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Dong X, Tsang CCS, Wan JY, Chisholm-Burns MA, Finch CK, Tsao JW, Browning JA, Garuccio J, Zeng R, Wang J. Effects of Medicare Part D medication therapy management on racial/ethnic disparities in adherence to antidementia medications among patients with Alzheimer's disease and related dementias: An observational study. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2024; 13:100420. [PMID: 38420610 PMCID: PMC10900920 DOI: 10.1016/j.rcsop.2024.100420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 08/18/2023] [Accepted: 02/08/2024] [Indexed: 03/02/2024] Open
Abstract
Background Evidence is sparse on the effects of Medicare medication therapy management (MTM) on racial/ethnic disparities in medication adherence among patients with Alzheimer's disease and related dementias. Objectives This study examined the Medicare MTM program's effects on racial/ethnic disparities in the adherence to antidementia medications among patients with Alzheimer's disease and related dementias. Methods This is a retrospective analysis of 100% of 2010-2017 Medicare Parts A, B, and D data linked to Area Health Resources Files. The study outcome was nonadherence to antidementia medications, and intervention was defined as new MTM enrollment in 2017. Propensity score matching was conducted to create intervention and comparison groups with comparable characteristics. A difference-in-differences model was employed with logistic regression, including interaction terms of dummy variables for the intervention group and racial/ethnic minorities. Results Unadjusted comparisons revealed that Black, Hispanic, and Asian/Pacific Islander patients were more likely to be nonadherent than non-Hispanic White (White) patients in 2016. Differences in odds of nonadherence between Black and White patients among the intervention group were lower in 2017 than in 2016 by 27% (odds ratios [OR]: 0.73, 95% confidence interval [CI]: 0.65-0.82). A similar lowering was seen between Hispanic and White patients by 26% (OR: 0.74, 95% CI: 0.63-0.87). MTM enrollment was associated with reduced disparities in nonadherence for Black-White patients of 33% (OR: 0.67, 95% CI: 0.57-0.78) and Hispanic-White patients of 19% (OR: 0.81, 95% CI: 0.67-0.99). Discussion The Medicare MTM program was associated with lower disparities in adherence to antidementia medications between Black and White patients, and between Hispanic and White patients in the population with Alzheimer's disease and related dementias. Conclusions Expanding the MTM program may particularly benefit racial/ethnic minorities in Alzheimer's disease and related dementia care.
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Affiliation(s)
- Xiaobei Dong
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, 881 Madison Avenue, Memphis, TN 38163, USA
| | - Chi Chun Steve Tsang
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, 881 Madison Avenue, Memphis, TN 38163, USA
| | - Jim Y. Wan
- Department of Preventive Medicine, University of Tennessee Health Science Center College of Medicine, 66 North Pauline St, Memphis, TN 38163, USA
| | - Marie A. Chisholm-Burns
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, 881 Madison Avenue, Memphis, TN 38163, USA
| | - Christopher K. Finch
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, 881 Madison Avenue, Memphis, TN 38163, USA
| | - Jack W. Tsao
- Department of Neurology, University of Tennessee Health Science Center College of Medicine, 855 Monroe Avenue, Memphis, TN 38163, USA
| | - Jamie A. Browning
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, 881 Madison Avenue, Memphis, TN 38163, USA
| | - Joseph Garuccio
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, 881 Madison Avenue, Memphis, TN 38163, USA
| | - Rose Zeng
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, 881 Madison Avenue, Memphis, TN 38163, USA
| | - Junling Wang
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, 881 Madison Avenue, Memphis, TN 38163, USA
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Paquet S, Sassenou J, Ringa V, Czernichow S, Zins M, Ozguler A, Rigal L. Women with type 2 diabetes have LDL cholesterol levels higher than those of men, regardless of their treatment and their cardiovascular risk level. Nutr Metab Cardiovasc Dis 2023; 33:1254-1262. [PMID: 37088650 DOI: 10.1016/j.numecd.2023.03.015] [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: 07/28/2022] [Revised: 02/14/2023] [Accepted: 03/20/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND AND AIMS Several works have shown that control of the principal cardiovascular risk factors, especially LDL-C, is poorer among women with type 2 diabetes than men with this disease. Our objectives were to compare the statin treatments and LDL-C levels between men and women with type 2 diabetes, according to the potency of the statin they take, while taking their cardiovascular risk level into account. METHOD AND RESULTS This is a descriptive cross-sectional study within the French CONSTANCES cohort. At inclusion, each individual completed several self-administered questionnaires. Data were then matched to their health insurance fund reimbursement data. The study population comprises cohort members with pharmacologically treated type 2 diabetes. We identified 2541 individuals with type 2 diabetes; 2214 had an available LDL-C value. In the total sample, treatment by statins did not differ between men and women, while the women had a higher mean LCL-C level than men. The analyses stratified by cardiovascular risk showed that women at very high cardiovascular risk received significantly less frequent statin delivery than men (OR = 0.72 [0.56-0.92]; p = 0.01). At the same time, women received the same rate of high-potency statins as men. Women taking equivalently potent statins had significantly higher LDL-C levels than men did. CONCLUSION For the same cardiovascular risk level and the same statin treatment, women had an LDL-C level higher than that of men. They thus present a residual cardiovascular risk that justifies intensification of their statin treatment if tolerance allows.
