured as HbA1c during 6-12 months following the first qualifying HbA1c ≥9.0% (75 mmol/mol) laboratory result. Complications severity (via Diabetes Complication Severity Index (DCSI)) and costs were measured after 12, 24, and 36 months. Unadjusted comparisons and multivariable models were used to examine the relationship between early treatment revision (within 90 days of HbA1c) and outcomes after controlling for potentially confounding factors measured during a 12-month baseline period. RESULTS 8463 participants were included with a mean baseline HbA1c of 10.2% (75 mmol/mol). Early treatment revision was associated with greater reduction in HbA1c at 6-12 months (-2.10% vs -1.87%; p<0.001). No significant relationship was observed between early treatment revision and DCSI at 12, 24, or 36 months (p=0.931, p=0.332, and p=0.418). Total costs, medical costs, and pharmacy costs at 12, 24, or 36 months were greater for the early treatment revision group compared with the delayed treatment revision group (all p<0.05). CONCLUSIONS The findings suggest that in patients with type 2 diabetes mellitus, treatment revision within 90 days of finding an HbA1c ≥9.0% is associated with a greater level of near-term glycemic control and higher cost. The impact on end points such as diabetic complications may not be realized over relatively short time frames.
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Affiliation(s)
- Phil Schwab
- Comprehensive Health Insights, Inc., A Humana Company, Louisville, Kentucky, USA
| | - Vishal Saundankar
- Comprehensive Health Insights, Inc., A Humana Company, Louisville, Kentucky, USA
| | | | | | - Brandon Suehs
- Comprehensive Health Insights, Inc., A Humana Company, Louisville, Kentucky, USA
| | - Chad Moretz
- Comprehensive Health Insights, Inc., A Humana Company, Louisville, Kentucky, USA
| | - Elsie Allen
- Novo Nordisk Inc., Plainsboro, New Jersey, USA
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Grigoryan L, Zoorob R, Wang H, Trautner BW. Low Concordance With Guidelines for Treatment of Acute Cystitis in Primary Care. Open Forum Infect Dis 2015; 2:ofv159. [PMID: 26753168 PMCID: PMC4675917 DOI: 10.1093/ofid/ofv159] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 10/22/2015] [Indexed: 12/24/2022] Open
Abstract
We found low concordance with the updated 2010 IDSA guidelines for both the choice of drug and duration of therapy for acute cystitis. Interventions to decrease overuse of fluoroquinolones are needed to preserve the antimicrobial efficacy of these important antimicrobials. Background. The updated 2010 Infectious Diseases Society of America guidelines recommended 3 first-line therapies for uncomplicated cystitis: nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), and fosfomycin, while fluoroquinolones (FQs) remained as second-line agents. We assessed guideline concordance for antibiotic choice and treatment duration after introduction of the updated guidelines and studied patient characteristics associated with prescribing of specific antibiotics and with treatment duration. Methods. We used the Epic Clarity database (electronic medical record system) to identify all female patients aged ≥18 years with uncomplicated cystitis in 2 private family medicine clinics in the period of 2011–2014. For each eligible visit, we extracted type of antibiotic prescribed, duration of treatment, and patient and visit characteristics. Results. We included 1546 visits. Fluoroquinolones were the most common antibiotic class prescribed (51.6%), followed by nitrofurantoin (33.5%), TMP-SMX (12.0%), and other antibiotics (3.2%). A significant trend occurred toward increasing TMP-SMX and toward decreasing nitrofurantoin use. The duration of most prescriptions for TMP-SMX, nitrofurantoin, and FQs was longer than guidelines recommendations (longer durations were prescribed for these agents in 82%, 73%, and 71% of the prescriptions, respectively). No patient or visit characteristic was associated with use of specific antibiotics. Older age and presence of diabetes were independently associated with longer treatment duration. Conclusions. We found low concordance with the updated guidelines for both the choice of drug and duration of therapy for uncomplicated cystitis in primary care. Identifying barriers to guideline adherence and designing interventions to decrease overuse of FQs may help preserve the antimicrobial efficacy of these important antimicrobials.
