The association between medication adherence and treatment intensification with blood pressure control in resistant hypertension

Patients with resistant hypertension are at risk for poor outcomes. Medication adherence and intensification improve blood pressure (BP) control; however, little is known about these processes or their association with outcomes in resistant hypertension. This retrospective study included patients from 2002 to 2006 with incident hypertension from 2 health systems who developed resistant hypertension or uncontrolled BP despite adherence to ≥3 antihypertensive medications. Patterns of hypertension treatment, medication adherence (percentage of days covered), and treatment intensification (increase in medication class or dose) were described in the year after resistant hypertension identification. Then, the association between medication adherence and intensification with 1-year BP control was assessed controlling for patient characteristics. Of the 3550 patients with resistant hypertension, 49% were male, and mean age was 60 years. One year after resistance hypertension determination, fewer patients were taking diuretics (77.7% versus 92.2%; P<0.01), β-blockers (71.2% versus 79.4%; P<0.01), and angiotensinogen-converting enzyme inhibitor/angiotensin receptor blocker (64.8% versus 70.1%; P<0.01) compared with baseline. Rates of BP control improved over 1 year (22% versus 55%; P<0.01). During this year, adherence was not associated with 1-year BP control (adjusted odds ratio, 1.18 [95% CI: 0.94-1.47]). Treatment was intensified in 21.6% of visits with elevated BP. Increasing treatment intensity was associated with 1-year BP control (adjusted odds ratio, 1.64 [95% CI, 1.58-1.71]). In this cohort of patients with resistant hypertension, treatment intensification but not medication adherence was significantly associated with 1-year BP control. These findings highlight the need to investigate why patients with uncontrolled BP do not receive treatment intensification.

Patterns of beta-blocker intensification in ambulatory heart failure patients and short-term association with hospitalization

Background

In response to the short-term negative inotropic and chronotropic effects of β-blockers, heart failure (HF) guidelines recommend initiating β-blockers at low dose with gradual uptitration as tolerated to doses used in clinical trials. However, patterns and safety of β-blocker intensification in routine practice are poorly described.

Methods

We described β-blocker intensification among Kaiser Colorado enrollees with a primary discharge diagnosis of HF between 2001–2009. We then assessed β-blocker intensification in the 30 days prior to first hospital readmission for cases compared to the same time period following index hospitalization for non-rehospitalized matched controls. In separate analysis of the subgroup initiated on β-blocker after index hospital discharge, we compared adjusted rates of 30-day hospitalization following initiation of high versus low dose β-blocker.

Results

Among 3,227 patients, median age was 76 years and 37% had ejection fraction ≤40% (LVSD). During a median follow up of 669 days, 14% were never on β-blocker, 21% were initiated on β-blocker, 43% were discharged on β-blocker but never uptitrated, and 22% had discharge β-blocker uptitrated; 63% were readmitted and 49% died. β-blocker intensification occurred in the 30 days preceding readmission for 39 of 1,674 (2.3%) readmitted cases compared to 27 (1.6%) of matched controls (adjusted OR 1.36, 95% CI 0.81-2.27). Among patients initiated on therapy, readmission over the subsequent 30 days occurred in 6 of 155 (3.9%) prescribed high dose and 9 of 513 (1.8%) prescribed low dose β-blocker (adjusted OR 3.10, 95% CI 1.02-9.40). For the subgroup with LVSD, findings were not significantly different.

Conclusion

While β-blockers were intensified in nearly half of patients following hospital discharge and high starting dose was associated with increased readmission risk, the prevailing finding was that readmission events were rarely preceded by β-blocker intensification. These data suggest that β-blocker intensification is not a major precipitant of hospitalization, provided recommended dosing is followed.

A comparison between antihypertensive medication adherence and treatment intensification as potential clinical performance measures

BACKGROUND

Medication adherence and treatment intensification have been advocated as performance measures to assess the quality of care provided. Whereas previous studies have shown that adherence and treatment intensification (TI) of antihypertensive medications is associated with blood pressure (BP) control at the patient level, less is known about whether adherence and TI is associated with BP control at the clinic level.

METHODS AND RESULTS

We included 162 879 patients among 89 clinics in the Cardiovascular Research Network Hypertension Registry with incident hypertension who were started on antihypertensive medications. Adherence was measured by the proportion of days covered (PDC). TI was defined by the standard based method with scores ranging between -1 to 1 and categorized as: -1 indicated no TI occurred when BP was elevated; 0 indicated TI occurred when BP was elevated; and 1 indicated that TI was made at all visits, even when BP was not elevated. Logistic regression models assessed the association between adherence and TI with blood pressure control (BP ≤ 140/90 at the clinic visit closest to 12 months after study entry) at the patient and clinic levels. Mean adherence was 0.77 ± 0.28 (PDC ± SD) at the patient level and 0.78 ± 0.05 at the clinic level. Mean TI was 0.026 ± 0.23 at the patient level and 0.01 ± 0.04 at the clinic level. At the patient level, for each 0.25 increase in adherence and TI, the odds (OR) of achieving blood pressure control increased by 28% and 55%, respectively [OR for adherence, 1.28 (1.26-1.29), and for TI, 1.55 (1.53-1.57)]. At the clinic level, each 0.04 increment increase in treatment intensification was associated with a 25% increased odds of achieving blood pressure control (OR, 1.24; 95% CI, 1.21-1.27). In contrast, there was an inverse association between increasing adherence and BP control (OR, 0.93; 95% confidence interval, 0.90-0.95).

CONCLUSIONS

Patient adherence to antihypertensive medications is not associated with BP control at the clinic level and may not be suitable as a performance measure. TI is associated with BP control, but its use as a performance measure may be constrained by challenges in measuring it and by concerns about unintended consequences of aggressive hypertension treatment in some subgroups of patients.

Abstract 186: Decision Making Experiences of Patients With Implantable Cardioverter-Defibrillators (ICDs)

Introduction: Decision making surrounding ICDs is complicated, involving balancing benefits of prolonging life with potential harms. As such, it is essential to include patients’ perspectives and values in ICD decision making. Research on other interventions suggests that some patients regret medical decisions that they make (or that were made for them). The objective of this study was to describe the decision-making experiences of patients who reported that they did not want an ICD at the time of implantation.

Methods: We conducted a mailed survey of 412 patients in the Kaiser Colorado health system with ICDs about their experience in ICD decision making. The survey included a question: “Did you want an ICD?” The survey also asked questions about participation in their decision making and the validated decision regret scale (scored 0-100). Those responding “yes” or “no” to wanting an ICD were compared using Pearson’s Chi-squared test of association for dichotomous outcomes and t-tests for continuous outcomes.

Results: A total of 295 patients with ICDs responded to this survey (response rate 72%, 295 out of 410). Of these, 19% (56 of 295) reported not wanting their ICD at the time of implantation. Patients who stated that they did not want the ICD were younger (<65 years-old; 74% vs. 43%, p <0.01, 36 vs. 91 of 127, respectively), had higher decision regret (31/100 vs. 11/100, p<0.01), and reported less participation in their decision making (See Table). Patients wanting and not wanting their ICD were equally likely to have experienced a shock (43% vs. 53%, 88 vs. 26 of 114, respectively, p = .19).

Conclusions: Patients who reported not wanting their ICD also reported less participation in their decision making and higher decision regret. On one hand, these results are limited by recall bias and patients may be expressing frustrations with experiences that occurred after the ICD was implanted. On the other hand, they may suggest potential opportunities for improvement in decision making at the time of implantation. Future research should test whether a better decision-making process at the time of implantation could improve outcomes such as decision regret, decision participation, and decision quality.

Abstract 124: Patient-Identified Factors Related to Heart Failure Readmissions

Background : Readmission following hospitalization for heart failure (HF) has received increasing attention yet relatively little is known about its root causes. The purpose of our study was to systematically investigate the experiences of patients to gain a better understanding of factors related to readmission. Although prior studies have relied on administrative databases, retrospective chart review, and single-question surveys, ours involves systematic, in-depth primary data collection.

Methods : Qualitative semi-structured interviews, paired with chart reviews, were conducted on 28 patients readmitted within 6 months of index hospitalization for HF. Interview questions focused on reasons for readmission and other readmission-related topics and suggestions for improving care. Combinations of both inductive and deductive qualitative approaches were used to code and interpret data.

