Impact of Medication Adherence on Mortality and Cardiovascular Morbidity: Protocol for a Population-Based Cohort Study

BACKGROUND

Cardiovascular disease (CVD) is a group of disorders of the heart and blood vessels, such as coronary heart disease (CHD), cerebrovascular disease, and peripheral artery disease. CVD is the leading threat to global health, whether measured by mortality, morbidity, or economic cost. Long-term administration of aspirin, statins, beta-blockers, and angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers improves survival in patients with stablished coronary heart disease. Nevertheless, adherence to prescribed medication is poor for long-term drug treatment.

OBJECTIVE

We aim to assess the relationship between adherences to the four pharmacological groups recommended for secondary prevention and the clinical outcomes of cardiovascular morbidity and mortality in patients with established CHD according to the level of adherence to these drugs in a population of incident cases of acute coronary syndrome (ACS).

METHODS

Population-based cohort study of patients with a first episode of ACS during 2006-2015 in the Information System for Research in Primary Care (SIDIAP) database. We will estimate adherence to these drugs. The primary endpoint is a composite of all-cause mortality, ACS, and ischaemic stroke. Bivariate analyses will be performed estimating odds ratios for categorical variables and mean differences for continuous variables. Hazard ratios for adherences will be calculated for outcome events using Cox proportional hazard regression models, and proportionality of hazards assumption will be tested.

RESULTS

We expect to estimate adherence to all four study treatments, the incidence of MACE, and to analyze if this incidence is associated with the level of drug adherence.

CONCLUSIONS

We expect to find that adherent patients have a lower risk of the primary endpoints compared with nonadherent patients.

TRIAL REGISTRATION

This study protocol was classified as EPA-OD by the AEMPS (IJG-EST-2017-01-2017-01, 07/04/2017) and registered in the EU PAS register (EUPAS19017, 09/05/2017).

Analgesic Use and Risk for Acute Coronary Events in Patients With Osteoarthritis: A Population-based, Nested Case-control Study

PURPOSE

Recent controversies on the safety profiles of opioids and paracetamol (acetaminophen) have led to changes in clinical guidance on osteoarthritis (OA) management. We studied the existing association between the use of different OA drug therapies and the risk for acute coronary events.

METHODS

A cohort of patients with clinically diagnosed OA (according to ICD-10 codes) was identified in the SIDIAP database. Within the cohort, cases with incident acute coronary events (acute myocardial infarction or unstable angina) between 2008 and 2012 were identified using ICD-10 codes and data from hospital admission. Controls were matched 3:1 to acute coronary event-free patients matched by sex, age (±5 years), geographic area, and years since OA diagnosis (±2 years). Linked pharmacy dispensation data were used for assessing exposure to drug therapies. Multivariate conditional logistic regression models were fitted to estimate adjusted odds ratios of acute coronary events.

FINDINGS

Totals of 5663 cases and 16,989 controls were studied. Previous morbidity and cardiovascular risk were higher in cases than in controls, with no significant differences in type or number of joints with OA. Multivariate adjusted analyses showed increased risks (odds ratio; 95% CI) related to the use of diclofenac (1.16; 1.06-1.27), naproxen (1.25; 1.04-1.48), and opioid analgesics (1.13; 1.03-1.24). No significant associations were observed with cyclooxygenase-2 selective NSAIDs, topical NSAIDs, glucosamine, chondroitin sulfate, paracetamol, or metamizole.

IMPLICATIONS

In patients with clinically diagnosed OA, the use of nonselective NSAIDs or opioid analgesics is associated with an increased risk for acute coronary events. These risks should be considered when selecting treatments of OA in patients at high cardiovascular risk.

Efficacy of high doses of penicillin versus amoxicillin in the treatment of uncomplicated community acquired pneumonia in adults. A non-inferiority controlled clinical trial

Introduction

Community-acquired pneumonia (CAP) is treated with penicillin in some northern European countries.

Objectives

To evaluate whether high-dose penicillin V is as effective as high-dose amoxicillin for the treatment of non-severe CAP.

Design

Multicentre, parallel, double-blind, controlled, randomized clinical trial.

Setting

31 primary care centers in Spain.