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Affiliation(s)
- Sylvain Paquet
- Department of General Practice, University of Paris-Saclay, Paris, France; CESP (Centre for Research in Epidemiology and Population Health), Inserm U1018, Université Paris-Saclay, équipe soins primaires et prévention, Villejuif, France.
| | - Jeanne Sassenou
- Department of General Practice, University of Paris-Saclay, Paris, France; CESP (Centre for Research in Epidemiology and Population Health), Inserm U1018, Université Paris-Saclay, équipe soins primaires et prévention, Villejuif, France.
| | - Virginie Ringa
- CESP (Centre for Research in Epidemiology and Population Health), Inserm U1018, Université Paris-Saclay, équipe soins primaires et prévention, Villejuif, France.
| | - Sébastien Czernichow
- Université de Paris, Paris, France; AP-HP, Service de Nutrition, Centre Spécialisé Obésité, Hôpital Européen Georges Pompidou, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM), UMR 1153, Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité, Paris, France.
| | - Marie Zins
- Inserm, Population-based Epidemiologic Cohorts Units, UMS 011, Villejuif, France.
| | - Anna Ozguler
- Inserm, Population-based Epidemiologic Cohorts Units, UMS 011, Villejuif, France.
| | - Laurent Rigal
- Department of General Practice, University of Paris-Saclay, Paris, France; CESP (Centre for Research in Epidemiology and Population Health), Inserm U1018, Université Paris-Saclay, équipe soins primaires et prévention, Villejuif, France.
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Dunn K, Kopel J, Diab M, Babb F. Analyzing and Improving the Utilization of Statin Drugs in Family Medicine Patients with Type II Diabetes. J Community Hosp Intern Med Perspect 2023; 13:35-38. [PMID: 37877046 PMCID: PMC10593177 DOI: 10.55729/2000-9666.1162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/25/2022] [Accepted: 01/05/2023] [Indexed: 10/26/2023] Open
Abstract
Background Statins are the primary drug used to reduce morbidity and mortality for cardiovascular disease. However, many type II diabetes mellitus (T2DM) patients who are currently not on a statin would otherwise qualify. Therefore, we investigated the proportion of T2DM patients on a statin compared to the total number of T2DM patients eligible to be on a statin. We also examined potential barriers that prevent T2DM patients from being prescribed statins by physicians. Methods A retrospective chart study on family medicine patients was collected data on age, race, cholesterol readings, blood pressure, and whether the patient was on blood pressure medications, aspirin, and/or a statin. The information gathered was used to determine the patients' 10-year risk of cardiovascular disease. A survey was given to residents and faculty to assess the cost, side effects, and other behavioral factors had on a patients' choice to be on a statin. Results Among the 706 T2DM patients, we found that a large proportion (75.2%) were both eligible and prescribed a statin according to the American Heart Association Guidelines. In addition, over 58% of the patients had a 0%-25% 10-year risk of cardiovascular disease risk. Among the 14 family medicine physicians surveyed, the fear of or history of side effects with statin medications were the greatest barriers to starting statins. Conclusion The large proportion of family medicine patients that were eligible were prescribed a statin. According to the survey, physicians Believed that the greatest barrier for a patient starting on a statin is the fear of or history of side effects with statin medications.