Results : Patient median age was 61, 29% were African American, Latino, or Native American, 50% were married, 32% had preserved ejection fraction, with multimorbidity common. Adherence to self-care behaviors (diet, fluid, medications) was high for most patients. Depression and anxiety, comorbidities, access to care, and economic hardship were identified as significant difficulties for many patients in managing HF. Patient perspectives on the causes of readmission coalesced into 4 common themes: 1) symptom focused (rather than diagnoses based), 2) readmission was unavoidable, often due to the inexorable progression of HF, 3) self-blaming for behaviors related to self care, and 4) health care system failures, including premature discharge from index hospitalization. Interestingly, patient perspectives about reasons for readmission were multi-dimensional in nature, with any single reason rarely given. Patient interviews and provider documentation in charts, while not conflicting, generally did not offer similar causes of readmission in the majority of cases.

Conclusions : Our study provides the first systematic qualitative assessment of patient perspectives on HF readmission. Contrary to previous research, we found that patient experiences highlighted a variety of contributing factors for readmission which made it difficult to categorize a readmission as preventable. These findings highlight the importance of considering the patient perspective in designing policies and interventions aimed at reducing unnecessary HF readmissions.

Abstract 24: Outcomes of Single and Dual Chamber ICDs for Primary Prevention of Sudden Cardiac Death

Background: Randomized trials demonstrating the efficacy of implantable cardioverter defibrillator (ICD) therapy for primary prevention of sudden cardiac death in patients with systolic heart failure (HF) predominantly used single chamber devices. However, in clinical practice, patients often receive dual chamber ICDs even in the absence of indications for pacing. The long-term safety of dual chamber devices relative to single chamber devices is uncertain.

Methods: We identified all Medicare patients in the National Cardiovascular Data Registry's (NCDR®) ICD Registry™ from 2006-2009 who received an ICD for primary prevention that could be matched to CMS claims data. Patients were excluded if they had an EF >35%, received a bi-ventricular device or had a documented indication for pacing. Adjusted risks of complications, mortality, all cause readmission and HF readmission were estimated with propensity-score matching based on demographic, clinical and diagnostic information.

Results: Among 32,034 eligible patients, 38% (n=12,246) received single chamber device and 62% (n=19,788) received a dual chamber device. Unadjusted rates of complications and 6-month all-cause readmission were lower among patients who received a single chamber device (3.5% vs. 4.8%; p <0.001, and 31.7% vs. 33.2%; p=0.004). According to analysis of matched pairs (12,133 single and 12,133 dual), rates of complications were lower among patients who received a single chamber device (3.5% vs.4.6%; p<0.001), but rates of all other outcomes did not differ significantly between the two groups. (Table)

Conclusions: Dual chamber ICDs are associated with higher rates of complications. No significant differences between single and dual chamber ICDs were observed for death, all-cause readmission or HF readmission. Future studies should evaluate the potential benefit of dual chamber devices in reducing inappropriate shocks. In Medicare patients undergoing primary prevention ICD placement without clear indications for pacing, the decision to implant a dual chamber device should be considered carefully given the higher risk of complications with this strategy.

Abstract 5: A Comparison between Antihypertensive Medication Adherence and Treatment Intensification as Potential Clinical Performance Measures

Background: Medication adherence and treatment intensification have been advocated as performance measures to assess the quality of care. While previous studies have shown that adherence and treatment intensification (TI) of antihypertensive medications is associated with blood pressure control at the patient level, less is known about whether adherence and TI is associated with blood pressure control assessed at the clinic level.

Methods: We included 162,879 patients from 89 clinics in the CVRN Hypertension Registry with incident hypertension who were started on antihypertensive medications. Medication adherence was calculated by the proportion of days covered for five different classes of antihypertensive medications. TI was calculated as the number of observed medication intensifications minus the number of expected medication intensifications divided by the number of clinic visits in the observation period. TI is expected whenever measured blood pressure during a clinic visit is higher than the blood pressure goal. A TI score of -1 indicates that no treatment intensification was made when the BP was elevated, a score of 0 indicates that treatment intensification was made only when the blood pressure was elevated, and a score of 1 indicates that treatment intensification was made when the blood pressure was normal. Multivariable logistic regression assessed the association between medication adherence and treatment intensification with blood pressure control at the patient and clinic levels.

Results: The average patient age was 56 years, 13.6% had diabetes, 1.0% had previous MI, 3.8% had chronic kidney disease, 1.7% had a previous ischemic stroke, and 0.9% had CHF. Adherence measured by proportion of days covered was 0.77 ± 0.28 at the patient level and 0.78± 0.05 at the clinic level. The average patient TI score was 0.026 ± 0.23 and the average clinic TI score was 0.01± 0.04. Both adherence and treatment intensification were associated with blood pressure control at the patient level [OR for adherence of 1.28 (1.26 - 1.29) and OR for treatment intensification of 1.55 (1.53 - 1.57)]. In contrast, treatment intensification, but not adherence, was associated with blood pressure control at the clinic level [OR for TI at the clinic level 1.21 (1.17 - 1.25) and OR for adherence at the clinic level 1.01 (0.98 - 1.04)].

Conclusion: In this study, patient adherence to antihypertensive medications was not related to blood pressure control at the clinic level and may not be suitable as a performance measure. Treatment intensification was associated with BP control, but its use as a performance measure may be constrained by challenges in measuring it and by concerns about unintended consequences of aggressive hypertension treatment in some subgroups of patients.

Incidence and prognosis of resistant hypertension in hypertensive patients

BACKGROUND

Despite a recent American Heart Association (AHA) consensus statement emphasizing the importance of resistant hypertension, the incidence and prognosis of this condition are largely unknown.

METHODS AND RESULTS

This retrospective cohort study in 2 integrated health plans included patients with incident hypertension in whom treatment was begun between 2002 and 2006. Patients were followed up for the development of resistant hypertension based on AHA criteria of uncontrolled blood pressure despite use of ≥3 antihypertensive medications, with data collected on prescription filling information and blood pressure measurement. We determined incident cardiovascular events (death or incident myocardial infarction, heart failure, stroke, or chronic kidney disease) in patients with and without resistant hypertension with adjustment for patient and clinical characteristics. Among 205 750 patients with incident hypertension, 1.9% developed resistant hypertension within a median of 1.5 years from initial treatment (0.7 cases per 100 person-years of follow-up). These patients were more often men, were older, and had higher rates of diabetes mellitus than nonresistant patients. Over 3.8 years of median follow-up, cardiovascular event rates were significantly higher in those with resistant hypertension (unadjusted 18.0% versus 13.5%, P<0.001). After adjustment for patient and clinical characteristics, resistant hypertension was associated with a higher risk of cardiovascular events (hazard ratio, 1.47; 95% confidence interval, 1.33-1.62).

CONCLUSIONS

Among patients with incident hypertension in whom treatment was begun, 1 in 50 patients developed resistant hypertension. Patients with resistant hypertension had an increased risk of cardiovascular events, which supports the need for greater efforts toward improving hypertension outcomes in this population.

Identifying high-risk geographic areas for cardiac arrest using three methods for cluster analysis

OBJECTIVES

  The objective was to identify high-risk census tracts, defined as those areas that have both a high incidence of out-of-hospital cardiac arrest (OHCA) and a low prevalence of bystander cardiopulmonary resuscitation (CPR), by using three spatial statistical methods.

METHODS

  This was a secondary analysis of two prospectively collected registries in the city of Columbus, Ohio. Consecutive adult (≥18 years) OHCA patients, restricted to those of cardiac etiology and treated by emergency medical services (EMS) from April 1, 2004, to April 30, 2009, were studied. Three different spatial analysis methods (Global Empirical Bayes, Local Moran's I, and SaTScan's spatial scan statistic) were used to identify high-risk census tracts.

RESULTS

  A total of 4,553 arrests in 200 census tracts occurred during the study period, with 1,632 arrests included in the final sample after exclusions for no resuscitation attempt, noncardiac etiology, etc. The overall incidence for OHCA was 0.70 per 1,000 people for the 6-year study period (SD = ±0.52). Bystander CPR occurred in 20.2% (n = 329), with 10.0% (n = 167) surviving to hospital discharge. Five high-risk census tracts were identified by all three analytic methods.