Participants

Patients from 18 to 75 years of age with no significant associated comorbidity and with symptoms of lower respiratory tract infection and radiological confirmation of CAP were randomized to receive either penicillin V 1.6 million units, or amoxicillin 1000 mg three times per day for 10 days.

Main measurements

The main outcome was clinical cure at 14 days, and the primary hypothesis was that penicillin V would be non-inferior to amoxicillin with regard to this outcome, with a margin of 15% for the difference in proportions. EudraCT register 2012-003511-63.

Results

A total of 43 subjects (amoxicillin: 28; penicillin: 15) were randomized. Clinical cure was observed in 10 (90.9%) patients assigned to penicillin and in 25 (100%) patients assigned to amoxicillin with a difference of −9.1% (95% CI, −41.3% to 6.4%; p = .951) for non-inferiority. In the intention-to-treat analysis, amoxicillin was found to be 28.6% superior to penicillin (95% CI, 7.3–58.1%; p = .009 for superiority). The number of adverse events was similar in both groups.

Conclusions

There was a trend favoring high-dose amoxicillin versus high-dose penicillin in adults with uncomplicated CAP. The main limitation of this trial was the low statistical power due to the low number of patients included.

Effectiveness and safety of drugs used for stroke prevention in a cohort of non-valvular atrial fibrillation patients from a primary care electronic database

PURPOSE

The aim of this study was to assess effectiveness and safety of antithrombotics for stroke prevention in non-valvular atrial fibrillation in real-use conditions.

METHODS

We used a population-based retrospective cohort study. Information emerges from SIDIAP, a database containing anonymized information from electronic health records from 274 primary healthcare centres of the Catalan Health Institute, Catalonia (Spain), with a reference population of 5 835 000 people. Population includes all adults with a new diagnosis of non-valvular atrial fibrillation registered in SIDIAP from 2007 to 2012. The main outcome of antithrombotics' effectiveness was stroke. The main outcomes of safety were cerebral and gastrointestinal haemorrhages. We also estimated all-cause mortality. We used multivariable Cox proportional hazard models to examine association between antithrombotic treatment and main outcomes.

RESULTS

We included 22 205 subjects with non-valvular atrial fibrillation; 40.8% initiated on vitamin K antagonists (VKA), 33.4% on antiplatelets and 25.8% untreated. We found stroke-risk reduction with VKA, hazard ratio (HR) 0.72 (95% confidence interval (CI), 0.58-0.91), also seen in patients with CHADS₂  ≥ 2, HR 0.65 (95%CI, 0.49-0.86), and CHA₂ DS₂ -VASc ≥ 2, HR 0.66 (95%CI, 0.52-0.84). We observed a higher risk of digestive bleeding with antiplatelets, HR 1.32 (95%CI, 1.01-1.73). Both VKA and antiplatelets were associated with reduction of all-cause mortality risk; HR 0.55 (95%CI, 0.49-0.62) and HR 0.89 (95%CI, 0.80-0.97), respectively.

CONCLUSIONS

This study found a stroke-risk reduction associated with VKA and an increased risk of gastrointestinal bleeding associated with platelet-aggregation inhibitors in comparison with untreated patients. Both antithrombotic groups showed a reduction in all-cause mortality. Copyright © 2016 John Wiley & Sons, Ltd.

Effectiveness, safety and costs of thromboembolic prevention in patients with non-valvular atrial fibrillation: phase I ESC-FA protocol study and baseline characteristics of a cohort from a primary care electronic database

PURPOSE

Atrial fibrillation is the most common arrhythmia. Its management aims to reduce symptoms and to prevent complications through rate and rhythm control, management of concomitant cardiac diseases and prevention of related complications, mainly stroke. The main objective of Effectiveness, Safety and Costs in Atrial Fibrillation (ESC-FA) study is to analyse the drugs used for the management of the disease in real-use conditions, particularly the antithrombotic agents for stroke prevention. The aim of this work is to present the study protocol of phase I of the ESC-FA study and the baseline characteristics of newly diagnosed patients with atrial fibrillation in Catalonia, Spain.