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Affiliation(s)
| | | | | | - Barbara W Trautner
- Section of Infectious Diseases, Departments of Medicine and Surgery, Baylor College of Medicine; Houston VA Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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Carter BL, Coffey CS, Chrischilles EA, Ardery G, Ecklund D, Gryzlak B, Vander Weg MW, James PA, Christensen AJ, Parker CP, Gums T, Finkelstein RJ, Uribe L, Polgreen LA. A Cluster-Randomized Trial of a Centralized Clinical Pharmacy Cardiovascular Risk Service to Improve Guideline Adherence. Pharmacotherapy 2015; 35:653-62. [PMID: 26111939 DOI: 10.1002/phar.1603] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Numerous studies have demonstrated the value of including pharmacists in team-based care to improve adherence to cardiovascular (CV) guidelines, medication adherence, and risk factor control. However, there is limited information on whether these models can be successfully implemented more widely in diverse settings and populations. The purpose of this study is to evaluate whether a centralized, web-based cardiovascular risk service (CVRS) managed by clinical pharmacists will improve guideline adherence in multiple primary care medical offices with diverse geographic and patient characteristics. METHODS This study is a prospective trial in 20 primary care offices stratified by the percent of under-represented minorities and then randomized to either the CVRS intervention or usual care. The intervention will last for 12 months and all subjects will have research visits at baseline and 12 months. The primary outcome is the difference in guideline adherence between groups. Data will also be abstracted from the medical record at 24 months to determine if the intervention effect is sustained after it is discontinued. CONCLUSIONS Patient enrollment will continue through 2016, with results expected in 2019. This study will provide information on whether a distant, centralized CVRS can be implemented in large numbers of medical offices, if it is effective in diverse populations, and if there is a long-term sustained effect.
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Affiliation(s)
- Barry L Carter
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City, Iowa.,Department of Family Medicine, Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa
| | | | | | - Gail Ardery
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City, Iowa
| | - Dixie Ecklund
- Department of Biostatistics, College of Public Health, Iowa City, Iowa
| | - Brian Gryzlak
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City, Iowa.,Department of Epidemiology, College of Public Health, Iowa City, Iowa
| | - Mark W Vander Weg
- Iowa City Veterans Administration, Iowa City, Iowa.,Department of Internal Medicine, Carver College of Medicine, Iowa City, Iowa.,Department of Psychology, College of Liberal Arts, The University of Iowa, Iowa City, Iowa
| | - Paul A James
- Department of Family Medicine, Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa
| | - Alan J Christensen
- Department of Internal Medicine, Carver College of Medicine, Iowa City, Iowa.,Department of Psychology, College of Liberal Arts, The University of Iowa, Iowa City, Iowa
| | - Christopher P Parker
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City, Iowa
| | - Tyler Gums
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City, Iowa
| | - Rachel J Finkelstein
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City, Iowa
| | - Liz Uribe
- Department of Biostatistics, College of Public Health, Iowa City, Iowa
| | - Linnea A Polgreen
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City, Iowa
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Solomon A, Schoenthaler A, Seixas A, Ogedegbe G, Jean-Louis G, Lai D. Medication Routines and Adherence Among Hypertensive African Americans. J Clin Hypertens (Greenwich) 2015; 17:668-72. [PMID: 25952495 DOI: 10.1111/jch.12566] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 02/17/2015] [Accepted: 02/19/2015] [Indexed: 01/09/2023]
Abstract
Poor adherence to prescribed medication regimens remains an important challenge preventing successful treatment of cardiovascular diseases such as hypertension. While studies have documented differences in the time of day or weekday vs weekend on medication adherence, no study has examined whether having a medication-taking routine contributes to increased medication adherence. The purpose of this study was to: (1) identify patients' sociodemographic factors associated with consistent medication-taking routine; (2) examine associations between medication-taking consistency, medication adherence, and blood pressure (BP) control. The study included black patients with hypertension (n = 190; 22 men and 168 women; age, mean±standard deviation 54 ± 12.08 years) who completed a practice-based randomized controlled trial. Findings showed that medication-taking consistency was significantly associated with better medication adherence (F = 9.54, P = .002). Associations with the consistency index were not statistically significant for diastolic BP control (odds ratio, 1.319; 95% confidence interval, 0.410-4.246; P = .642) and systolic BP control (odds ratio, 0.621; 95% confidence interval, 0.195-1.974; P = .419).
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Affiliation(s)
| | - Antoinette Schoenthaler
- Prairie View A&M University, Houston, TX.,Center for Healthful Behavior Change, Division of Health and Behavior, Department of Population Health, New York University Medical Center, New York, NY
| | - Azizi Seixas
- Center for Healthful Behavior Change, Division of Health and Behavior, Department of Population Health, New York University Medical Center, New York, NY
| | - Gbenga Ogedegbe
- Center for Healthful Behavior Change, Division of Health and Behavior, Department of Population Health, New York University Medical Center, New York, NY
| | - Girardin Jean-Louis
- Center for Healthful Behavior Change, Division of Health and Behavior, Department of Population Health, New York University Medical Center, New York, NY
| | - Dejian Lai
- Center for Healthful Behavior Change, Division of Health and Behavior, Department of Population Health, New York University Medical Center, New York, NY
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A centralized cardiovascular risk service to improve guideline adherence in private primary care offices. Contemp Clin Trials 2015; 43:25-32. [PMID: 25952471 DOI: 10.1016/j.cct.2015.04.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 04/25/2015] [Accepted: 04/27/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Many large health systems now employ clinical pharmacists in team-based care to assist patients and physicians with management of cardiovascular (CV) diseases. However, small private offices often lack the resources to hire a clinical pharmacist for their office. The purpose of this study is to evaluate whether a centralized, web-based CV risk service (CVRS) managed by clinical pharmacists will improve guideline adherence in primary care medical offices in rural and small communities. METHODS This study is a cluster randomized prospective trial in 12 primary care offices. Medical offices were randomized to either the CVRS intervention or usual care. The intervention will last for 12 months and all subjects will have research visits at baseline and 12 months. Primary outcomes will include adherence to treatment guidelines and control of key CV risk factors. Data will also be abstracted from the medical record at 30 months to determine if the intervention effect is sustained after it is discontinued. CONCLUSIONS This study will enroll subjects through 2015 and results will be available in 2018. This study will provide information on whether a distant, centralized CV risk service can improve guideline adherence in medical offices that lack the resources to employ clinical pharmacists.