CONCLUSIONS

  The five high-risk census tracts identified may be possible sites for high-yield targeted community-based interventions to improve CPR training and cardiovascular disease education efforts and ultimately improve survival from OHCA.

Abstract P267: A Pharmacist-Led, AHA Heart 360 Supported Home Blood Pressure Monitoring Program Improves Blood Control in Patients With Uncontrolled Hypertension

Objective: Treating hypertension (HTN) reduces morbidity and mortality, yet blood pressure (BP) remains inadequately controlled in a large proportion of patients with HTN. The purpose of this study was to determine if a pharmacist-led home BP monitoring (HBPM) program supported by the American Heart Association's (AHA) Heart 360 website improves BP control for patients with uncontrolled HTN.

Methods: This practical randomized controlled study was conducted at Kaiser Permanente Colorado. A total of 353 patients 18 to 85 years of age with uncontrolled HTN, receiving ≤ 3 antihypertensive medications, and with internet access were randomized to the Usual Care (UC, n=174) or the home BP monitoring (HBPM, n=179) group. All patients were seen in clinic at baseline and 6 months for BP measurements. The HBPM group used the AHA Heart 360 website to transmit home BP readings via the internet to clinical pharmacy specialists who made adjustments to patients' antihypertensive medications and/or ordered labs as necessary based on collaborative drug therapy management (CDTM) protocols. The primary endpoint was BP control at 6 months (<130/80 mm Hg for patients with diabetes or chronic kidney disease and <140/90 mm Hg for all others). The number of office, telephone, and email contacts was also compared between groups.

Results: Six-month follow-up data were available on 245 patients (245 of 353 (70%)) (n=120 HBPM, n=125 UC). The mean age of the participants was 58 years; 61% were male. There were no significant differences in age or gender between groups. Baseline mean systolic BP was 149 mm Hg in the HBPM group and 145 mm Hg in the UC group (p = 0.08). Rates of 6-month BP control were significantly higher in the HBPM ((58%) 69 of 120) versus the UC group ((38%) 47 of 125) (p < 0.01). The 6-month decrease in systolic BP was larger in the HBPM group (-21 mm Hg) versus the UC group (-9 mm Hg) (p < 0.01). The adjusted relative likelihood of BP goal attainment was 1.5; 95% CI, 1.2 to 2.0. There were no significant differences between groups in the number of office visits; however telephone and email contacts were significantly higher in the HBPM group.

Conclusion: A pharmacist-led, HBPM program supported by the AHA Heart 360 website improves BP control for patients with uncontrolled HTN compared to UC.

Relationship between blood pressure and incident chronic kidney disease in hypertensive patients

BACKGROUND AND OBJECTIVES

Hypertension is an important cause of chronic kidney disease (CKD). Identifying risk factors for progression to CKD in patients with normal kidney function and hypertension may help target therapies to slow or prevent decline of kidney function. Our objective was to identify risk factors for development of incident CKD and decline in estimated GFR (eGFR) in hypertensive patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Cox proportional hazards models were used to assess the relationship between incident CKD (defined as eGFR <60 ml/min per 1.73 m(2)) and potential risk factors for CKD from a registry of hypertensive patients.

RESULTS

Of 43,305 patients meeting the inclusion criteria, 12.1% (5236 patients) developed incident CKD. Diabetes was the strongest predictor of incident CKD (hazard ratio, 1.96; 95% confidence interval, 1.84 to 2.09) and was associated with the greatest rate of decline in eGFR (-2.2 ml/min per 1.73 m(2) per year). Time-varying systolic BP was associated with incident CKD with risk increasing above 120 mmHg; each 10-mmHg increase in baseline and time-varying systolic BP was associated with a 6% increase in the risk of developing CKD (hazard ratio, 1.06; 95% confidence interval, 1.04 to 1.08 for both). Time-weighted systolic BP was associated with a more rapid decline in eGFR of an additional 0.2 ml/min per 1.73 m(2) per year decline for every 10-mmHg increase in systolic BP.

CONCLUSIONS

We found that time-varying systolic BP was associated with incident CKD, with an increase in risk above a systolic BP of 120 mmHg among individuals with hypertension.

Gender differences in the prognostic value of exercise treadmill test characteristics

BACKGROUND

Although exercise treadmill testing (ETT) is less sensitive and specific for diagnosis of coronary disease in women, little is known about gender differences in the prognostic importance of ETT variables.

METHODS

We studied 9,569 consecutive patients (46.8% women) referred for ETT between July 2001 and June 2004 in a community-based system. We assessed the association between ETT variables (exercise capacity, symptoms, ST-segment deviations, heart rate recovery, and chronotropic response) and time to all-cause death and myocardial infarction (MI), adjusting for patient and stress test characteristics. Models were stratified by gender to determine the relationship between ETT variables and outcomes.

RESULTS

In the entire population, exercise capacity and heart rate recovery were significantly associated with all-cause death, whereas exercise capacity, chest pain, and ST-segment deviations were significantly associated with subsequent MI. The relationship between ETT variables and outcomes were similar between men and women, except for abnormal exercise capacity, which had a significantly stronger association with death in men (men: hazard ratio [HR] 2.89 and 95% CI 1.89-4.44, women: HR 0.99 and 95% CI 0.52-1.93, and interaction P = .01), and chronotropic incompetence, which had a significantly stronger relationship with MI in women (men: HR 1.29 and 95% CI 0.74-2.20, women: HR 2.79 and 95% CI 0.94-8.27, and interaction P = .04).

CONCLUSIONS

Although many traditional ETT variables had similar prognostic value in both men and women, exercise capacity was more prognostically important in men, and chronotropic incompetence was more important in women. Future studies should confirm these findings in additional populations.

Health literacy and outcomes among patients with heart failure

CONTEXT

Little is known about the effects of low health literacy among patients with heart failure, a condition that requires self-management and frequent interactions with the health care system.

OBJECTIVE

To evaluate the association between low health literacy and all-cause mortality and hospitalization among outpatients with heart failure.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort study conducted at Kaiser Permanente Colorado, an integrated managed care organization. Outpatients with heart failure were identified between January 2001 and May 2008, were surveyed by mail, and underwent follow-up for a median of 1.2 years. Health literacy was assessed using 3 established screening questions and categorized as adequate or low. Responders were excluded if they did not complete at least 1 health literacy question or if they did not have at least 1 year of enrollment prior to the survey date.

MAIN OUTCOME MEASURES

All-cause mortality and all-cause hospitalization.

RESULTS

Of the 2156 patients surveyed, 1547 responded (72% response rate). Of 1494 included responders, 262 (17.5%) had low health literacy. Patients with low health literacy were older, of lower socioeconomic status, less likely to have at least a high school education, and had higher rates of coexisting illnesses. In multivariable Cox regression, low health literacy was independently associated with higher mortality (unadjusted rate, 17.6% vs 6.3%; adjusted hazard ratio, 1.97 [95% confidence interval, 1.3-2.97]; P = .001) but not hospitalization (unadjusted rate, 30.5% vs 23.2%; adjusted hazard ratio, 1.05 [95% confidence interval, 0.8-1.37]; P = .73).

CONCLUSION

Among patients with heart failure in an integrated managed care organization, low health literacy was significantly associated with higher all-cause mortality.

A multimodal blood pressure control intervention in 3 healthcare systems

OBJECTIVE

To determine if a multimodal intervention composed of patient education, home blood pressure (BP) monitoring, BP measurement reporting to an interactive voice response (IVR) phone system, and clinical pharmacist follow-up improves BP control compared with usual care.

STUDY DESIGN

Prospective study with patient enrollment, medication consultation and adjustment, remote BP monitoring, and follow-up at 6 months.

METHODS

This randomized controlled trial was conducted at 3 healthcare systems in Denver, Colorado, including a large health maintenance organization, a Veterans Affairs medical center, and a county hospital. At each site, patients with uncontrolled BP were randomized to the multimodal intervention vs usual care for 6 months, with the primary end point of BP reduction.