PARTICIPANTS

The data source is System for the Improvement of Research in Primary Care (SIDIAP) database. The population included are all patients with non-valvular atrial fibrillation diagnosis registered in the electronic health records during 2007-2012.

FINDINGS TO DATE

A total of 22,585 patients with non-valvular atrial fibrillation were included in the baseline description. Their mean age was 72.8 years and 51.6% were men. The most commonly prescribed antithrombotics were vitamin K antagonists (40.1% of patients) and platelet aggregation inhibitors (32.9%); 25.3% had not been prescribed antithrombotic treatment. Age, gender, comorbidities and co-medication at baseline were similar to those reported for previous studies.

FUTURE PLANS

The next phase in the ESC-FA study will involve assessing the effectiveness and safety of antithrombotic treatments, analysing stroke events and bleeding episodes' rates in our patients (rest of phase I), describing the current management of the disease and its costs in our setting, and assessing how the introduction of new oral anticoagulants changes the stroke prevention in non-valvular atrial fibrillation.

[Prevalence of nasal carriage of Staphylococcus aureus and Streptococcus pneumoniae in Primary Care and factors associated with colonization]

OBJECTIVE

To determine (i) the prevalence of Staphylococcus aureus (S.aureus) and Streptococcus pneumoniae (S.pneumoniae) nasal carriage in Primary Health Care patients in area of Barcelona, and (ii) the factors associated with S.aureus and S.pneumoniae colonization.

METHODS

Multi-center cross-sectional study conducted in 2010-2011 with the participation of 27 Primary Health Care professionals. Nasopharyngeal swabs were obtained from 3,969 patients over 4 years of age who did not present with any sign of infection.

DEPENDENT VARIABLES

S.aureus and/or S.pneumoniae carrier state.

INDEPENDENT VARIABLES

socio-demographic characteristics, health status, vaccination status, occupation, and living with children. A descriptive analysis was performed. The prevalence of carriers of S.aureus and/or S.pneumoniae was calculated and logistic regression models were adjusted by age.

RESULTS

In children from 4 to 14 years old, the prevalence of S.aureus carriers was 35.7%, of S.pneumoniae 27.1%, and 5.8% were co-colonized. In adults older than 14 years old, the prevalence was 17.8%, 3.5%, and 0.5%, respectively. In children, S.aureus carrier state was inversely associated with S.pneumoniae carrier state; S.pneumoniae was associated with younger age, and inversely associated with S.aureus carrier state. In adults, being a carrier of S.aureus was associated with male gender, younger age, and a health-related occupation, whereas S.pneumoniae carrier state was associated with living with children under 6 years of age. The proportion of co-colonized carriers was low (1.0%).

CONCLUSIONS

The proportion of S.aureus and S.pneumoniae carriers was higher in children than in adults. Age was the only factor associated with healthy carrier status for S.aureus and for S.pneumoniae.

Drug utilization in patients with OA: a population-based study

OBJECTIVE

Patients with OA use different drugs in their search for relief. We aimed to study the prevalence of use and combinations of different medications for OA in a population-based cohort of OA patients in Catalonia, Spain, while characterizing users of each of the drugs available, with a particular focus on cardiovascular risk factors.

METHODS

Data were obtained from the Sistema d'Informació per al Desenvolupament de l'Investigació en Atenció Primària (SIDIAP) database, which includes electronic medical records and pharmacy invoice data for >5 million people from Catalonia. Study participants were those with a clinical diagnosis of OA in 2006-10. Drugs studied included oral and topical NSAIDs, analgesics (paracetamol, metamizole), opioids (tramadol, fentanyl), cyclooxygenase 2 (COX-2) inhibitors and symptomatic slow-acting drugs in OA. Drug utilization was described using medication possession ratios (MPRs), equivalent to the proportion of days covered with the drug of interest. The annual incidence of new users in the first year after OA diagnosis from 2006 to 2010 was estimated for all studied drugs among newly diagnosed OA patients using Poisson regression.

RESULTS

We identified 238 536 study participants. The most common regimen of treatment consisted of at least three drugs (53.9% of patients). The drugs most frequently used regularly (MPR ≥50%) were chondroitin (21.2%), glucosamine (15.8%) and oral NSAIDs (14.4%). The incidence of the use of opioids, COX-2 inhibitors and chondroitin increased over the 5 year period, whereas all others decreased.