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Randomized trial of a health IT tool to support between-visit-based laboratory monitoring for chronic disease medication prescriptions. J Gen Intern Med 2015; 30:619-25. [PMID: 25560319 PMCID: PMC4395618 DOI: 10.1007/s11606-014-3152-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 12/01/2014] [Accepted: 12/04/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Lack of timely medication intensification and inadequate medication safety monitoring are two prevalent and potentially modifiable barriers to effective and safe chronic care. Innovative applications of health information technology tools may help support chronic disease management. OBJECTIVE To examine the clinical impact of a novel health IT tool designed to facilitate between-visit ordering and tracking of future laboratory testing. DESIGN AND PARTICIPANTS Clinical trial randomized at the provider level (n = 44 primary care physicians); patient-level outcomes among 3,655 primary care patients prescribed 5,454 oral medicines for hyperlipidemia, diabetes, and/or hypertension management over a 12-month period. MAIN MEASURES Time from prescription to corresponding follow-up laboratory testing; proportion of follow-up time that patients achieved corresponding risk factor control (A1c, LDL); adverse event laboratory monitoring 4 weeks after medicine prescription. KEY RESULTS Patients whose physicians were allocated to the intervention (n = 1,143) had earlier LDL laboratory assessment compared to similar patients (n = 703) of control physicians [adjusted hazard ratio (aHR): 1.15 (1.01-1.32), p = 0.04]. Among patients with elevated LDL (486 intervention, 324 control), there was decreased time to LDL goal in the intervention group [aHR 1.26 (0.99-1.62)]. However, overall there were no significant differences between study arms in time spent at LDL or HbA1c goal. Follow-up safety monitoring (e.g., creatinine, potassium, or transaminases) was relatively infrequent (ranging from 7 % to 29 % at 4 weeks) and not statistically different between arms. Intervention physicians indicated that lack of reimbursement for non-visit-based care was a barrier to use of the tool. CONCLUSIONS A health IT tool to support between-visit laboratory monitoring improved the LDL testing interval but not LDL or HbA1c control, and it did not alter safety monitoring. Adoption of innovative tools to support physicians in non-visit-based chronic disease management may be limited by current visit-based financial and productivity incentives.
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Brown EC, Robicsek A, Billings LK, Barrios B, Konchak C, Paramasivan AM, Masi CM. Evaluating Primary Care Physician Performance in Diabetes Glucose Control. Am J Med Qual 2015; 31:392-9. [PMID: 25921589 DOI: 10.1177/1062860615585138] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study demonstrates that it is possible to identify primary care physicians (PCPs) who perform better or worse than expected in managing diabetes. Study subjects were 14 033 adult diabetics and their 133 PCPs. Logistic regression was used to predict the odds that a patient would have uncontrolled diabetes (defined as HbA1c ≥8%) based on patient-level characteristics alone. A second model predicted diabetes control from physician-level identity and characteristics alone. A third model combined the patient- and physician-level models using hierarchical logistic regression. Physician performance is calculated from the difference between the expected and observed proportions of patients with uncontrolled diabetes. After adjusting for important patient characteristics, PCPs were identified who performed better or worse than expected in managing diabetes. This strategy can be used to characterize physician performance in other chronic conditions. This approach may lead to new insights regarding effective and ineffective treatment strategies.