RESULTS

Of 338 patients randomized, 283 (84%) completed the study, including 138 intervention patients and 145 usual care patients. Baseline BP was higher in the intervention group vs the usual care group (150.5/89.4 vs 143.8/85.3 mm Hg). At 6 months, BPs were similar in the intervention group vs the usual care group (137.4 vs 136.7 mm Hg, P = .85 for systolic; 82.9 vs 81.1 mm Hg, P = .14 for diastolic). However, BP reductions were greater in the intervention group vs the usual care group (−13.1 vs −7.1 mm Hg, P = .006 for systolic; −6.5 vs −4.2 mm Hg, P = .07 for diastolic). Adherence to medications was similar between the 2 groups, but intervention patients had a greater increase in medication regimen intensity.

CONCLUSIONS

A multimodal intervention of patient education, home BP monitoring, BP measurement reporting to an IVR system, and clinical pharmacist follow-up achieved greater reductions in BP compared with usual care.

Missed opportunities in cardiovascular disease prevention?: low rates of hypertension recognition for women at medicine and obstetrics-gynecology clinics

Younger women use both internal medicine and obstetrics-gynecology (OBGYN) clinics as primary sources of health care. However, the role of OBGYN clinics in cardiovascular disease prevention is largely unexplored. The objective of this study was to examine rates of hypertension recognition in women<50 years of age who presented with elevated blood pressures in family practice and internal medicine (medicine) OBGYN clinics and to compare these rates across clinic type. The study's population consisted of 34 627 nonpregnant women ages 18 to 49 years with new-onset hypertension (defined as 2 consecutive visits with elevated blood pressures of systolic blood pressure≥140 mm Hg or diastolic blood pressure≥90 mm Hg with no previous hypertension history) from 2002 to 2006. Multivariate logistic regressions predicting the clinical recognition of hypertension (a recorded diagnosis of hypertension and/or an antihypertensive prescription by any provider within 1 year of the second elevated blood pressure) assessed the association between hypertension recognition and the clinic where the second elevated blood pressure was recorded. Analysis showed that hypertension was recognized in <33% of women with new-onset hypertension. Women whose second consecutive elevated blood pressure was recorded in OBGYN clinics were less likely to be recognized as having hypertension within 12 months by any provider compared with women whose second consecutive elevated blood pressure was recorded in a medicine clinic (odds ratio: 0.51 [95% CI: 0.48 to 0.54]). This study suggests that further attention be paid to identifying and treating cardiovascular disease risk factors in women<50 years of age presenting in both medicine and OBGYN clinics and that improved coordination across care settings has the potential to improve cardiovascular disease prevention in young women.

Systolic blood pressure control after participation in a hypertension intervention study

OBJECTIVE

To evaluate whether systolic blood pressure (SBP) control is maintained following participation in a multimodal hypertension intervention.

STUDY DESIGN

This was a retrospective cohort of patients completing the Improving Blood Pressure in Colorado study, a randomized trial comparing a multimodal intervention with usual care for patients who had uncontrolled hypertension. Chart review assessed the first SBP measurement recorded as part of routine care after the study ended. Among patients who had controlled SBP at the final study visit, the proportions who had uncontrolled SBP during follow-up were compared for the intervention and usual care (UC) groups. Kaplan-Meier estimates assessed time to uncontrolled SBP by treatment arm.

RESULTS

Of 283 patients completing the Improving Blood Pressure in Colorado study, 51.5% in the intervention and 46.9% in the UC group had controlled SBP at the final study visit. Of patients with controlled SBP, 37.0% and 46.4% of patients in the intervention and UC groups, respectively, had uncontrolled SBP at their initial measurement during follow-up (P = .32). There was no difference in median time to uncontrolled SBP (126 vs 114 days for the intervention and UC groups, respectively; P = .47).

CONCLUSIONS

SBP control was not maintained in a significant proportion of patients in both groups following hypertension study participation. These findings suggest the need for interventions to focus on longer-term BP control in contrast to the short duration of most hypertension intervention trials.

Parental decline of pneumococcal vaccination and risk of pneumococcal related disease in children

BACKGROUND

An increasing number of parents are choosing to decline immunizations for their children. This study examined the association between the parental decision to decline pneumococcal conjugate (PCV7) vaccinations and the risk of hospitalization due to pneumococcal disease or lobar pneumonia in children.

METHODS

We conducted a case-control study nested within a cohort of children enrolled in the Kaiser Permanente Colorado (KPCO) health plan between 2004 and 2009. Each child hospitalized with pneumococcal disease or lobar pneumonia (n=106) was matched to 4 randomly selected controls (n=401). Cases were matched to controls by age, sex, high-risk status, calendar time, and length of enrollment in KPCO. Disease status and parental vaccination decisions were validated with medical record review. Cases and controls were classified as vaccine decliners or vaccine acceptors.

RESULTS

Among 106 cases, there were 6 (6%) PCV7 vaccine decliners; among 401 controls, there were 4 (1%) vaccine decliners. Children of parents who declined PCV7 immunization were 6.5 times (OR=6.5; 95% CI=1.7, 24.5) more likely to be hospitalized for invasive pneumococcal disease or lobar pneumonia than vaccinated children.

CONCLUSIONS

Parental decline of pneumococcal vaccination apparently increases the risk for hospitalization due to pneumococcal disease or lobar pneumonia in children. Providers can use this information when helping parents weigh the benefits and risks of immunizing their children.

Comparison of outcomes in patients aged <75, 75 to 84, and ≥ 85 years with ST-elevation myocardial infarction (from the ACTION Registry-GWTG)

ST-segment elevation myocardial infarction (STEMI) is common in older adults and has high age-related mortality. We describe contemporary STEMI care using the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Network Registry-Get With The Guidelines (ACTION-GWTG) database. Patients with STEMI (n = 30,188) from 285 ACTION-GWTG sites from January 1, 2007 to June 30, 2008 were grouped by age (<75, 75 to 84, and ≥ 85 years) to compare baseline characteristics, reperfusion, and in-hospital outcomes. In this population, 79.7% (24,070) were <75 years old, 14.2% (4,273) were 75 to 84 years old, and 6.1% (1,845) were ≥ 85 years old (the oldest old). Compared to younger patients, the oldest-old patients (median age 88 years, interquartile range 86 to 91) were more often women, had more hypertension, and end-organ co-morbidity (heart failure and stroke, p <0.0001 for all). More than 42% of the oldest old were also cited as having contraindications to reperfusion, but with absolute or relative contraindications noted in only 10%, and patient preference was the most common reason indicated (45%). Even in reperfusion-eligible patients, the oldest old were less likely to receive it. Although patients who received reperfusion had better outcomes than those who did not, this was significant only for younger patients (< 75 years old, odds ratio 0.58, confidence interval 0.40 to 0.84). In conclusion, > 42% of the oldest old have reported contraindications to reperfusion, with neither mortality benefit nor harm in those who receive it. Disparities in process of care and co-morbidity may explain these observational findings. Whether efforts to optimize patient selection and initiate reperfusion therapy can improve outcomes in the oldest old with STEMI is unknown.

Antithrombotic strategy in non-ST-segment elevation myocardial infarction patients undergoing percutaneous coronary intervention: insights from the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry

OBJECTIVES

The aim of this study was to examine the use of and outcomes associated with antithrombotic strategies in patients with non-ST-segment elevation myocardial infarction (NSTEMI) who undergo percutaneous coronary intervention (PCI).

BACKGROUND

A variety of antithrombotic strategies have been tested in clinical trials for NSTEMI patients treated with PCI.

METHODS

Antithrombotic strategies for NSTEMI patients undergoing PCI at 217 ACTION (Acute Coronary Treatment and Intervention Outcomes Network) hospitals from January 1, 2007, to December 31, 2007, (n = 11,085) were classified into commonly observed antithrombotic groups: heparin alone (Hep alone; low-molecular-weight heparin or unfractionated heparin), bivalirudin alone (Bival alone), heparin with glycoprotein IIb/IIIa inhibitors (Hep/GPI), and bivalirudin with GPI (Bival/GPI). Baseline characteristics are shown across treatment groups. In addition, unadjusted and adjusted rates of in-hospital major bleeding and death are shown.

