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Gaviria-Mendoza A, Zapata-Carmona JA, Restrepo-Bastidas AA, Betancur-Pulgarín CL, Machado-Alba JE. Prior Use of Medication for Primary Prevention in Patients with Coronary Syndrome. J Prim Care Community Health 2020; 11:2150132720946949. [PMID: 32755281 PMCID: PMC7543101 DOI: 10.1177/2150132720946949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/09/2020] [Accepted: 07/09/2020] [Indexed: 12/27/2022] Open
Abstract
Background: Cardiovascular disease, especially coronary disease, represents one of the main causes of morbidity and mortality. Objective: To determine the drug prescription profile for primary cardiovascular prevention prior to a first acute coronary syndrome event. Methods: Cross-sectional study. We included adult patients of any sex affiliated with one healthcare insurer of the Colombian Health System, with a diagnosis of a first episode of acute coronary syndrome that occurred during the period of 2015 to 2016. Sociodemographic, clinical and pharmacological variables were evaluated from clinical records. The cardiovascular risk score prior to the event was calculated, and the need for the use of statins and aspirin in primary prevention was defined according to the recommendations of clinical practice guidelines. Results: Clinical records of 322 patients were reviewed with mean age of 61.9 ± 10.8 years, and 77.3% were men. The most frequent comorbidities were dyslipidemia (64.3%), arterial hypertension (62.7%) and diabetes mellitus (30.1%); 22% of the patients were obese, and 33.5% were smokers. The cardiovascular risk score was calculated in 211 patients (65.5%) who had the necessary variables complete. The median 10-year risk according to Framingham risk score was 21.4%, and it was 16.3% according to the American Heart Association. From the 211 patients with risk scores, there were 179 (84.8%) who needed statins (175 of high intensity, 97.8%), and 88 (27.3%) required aspirin as a primary prevention; however, 56 of these patients (31.3%) did not receive any statins, 127 (72.6%) did not receive the high intensity statin they needed, and 38 (43.2% of those with indication) lacked aspirin. Conclusion: Real-life data show that among a group of patients with high cardiovascular risk, a substantial proportion were not receiving medications for primary prevention necessary to reduce their risk and finally suffered an acute coronary event.
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Affiliation(s)
- Andrés Gaviria-Mendoza
- Grupo ZIPATEFI (Zona de investigaciones posgrados Andina Terapia respiratoria y Fisioterapia), Fundación Universitaria del Área Andina, Pereira, Colombia
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
- Grupo de Investigación Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | - Julián Andrés Zapata-Carmona
- Grupo ZIPATEFI (Zona de investigaciones posgrados Andina Terapia respiratoria y Fisioterapia), Fundación Universitaria del Área Andina, Pereira, Colombia
| | - Andrés Alirio Restrepo-Bastidas
- Grupo ZIPATEFI (Zona de investigaciones posgrados Andina Terapia respiratoria y Fisioterapia), Fundación Universitaria del Área Andina, Pereira, Colombia
| | - Carmen Luisa Betancur-Pulgarín
- Grupo ZIPATEFI (Zona de investigaciones posgrados Andina Terapia respiratoria y Fisioterapia), Fundación Universitaria del Área Andina, Pereira, Colombia
| | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
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Mehta S, Ghosh S, Sander S, Kuti E, Mountford WK. Differences in All-Cause Health Care Utilization and Costs in a Type 2 Diabetes Mellitus Population with and Without a History of Cardiovascular Disease. J Manag Care Spec Pharm 2018; 24:280-290. [PMID: 29485954 PMCID: PMC10397852 DOI: 10.18553/jmcp.2018.24.3.280] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Multiple studies have reported that type 2 diabetes mellitus (T2DM) is a major risk factor for cardiovascular diseases (CVD), and presence of T2DM and CVD increases risk of death. There is growing interest in examining the effects of antidiabetic treatments on the reduction of cardiovascular events in T2DM adults with a history of CVD and thus at higher risk of cardiovascular events. OBJECTIVE To estimate the incremental all-cause health care utilization and costs among adults with T2DM and a history of CVD compared with adults without a history of CVD, using a national linked electronic medical records (EMR) and claims database. METHODS Adults aged ≥ 18 years with evidence of at least 1 T2DM-related diagnosis code or antidiabetic medication (date of earliest occurrence was defined as the index date) in calendar year 2012 were identified. The population was divided into 2 cohorts (with and without a history of CVD) and followed until the end of their enrollment coverage, death, or 12 months, whichever came first. Multivariable generalized linear models were used to assess differences in health care utilization and per patient per month (PPPM) total costs (plan- and patient-paid amount for health care services) between the 2 groups during the post-index year, while adjusting for an a priori list of demographic and clinical characteristics. RESULTS A total of 138,018 adults with T2DM was identified, of which 16,547 (12%) had a history of CVD. The unadjusted resource utilization (outpatient: 27.5 vs. 17.8; emergency room [ER]: 0.8 vs. 0.4; inpatient: 0.4 vs. 0.2 days; and total unique drug prescriptions: 10.1 vs. 8.3) and PPPM total health care costs ($2,655.1 vs. $1,435.0) were significantly higher in T2DM adults with a history of CVD versus T2DM adults without a history of CVD. The adjusted models revealed that T2DM adults with a history of CVD had a 31% higher number of ER visits (rate ratio [RR] = 1.31, 95% CI = 1.25-1.37); 27% more inpatient visits (RR = 1.27, 95% CI = 1.21-1.34); 15% longer mean inpatient length of stay (RR = 1.15, 95% CI = 1.06-1.25); and 11% more outpatient visits (RR = 1.11, 95% CI = 1.09-1.13) compared with T2DM adults without a history of CVD. Furthermore, the difference in total PPPM health care cost was found to be 