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Affiliation(s)
- Eric C Brown
- NorthShore University HealthSystem, Evanston, IL University of Chicago, Chicago, IL
| | - Ari Robicsek
- NorthShore University HealthSystem, Evanston, IL University of Chicago, Chicago, IL
| | - Liana K Billings
- NorthShore University HealthSystem, Evanston, IL University of Chicago, Chicago, IL
| | | | - Chad Konchak
- NorthShore University HealthSystem, Evanston, IL
| | | | - Christopher M Masi
- NorthShore University HealthSystem, Evanston, IL University of Chicago, Chicago, IL
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Bagonza J, Rutebemberwa E, Bazeyo W. Adherence to anti diabetic medication among patients with diabetes in eastern Uganda; a cross sectional study. BMC Health Serv Res 2015; 15:168. [PMID: 25898973 PMCID: PMC4405852 DOI: 10.1186/s12913-015-0820-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 03/26/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Lack of adherence to anti diabetic medication causes suboptimal blood sugar control among patients with diabetes and can lead to treatment failures, accelerated development of complications and increased mortality. This study assessed factors associated with adherence to anti diabetic medication in rural eastern Uganda. METHODS A cross sectional study was conducted among 521 patients with diabetes in Iganga and Bugiri hospitals between October 2012 and January 2013. Respondents were patients who were18 years and above and had been on diabetic treatment for not less than a month. Pretested questionnaires were used. Variables that were collected included socio-demographic characteristics, possible barriers to adherence, and self management efforts. Adherence was assessed using self reports. Descriptive and inferential statistics were done to determine adherence to anti diabetic medication and the associated factors. RESULTS The level of adherence to anti diabetic medication was 83.3% and factors that were independently associated with adherence were; having been on anti diabetic drugs for at least three years (OR = 1.89, 95% CI = 1.11 - 3.22), availability of diabetic drugs (OR = 2.59, 95% CI = 1.54 - 3.70), and having ever had diabetic health education (OR = 4.24, 95% CI =1.15 - 15.60). CONCLUSION About four in five patients adhere to anti-diabetic treatment. Strategies aimed at improving anti diabetic drug availability and providing health education could improve adherence.
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Affiliation(s)
- James Bagonza
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Elizeus Rutebemberwa
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - William Bazeyo
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
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Gencer B, Auer R, Nanchen D, Räber L, Klingenberg R, Carballo D, Blum M, Vogt P, Carballo S, Meyer P, Matter CM, Windecker S, Lüscher TF, Mach F, Rodondi N. Expected impact of applying new 2013 AHA/ACC cholesterol guidelines criteria on the recommended lipid target achievement after acute coronary syndromes. Atherosclerosis 2015; 239:118-24. [DOI: 10.1016/j.atherosclerosis.2014.12.049] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 12/14/2014] [Accepted: 12/18/2014] [Indexed: 10/24/2022]
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Rajpathak SN, Rajgopalan S, Engel SS. Impact of time to treatment intensification on glycemic goal attainment among patients with type 2 diabetes failing metformin monotherapy. J Diabetes Complications 2014; 28:831-5. [PMID: 25104238 DOI: 10.1016/j.jdiacomp.2014.06.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 05/27/2014] [Accepted: 06/10/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with type 2 diabetes on metformin monotherapy frequently require treatment intensification with another anti-hyperglycemic medication over time. Previous studies have indicated that a high proportion of patients with diabetes have a significant delay in the initiation of oral add-on therapy after metformin alone fails to achieve targeted glycemic control. In this study, we evaluated the impact of the timing of treatment intensification with oral add-on drug on glycemic goal attainment among diabetic patients failing metformin monotherapy. RESEARCH DESIGN AND METHODS Using the General Electric (GE) Centricity Electronic Medical Record database (January 2004 through December 2009), we identified 5,870 patients with type 2 diabetes with treatment failure on metformin monotherapy - defined by a glycosylated hemoglobin (HbA1c) of ≥7.5% (index date). This cut-off of ≥7.5% (trigger HbA1c) was chosen rather than that of >7.0% to ensure that selected patients were more likely to be indicated for treatment intensification with add-on drug. Continuous enrollment of one year prior and two years after index date was required to be included in the study. Add-on treatment was defined as prescription of second oral agent from any available therapeutic classes while continuing metformin. Early treatment intensification was defined as initiation of oral add-on therapy within 3 months (n=1,012) of index date while late intensification was defined as add-on initiation between 10 and 15 months after index date (n=461). The study outcome was defined as glycemic goal attainment (HbA1c<7%), which was evaluated between 18 and 24 months after index date. RESULTS Our results suggested that at the end of the follow-up period, 47.2% of patients in the early add-on group were at glycemic goal compared to 41.7% in the late add-on group (p=0.039). In a multivariable logistic regression model that accounted for age, gender, trigger HbA1c level, Charlson comorbidity index, anti-hypertensive and anti-hyperlipidemic drug use and history of cardiovascular disease, the adjusted odds ratio (OR) for glycemic goal attainment was 1.36 (95% confidence intervals [CI]: 1.09-1.72) comparing early add-on to late add-on treatment. This association was stronger among patients with higher trigger HbA1c at baseline; ORs of 1.53 (95% CI: 1.08-2.19) for HbA1c ≥8% and 2.63 (95% CI: 1.40-5.27) for HbA1c ≥9%. CONCLUSION These results suggest that earlier use of oral add-on drug in treatment regimen helps better achieve glycemic goal attainment in patients with metformin failure. Future studies should evaluate whether earlier treatment intensification is also associated with longer term health outcomes such as risk of microvascular and macrovascular complications.