RESULTS

The standard strategy used was Hep/GPI (64%), followed by Hep or Bival alone (28%), and Bival/GPI (8%). Patients who received Hep or Bival alone were older with more comorbidities, higher baseline bleeding and mortality risk, and lower peak troponin. Compared with patients who received Hep/GPI , those who received Hep alone and Bival alone had lower rates of major bleeding (adjusted odds ratio [OR]: 0.52; 95% confidence interval [CI]: 0.42 to 0.65; adjusted OR: 0.48; 95% CI: 0.39 to 0.60; respectively), yet only patients who received Bival alone had lower mortality (adjusted OR: 0.39; 95% CI: 0.21 to 0.71).

CONCLUSIONS

NSTEMI patients undergoing PCI are more likely to receive Bival or Hep alone when at higher baseline bleeding risk than when at lower baseline bleeding risk. Despite higher baseline risk, those receiving Bival or Hep alone had less bleeding.

Quality of care for acute myocardial infarction in 58 U.S. emergency departments

OBJECTIVES

The objectives of this study were to determine concordance of emergency department (ED) management of acute myocardial infarction (AMI) with guideline recommendations and to identify ED and patient characteristics predictive of higher guideline concordance.

METHODS

The authors conducted a chart review study of ED AMI care as part of the National Emergency Department Safety Study (NEDSS). Using a primary hospital discharge diagnosis of AMI (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM], codes 410.XX), a random sample of ED visits for AMI in 58 urban EDs across 20 U.S. states between 2003 and 2006 were identified. Concordance with American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations was evaluated using five individual quality measures and a composite concordance score. Concordance scores were calculated as the percentage of eligible patients who received guidelines-recommended care. These percentage scores were rescaled from 0 to 100, with 100 indicating perfect concordance.

RESULTS

The cohort consisted of 3,819 subjects; their median age was 65 years, and 62% were men. The mean (± standard deviation [SD]) ED composite concordance score was 61 ± 8), with a broad range of values (42 to 84). Except for aspirin use (mean concordance, 82), ED concordance scores were low (beta-blocker use, 56; timely electrocardiogram [ECG], 41; timely fibrinolytic therapy, 26; timely ED disposition for primary percutaneous coronary intervention [PCI] candidates, 43). In multivariable analyses, older age (beta-coefficient per 10-year increase, -1.5; 95% confidence interval [CI] = -2.4 to -0.5) and southern EDs (beta-coefficient, -5.2; 95% CI = -9.6 to -0.9) were associated with lower guideline concordance, whereas ST-segment elevation on initial ED ECG was associated with higher guideline concordance (beta-coefficient, 3.6; 95% CI = 1.5 to 5.7).

CONCLUSIONS

Overall ED concordance with guideline-recommended processes of care was low to moderate. Emergency physicians should continue to work with other stakeholders in AMI care, such as emergency medical services (EMS) and cardiologists, to develop strategies to improve care processes.

Comparative effectiveness of angiotensin-converting enzyme inhibitors versus beta-blockers as second-line therapy for hypertension

BACKGROUND

Trials comparing hypertension monotherapies have found either no difference or modest differences in blood pressure (BP) and cardiovascular events. However, no trial has assessed the comparative effectiveness of 2nd-line therapy in patients whose BP was not controlled with a thiazide diuretic.

METHODS AND RESULTS

This was an observational study conducted with a hypertension registry of adults enrolled in 3 large integrated health care delivery systems from 2002 to 2007. Patients newly started on thiazide monotherapy whose BP remained uncontrolled were observed after addition of either an angiotensin-converting enzyme (ACE) inhibitor or β-blocker for subsequent BP control and cardiovascular events. Patients for whom either add-on drug was indicated or contraindicated were excluded. After adjustment for patient characteristics and study year, BP control during the subsequent 6 to 18 months was comparable for the 2 agents (70.5% ACE, 69.0% β-blockers; P=0.09). Rates of incident myocardial infarction (hazard ratio, 1.05; 95% confidence interval, 0.69 to 1.58) and stroke (hazard ratio, 1.01; 95% confidence interval, 0.68 to 1.52) were also similar for the ACE inhibitor and β-blocker groups during an average of 2.3 years of follow-up. There were also no differences in heart failure or renal function.

CONCLUSIONS

ACE inhibitors and β-blockers are equally effective in lowering BP and preventing cardiovascular events for patients whose BP is not controlled with a thiazide diuretic alone and who have no compelling indication for a specific 2nd-line agent.

Trends in time to confirmation and recognition of new-onset hypertension, 2002-2006

Achieving full benefits of blood pressure control in populations requires prompt recognition of previously undetected hypertension. In 2003, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure provided definitions of hypertension and recommended that single elevated readings be confirmed within 1 to 2 months. We sought to determine whether the time required to confirm and recognize (ie, diagnose and/or treat) new-onset hypertension decreased from 2002 to 2006 for adult members of 2 large integrated healthcare delivery systems, Kaiser Permanente Northern California and Colorado. Using electronically stored office blood pressure readings, physician diagnoses, and pharmacy prescriptions, we identified 200 587 patients with new-onset hypertension (2002-2006) marked by 2 consecutive elevated blood pressure readings in previously undiagnosed, untreated members. Mean confirmation intervals (time from the first to second consecutive elevated reading) declined steadily from 103 to 89 days during this period. For persons recognized within 12 months after confirmation, the mean interval to recognition declined from 78 to 61 days. However, only 33% of individuals were recognized within 12 months. One third were never recognized during observed follow-up. For these patients, most subsequent blood pressure recordings were not elevated. Higher initial blood pressure levels, history of previous cardiovascular disease, and older age were associated with shorter times to recognition. Times to confirmation and recognition of new-onset hypertension have become shorter in recent years, especially for patients with higher cardiovascular disease risk. Variability in office-based blood pressure readings suggests that further improvements in recognition and treatment may be achieved with more specific automated approaches to identifying hypertension.

The Cardiovascular Research Network: a new paradigm for cardiovascular quality and outcomes research

BACKGROUND

A clear need exists for a more systematic understanding of the epidemiology, diagnosis, and management of cardiovascular diseases. More robust data are also needed on how well clinical trials are translated into contemporary community practice and the associated resource use, costs, and outcomes.

METHODS AND RESULTS

The National Heart, Lung, and Blood Institute recently established the Cardiovascular Research Network, which represents a new paradigm to evaluate the epidemiology, quality of care, and outcomes of cardiovascular disease and to conduct future clinical trials using a community-based model. The network includes 15 geographically distributed health plans with dedicated research centers, National Heart, Lung, and Blood Institute representatives, and an external collaboration and advisory committee. Cardiovascular research network sites bring complementary content and methodological expertise and a diverse population of approximately 11 million individuals treated through various health care delivery models. Each site's rich electronic databases (eg, sociodemographic characteristics, inpatient and outpatient diagnoses and procedures, pharmacy, laboratory, and cost data) are being mapped to create a standardized virtual data warehouse to facilitate rapid and efficient large-scale research studies. Initial projects focus on (1) hypertension recognition and management, (2) quality and outcomes of warfarin therapy, and (3) use, outcomes, and costs of implantable cardioverter defibrillators.

CONCLUSIONS

The Cardiovascular Research Network represents a new paradigm in the approach to cardiovascular quality of care and outcomes research among community-based populations. Its unique ability to characterize longitudinally large, diverse populations will yield novel insights into contemporary disease and risk factor surveillance, management, outcomes, and costs. The Cardiovascular Research Network aims to become the national research partner of choice for efforts to improve the prevention, diagnosis, treatment, and outcomes of cardiovascular diseases.

Increased Risk of Bleeding in Patients on Clopidogrel Therapy After Drug-Eluting Stents Implantation

Background—

Studies suggest that extended clopidogrel use after drug-eluting stent (DES) implantation may decrease the risk of myocardial infarction (MI) and death. Little is known about the competing risk of bleeding from clopidogrel in “real world” clinical practice.