16% ($200) higher in adults with a history of CVD (RR = 1.16, 95% CI = 1.13-1.19). PPPM costs associated with outpatient and ER visits were approximately 21% and 19% higher among adults with a history of CVD, respectively (P < 0.0001), while costs for inpatient visits were similar between the 2 groups. In addition, a subgroup analysis revealed that adjusted differences in PPPM total cost was larger in the younger age group (56% higher cost in those aged < 45 years) and diminished in the older age group (only 2% higher in those aged ≥ 65 years). CONCLUSIONS Study findings showed that resource utilization and costs remains significantly higher in T2DM patients with a history of CVD compared with patients without a history of CVD even after controlling for significant patient comorbid and demographic characteristics. Also, younger age groups had higher differences in outcomes compared with older age groups. This study underscores the importance of cost-effective interventions that may reduce economic burden in this T2DM population with a history of CVD. DISCLOSURES This study was funded by Boehringer Ingelheim. At the time of this study, Mehta and Mountford were employed by IQVIA, which received funding from Boehringer Ingelheim to conduct this study. Mountford is employed by Allergan, which has no connection with this study. Ghosh, Sander, and Kuti are employed by Boehringer Ingelheim. Study concept and design were contributed by Mountford, Mehta, and Ghosh, along with Sander and Kuti. Mountford and Mehta collected the data, and data interpretation was performed by all the authors. The manuscript was written by Sander and Kuti, along with the other authors, and revised by Mehta and Gosh, along with the other authors.
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Affiliation(s)
| | | | | | - Effie Kuti
- 2 Boehringer Ingelheim, Ridgefield, Connecticut
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Grimes RT, Ensor J, Bennett K, Henman MC. Use of cardiovascular medicines in newly treated type 2 diabetes patients: A retrospective cohort study in general practice. Prim Care Diabetes 2016; 10:237-243. [PMID: 26654852 DOI: 10.1016/j.pcd.2015.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 10/14/2015] [Accepted: 11/03/2015] [Indexed: 10/22/2022]
Abstract
AIMS To describe the drug utilisation patterns of aspirin, antihypertensives, vasodilators, and statins in a cohort of newly treated type 2 diabetes subjects previously unexposed to CVD agents. METHODS A population-based retrospective cohort study was conducted using a national pharmacy claims database of newly treated type 2 diabetes subjects aged 40 years or older. Data on the use of aspirin, antihypertensives, vasodilators, and statins 1 year after antidiabetic agent initiation were analysed. Poisson regression with a robust error variance was used to estimate adjusted relative risk (RRadj) and 95% CIs between socio-demographic and treatment factors on CVD agent use. RESULTS Over a 2-year period (2008-2009), 6093 subjects were identified. One year after antidiabetic agent initiation, 82% of the study population received at least one CVD agent, with 54% receiving aspirin, 64% receiving antihypertensives, 6% vasodilators, and 62% receiving statins. Subjects aged 40-49 years were significantly less likely than those aged 60-69 years to receive CVD agents (RRadj 0.83, 95% CI 0.80-0.87). Over 40% of subjects received antihypertensives without aspirin and statins, while 30% of subjects on statins did not receive aspirin. CONCLUSIONS Substantial CVD agent utilisation was noted 1 year after antidiabetic agent initiation. Being aged younger than 60-69 years was associated with decreased utilisation of CVD agents.
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Affiliation(s)
- Ronan T Grimes
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Ireland.
| | - Jane Ensor
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Ireland
| | - Kathleen Bennett
- Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, St James's Hospital, Dublin 8, Ireland
| | - Martin C Henman
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Ireland
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Major R, Shepherd D, Warwick G, Brunskill N. Prescription Rates of Cardiovascular Medications in a Large UK Primary Care Chronic Kidney Disease Cohort. Nephron Clin Pract 2016; 133:15-22. [PMID: 27160883 DOI: 10.1159/000445387] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 03/10/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND AIMS Chronic kidney disease (CKD) is associated with increased cardiovascular (CV) risk. Guidelines have suggested the universal use of statins in CKD but aspirin's role is less well defined. The aim of this study was to determine prescription rates for statins and aspirin in a UK-based CKD cohort and to establish factors that influenced prescription rates. METHODS We used data from a UK primary care CKD cohort to study rates of prescription of statins and aspirin. Simple rates were initially calculated. Binary logistic regression was utilized with either statin or aspirin prescription as the outcome variable and covariates including demographic details and comorbidities. RESULTS There were 31,056 individuals in the cohort with at least one estimated glomerular filtration rate (eGFR) of <60 ml/min/1.73 m2, and 65.1% individuals had 2 eGFR results <60 ml/min/1.73 m2 more than 3 months apart. Mean eGFR at baseline was 51.1 ml/min/1.73 m2 (SD 9.1), and 64.9% had a diagnosis of hypertension (HTN), 18.8% had diabetes mellitus (DM) and 29.8% a history of CV disease. Statins were prescribed to 14,972 (48.2%) and aspirin to 11,023 (35.5%). The regression model suggested that CV disease, HTN and DM influenced the prescriptions of statins and aspirin but overall CKD stage, calculated by either eGFR or proteinuria, did not. CONCLUSIONS Prescriptions of statins and aspirin in CKD is based more on the presence of comorbidities than the CKD severity. Further physician and patient education of the increased CV risk associated with CKD and its suitability for CV medication intervention is required.