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Weiler S, Gemperli A, Collet TH, Bauer DC, Zimmerli L, Cornuz J, Battegay E, Gaspoz JM, Kerr EA, Aujesky D, Rodondi N. Clinically relevant quality measures for risk factor control in primary care: a retrospective cohort study. BMC Health Serv Res 2014; 14:306. [PMID: 25027581 PMCID: PMC4105792 DOI: 10.1186/1472-6963-14-306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 06/27/2014] [Indexed: 11/15/2022] Open
Abstract
Background Assessment of the proportion of patients with well controlled cardiovascular risk factors underestimates the proportion of patients receiving high quality of care. Evaluating whether physicians respond appropriately to poor risk factor control gives a different picture of quality of care. We assessed physician response to control cardiovascular risk factors, as well as markers of potential overtreatment in Switzerland, a country with universal healthcare coverage but without systematic quality monitoring, annual report cards on quality of care or financial incentives to improve quality. Methods We performed a retrospective cohort study of 1002 randomly selected patients aged 50–80 years from four university primary care settings in Switzerland. For hypertension, dyslipidemia and diabetes mellitus, we first measured proportions in control, then assessed therapy modifications among those in poor control. “Appropriate clinical action” was defined as a therapy modification or return to control without therapy modification within 12 months among patients with baseline poor control. Potential overtreatment of these conditions was defined as intensive treatment among low-risk patients with optimal target values. Results 20% of patients with hypertension, 41% with dyslipidemia and 36% with diabetes mellitus were in control at baseline. When appropriate clinical action in response to poor control was integrated into measuring quality of care, 52 to 55% had appropriate quality of care. Over 12 months, therapy of 61% of patients with baseline poor control was modified for hypertension, 33% for dyslipidemia, and 85% for diabetes mellitus. Increases in number of drug classes (28-51%) and in drug doses (10-61%) were the most common therapy modifications. Patients with target organ damage and higher baseline values were more likely to have appropriate clinical action. We found low rates of potential overtreatment with 2% for hypertension, 3% for diabetes mellitus and 3-6% for dyslipidemia. Conclusions In primary care, evaluating whether physicians respond appropriately to poor risk factor control, in addition to assessing proportions in control, provide a broader view of the quality of care than relying solely on measures of proportions in control. Such measures could be more clinically relevant and acceptable to physicians than simply reporting levels of control.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Nicolas Rodondi
- Department of General Internal Medicine, University of Bern, Bern, Switzerland.
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González-Clemente JM, Font B, Lahoz R, Llauradó G, Gambús G. Inercia clínica en pacientes con diabetes mellitus tipo 2 no insulinizados en tratamiento con hipoglucemiantes orales. Estudio INERCIA. Med Clin (Barc) 2014; 142:478-84. [DOI: 10.1016/j.medcli.2013.02.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 02/19/2013] [Accepted: 02/21/2013] [Indexed: 11/26/2022]
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Simonetti JA, Fine MJ, Chen YF, Simak D, Hess R. Racial comparisons of diabetes care and intermediate outcomes in a patient-centered medical home. Diabetes Care 2014; 37:993-1001. [PMID: 24255103 PMCID: PMC3964485 DOI: 10.2337/dc13-1332] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess racial differences in diabetes processes and intermediate outcomes of care in an internal medicine, patient-centered medical home (PCMH) group practice. RESEARCH DESIGN AND METHODS We conducted a retrospective cohort study of 1,457 adults with diabetes receiving care from 89 medical providers within a PCMH-designated academic practice between 1 July 2009 and 31 July 2010. We used mixed models to assess independent associations between patient race (non-Hispanic white or black) and 1) receipt of processes of care (A1C and LDL testing, foot and retinal examination, and influenza and pneumococcal vaccination) and 2) achievement of intermediate outcomes (LDL <100 mg/dL, blood pressure [BP] <140/90 mmHg, A1C <7.0% [<53 mmol/mol], and A1C >9.0% [>75 mmol/mol]), controlling for sociodemographic factors, health status, treatment intensity, and clinical continuity. RESULTS Compared with non-Hispanic white patients, black patients were younger, were more often single, had lower educational attainment, and were less likely to have commercial insurance. In unadjusted analyses, fewer black patients received a retinal examination and influenza vaccination during the study period or any lifetime pneumococcal vaccination (P < 0.05 [all comparisons]). Fewer black patients achieved an LDL <100 mg/dL, BP <140/90 mmHg, or A1C <7.0% (<53 mmol/mol), while more black patients had an A1C >9.0% (>75 mmol/mol) (P < 0.05 [all comparisons]). In multivariable models, black patients were less likely to receive A1C testing (odds ratio [OR] 0.57 [95% CI 0.34-0.95]) or influenza vaccination (OR 0.75 [95% CI 0.57-0.99]) or to achieve an LDL <100 mg/dL (OR 0.74 [95% CI 0.55-0.99]) or BP <140/90 mmHg (OR 0.64 [95% CI 0.49-0.84]). CONCLUSIONS Racial differences in processes and intermediate outcomes of diabetes care were present within this PCMH-designated practice, controlling for differences in sociodemographic, clinical, and treatment factors.