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Affiliation(s)
- Keegan Dunn
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX,
USA
| | - Jonathan Kopel
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX,
USA
| | - Mousab Diab
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX,
USA
| | - Franklyn Babb
- Professor of Family Medicine, Texas Tech University Health Sciences Center, Lubbock, TX,
USA
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Cardiovascular Risk Screening among Women Veterans: Identifying Provider and Patient Barriers and Facilitators to Develop a Clinical Toolkit. Womens Health Issues 2022; 32:284-292. [PMID: 35115227 DOI: 10.1016/j.whi.2021.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 11/15/2021] [Accepted: 12/09/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Cardiovascular (CV) disease is the leading cause of death among women in the United States, making CV risk screening and management a women's health priority. Objectives were to elicit barriers and facilitators to CV risk identification and reduction among women veterans, and iteratively cocreate clinical tools to identify CV risk factors and promote goal-setting for lifestyle changes. METHODS We conducted three exploratory focus groups with 21 Veterans Health Administration primary care team members and piloted patient CV screeners with brief interviews with 19 patients from two Veterans Health Administration women's clinics to inform toolkit development. We then conducted two focus groups and one interview for feedback from a total of 12 staff on the proposed toolkit components. Transcripts were summarized, and a matrix analysis was used to synthesize qualitative findings. RESULTS Provider-identified barriers included difficulties disseminating CV information in clinic, limited patient knowledge, and lack of organized resources for provider communication and available referrals. Women's complex health needs were notable challenges to CV risk reduction. Facilitators included having a single place to track patient CV risks (e.g., an electronic template note), a patient screening worksheet, and aids to complete referrals. Patient-identified barriers included difficulties balancing health, finances, and physical and mental health concerns. Facilitators included resources for accountability and gender-specific information about CV risks and complications. Providers requested easy, accessible tools in the electronic record with gender-specific CV data and resources linked. Patients requested lifestyle change supports, including trustworthy sources vetted by providers. CONCLUSIONS Iteratively eliciting end-users' perspectives is critical to developing user-friendly, clinically relevant tools. CV risk reduction among women veterans will require multilevel tools and resources that meet providers' and women's needs.
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Ahmed F, Lin J, Ahmed T, Siddiqui D, Nguyen J, Sarpong D. Health Disparities: Statin Prescribing Patterns Among Patients with Diabetes in a Family Medicine Clinic. Health Equity 2022; 6:291-297. [PMID: 35557548 PMCID: PMC9081035 DOI: 10.1089/heq.2021.0144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 11/19/2022] Open
Abstract
Purpose: To analyze the impact of gender and race on statin prescribing patterns in patients with diabetes in a family medicine clinic. Methods: This study (n=192) was a single-center, cross-sectional study that examined statin prescribing patterns at a family medicine clinic. Patients were obtained from January 2015 to November 2018, who were considered eligible for statin therapy based on a documented diagnosis of diabetes. The patients were divided into four subgroups for analysis (white males, non-white males, white females, and non-white females). Results: Females were found to have higher rates of prescribed statin therapy and appropriate statin intensity therapy when compared to males (p>0.05). When evaluating gender and race, white females were more likely to be prescribed an appropriate statin when compared to non-white females (p<0.05). Conclusion: The study shows that although males had a significantly higher mean 10-year atherosclerotic cardiovascular disease risk score, they were less likely than females to receive the appropriate intensity statin. Previous studies have shown race and gender disparities exist in the prevention of cardiovascular disease. A more collective, unified approach to improve prescribing patterns for statin therapy can eliminate these disparities.
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Affiliation(s)
- Fahamina Ahmed
- Division of Clinical and Administrative Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, Louisiana, USA
| | - Jonathan Lin
- Division of Clinical and Administrative Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, Louisiana, USA
| | - Taha Ahmed
- School of Medicine, Ross University, Miramar, Florida, USA
| | - Danish Siddiqui
- School of Medicine, American University of Integrative Sciences, Tucker, Georgia, USA
| | - John Nguyen
- Division of Clinical and Administrative Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, Louisiana, USA
| | - Daniel Sarpong
- Division of Clinical and Administrative Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, Louisiana, USA
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The Magnitude and Potential Causes of Sex Disparities in Statin Therapy in Veterans with Type 2 Diabetes: A 10-year Nationwide Longitudinal Cohort Study. Womens Health Issues 2021; 32:274-283. [PMID: 34949527 DOI: 10.1016/j.whi.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/01/2021] [Accepted: 10/15/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Past research has shown that women eligible for statin therapy are less likely than their male counterparts to receive any statin therapy or be prescribed a statin at the guideline-recommended intensity. We compared statin treatment in men and women veterans from a national cohort of older veterans with type 2 diabetes. METHODS The Veterans Health Administration Corporate Data Warehouse and Centers for Medicare and Medicaid Services data were used to create a unique dataset and perform a longitudinal study of veterans with type 2 diabetes from 2007 to 2016. Mixed-effects logistic regression was used to model the association between the primary exposure (sex) and statin use. RESULTS The study included 714,212 veterans with diabetes, including 9,608 women, with an overall mean age of 75.9 years. In the unadjusted model for any statin use, women veterans had a 14% significantly lower odds of having any statin use compared with men. After adjusting for all covariates, including markers of Veterans Administration care use (service-connected disability rating, Veterans Administration use, and primary care visits) that serve as proxies for access and mental health comorbidities (depression and psychiatric disorder), this disparity narrowed from 14% to 3% and was no longer statistically significant. In the model for high-intensity statin therapy (high-intensity vs. low or none), women were 10% less likely than men to use high-intensity statins in the base model that included only time and sex. After adjusting for all measured covariates, the direction of the association changed and women had 16% higher odds of high-intensity statin use compared with men (odds ratio, 1.16; 95% confidence interval, 1.03-1.31). CONCLUSIONS Consistent with prior research, in the unadjusted analysis a significant sex disparity was observed in statin use, with lower rates observed in women. For the outcome of any statin use, after adjustment for covariates that included variables that are proxies for access as well as psychiatric and depression comorbidities, this disparity lost statistical significance and narrowed. In the high-intensity statin versus low or none model, the direction of the association changed after controlling for measured covariates and women had a 16% higher odds of high-intensity statin use compared with men. This study highlights a persistent health disparity in lipid-lowering therapy for women veterans. Additional research is needed to further elucidate the reasons for and develop interventions to mitigate this persistent sex disparity in cholesterol management for veterans with diabetes.