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Affiliation(s)
- Rupert Major
- Department of Nephrology, Leicester General Hospital, Leicester, UK
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Simmons RK, Carlsen AH, Griffin SJ, Charles M, Christiansen JS, Borch-Johnsen K, Sandbaek A, Lauritzen T. Variation in prescribing of lipid-lowering medication in primary care is associated with incidence of cardiovascular disease and all-cause mortality in people with screen-detected diabetes: findings from the ADDITION-Denmark trial. Diabet Med 2014; 31:1577-85. [PMID: 25185778 PMCID: PMC4283975 DOI: 10.1111/dme.12574] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 06/16/2014] [Accepted: 08/25/2014] [Indexed: 12/03/2022]
Abstract
AIMS To examine variation between general practices in the prescription of lipid-lowering treatment to people with screen-detected Type 2 diabetes, and associations with practice and participant characteristics and risk of cardiovascular events and all-cause mortality. METHODS Observational cohort analysis of data from 1533 people with screen-detected Type 2 diabetes aged 40-69 years from the ADDITION-Denmark study. One hundred and seventy-four general practices were cluster randomized to receive: (1) routine diabetes care according to national guidelines (623 individuals), or (2) intensive multifactorial target-driven management (910 individuals). Multivariable logistic regression was used to quantify the association between the proportion of individuals in each practice who redeemed prescriptions for lipid-lowering medication in the two years following diabetes diagnosis and a composite cardiovascular disease (CVD) outcome, adjusting for age, sex, prevalent chronic disease, baseline CVD risk factors, smoking and lipid-lowering medication, and follow-up time. RESULTS The proportion of individuals treated with lipid-lowering medication varied widely between practices (0-100%). There were 118 CVD events over 9431 person-years of follow-up. For the whole trial cohort, the risk of CVD was significantly higher in practices in the lowest compared with the highest quartile for prescribing lipid-lowering medication [adjusted odds ratio (OR) 3.4, 95% confidence interval (CI) 1.6-7.3]. Similar trends were found for all-cause mortality. CONCLUSIONS More frequent prescription of lipid-lowering treatment was associated with a lower incidence of CVD and all-cause mortality. Improved understanding of factors underlying practice variation in prescribing may enable more frequent use of lipid-lowering treatment. The results highlight the benefits of intensive treatment of people with screen-detected diabetes (Clinical Trials Registry No; NCT 00237549).
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Affiliation(s)
- R K Simmons
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK
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Kasteleyn MJ, Wezendonk A, Vos RC, Numans ME, Jansen H, Rutten GEHM. Repeat prescriptions of guideline-based secondary prevention medication in patients with type 2 diabetes and previous myocardial infarction in Dutch primary care. Fam Pract 2014; 31:688-93. [PMID: 25106412 DOI: 10.1093/fampra/cmu042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Secondary prevention is efficient in reducing morbidity and mortality after a myocardial infarction (MI). However, both short-term and long-term mortality after MI remains relativity high in type 2 diabetes patients. OBJECTIVE To evaluate repeat prescriptions of secondary prevention medication (anti-thrombotic agent, beta-blocker and statin) in type 2 diabetes patients with a previous MI. METHODS Data of 1009 type 2 diabetes patients with a previous MI were extracted from the Julius General Practitioners' Network database. The proportion of patients with recent repeat prescriptions of guideline-based medication was determined. Furthermore, repeat prescriptions was determined 6 months, 1 year, 2 years and 5 years after MI. Generalized linear models were used to examine changes over time. Multivariate logistic regression analysis was used to analyse the association between patient characteristics and prescription. RESULTS Only 46% of all type 2 diabetes patients with a previous MI had a recent repeat prescription for all three medicines. An increase in prescription over time was found for statins (P = 0.001). Older aged people [odds ratio (OR): 0.99, 95% confidence interval (CI): 0.98-1.00] were less likely to receive the combination of all three. CONCLUSION A substantial proportion of type 2 diabetes patients with a previous MI did not receive guideline-based secondary prevention. Prescription rates were quite stable over time. This study confirms the need for a different approach to achieve an improvement of secondary prevention in type 2 diabetes patient with a previous MI. GPs can play an important role in this respect by being extra alert that prescription occurs according to the guidelines.