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Davis J, Chavez B, Juarez DT. Adjustments to Diabetes Medications in Response to Increases in Hemoglobin A1c. Ann Pharmacother 2014; 48:41-7. [DOI: 10.1177/1060028013517870] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: The primary objective was to assess associations between increases in glycated hemoglobin (HbA1c) levels and medication adjustments among patients with diabetes. A secondary objective was to measure the effect of adjustments on subsequent HbA1c levels. Methods: A retrospective analysis of administrative data from a large health insurer in Hawaii of 7654 patients with diabetes mellitus type II, HbA1c levels greater than 7%, and who were taking oral diabetic medications. Patients were eligible if they had an HbA1c measurement in 2009, a prior measure 30 or more days previously, and at least 30 days of follow-up to identify medication adjustments. Patients were classified into 3 groups based on their extent of change in HbA1c levels. Patients were followed to determine the frequency of medication adjustments and to observe the possible benefit of making adjustments on subsequent HbA1c levels. Results: Medication adjustments were the exception, occurring among less than a fourth of patients. Compared with patients without HbA1c increases, patients with <1% HbA1c increases made adjustments 20% more frequently, and patients with increased HbA1c levels of 1% or more made adjustments 60% more frequently. Patients with similar HbA1c increases were more likely to adjust their medications if they had higher baseline HbA1c levels. Medication adjustments were mostly for oral diabetes medications; insulin use was seldom initiated, and then primarily by patients with HbA1c levels of 9% or higher. Patients with medication adjustments averaged about 0.40% lower HbA1c levels when reassessed after 120 days or more. Conclusion: The results show limited responsiveness to increases in HbA1c levels and a low initiation rate of insulin use. Patients adjusting their medications, however, had clinically significant improvements in their HbA1c levels. Clinical inertia and patient concerns are discussed as factors possibly limiting the frequency of medication adjustments.
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Affiliation(s)
- James Davis
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Benjamin Chavez
- Daniel K. Inouye College of Pharmacy, University of Hawaii, Hilo, HI, USA
- Pacific University School of Pharmacy, Hillsboro, OR, USA
| | - Deborah T. Juarez
- Daniel K. Inouye College of Pharmacy, University of Hawaii, Hilo, HI, USA
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Chow J, Bungard TJ. Cardiovascular risk factor modification among high-risk patients. Can Pharm J (Ott) 2013; 146:257-61. [DOI: 10.1177/1715163513499125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jeffrey Chow
- Regional Pharmacy Services (Chow), Alberta Health Services—Glenrose Rehabilitation Hospital, Edmonton, University of Alberta, Edmonton, Alberta
- Anticoagulation Management Service (Bungard), Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta
| | - Tammy J. Bungard
- Regional Pharmacy Services (Chow), Alberta Health Services—Glenrose Rehabilitation Hospital, Edmonton, University of Alberta, Edmonton, Alberta
- Anticoagulation Management Service (Bungard), Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta
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Abstract
Personalized medicine is a much talked about subject that is a timely and important development to healthcare in general and also specifically for patients affected by osteoarthritis. This review uses biomarker examples pertinent to osteoarthritis to highlight the current status of the field, while also highlighting probable future developments. It is not meant to be an exhaustive account. The BIPED(s) [Burden of disease, Investigative, Prognosis, Efficacy, Diagnosis (safety)] classification system is used to organize the discussion of examples. Biomarkers pertaining to burden, investigation, prognosis, efficacy, diagnosis and safety are highlighted. The examples are followed by a discussion of issues related to interpretation and application of biomarker results and approaches to solve the challenges interpretation faces, including graphical, mathematical and synthetic representations. Through this review, it is hoped that a better appreciation can be gained of the potential and pitfalls of personal medicine in the care of patients with osteoarthritis.