CONCLUSION

Drug combinations are common in the treatment of OA patients, who are thus exposed to potential drug interactions, with unknown impacts on their health. The increasing use of opioids and COX-2 inhibitors is noteworthy because of the potential impact on safety and costs.

Is C-reactive protein testing useful to predict outcome in patients with acute bronchitis?

BACKGROUND

A recent clinical trial could not find differences between anti-inflammatory drugs, antibiotics and placebo in shortening the duration of symptoms in acute bronchitis.

OBJECTIVES

To investigate if C-reactive protein (CRP) concentrations at presentation are predictive of symptom resolution in these patients.

METHODS

We performed a secondary analysis of the data from a placebo-controlled, randomized clinical trial carried out in primary care. Patients from 18 to 70 years of age presenting a respiratory tract infection of <1 week of evolution, with cough as the predominant symptom and the presence of discoloured expectoration, were enrolled in the study. On the baseline visit, CRP was determined in capillary blood and a five-item symptom diary was given. Patients were followed up to 30 days. The main outcome measure was the number of days with persistent cough.

RESULTS

A total of 312 subjects fulfilled all the criteria for the efficacy analysis and had undergone the CRP test; of these, 56.4% presented a CRP value <8 mg/l and 76% presented <20 mg/l. There were no significant differences in the median duration of cough: 10 days among patients with CRP concentrations <8 mg/l [95% confidence interval (CI): 8-11 days], 11 days among those with concentrations ranging from 8 to 19 mg/l (95% CI: 8-16) and 11 days in those with CRP >20 mg/l (95% CI: 9-12) (P = 0.337).

CONCLUSION

Among patients with uncomplicated acute bronchitis and discoloured sputum, the CRP concentrations at presentation are not helpful for predicting symptom resolution.

Effectiveness of an intervention designed to optimize statins use: a primary prevention randomized clinical trial

BACKGROUND

Although hypercholesterolemia is considered a cardiovascular risk factor, in isolation it is not necessarily sufficient cause for a cardiovascular event. To improve event prediction, cardiovascular risk calculators have been developed; the REGICOR calculator has been validated for use in our population. The objective of this project is to develop an intervention with general practitioners (GPs) and evaluate its impact on prescription adequacy of cholesterol-lowering drugs in primary prevention of cardiovascular disease and in controlling the costs associated with this disease.

METHODS

This nonblinded, cluster-randomized clinical trial analyzes data from primary care electronic medical records (ECAP) and other databases. Inclusion criteria are patients aged 35 to 74 years with no known cardiovascular disease and a new prescription for cholesterol-lowering drugs during the 2-year study period. Dependent variables include the following: RETIRA, defined as new cholesterol-lowering drugs initiated during the year preceding the intervention, considered inadequate, and withdrawn during the study period; EVITA, defined as new cholesterol-lowering drugs initiated during the study period and considered inadequate; COST, defined as the total cost of inadequate new treatments prescribed; and REGISTER, defined as the recording of cardiovascular risk factors. Independent variables include the GP's quality-of-care indicators and randomly assigned study group (intervention vs control), patient demographics, and clinical variables. Aggregated descriptive analysis will be done at the GP level and multilevel analysis will be performed to estimate the intervention effect, adjusted for individual and GP variables.

DISCUSSION

The study objective is to generate evidence about the effectiveness of implementing feedback information programs directed to GPs in the context of Primary Care. The goal is to improve the prescription adequacy of lipid-lowering therapies for primary prevention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01997671. November 28, 2013.

Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial

OBJECTIVE

To evaluate the efficacy of oral anti-inflammatory or antibiotic treatment compared with placebo in the resolution of cough in patients with uncomplicated acute bronchitis and discoloured sputum.

DESIGN

Multicentre, parallel, single blinded placebo controlled, randomised clinical trial.

SETTING

Nine primary care centres in Spain.

PARTICIPANTS

Adults aged 18 to 70 presenting symptoms associated with respiratory tract infection of less than one week's duration, with cough as the predominant symptom, the presence of discoloured sputum, and at least one other symptom of lower respiratory tract infection (dyspnoea, wheezing, chest discomfort, or chest pain).