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Affiliation(s)
- Marise J Kasteleyn
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht and
| | - Aryan Wezendonk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht and
| | - Rimke C Vos
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht and
| | - Mattijs E Numans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht and Department for Public Health and Primary Care, Leiden University Medical Centre, Leiden, the Netherlands
| | - Hanneke Jansen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht and
| | - Guy E H M Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht and
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Monesi L, Tettamanti M, Cortesi L, Baviera M, Marzona I, Avanzini F, Monesi G, Nobili A, Riva E, Fortino I, Bortolotti A, Fontana G, Merlino L, Trevisan R, Roncaglioni MC. Elevated risk of death and major cardiovascular events in subjects with newly diagnosed diabetes: findings from an administrative database. Nutr Metab Cardiovasc Dis 2014; 24:263-270. [PMID: 24418374 DOI: 10.1016/j.numecd.2013.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 07/16/2013] [Accepted: 08/05/2013] [Indexed: 11/28/2022]
Abstract
AIMS To investigate the incidence of major cardiovascular complications and mortality in the first years of follow-up in patients with newly diagnosed diabetes. METHODS AND RESULTS We examined incidence rates of hospitalization for cardiovascular reasons and death among new patients with diabetes using the administrative health database of the nine million inhabitants of Lombardy followed from 2002 to 2007. Age and sex-adjusted rates were calculated and hazard ratios (HR) were estimated with a matched population without diabetes of the same sex, age (± 1 year) and general practitioner. There were 158,426 patients with newly diagnosed diabetes and 314,115 subjects without diabetes. Mean follow-up was 33.0 months (SD ± 17.5). 9.7% of patients with diabetes were hospitalized for cardiovascular events vs. 5.4% of subjects without diabetes; mortality rate was higher in patients with diabetes (7.7% vs. 4.4%). The estimated probability of hospitalization during the follow up was higher in patients with diabetes than in subjects without for coronary heart disease (HR 1.4, 95% CI 1.3-1.4), cerebrovascular disease (HR 1.3.95% CI 1.2-1.3), heart failure (HR 1.4, 95% CI 1.3-1.4) as was mortality (HR 1.4, 95% CI 1.4-1.4). Younger patients with diabetes had a risk of death or hospital admission for cardio-cerebrovascular events similar to subjects without diabetes ten years older. CONCLUSIONS The elevated morbidity and mortality risks were clear since the onset of diabetes and rose over time. These data highlight the importance of prompt and comprehensive patients care in addition to anti-diabetic therapy in patients with newly diagnosed diabetes.
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Affiliation(s)
- L Monesi
- Laboratory of General Practice Research, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa, 19, 20156 Milan, Italy
| | - M Tettamanti
- Laboratory of Geriatric Neuropsychiatry, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - L Cortesi
- Laboratory of General Practice Research, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa, 19, 20156 Milan, Italy
| | - M Baviera
- Laboratory of General Practice Research, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa, 19, 20156 Milan, Italy
| | - I Marzona
- Laboratory of General Practice Research, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa, 19, 20156 Milan, Italy
| | - F Avanzini
- Laboratory of General Practice Research, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa, 19, 20156 Milan, Italy
| | - G Monesi
- Diabetes Unit, "S. Maria della Misericordia" Hospital, Rovigo, Italy
| | - A Nobili
- Laboratory for Quality Assessment of Geriatric Therapies and Services, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - E Riva
- Laboratory of Geriatric Neuropsychiatry, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - I Fortino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - A Bortolotti
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - G Fontana
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - L Merlino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - R Trevisan
- Diabetology Unit, Department of Internal Medicine, Ospedali Riuniti di Bergamo, Italy
| | - M C Roncaglioni
- Laboratory of General Practice Research, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa, 19, 20156 Milan, Italy.
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Naughton C, Bennett K, Feely J. Regional variation in prescribing for chronic conditions among an elderly population using a pharmacy claims database. Ir J Med Sci 2013; 175:32-9. [PMID: 17073245 DOI: 10.1007/bf03169170] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Age, gender and geographical regions are recognised factors in inequalities in prescribing for chronic diseases in the elderly. AIM To compare the health board regional distribution of chronic disease among the elderly and to examine variation in quality prescribing across age, gender and regions. METHODS Population based study of prescribing for chronic disease using a national pharmacy claims database. All individuals aged 70 years and over (n = 271,518) were eligible. RESULTS Over 60% of the elderly in all regions received cardiovascular related medication. The South Eastern, North Western and Western Health Boards had below average prescribing for many chronic conditions. Logistic regression identified age, gender and regional variations in prescribing of preventative therapies for CVD and diabetes. CONCLUSION There is a high prevalence of prescribing for chronic conditions in the elderly in Ireland, and there is evidence of gender, age and residing health board inequalities in prescribing.
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Affiliation(s)
- C Naughton
- Dept Pharmacology and Therapeutics, Trinity College Dublin, Trinity Centre for Health Science, St James's Hospital, Dublin.
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9
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Gallagher N, Bennett K, Smith SM, O'Reilly D. Impact of two different health systems on the burden of type 2 diabetes. J Health Serv Res Policy 2013; 19:69-76. [PMID: 24013554 DOI: 10.1177/1355819613502012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Health policy directs the management of patients with chronic disease in a country, but evaluating nationwide policies is difficult, not least because of the absence of suitable comparators. This paper examines the management of patients with type 2 diabetes in two demographically comparable populations with different health care systems to see if this represents a viable approach to evaluation. METHODS A secondary analysis of centralized prescribing databases for 2010 was undertaken to compare the levels and costs of care of patients with type 2 diabetes in Northern Ireland's National Health Service (NHS) (NI, n = 1.8 million) which has structured care, financial incentives related to diabetes care and an emphasis on generic prescribing, with that of the Republic of Ireland (ROI, n = 4.3 million) where management of diabetes care is guided solely by clinical and other guidelines. RESULTS The prevalence of treated type 2 diabetes was 3.59% in NI and 3.09% in ROI, but there were similar and high levels of prescribing of secondary cardiovascular medications. Medication costs per person for anti-diabetic, anti-obesity and cardiovascular medication were 46% higher in ROI than NI, due to differences in levels of generic prescribing. CONCLUSIONS These different health care systems appear to be producing similar levels of care for patients with type 2 diabetes, although at different levels of cost. The findings question the need for financial incentives in NI and highlight the large cost savings potentially accruing from a greater shift to generic prescribing in ROI. Cross-country comparison, though not without difficulties, may prove a useful adjunct to within-country analysis of policy impact.