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Affiliation(s)
- Allen Dale Sawitzke
- Internal Medicines, University of Utah, 30N 1900E SOM, 4B200, Salt Lake City, UT 84132, USA
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Bullock KC, Edwards KL, Greene RS, Shah SR, Blaszczyk AT. Race as a factor for intensification of diabetes medications. DIABETES EDUCATOR 2013; 39:335-43. [PMID: 23475185 DOI: 10.1177/0145721713479145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE The purpose of this study was to investigate if patients of nonwhite race are less likely to receive insulin therapy for treatment of poorly controlled diabetes than patients of white race. METHODS A retrospective review was performed of patients with an A1C >10%. The primary objective was to determine any difference in the initiation of insulin between white and nonwhite patients. Secondary outcomes measured the impact of clinic type and provider specialty on the initiation of insulin therapy. Exclusion criteria included those patients with type 1 diabetes mellitus, those who were previously receiving insulin, and those without an outpatient clinic visit within 14 days of an A1C >10%. RESULTS A total of 277 patients were included. Of these patients, 132 (47.7%) were white, followed by 95 (34.2%) black non-Hispanic patients and 30 (10.8%) Hispanic/Latino patients. No difference was found in receipt of insulin therapy for nonwhite patients as compared to white patients (12.5 vs 21.4, P = .117). Neither clinic type nor provider specialty impacted initiation of insulin therapy. No changes to medication regimen were made at 35% of clinic visits. CONCLUSIONS Failure to intensify diabetic medications was common in this outpatient setting. There were no disparities in the receipt of insulin therapy between white and nonwhite patients.
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Affiliation(s)
- Katura C Bullock
- Texas Tech University Health Sciences Center School of Pharmacy, Department of Pharmacy Practice; Veterans Affairs North Texas Health
Care System (VANTHCS), Dallas, Texas (Dr Bullock, Dr Edwards, Dr Greene, Dr Shah, Dr Blaszczyk)
| | - Krystal L Edwards
- Texas Tech University Health Sciences Center School of Pharmacy, Department of Pharmacy Practice; Veterans Affairs North Texas Health
Care System (VANTHCS), Dallas, Texas (Dr Bullock, Dr Edwards, Dr Greene, Dr Shah, Dr Blaszczyk)
| | - Ronald Shane Greene
- Texas Tech University Health Sciences Center School of Pharmacy, Department of Pharmacy Practice; Veterans Affairs North Texas Health
Care System (VANTHCS), Dallas, Texas (Dr Bullock, Dr Edwards, Dr Greene, Dr Shah, Dr Blaszczyk)
| | - Sachin R Shah
- Texas Tech University Health Sciences Center School of Pharmacy, Department of Pharmacy Practice; Veterans Affairs North Texas Health
Care System (VANTHCS), Dallas, Texas (Dr Bullock, Dr Edwards, Dr Greene, Dr Shah, Dr Blaszczyk)
| | - Amie Taggart Blaszczyk
- Texas Tech University Health Sciences Center School of Pharmacy, Department of Pharmacy Practice; Veterans Affairs North Texas Health
Care System (VANTHCS), Dallas, Texas (Dr Bullock, Dr Edwards, Dr Greene, Dr Shah, Dr Blaszczyk)
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Beard AJ, Hofer TP, Downs JR, Lucatorto M, Klamerus ML, Holleman R, Kerr EA. Assessing appropriateness of lipid management among patients with diabetes mellitus: moving from target to treatment. Circ Cardiovasc Qual Outcomes 2013; 6:66-74. [PMID: 23233749 PMCID: PMC3699178 DOI: 10.1161/circoutcomes.112.966697] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 10/11/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Performance measures that emphasize only a treat-to-target approach may motivate overtreatment with high-dose statins, potentially leading to adverse events and unnecessary costs. We developed a clinical action performance measure for lipid management in patients with diabetes mellitus that is designed to encourage appropriate treatment with moderate-dose statins while minimizing overtreatment. METHODS AND RESULTS We examined data from July 2010 to June 2011 for 964 818 active Veterans Affairs primary care patients ≥18 years of age with diabetes mellitus. We defined 3 conditions as successfully meeting the clinical action measure for patients 50 to 75 years old: (1) having a low-density lipoprotein (LDL) <100 mg/dL, (2) taking a moderate-dose statin regardless of LDL level or measurement, or (3) receiving appropriate clinical action (starting, switching, or intensifying statin therapy) if LDL is ≥100 mg/dL. We examined possible overtreatment for patients ≥18 years of age by examining the proportion of patients without ischemic heart disease who were on a high-dose statin. We then examined variability in measure attainment across 881 facilities using 2-level hierarchical multivariable logistic models. Of 668 209 patients with diabetes mellitus who were 50 to 75 years of age, 84.6% passed the clinical action measure: 67.2% with LDL <100 mg/dL, 13.0% with LDL ≥100 mg/dL and either on a moderate-dose statin (7.5%) or with appropriate clinical action (5.5%), and 4.4% with no index LDL on at least a moderate-dose statin. Of the entire cohort ≥18 years of age, 13.7% were potentially overtreated. Facilities with higher rates of meeting the current threshold measure (LDL <100 mg/dL) had higher rates of potential overtreatment (P<0.001). CONCLUSIONS Use of a performance measure that credits appropriate clinical action indicates that almost 85% of diabetic veterans 50 to 75 years of age are receiving appropriate dyslipidemia management. However, many patients are potentially overtreated with high-dose statins.