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Dong X, Tsang CCS, Zhao S, Wan JY, Shih YCT, Chisholm-Burns MA, Dagogo-Jack S, Cushman WC, Hines LE, Wang J. Effects of the Medicare Part D Comprehensive Medication Review on Racial and Ethnic Disparities in Medication Adherence. AMERICAN HEALTH & DRUG BENEFITS 2021; 14:101-109. [PMID: 35261713 PMCID: PMC8845523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/30/2021] [Indexed: 06/14/2023]
Abstract
Background Substantial research has documented inequalities between US minorities and whites in meeting the eligibility criteria for the Medicare Part D medication therapy management (MTM) program. Even though the Centers for Medicare & Medicaid Services attempted to relax the eligibility criteria, a critical barrier to effective MTM reform is a lack of stronger evidence about the effects of MTM on minorities' health outcomes. Objective To examine the effects of comprehensive medication review (CMR), an MTM core component, on racial and ethnic disparities in adherence to diabetes, hypertension, and hyperlipidemia medications among Medicare beneficiaries aged ≥65 years. Methods This study used full-year 2017 Medicare Parts A, B, and D claims data, including MTM data, linked to the Area Health Resources Files. Racial and ethnic disparities in nonadherence to diabetes, hypertension, and hyperlipidemia medications were compared between CMR recipients and nonrecipients matched by their propensity scores. To determine the changes in racial and ethnic disparities after receiving CMR, a difference-in-differences framework was applied, by including in logistic regression analyses interaction terms between dummy variables for CMR receipt and each racial or ethnic minority group. Results Compared with CMR nonrecipients, CMR recipients had significantly lower racial and ethnic disparities across the 3 outcome measures, with the exception of the difference between whites and blacks in nonadherence to diabetes medications. For example, compared with CMR nonrecipients, among CMR recipients the differences in the odds of nonadherence to hypertension medications were reduced, respectively, by 8% (95% confidence interval [CI], 0.88-0.96) between whites and blacks; by 18% (95% CI, 0.78-0.86) between whites and Hispanics; by 16% (95% CI, 0.77-0.91) between whites and Asians; and by 9% (95% CI, 0.85-0.98) between whites and other racial and ethnic groups. Conclusion Receiving a CMR reduced the racial and ethnic disparities in adherence to diabetes, hypertension, and hyperlipidemia medications among Medicare beneficiaries aged ≥65 years. These findings provide critical empirical evidence that may inform the future design of the Medicare Part D MTM program, which is valuable for improving pharmacotherapy outcomes and could further realize its potential when additional people from racial and ethnic minorities are enrolled.