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Affiliation(s)
- Naomh Gallagher
- Research Fellow, Centre of Excellence for Public Health, Queen's University Belfast, UK
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10
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Keller H, Hirsch O, Kaufmann-Kolle P, Krones T, Becker A, Sönnichsen AC, Baum E, Donner-Banzhoff N. Evaluating an implementation strategy in cardiovascular prevention to improve prescribing of statins in Germany: an intention to treat analysis. BMC Public Health 2013; 13:623. [PMID: 23819600 PMCID: PMC3716622 DOI: 10.1186/1471-2458-13-623] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 04/30/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The prescription of statins is an evidence-based treatment to reduce the risk of cardiovascular events in patients with elevated cardiovascular risk or with a cardiovascular disorder (CVD). In spite of this, many of these patients do not receive statins. METHODS We evaluated the impact of a brief educational intervention in cardiovascular prevention in primary care physicians' prescribing behaviour regarding statins beyond their participation in a randomised controlled trial (RCT). For this, prescribing data of all patients > 35 years who were counselled before and after the study period were analysed (each n > 75,000). Outcome measure was prescription of Hydroxymethylglutaryl-CoA Reductase Inhibitors (statins) corresponding to patients' overall risk for CVD. Appropriateness of prescribing was examined according to different risk groups based on the Anatomical Therapeutic Chemical Classification System (ATC codes). RESULTS There was no consistent association between group allocation and statin prescription controlling for risk status in each risk group before and after study participation. However, we found a change to more significant drug configurations predicting the prescription of statins in the intervention group, which can be regarded as a small intervention effect. CONCLUSION Our results suggest that an active implementation of a brief evidence-based educational intervention does not lead to prescription modifications in everyday practice. Physician's prescribing behaviour is affected by an established health care system, which is not easy to change. TRIAL REGISTRATION ISRCTN71348772.
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Affiliation(s)
| | - Oliver Hirsch
- Department of General Practice/Family Medicine, Philipps University of Marburg, Karl-von-Frisch-Strasse 4, Marburg, 35043, Germany.
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11
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Lai LL, Tan MH, Lai YC. Prevalence and factors associated with off-label antidepressant prescriptions for insomnia. DRUG HEALTHCARE AND PATIENT SAFETY 2011; 3:27-36. [PMID: 21904465 PMCID: PMC3163935 DOI: 10.2147/dhps.s21079] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Indexed: 12/13/2022]
Abstract
Background: The primary objective of our study was to investigate the prevalence of off-label antidepressant drug use in insomnia. The secondary objective was to compare prescribing patterns between off-label antidepressants vs hypnotics approved by the US Food and Drug Administration for insomnia, with particular emphasis on socioeconomic characteristics of patients and physicians. Methods: We undertook a secondary data analysis using the national longitudinal database from the 2006 National Ambulatory Medical Care Survey. Subjects were identified from outpatient visits in which at least one insomnia drug was prescribed. A series of weighted Chi-squared statistics was used to compare drug use for insomnia across various patient and physician characteristics. Multivariate logistic regression was conducted to identify factors associated with off-label antidepressant drug use. Results: Among 901.95 million outpatient visits that took place in the US in 2006, an estimated 30.43 million visits included at least one drug prescription for insomnia. Off-label antidepressants were prescribed significantly more frequently (45.1%) than nonbenzodiazepine z-hypnotics (43.2%) and benzodiazepines (11.7%). Insomnia prescribing patterns were significantly influenced by physician specialty and physician office settings. Pediatricians (odds ratio [OR]: 65.892; 95% confidence interval [CI]: 5.536–810.564) and neurologists (OR: 4.784; 95% CI: 2.044–11.201) were more likely to prescribe off-label antidepressants than psychiatrists. Self-paying patients were more likely to receive off-label antidepressants as treatment for insomnia than patients with private insurance (OR 2.594; 95% CI: 1.128–5.967). Conclusion: Our findings indicate significant socioeconomic disparities in the use of off-label antidepressants. Future studies might explore interventional and educational strategies to ensure well informed clinical decisions that can withstand pharmaceutical marketing strategies and diagnostic uncertainties regarding the treatment of insomnia.