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Affiliation(s)
- Ashley J Beard
- Center for Clinical Management Research, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Aspectos prácticos de la combinación de 3 fármacos antihipertensivos a dosis fijas. HIPERTENSION Y RIESGO VASCULAR 2013. [DOI: 10.1016/s1889-1837(13)70016-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Hellemons ME, Denig P, de Zeeuw D, Voorham J, Lambers Heerspink HJ. Is albuminuria screening and treatment optimal in patients with type 2 diabetes in primary care? Observational data of the GIANTT cohort. Nephrol Dial Transplant 2012; 28:706-15. [PMID: 23262433 DOI: 10.1093/ndt/gfs567] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Failure of diagnosing and treatment of albuminuria play a role in morbidity and mortality in type 2 diabetes (T2DM). We evaluated guideline adherence and factors associated with albuminuria screening and treatment in T2DM patients in primary care. METHODS Guidelines recommend annual measurement of albuminuria and, if increased, treatment with renin-angiotensin-aldosterone system (RAAS) blockers. We performed a cohort study of T2DM patients managed by 182 Dutch general practitioners (GPs; Groningen Initiative to Analyse Type 2 diabetes Treatment database), and evaluated guideline adherence in the years 2007-2009. We assessed whether demographic, clinical, organizational or provider factors determined guideline adherence with multilevel analyses. RESULTS Data were available for 14 120 T2DM patients [47.6% male, mean age 67.3 ± 11.7 years, median diabetes duration 6 (IQR: 3-10) years]. The albumin-creatinine ratio (ACR) was measured in 45.2% in 2007, 57.4% in 2008 and 56.8% in 2009. Only 23.7% of all patients were measured every year and 21.4% were never measured. The ACR was more often measured in patients <75 years, with a previous ACR measurement, using anti-diabetic medication, and receiving additional care by a diabetes support facility. RAAS treatment was prescribed to 78.4% of patients with prevalent micro/macroalbuminuria, 66.5% with incident micro/macroalbuminuria, 59.3% with normoalbuminuria and 52.1% of those without ACR measurements. In those not treated with RAAS blockers, it was initiated in 14.3, 12.3, 3.0 and 2.3%, respectively. The presence of micro/macroalbuminuria, higher blood pressure, incidence of cardiovascular events and treatment with antihypertensive medication were the determinants of RAAS-treatment initiation. CONCLUSIONS Guideline implementation regarding the management of albuminuria in T2DM patients in primary care should be further improved.
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Affiliation(s)
- Merel E Hellemons
- Department of Clinical Pharmacology, University Medical Center Groningen, Groningen, the Netherlands
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Garzón González G, Rodríguez Morales D, Rodríguez Palomino MÁ, Toledo Gómez D, Hernández Barrera V, Gil De Miguel A. [Assessment of electronic medical records. Relationship between process indicators measured using electronic records and intermediate health outcomes in patients with hypertension]. Aten Primaria 2012; 44:709-19. [PMID: 22980946 DOI: 10.1016/j.aprim.2012.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 06/11/2012] [Accepted: 06/12/2012] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To study relationship between institutional process indicators (measured using electronic records) and intermediate outcomes of patients with hypertension. DESIGN Cross-sectional epidemiological study. SETTING Primary Care Health District 1. Madrid. 2010. PATIENTS All patients with hypertension. n=80,306. MAIN MEASUREMENTS Variables. Independent. Institutional process indicators. Dependent. Intermediate outcomes: blood pressure within target limits, LDL-cholesterol, tobacco and weight and detected complications. Confounding. Age, gender, co-morbidity, drugs and professional variables. RESULTS The BP of 55.1% (SE 0.2%) of patients was within target limits. Bivariate analysis and multivariate logistic regression showed that the recording of some process indicators was associated with an increase in the probability to achieve targets in intermediate outcomes: smoking advice (OR: 1.69, 95% CI: 1.61 - 1.77), reviewing personal history (OR: 1.54, 95% CI:1.42-1.68), increase was less or biased: BP (OR: 1.19, 95% CI:1.14-1.25), sodium and potassium (OR: 1.14, 95% CI:1.09-1.19), BMI (OR 1.08, 95% CI:1.04-1.12); also diabetes, edema, and creatinine, but there was timing bias. The relationship between other indicators (those oriented to lifestyle, family history, classification, urine examination, reviewing of drug therapy, LDL, electrocardiogram and cardiac auscultation) and a higher probability to achieve targets was not found. CONCLUSIONS In hypertension, some institutional process indicators measured on electronic records were associated with an increase in the probability to achieve targets in intermediate outcomes. No relationship was found between other indicators. This suggests maintaining process and outcome measurement, to include the impact of interventions, to prioritize improvements in process indicators that show low performance and high impact and to remove or to change process indicators where no relationship is found.
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