INTERVENTIONS

Patients were randomised to receive either ibuprofen 600 mg three times daily, amoxicillin-clavulanic acid 500 mg/125 mg three times daily, or placebo three times daily for 10 days. The duration of symptoms was measured with a diary card.

MAIN OUTCOME MEASURE

Number of days with frequent cough after the randomisation visit.

RESULTS

416 participants were randomised (136 to ibuprofen, 137 to antibiotic, and 143 to placebo) and 390 returned their symptom diaries fully completed. The median number of days with frequent cough was slightly lower among patients assigned to ibuprofen (9 days, 95% confidence interval 8 to 10 days) compared with those receiving amoxicillin-clavulanic acid (11 days, 10 to 12 days) or placebo (11 days, 8 to 14 days), albeit without statistically significant differences. Neither amoxicillin-clavulanic acid nor ibuprofen increased the probability of cough resolution (hazard ratio 1.03, 95% confidence interval 0.78 to 1.35 and 1.23, 0.93 to 1.61, respectively) compared with placebo. Adverse events were observed in 27 patients, and were more common in the antibiotic arm (12%) than ibuprofen or placebo arms (5% and 3%, respectively; P<0.01).

CONCLUSION

No significant differences were observed in the number of days with cough between patients with uncomplicated acute bronchitis and discoloured sputum treated with ibuprofen, amoxicillin-clavulanic acid, or placebo.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN07852892.

Efficacy of high doses of oral penicillin versus amoxicillin in the treatment of adults with non-severe pneumonia attended in the community: study protocol for a randomised controlled trial

Background

Streptococcus pneumoniae is the bacterial agent which most frequently causes pneumonia. In some Scandinavian countries, this infection is treated with penicillin V since the resistances of pneumococci to this antibiotic are low. Four reasons justify the undertaking of this study; firstly, the cut-off points which determine whether a pneumococcus is susceptible or resistant to penicillin have changed in 2008 and according to some studies published recently the pneumococcal resistances to penicillin in Spain have fallen drastically, with only 0.9% of the strains being resistant to oral penicillin (minimum inhibitory concentration>2 μg/ml); secondly, there is no correlation between pneumococcal infection by a strain resistant to penicillin and therapeutic failure in pneumonia; thirdly, the use of narrow-spectrum antibiotics is urgently needed because of the dearth of new antimicrobials and the link observed between consumption of broad-spectrum antibiotics and emergence and spread of antibacterial resistance; and fourthly, no clinical study comparing amoxicillin and penicillin V in pneumonia in adults has been published. Our aim is to determine whether high-dose penicillin V is as effective as high-dose amoxicillin for the treatment of uncomplicated community-acquired pneumonia.

Methods

We will perform a parallel group, randomised, double-blind, trial in primary healthcare centres in Spain. Patients aged 18 to 65 without significant associated comorbidity attending the physician with signs and symptoms of lower respiratory tract infection and radiological confirmation of the diagnosis of pneumonia will be randomly assigned to either penicillin V 1.6 million units thrice-daily during 10 days or amoxicillin 1,000 mg thrice-daily during 10 days. The main outcome will be clinical cure at 14 days, defined as absence of fever, resolution or improvement of cough, improvement of general wellbeing and resolution or reduction of crackles indicating that no other antimicrobial treatment will be necessary. Any clinical result other than the anterior will be considered as treatment failure. A total of 210 patients will be recruited to detect a non-inferiority margin of 15% between the two treatments with a minimum power of 80% considering an alpha error of 2.5% for a unilateral hypothesis and maximum possible losses of 15%.

Discussion

This pragmatic trial addresses the long-standing hypothesis that the administration of high doses of a narrow-spectrum antibiotic (penicillin V) in patients with non-severe pneumonia attended in the community is not less effective than high doses of amoxicillin (treatment currently recommended) in patients under the age of 65 years.

Trial registration

EudraCT number 2012-003511-63.

Control of glycemia and cardiovascular risk factors in patients with type 2 diabetes in primary care in Catalonia (Spain)

OBJECTIVE

The objective of this study was to analyze the clinical characteristics and levels of glycemic and cardiovascular risk factor control in patients with type 2 diabetes that are in primary health care centers in Catalonia (Spain).