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Affiliation(s)
- L Leanne Lai
- Department of Sociobehavioral and Administrative Pharmacy, College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA
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Baviera M, Monesi L, Marzona I, Avanzini F, Monesi G, Nobili A, Tettamanti M, Riva E, Cortesi L, Bortolotti A, Fortino I, Merlino L, Fontana G, Roncaglioni MC. Trends in drug prescriptions to diabetic patients from 2000 to 2008 in Italy's Lombardy Region: a large population-based study. Diabetes Res Clin Pract 2011; 93:123-30. [PMID: 21621869 DOI: 10.1016/j.diabres.2011.05.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Revised: 02/24/2011] [Accepted: 05/05/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To analyze the prescribing patterns of antidiabetic and cardiovascular medications among diabetics in the most highly populated Italian Region, from 2000 to 2008. METHODS Data were obtained from the Lombardy Region administrative health databases. The standardized prevalence of antidiabetic and cardiovascular drugs use was calculated within each study year. The prescription trends of initial treatment with antidiabetic drugs were also analyzed. RESULTS From 2000 to 2008 there was an increase in the proportion of patients treated with biguanides (from 53.4% to 66.5%; p<0.0001) while those receiving sulfonylurea decreased (from 78.6% to 56.4%; p<0.0001). A sharp increase of metformin (as monotherapy) as initial treatment was also observed (from 15.2% to 48.8%; p<0.0001). The percentage of patients receiving renin-angiotensin system inhibitors, lipid-lowering drugs and antiplatelets increased between 2000 and 2008, from respectively 45.1% to 63.3%, 13.6% to 43.2% and 21.6% to 40.9 (p<0.0001). Multivariate analyses indicated that changes in prescriptions were statistically significant for both antidiabetic and cardiovascular drugs. CONCLUSION This study documents progressive changes in the prescription of antidiabetic and cardiovascular drugs in accordance with guidelines. However, the use of metformin as first line therapy was still suboptimal and cardiovascular preventive strategies were only partially implemented in community practice.
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Affiliation(s)
- Marta Baviera
- Laboratory of General Practice Research, Mario Negri Institute for Pharmacological Research, Via Giuseppe La Masa 19, 20156 Milan, Italy.
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Wan Md Adnan WAH, Zaharan NL, Bennett K, Wall CA. Trends in co-prescribing of angiotensin converting enzyme inhibitors and angiotensin receptor blockers in Ireland. Br J Clin Pharmacol 2011; 71:458-66. [PMID: 21284706 DOI: 10.1111/j.1365-2125.2010.03835.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
AIMS (i) To examine the trends in co-prescribing of angiotensin converting enzyme inhibitor (ACEI) and angiotensin-II receptor blocker (ARB) therapy and (ii) to examine the influence of major clinical trials (CALM, COOPERATE, VALIANT and ONTARGET) on co-prescribing. METHODS The Irish HSE-Primary Care Reimbursement Services database was used to identify patients ≥16 years old co-prescribed ACEIs and ARBs between January 2000 and April 2009 (n= 266 554 prescriptions). The rate of prescribing per 1000 general medical services (GMS) scheme population was calculated for each month. Patients with diabetes, hypertension, heart failure and ischaemic heart disease were also identified by prescribing of certain medications. A linear trend test was used to examine prescribing trends. Logistic regression was used to examine prescribing according to patient characteristics. The effects of the major trials on prescribing were examined using segmented regression analysis for 12 months pre- and post-trials. RESULTS There was a significant linear trend in overall ACEI and ARB co-prescribing over the study period (P < 0.001). Rate of co-prescribing in January 2000 and April 2009 was 0.16 and 5.72, per 1000 eligible population, respectively. Those 45-64 years old (OR = 2.88, 95% confidence interval (CI) 2.71, 3.06) and ≥65 years (OR = 2.52, 95% CI 2.36, 2.68) were more likely to receive dual therapy compared with those <45 years old. Those with hypertension (OR = 8.85, 95% CI 8.45, 9.27), diabetes (OR = 4.10, 95% CI 3.97, 4.23) and heart failure (OR = 1.78, 95% CI 1.72, 1.84) were more likely to receive dual therapy compared with the general population. Significant increases in prescribing were observed only after the CALM (P= 0.03) and VALIANT (P= 0.007) trials. CONCLUSION Increased co-prescribing of ACEIs and ARBs was observed in Ireland during 2000-09. Prescribing patterns did not appear to be affected by results from major trials.
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Affiliation(s)
- Wan A H Wan Md Adnan
- Department of Renal Medicine, Adelaide & Meath Hospital Incorporating National Children Hospital (AMNCH), Dublin 24, Ireland.