Methods and Results—

We studied 7689 patients undergoing drug-eluting stent implantation enrolled in the HMO Research Network-Stent Registry between 2004 and 2007. Patients were analyzed in 6-month intervals for the occurrence of major bleeding, MI, and death. Clopidogrel use was determined by pharmacy dispensing data. Regression models assessed the association between clopidogrel use and outcomes. Overall, 3603 patients (49.1%) received clopidogrel for >6 months. During a mean follow-up of 418 days (SD, ±168 days), 217 (2.9%) patients died, 279 (3.7%) had a MI, and 271 (3.6%) had major bleeding. After adjustment, patients on clopidogrel therapy were associated with increased major bleeding in all time intervals (0 to 6 months: relative risk (RR)=2.70, 95% CI=1.41 to 5.19; 7 to 12 months: RR=1.71, 95% CI=1.05 to 2.79; 13 to 18 months: RR=2.34, 95% CI=1.26 to 4.34), compared with patients off clopidogrel. Clopidogrel use was also associated with decreased risk of MI for all time intervals (0 to 6 months: RR=0.52, 95% CI=0.36 to 0.77; 7 to 12 months: RR=0.46, 95% CI=0.30 to 0.70; 13 to 18 months: RR=0.53, 95% CI=0.29 to 0.99) and decreased death in the 7 to 12 month interval (RR=0.50, 95% CI=0.30 to 0.83).

Conclusions—

Clopidogrel use was associated with increased major bleeding and decreased MI persisting to 18 months. Bleeding risks on clopidogrel therapy deserve consideration in the ongoing debate regarding optimal clopidogrel duration after PCI.

Blood pressure trajectories and associations with treatment intensification, medication adherence, and outcomes among newly diagnosed coronary artery disease patients

BACKGROUND

Blood pressure (BP) control among coronary artery disease patients remains suboptimal in clinical practice, potentially due to gaps in treatment intensification and medication adherence. However, longitudinal studies evaluating these relationships and outcomes are limited.

METHODS AND RESULTS

We assessed BP trajectories among health maintenance organization patients with hypertension and incident coronary artery disease. BP trajectories were modeled over the year after coronary artery disease diagnosis, stratified by target BP goal. Treatment intensification (increase in BP therapies in the setting of an elevated BP), medication adherence (percentage of days covered with BP therapies), and outcomes (all-cause mortality, myocardial infarction, and revascularization) were evaluated in multivariable models: 9569 patients had a <140/90 mm Hg BP target and 12,861 had a <130/80 mm Hg BP target. Within each group, 4 trajectories were identified: good, borderline, improved, and poor control. After adjustment, increasing BP treatment intensity was significantly associated with better BP trajectories in both groups. Medication adherence had inconsistent effects. There were no significant differences in combined outcomes by BP trajectory, but among the diabetes and renal disease cohort, borderline control patients were less likely to have myocardial infarction (odds ratio, 0.61; 95% confidence interval, 0.40-0.93), and good control patients were less likely to have myocardial infarction (odds ratio, 0.53; 95% confidence interval, 0.34-0.84) or a revascularization procedure (odds ratio, 0.66; 95% confidence interval, 0.47-0.93) compared with poor control patients.

CONCLUSIONS

In this health maintenance organization population, treatment intensification but not medication adherence significantly affects BP trajectories in the year after coronary artery disease diagnosis. Better BP trajectories are associated with lower rates of myocardial infarction and revascularization.

Adverse Events After Stopping Clopidogrel in Post–Acute Coronary Syndrome Patients

Background— A prior study from the Veterans Health Administration found a clustering of cardiovascular events after clopidogrel cessation. We sought to confirm and expand these findings.

Methods and Results— This was a retrospective cohort study of 2017 patients with acute coronary syndrome discharged on clopidogrel from an integrated health care delivery system. Rates of all-cause mortality or acute myocardial infarction (MI) within 1 year after stopping clopidogrel were assessed among patients who did not have an event before stopping clopidogrel. Death/MI occurred in 4.3% (n=71) of patients. The rates of death/MI were 3.07, 1.62, 0.70, and 0.95 per 10 000 patient-days for the time intervals of 0 to 90, 91 to 180, 181 to 270, and 271 to 360 days after stopping clopidogrel. In multivariable analysis, the 0- to 90-day interval after stopping clopidogrel was associated with higher risk of death/MI (incidence rate ratio, 2.74; 95% confidence interval, 1.69 to 4.44) compared with 91- to 360-day interval. There was a similar trend of increased events after stopping clopidogrel for various subgroups (women versus men, medical therapy versus percutaneous coronary intervention, stent type, and ≥6 months or <6 months of clopidogrel treatment). Among patients taking clopidogrel but stopping ACE inhibitor medications, the event rates were similar in the 0- to 90-day versus the 91- to 360-day interval (2.67 versus 2.91 per 10 000 patient-days; P =0.91).

Conclusions— We observed a clustering of adverse events in the 0 to 90 days after stopping clopidogrel. This clustering of events was not present among patients stopping ACE inhibitors. These findings are consistent with a possible rebound platelet hyper-reactivity after stopping clopidogrel and additional platelet studies are needed to confirm this effect.

Association of cardiometabolic risk factors and prevalent cardiovascular events

BACKGROUND

Although cardiovascular disease causes substantial morbidity and mortality, how individual and groups of risk factors contribute to cardiovascular outcomes is incompletely understood. This study evaluated cardiometabolic risk factors and their relationship to prevalent diagnosis of acute myocardial infarction (AMI) and stroke.

METHODS

We used retrospective data from 3 integrated health-care systems that systematically collect and store detailed patient-level data. Adult enrollees were eligible for inclusion if they had all of the following clinical measurements: weight, height, blood pressure, high density lipoproteins, triglycerides, and fasting blood glucose or evidence of diabetes from July 1, 2003, to June 30, 2005. We used National Cholesterol Education Program Adult Treatment Panel III guidelines to determine qualifying levels for cardiometabolic risk factors.

RESULTS

A total of 170,648 persons met the inclusion/exclusion criteria; 11,757 had no qualifying risk factors, 25,684 had 1, 38,176 had 2, and 95,031 had 3 or more risk factors. Compared to those without risk factors, persons with any 1 risk factor were 2.21 (95% confidence interval [CI], 1.78-2.74) times more likely to have had a diagnosis of AMI or stroke. The risk increased to 2.79 (95% CI, 2.26-3.42) for persons with 2, 3.45 (95% CI, 2.80-4.24) for persons with 3, 4.35 (95% CI, 3.54-5.35) for persons with 4, and 5.73 (95% CI, 4.65-7.07) for persons with 5 risk factors. The highest risk was conferred by having the combination of risk factors of diabetes, hypertension, and dyslipidemia, with or without weight risk.

CONCLUSIONS

This study demonstrates a direct association between an increasing number of cardiometabolic risk factors and prevalent diagnosis of AMI and stroke. The combination of risk factors conferring the highest risk was diabetes, hypertension, and dyslipidemia.

Parental refusal of varicella vaccination and the associated risk of varicella infection in children

OBJECTIVE

To quantify both the individual-level and attributable risk of varicella infection requiring medical care in children whose parents refuse varicella immunizations.

DESIGN

Matched case-control study with conditional logistic regression analysis.

SETTING

Kaiser Permanente of Colorado (KPCO) health plan between 1998 and 2008.

PARTICIPANTS

Each pediatric physician-diagnosed case of varicella (n = 133) was matched to 4 randomly selected controls (n = 493). Cases were matched by age, sex, and length of enrollment in KPCO. Main Exposures Varicella vaccine refusal.

OUTCOME MEASURES

Varicella infection.

RESULTS

There were 7 varicella vaccine refusers (5%) among the cases and 3 (0.6%) among the controls. Children of parents who refused varicella immunizations were at a greatly increased risk of varicella infection requiring medical care (odds ratio, 8.6; 95% confidence interval, 2.2-33.3) compared with children of parents who accepted vaccinations (P = .004). In the entire KPCO pediatric population, 5% of varicella cases were attributed to parental vaccine refusal.

CONCLUSIONS

Children of parents who refuse varicella immunizations are at high risk of varicella infection relative to vaccinated children. These results will be helpful to health care providers and parents when making decisions about immunizing children.

Association of longitudinal measures of hemoglobin and outcomes after hospitalization for heart failure

BACKGROUND

Cross-sectional assessments of hemoglobin (Hb) are associated with mortality in patients with heart failure (HF). Our objectives were to characterize patterns of change in Hb over time in patients with HF and to evaluate the relationship between longitudinal measures of Hb and adverse outcomes.