RESEARCH DESIGN AND METHODS

This was a cross-sectional study of a total population of 3,755,038 individuals aged 31-90 years at the end of 2009. Clinical data were obtained retrospectively from electronic clinical records.

RESULTS

A total of 286,791 patients with type 2 diabetes were identified (7.6%). Fifty-four percent were men, mean (SD) age was 68.2 (11.4) years, and mean duration of disease was 6.5 (5.1) years. The mean (SD) A1C value was 7.15 (1.5)%, and 56% of the patients had A1C values ≤7%. The mean (SD) blood pressure (BP) values were 137.2 (13.8)/76.4 (8.3) mmHg, mean total cholesterol concentration was 192 (38.6) mg/dL, mean HDL cholesterol concentration was 49.3 (13.2) mg/dL, mean LDL cholesterol (LDL-C) concentration was 112.5 (32.4) mg/dL, and mean BMI was 29.6 (5) kg/m(2). Thirty-one percent of the patients had BP values ≤130/80 mmHg, 37.9% had LDL-C values ≤100 mg/dL, and 45.4% had BMI values ≤30 kg/m(2). Twenty-two percent were managed exclusively with lifestyle changes. Regarding medicated diabetic patients, 46.9, 22.9, and 2.8% were prescribed one, two, or three antidiabetic drugs, respectively, and 23.4% received insulin therapy.

CONCLUSIONS

The results from this study indicate a similar or improved control of glycemia, lipids, and BP in patients with type 2 diabetes when compared with previous studies performed in Spain and elsewhere.

[Quality in compliance and prescription of nursing treatment orders for injectable drugs]

OBJECTIVES

To analyse the quality of prescription and compliance with nursing treatment orders (NTOs) in primary care teams (PCTs), in order to identify potential problems and establish interventions.

DESIGN

Observational, crossover study.

SETTING

Three health districts in Santa Coloma de Gramenet.

PATIENTS AND OTHER PARTICIPANTS

NTO forms for injectable medication referred to nursing from PCTs between March 1 and November 30, 1996.

MEASUREMENTS AND MAIN RESULTS

1,088 NTO sheets containing 1,119 prescriptions were evaluated. 64.61% of the NTOs came from PCTs. Compliance with the NTO on the length of treatment (63.33%), on length and guidelines taken together (58.00%) and on allergies to medicine (28.31%) was deficient. The most prescribed therapeutic groups were medicines for the locomotive apparatus (36.10%) and drugs for infections (24.66%). 56.03% of prescriptions had high intrinsic value. It was difficult to justify 72.48% of prescriptions.

CONCLUSIONS

Deficiencies were detected in compliance with NTOs, due to the absence of information which was vital for correct administration. There was low-quality prescription and over-use of parenteral administration.

[Secondary prevention of ischemic strokes: effect of dosage of aspirin]

INTRODUCTION AND OBJECTIVE

The value of acetylsalicylic acid (ASS) in the secondary prevention of ischemic stroke is well established. However, the optimum dose of AAS for stroke-threatened patients remains unsettled. This paper reviews the pattern of adverse reactions to AAS and their relationship to the dosage of ASS evaluated.

METHOD

All the clinical trials in which AAS was used as the sole antiaggregant in the secondary prevention of ischemic stroke were reviewed. The crude odds ratio for the different adverse reactions was calculated using three sub tests: AAS versus placebo; AAS < 330 mg/d versus AAS > 330 mg/d; and each dosage level versus a placebo.

RESULTS

There is an increased risk associated with the use of AAS as compared to a placebo with respect to gastrointestinal bleeding (OR 2.3, IC 95% (1.6-4.1)), peptic ulcer (10.1 (2.5-85.2)), intracerebral hemorrhage (2.2 (1.3-4)) and other hemorrhagic phenomena (2.6 (2-3.3)).

CONCLUSIONS

There seems to be a direct relationship between the dosage of AAS and the frequency with which adverse reactions occur, except in the case of intracerebral hemorrhage. In the latter case there was no relationship with the dose given (0.8 (0.5-1.4)).