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Berthet S, Grolleau S, Brefel-Courbon C, Montastruc JL, Lapeyre-Mestre M. Prise en charge thérapeutique des patients diabétiques en France : Apport de la Banque Nationale de Pharmacovigilance. Therapie 2007; 62:483-8. [DOI: 10.2515/therapie:2007076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Erdmann E, Dormandy JA, Charbonnel B, Massi-Benedetti M, Moules IK, Skene AM. The effect of pioglitazone on recurrent myocardial infarction in 2,445 patients with type 2 diabetes and previous myocardial infarction: results from the PROactive (PROactive 05) Study. J Am Coll Cardiol 2007; 49:1772-80. [PMID: 17466227 DOI: 10.1016/j.jacc.2006.12.048] [Citation(s) in RCA: 318] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2006] [Revised: 11/02/2006] [Accepted: 12/04/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This analysis from the PROactive (PROspective pioglitAzone Clinical Trial In macroVascular Events) study assesses the effects of pioglitazone on mortality and macrovascular morbidity in patients with type 2 diabetes and a previous myocardial infarction (MI). BACKGROUND People with type 2 diabetes have an increased incidence of MI compared with the general population. Those with diabetes and MI have a worse prognosis than nondiabetic patients with cardiovascular disease. METHODS The PROactive study was a prospective, multicenter, double-blind, placebo-controlled trial of 5,238 patients with type 2 diabetes and macrovascular disease. Patients were randomized to either pioglitazone or placebo in addition to their other glucose-lowering and cardiovascular medication. Treatment of diabetes, dyslipidemia, and hypertension was encouraged according to the International Diabetes Federation guidelines. Patients were followed for a mean of 2.85 years. The primary end point was the time to first occurrence of macrovascular events or death. Of the total cohort, the subgroup of patients who had a previous MI (n = 2,445 [46.7%]; n = 1,230 in the pioglitazone group and n = 1,215 in the placebo group) was evaluated using prespecified and post-hoc analyses. RESULTS Pioglitazone had a statistically significant beneficial effect on the prespecified end point of fatal and nonfatal MI (28% risk reduction [RR]; p = 0.045) and acute coronary syndrome (ACS) (37% RR; p = 0.035). There was a 19% RR in the cardiac composite end point of nonfatal MI (excluding silent MI), coronary revascularization, ACS, and cardiac death (p = 0.033). The difference in the primary end point defined in the main PROactive study did not reach significance in the MI population (12% RR; p = 0.135). The rates of heart failure requiring hospitalization were 7.5% (92 of 1,230) with pioglitazone and 5.2% (63 of 1,215) with placebo. Fatal heart failure rates were similar (1.4% [17 of the 92] with pioglitazone versus 0.9% [11 of the 63] with placebo). CONCLUSIONS In high-risk patients with type 2 diabetes and previous MI, pioglitazone significantly reduced the occurrence of fatal and nonfatal MI and ACS. (PROspective pioglitAzone Clinical Trial In macroVascular Events; http://www.clinicaltrials.gov/ct/show/NCT00174993?order = 1; ISRCTN NCT00174993).
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Affiliation(s)
- Erland Erdmann
- Medizinische Klinik III der Universität zu Köln, Köln, Germany.
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Rosenberg JM, Zerilli T, Nathan JP, McGuire H. Use of statins and gemfibrozil in patients with type 2 diabetes mellitus and cardiovascular risk factors attending adult day health care centers: an opportunity for pharmacists. ACTA ACUST UNITED AC 2007; 22:38-44. [PMID: 17367251 DOI: 10.4140/tcp.n.2007.38] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Identify the extent of statin use for primary prevention of macrovascular complications, the extent of statin or gemfibrozil use for the secondary prevention of cardiovascular morbidity and mortality, and the statin doses used in patients with type 2 diabetes and other cardiovascular risk factors. DESIGN Retrospective chart review. SETTING Three adult day health care centers in Brooklyn and Queens, New York. PATIENTS Patients with a diagnosis of type 2 diabetes and either a history of coronary artery disease or at least one other significant cardiovascular risk factor as defined by the American College of Physicians guidelines (i.e., age greater than 55 years, hypertension, left-ventricular hypertrophy, previous cerebrovascular disease, or peripheral arterial disease). MAIN OUTCOME MEASURES Percentage of patients prescribed a statin for primary prevention of macrovascular complications of type 2 diabetes, percentage of patients prescribed a statin or gemfibrozil for secondary prevention of cardiovascular mortality and morbidity, and the percentage of patients on at least moderate doses of statins. RESULTS Ninety-three patients were evaluated-51 in the primary-prevention group and 42 in the secondary-prevention group. In the primary-prevention group, 33 (64.7%) patients were prescribed a statin, while in the secondary-prevention group, 26 (61.9%) patients were on statins, a nonsignificant difference (P = 0.8308). No patients were prescribed gemfibrozil. Of all patients prescribed statins, 63.2% were at least on moderate doses. CONCLUSION This study demonstrates suboptimal treatment with statins in patients with type 2 diabetes and cardiovascular risk factors.
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Affiliation(s)
- Jack M Rosenberg
- International Drug Information Center, Long Island University, Brooklyn, New York 11201, USA.
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Mody R, Kalsekar I, Kavookjian J, Iyer S, Rajagopalan R, Pawar V. Economic impact of cardiovascular co-morbidity in patients with type 2 diabetes. J Diabetes Complications 2007; 21:75-83. [PMID: 17331855 DOI: 10.1016/j.jdiacomp.2006.02.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2005] [Revised: 02/14/2006] [Accepted: 02/28/2006] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To evaluate the impact of cardiovascular co-morbidity on total and diabetes-related healthcare costs in patients with type 2 diabetes. METHODS Retrospective analysis of the West Virginia state Medicaid claims data was conducted in patients with type 2 diabetes (ICD-9 codes: 250.0x-250.9x, where x=0 or 2) in the year 2001. Patients > or =65 years of age or those with managed care coverage were excluded. Presence of cardiovascular co-morbidity in the year 2001 was identified. Semi-logarithmic regression models were used to estimate the impact of cardiovascular co-morbidity on total and diabetes-related healthcare costs in the year 2002.Two-part models were used to study the impact of cardiovascular co-morbidity on ER/hospitalization, outpatient, and prescription costs. Smearing estimates were used to interpret the results from the semi-logarithmic models. RESULTS Presence of cardiovascular co-morbidity had a significant impact on all categories of total and diabetes-related healthcare costs, except diabetes-related prescription drug costs. Type 2 diabetes patients with cardiovascular co-morbidity had significantly higher total healthcare costs (38.9%, $12,550 vs. $9031), total ER/hospitalization costs (239.8%, $4845 vs. $1426), total outpatient costs (35.3%, $3956 vs. $2925), and total prescription drug costs (15.1%, $4686 vs. $4071) compared to those without cardiovascular co-morbidity. Similarly, type 2 diabetes patients with cardiovascular co-morbidity had significantly higher total diabetes-related healthcare costs (59.7%, $4349 vs. $2724), ER/hospitalization costs (346.8%, $1911 vs. $428), and outpatient costs (17.4%, $740 vs. $631) compared to patients without cardiovascular co-morbidity. CONCLUSIONS Presence of cardiovascular co-morbidity in patients with type 2 diabetes had a significant impact on total and diabetes-related healthcare costs.