METHODS

The study included 2,478 patients with a primary discharge diagnosis of HF from January 2001 to December 2006. Outcomes included time to death and time to death or HF hospitalization. The association between baseline Hb and outcomes was evaluated using multivariable Cox regression. The longitudinal association was evaluated using a time-dependent Hb predictor variable and using anemia trajectory groups.

RESULTS

For a median of 475 days, baseline Hb was associated with a trend toward increased mortality (hazard ratio [HR] 1.02, 95% CI 0.99-1.06 per g/dL decline). With a time-dependent approach, the magnitude of the association was greater (HR 1.35, 95% CI 1.30-1.39 per g/dL decline). In trajectory analysis, 35% of the cohort had variable patterns of anemia. Persistently low Hb (HR 1.65, 95% CI 1.27-2.14) and a progressive decline in Hb (HR 1.54, 95% CI 1.16-2.05) were associated with increased mortality risk. Patients with recovery of anemia had similar outcomes as those patients who are persistently nonanemic. Results were similar for the composite of death or HF hospitalization.

CONCLUSIONS

Variability in Hb over time is common in patients with HF, and declining Hb is associated with a poor prognosis. Longitudinal characterization of Hb levels has greater prognostic significance than a single measurement. Systematic surveillance of Hb levels may help identify high-risk patients with heart failure.

Health care utilization and costs by metabolic syndrome risk factors

BACKGROUND

This study compared prevalent health utilization and costs for persons with and without metabolic syndrome and investigated the independent associations of the various factors that make up metabolic syndrome.

METHODS

Subjects were enrollees of three health plans who had all clinical measurements (blood pressure, fasting plasma glucose, body mass index, triglycerides, and high-density lipoprotein cholesterol) necessary to determine metabolic syndrome risk factors over the 2-year study period (n = 170,648). We used clinical values, International Classification of Diseases, Ninth Revision (ICD-9) diagnoses, and medication dispensings to identify risk factors. We report unadjusted mean annual utilization and modeled mean annual costs adjusting for age, sex, and co-morbidity.

RESULTS

Subjects with metabolic syndrome (n = 98,091) had higher utilization and costs compared to subjects with no metabolic syndrome (n = 72,557) overall, and when stratified by diabetes (P < 0.001). Average annual total costs between subjects with metabolic syndrome versus no metabolic syndrome differed by a magnitude of 1.6 overall ($5,732 vs. $3,581), and a magnitude of 1.3 when stratified by diabetes (diabetes, $7,896 vs. $6,038; no diabetes, $4,476 vs. $3,422). Overall, total costs increased by an average of 24% per additional risk factor (P < 0.001). Costs and utilization differed by risk factor clusters, but the more prevalent clusters were not necessarily the most costly. Costs for subjects with diabetes plus weight risk, dyslipidemia, and hypertension were almost double the costs for subjects with prediabetes plus similar risk factors ($8,067 vs. $4,638).

CONCLUSIONS

Metabolic syndrome, number of risk factors, and specific combinations of risk factors are markers for high utilization and costs among patients receiving medical care. Diabetes and certain risk clusters are major drivers of utilization and costs.

Sociodemographic and clinical characteristics are not clinically useful predictors of refill adherence in patients with hypertension

BACKGROUND

Although many studies have identified patient characteristics or chronic diseases associated with medication adherence, the clinical utility of such predictors has rarely been assessed. We attempted to develop clinical prediction rules for adherence with antihypertensive medications in 2 healthcare delivery systems.

METHODS AND RESULTS

We performed retrospective cohort studies of hypertension registries in an inner-city healthcare delivery system (n=17 176) and a health maintenance organization (n=94 297) in Denver, Colo. Adherence was defined by acquisition of 80% or more of antihypertensive medications. A multivariable model in the inner-city system found that adherent patients (36.3% of the total) were more likely than nonadherent patients to be older, white, married, and acculturated in US society, to have diabetes or cerebrovascular disease, not to abuse alcohol or controlled substances, and to be prescribed fewer than 3 antihypertensive medications. Although statistically significant, all multivariate odds ratios were 1.7 or less, and the model did not accurately discriminate adherent from nonadherent patients (C statistic=0.606). In the health maintenance organization, where 72.1% of patients were adherent, significant but weak associations existed between adherence and older age, white race, the lack of alcohol abuse, and fewer antihypertensive medications. The multivariate model again failed to accurately discriminate adherent from nonadherent individuals (C statistic=0.576).

CONCLUSIONS

Although certain sociodemographic characteristics or clinical diagnoses are statistically associated with adherence to refills of antihypertensive medications, a combination of these characteristics is not sufficiently accurate to allow clinicians to predict whether their patients will be adherent with treatment.

Temporal changes in the use of drug-eluting stents for patients with non-ST-Segment-elevation myocardial infarction undergoing percutaneous coronary intervention from 2006 to 2008: results from the can rapid risk stratification of unstable angina patients supress ADverse outcomes with early implementation of the ACC/AHA guidelines (CRUSADE) and acute coronary treatment and intervention outcomes network-get with the guidelines (ACTION-GWTG) registries

BACKGROUND

The risks of late stent thrombosis with drug-eluting stents (DES) were intensely debated after the presentation of a number of studies highlighting this issue in September 2006. We evaluated trends in the use of DES for patients with non-ST-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI) from 2006 to 2008.

METHODS AND RESULTS

Temporal patterns of DES use were examined among non-ST-elevation myocardial infarction patients in the Can Rapid risk stratification of Unstable angina patients Supress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE; January 2006 to December 2006) and Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines (ACTION-GWTG; January 2007 to June 2008) registries to determine how practice patterns changed for patients with acute myocardial infarction undergoing PCI. Among the 54 662 patients analyzed, the percentage of patients undergoing PCI by quarter varied from 54% to 58% during the analysis time period. More than 90% of patients undergoing PCI received a DES in the first 3 quarters of 2006 before the public debate about the risks of DES began. Thereafter, the use of DES for PCI patients declined during the fourth quarter of 2006 through the first quarter of 2007 (82% to 67%), gradually declined during quarters 2 to 4 of 2007 (63% to 63% to 59%) but then slightly increased from the first to second quarter of 2008 (58% to 60%). Hospital characteristics did not seem to correlate with temporal changes in DES use, but by the last 2 quarters of the study period, patient characteristics such as white race, hypertension, diabetes mellitus, and private or managed care insurance were more common among patients who received a DES compared with the beginning 2 quarters of the study period.

CONCLUSIONS

These findings highlight how rapidly treatment decisions in contemporary practice can be affected by public debate related to scientific presentations and publications.

A pragmatic-explanatory continuum indicator summary (PRECIS): a tool to help trial designers

OBJECTIVE

To propose a tool to assist trialists in making design decisions that are consistent with their trial's stated purpose.

STUDY DESIGN AND SETTING

Randomized trials have been broadly categorized as either having a pragmatic or explanatory attitude. Pragmatic trials seek to answer the question, "Does this intervention work under usual conditions?," whereas explanatory trials are focused on the question, "Can this intervention work under ideal conditions?" Design decisions make a trial more (or less) pragmatic or explanatory, but no tool currently exists to help researchers make the best decisions possible in accordance with their trial's primary goal. During the course of two international meetings, participants with experience in clinical care, research commissioning, health care financing, trial methodology, and reporting defined and refined aspects of trial design that distinguish pragmatic attitudes from explanatory.

RESULTS

We have developed a tool (called PRECIS) with 10 key domains and which identifies criteria to help researchers determine how pragmatic or explanatory their trial is. The assessment is summarized graphically.

CONCLUSION

We believe that PRECIS is a useful first step toward a tool that can help trialists to ensure that their design decisions are consistent with the stated purpose of the trial.

Parental refusal of pertussis vaccination is associated with an increased risk of pertussis infection in children

OBJECTIVE

The objective of this study was to determine if children who contracted pertussis infection were more likely to have parents who refused pertussis vaccinations than a similar group of children who did not develop pertussis infection.

METHODS

We conducted a case-control study of children enrolled in the Kaiser Permanente of Colorado health plan between 1996 and 2007. Each pertussis case was matched to 4 randomly selected controls. Pertussis case status and vaccination status were ascertained by medical chart review.