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Affiliation(s)
- Reema Mody
- TAP Pharmaceutical Products Inc., Lake Forest, IL 60045, USA.
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Stafford RS, Monti V, Ma J. Underutilization of aspirin persists in US ambulatory care for the secondary and primary prevention of cardiovascular disease. PLoS Med 2005; 2:e353. [PMID: 16277554 PMCID: PMC1283363 DOI: 10.1371/journal.pmed.0020353] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2005] [Accepted: 08/25/2005] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite the proven benefits of aspirin therapy in the primary and secondary prevention of cardiovascular disease (CVD), utilization rates of aspirin remain suboptimal in relation to recommendations. We studied national trends of aspirin use among intermediate- to high-risk patients in the US ambulatory care settings and compared the priority given to aspirin versus statins for CVD risk reduction. We also examined patient and health care provider contributors to the underuse of aspirin. METHODS AND FINDINGS We used the 1993-2003 US National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to estimate aspirin use by cardiovascular risk. Physician-noted cardiovascular diseases defined high risk. Intermediate risk was defined as having diabetes mellitus or multiple major risk factors. The proportion of patient visits in which aspirin was reported increased from 21.7% (95% confidence interval: 18.8%-24.6%) in 1993-1994 to 32.8% (25.2%-40.4%) in 2003 for the high-risk category, 3.5% (2.0%-5.0%) to 11.7% (7.8%-15.7%) for visits by patients diagnosed with diabetes, and 3.6% (2.6%-4.6%) to 16.3% (11.4%-21.2%) for those with multiple CVD risk factors. Beginning in 1997-1998, statins were prioritized over aspirin as prophylactic therapy for reducing CVD risk, and the gaps remained wide through 2003. In addition to elevated CVD risk, greater aspirin use was independently associated with advanced age, male gender, cardiologist care, and care in hospital outpatient departments. CONCLUSION Improvements in use of aspirin in US ambulatory care for reducing risks of CVD were at best modest during the period under study, particularly for secondary prevention, where the strongest evidence and most explicit guidelines exist. Aspirin is more underused than statins despite its more favorable cost-effectiveness. Aggressive and targeted interventions are needed to enhance provider and patient adherence to consensus guidelines for CVD risk reduction.
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Affiliation(s)
- Randall S Stafford
- Program on Prevention Outcomes and Practices, Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California, United States of America.
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Usher C, Bennett K, Feely J. Regional variation in the prescribing for diabetes and use of secondary preventative therapies in Ireland. Pharmacoepidemiol Drug Saf 2005; 14:537-44. [PMID: 15818637 DOI: 10.1002/pds.1104] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
PURPOSE To compare the prescribing of secondary preventative therapies for patients with both insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) in the eight health board regions of Ireland. METHODS We utilized data from the national general medical services (GMS) prescribing database to examine the variability of prescribing for diabetes and associated secondary therapies between regions in those aged 45 years or more. Age-sex standardized prescribing rates of six secondary preventative therapies (aspirin, beta-blockers, statins, ACE inhibitors, angiotensin receptor (AT2) antagonists, and fibrates) were calculated for each region. RESULTS Variations exist between regions for treated NIDDM (1.5-fold) and IDDM (1.5-fold). Wide variations were observed between regions for prescribing of secondary preventative therapies with the highest variability observed for statin prescribing (1.5- to 1.6-fold) and for AT2 antagonist prescribing (2.0-fold) in NIDDM patients. In those with NIDDM, men were more likely to receive aspirin OR=1.26 (1.21--1.31), ACE inhibitors 1.14 (1.101.18), and fibrates OR=1.55 (1.23--1.96) than women and those aged over 75 years were less likely to receive statins OR=0.60 (0.56--0.65) and fibrates OR=0.25 (0.17--0.37) than those aged 45--74. Similar results were also shown for patients with IDDM. CONCLUSIONS The results suggest that access to secondary preventative therapy in diabetes patients is not equitable across regions, gender, and age in Ireland. While much of the variability remains unexplained, it may be due to differences in screening and health promotion between regions, prescriber uncertainty, variability in clinical need, or may be derived from a socioeconomic disparity among regions.
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Affiliation(s)
- Cara Usher
- Department of Pharmacology and Therapeutics, Trinity Centre, St. James' Hospital, Dublin, Ireland.
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Gikas A, Sotiropoulos A. Underuse of aspirin therapy among patients with type 2 diabetes mellitus attending primary care in Greece. Eur J Gen Pract 2004; 10:108. [PMID: 15534578 DOI: 10.3109/13814780409044547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2004; 12:699-714. [PMID: 14762987 DOI: 10.1002/pds.933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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