RESULTS

We identified 156 laboratory-confirmed pertussis cases and 595 matched controls. There were 18 (12%) pertussis vaccine refusers among the cases and 3 (0.5%) pertussis vaccine refusers among the controls. Children of parents who refused pertussis immunizations were at an increased risk for pertussis compared with children of parents who accepted vaccinations. In a secondary case-control analysis of children continuously enrolled in Kaiser Permanente of Colorado from 2 to 20 months of age, vaccine refusal was associated with a similarly increased risk of pertussis. In the entire Kaiser Permanente of Colorado pediatric population, 11% of all pertussis cases were attributed to parental vaccine refusal.

CONCLUSIONS

Children of parents who refuse pertussis immunizations are at high risk for pertussis infection relative to vaccinated children. Herd immunity does not seem to completely protect unvaccinated children from pertussis. These findings stress the need to further understand why parents refuse immunizations and to develop strategies for conveying the risks and benefits of immunizations to parents more effectively.

Improving laboratory monitoring of medications: an economic analysis alongside a clinical trial

OBJECTIVE

To test the efficiency and cost-effectiveness of interventions aimed at enhancing laboratory monitoring of medication.

STUDY DESIGN

Cost-effectiveness analysis.

METHODS

Patients of a not-for-profit, group-model HMO were randomized to 1 of 4 interventions: an electronic medical record reminder to the clinician, an automated voice message to patients, pharmacy-led outreach, or usual care. Patients were followed for 25 days to determine completion of all recommended baseline laboratory monitoring tests. We measured the rate of laboratory test completion and the cost-effectiveness of each intervention. Direct medical care costs to the HMO (repeated testing, extra visits, and intervention costs) were determined using trial data and a mix of other data sources.

RESULTS

The average cost of patient contact was $5.45 in the pharmacy-led intervention, $7.00 in the electronic reminder intervention, and $4.64 in the automated voice message reminder intervention. The electronic medical record intervention was more costly and less effective than other methods. The automated voice message intervention had an incremental cost-effectiveness ratio (ICER) of $47 per additional completed case, and the pharmacy intervention had an ICER of $64 per additional completed case.

CONCLUSIONS

Using the data available to compare strategies to enhance baseline monitoring, direct clinician messaging was not an efficient use of resources. Depending on a decision maker's willingness to pay, automated voice messaging and pharmacy-led efforts can be efficient choices to prompt therapeutic baseline monitoring, but direct clinician messaging is probably a less efficient use of resources.

Utilization and impact of pre-hospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction: data from the NCDR (National Cardiovascular Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry

OBJECTIVES

This study sought to determine the association of pre-hospital electrocardiograms (ECGs) and the timing of reperfusion therapy for patients with ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Pre-hospital ECGs have been recommended in the management of patients with chest pain transported by emergency medical services (EMS).

METHODS

We evaluated patients with STEMI from the NCDR (National Cardiovascular Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry who were transported by EMS from January 1, 2007, through December 31, 2007. Patients were stratified by the use of pre-hospital ECGs, and timing of reperfusion therapy was compared between the 2 groups.

RESULTS

A total of 7,098 of 12,097 patients (58.7%) utilized EMS, and 1,941 of these 7,098 EMS transport patients (27.4%) received a pre-hospital ECG. Among the EMS transport population, primary percutaneous coronary intervention was performed in 92.1% of patients with a pre-hospital ECG versus 86.3% with an in-hospital ECG, whereas fibrinolytic therapy was used in 4.6% versus 4.2% of patients. Median door-to-needle times for patients receiving fibrinolytic therapy (19 min vs. 29 min, p = 0.003) and median door-to-balloon times for patients undergoing primary percutaneous coronary intervention (61 min vs. 75 min, p < 0.0001) were significantly shorter for patients with a pre-hospital ECG. A suggestive trend for a lower risk of in-hospital mortality was observed with pre-hospital ECG use (adjusted odds ratio: 0.80, 95% confidence interval: 0.63 to 1.01).

CONCLUSIONS

Only one-quarter of these patients transported by EMS receive a pre-hospital ECG. The use of a pre-hospital ECG was associated with a greater use of reperfusion therapy, faster reperfusion times, and a suggested trend for a lower risk of mortality.

Quality of care for acute asthma in 63 US emergency departments

BACKGROUND

Little is known about the quality of acute asthma care in the emergency department (ED).

OBJECTIVES

We sought to determine the concordance of ED management of acute asthma with National Institutes of Health asthma guidelines, to identify ED characteristics predictive of higher guideline concordance, and to assess whether guideline concordance was associated with hospital admission.

METHODS

We conducted a retrospective chart review study of acute asthma as part of the National Emergency Department Safety Study. Using a principal diagnosis of asthma, we identified ED visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Concordance with guideline recommendations was evaluated by using item-by-item quality measures and composite concordance scores both at the patient and ED level. These scores ranged from 0 to 100, with 100 indicating perfect concordance.

RESULTS

The cohort consisted of 4,053 subjects; their median age was 34 years, and 64% were women. The overall patient guideline concordance score was 67 (interquartile range, 63-83), and the ED concordance score was 71 (SD, 7). Multivariable analysis showed southern EDs were associated with lower ED concordance scores (beta-coefficient, -8.2; 95% CI, -13.8 to -2.7) compared with northeastern EDs. After adjustment for the severity on ED presentation, patients who received all recommended treatments had a 46% reduction in the risk of hospital admission compared with others.

CONCLUSIONS

Concordance with treatment recommendations in the National Institutes of Health asthma guidelines was moderate. Significant variations in ED quality of asthma care were found, and geographic differences existed. Greater concordance with guideline-recommended treatments might reduce hospitalizations.

The safety of emergency care systems: Results of a survey of clinicians in 65 US emergency departments

STUDY OBJECTIVE

Well-functioning systems are critical to safe patient care, but little is known about the status of such systems in US health care facilities, including high-risk settings such as the emergency department (ED). The purpose of this study is to assess the degree to which EDs are designed, managed, and supported in ways that ensure patient safety.

METHODS

This was a validated, psychometrically tested survey of clinicians working in 65 US EDs that assessed clinician perceptions about the EDs' physical environment, staffing, equipment and supplies, nursing, teamwork, safety culture, triage and monitoring, information coordination and consultation, and inpatient coordination.

RESULTS

Overall 3,562 eligible respondents completed the survey (response rate=66%). Survey respondents commonly reported problems in 4 systems critical to ED safety: physical environment, staffing, inpatient coordination, and information coordination and consultation. ED clinicians reported that there was insufficient space for the delivery of care most (25%) or some (37%) of the time. Respondents indicated that the number of patients exceeded ED capacity to provide safe care most (32%) or some of the time (50%). Only 41% of clinicians indicated that most of the time specialty consultation for critically ill patients arrived within 30 minutes of being contacted. Finally, half of respondents reported that ED patients requiring admission to the ICU were rarely transferred from the ED to the ICU within 1 hour.

CONCLUSION

Reports by ED clinicians suggest that substantial improvements in institutional design, management, and support for emergency care are necessary to maximize patient safety in US EDs.

A survey of workplace violence across 65 U.S. emergency departments

OBJECTIVES

Workplace violence is a concerning issue. Healthcare workers represent a significant portion of the victims, especially those who work in the emergency department (ED). The objective of this study was to examine ED workplace violence and staff perceptions of physical safety.

METHODS

Data were obtained from the National Emergency Department Safety Study (NEDSS), which surveyed staff across 69 U.S. EDs including physicians, residents, nurses, nurse practitioners, and physician assistants. The authors also conducted surveys of key informants (one from each site) including ED chairs, medical directors, nurse managers, and administrators. The main outcome measures included physical attacks against staff, frequency of guns or knives in the ED, and staff perceptions of physical safety.

RESULTS

A total of 5,695 staff surveys were distributed, and 3,518 surveys from 65 sites were included in the final analysis. One-fourth of surveyed ED staff reported feeling safe sometimes, rarely, or never. Key informants at the sampled EDs reported a total of 3,461 physical attacks (median of 11 attacks per ED) over the 5-year period. Key informants at 20% of EDs reported that guns or knives were brought to the ED on a daily or weekly basis. In multivariate analysis, nurses were less likely to feel safe "most of the time" or "always" when compared to other surveyed staff.

CONCLUSIONS

This study showed that violence and weapons in the ED are common, and nurses were less likely to feel safe than other ED staff.