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Dong X, Tsang CCS, Wan JY, Shih YCT, Chisholm-Burns MA, Dagogo-Jack S, Cushman WC, Hines LE, Wang J. Exploring racial and ethnic disparities in medication adherence among Medicare comprehensive medication review recipients. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2021; 3. [PMID: 35434697 PMCID: PMC9009823 DOI: 10.1016/j.rcsop.2021.100041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background There has been a lack of evidence on whether there are racial and ethnic disparities in medication nonadherence among individuals receiving comprehensive medication review (CMR), a required component of the Medicare Part D medication therapy management (MTM) services. Objectives To explore racial/ethnic disparities in medication nonadherence among older MTM enrollees who received a CMR and to determine how much the identified disparities can be explained by observed characteristics. Methods The retrospective study used 100% of the 2017 Medicare claims, including MTM data. Linked Area Health Resources Files provided community characteristics. Nonadherence was defined as proportion of days covered <80%, and was measured for diabetes, hypertension, and hyperlipidemia medications. Racial/ethnic disparities were examined by logistic regressions that included racial/ethnic minority dummy variables. A nonlinear Blinder-Oaxaca decomposition method was applied to decompose the identified disparities. Results Compared with non-Hispanic Whites (Whites), Blacks were respectively 39% (odds ratio [OR] = 1.39, 95% confidence interval [CI] = 1.33–1.45), 27% (OR = 1.27, 95% CI = 1.22–1.32), and 43% (OR = 1.43, 95% CI = 1.39–1.47) more likely to be nonadherent to diabetes, hypertension, and hyperlipidemia medications; Hispanics were 20% (OR = 1.20, 95% CI = 1.14–1.27) more likely to be nonadherent to hyperlipidemia medications. The total portion of disparity explained was 13.42%, 7.66%, 14.87%, and 10.69% respectively for disparities in Black-White (B–W) diabetes, B–W hypertension, B–W hyperlipidemia, and Hispanic-White hyperlipidemia. The top three contributors were the proportion of married-couple families, census region, and male gender. Conclusions A lower level of community affluence and social support, regional variations, and a lower proportion of males in Blacks and Hispanics may contribute to the disparities in medication nonadherence. The large unexplained portion of the disparity attests that nonadherence is a complex issue. The Medicare MTM program needs to implement measures to reduce disparities in medication adherence. This retrospective study used 100% of the 2017 Medicare claims including MTM data. Racial/ethnic disparity in medication adherence was identified among CMR recipients. Blacks were more likely than Whites to be nonadherent to all medications studied. Hispanics were more likely than Whites to be hyperlipidemia medication nonadherent. Observed characteristics explained close to 15% of the identified disparity.
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Affiliation(s)
- Xiaobei Dong
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, 881 Madison Avenue, Room 214, Memphis, TN 38163, United States of America
| | - Chi Chun Steve Tsang
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, 881 Madison Avenue, Room 212, Memphis, TN 38163, United States of America
| | - Jim Y. Wan
- Department of Preventive Medicine, University of Tennessee Health Science Center College of Medicine, 66 N. Pauline, Suite 633, Memphis, TN 38163, United States of America
| | - Ya-Chen Tina Shih
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1444, Houston, TX 77030, United States of America
| | - Marie A. Chisholm-Burns
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, 881 Madison Avenue, Room 264, Memphis, TN 38163, United States of America
| | - Samuel Dagogo-Jack
- Division of Endocrinology, Diabetes & Metabolism, Clinical Research Center, University of Tennessee Health Science Center College of Medicine, 920 Madison Avenue, Suite 300A, Memphis, TN 38163, United States of America
| | - William C. Cushman
- Department of Preventive Medicine, University of Tennessee Health Science Center College of Medicine, 66 North Pauline Street, Suite 651, Memphis, TN 38163, United States of America
| | - Lisa E. Hines
- Pharmacy Quality Alliance, 5911 Kingstowne Village Parkway, Suite 130, Alexandria, VA 22315, United States of America
| | - Junling Wang
- Department of Clinical Pharmacy & Translational Science, University of Tennessee Health Science Center College of Pharmacy, 881 Madison Avenue, Room 221, Memphis, TN 38163, United States of America
- Corresponding author.
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The Gut Microbiota-Produced Indole-3-Propionic Acid Confers the Antihyperlipidemic Effect of Mulberry-Derived 1-Deoxynojirimycin. mSystems 2020; 5:5/5/e00313-20. [PMID: 33024047 PMCID: PMC7542557 DOI: 10.1128/msystems.00313-20] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Hyperlipidemia is a worldwide epidemic with an obvious gender disparity in incidence. Modulations on gut microbiota by traditional Chinese medicines (TCM) are emerging as a potential rationale governing the profitable effects of drugs on hyperlipidemia. However, it is unclear how gut microbes regulate the progression of hyperlipidemia. Here, we found that mulberry leaf extract (MLE) and its active component 1-deoxynojirimycin (DNJ) diminished hyperglycemia and hypertriglyceridemia with similar efficacy in male and female mice but preferentially alleviated hypercholesterolemia in female mice. Further investigations showed that DNJ sex-specifically downregulated the expression of lipogenic genes, especially cholesterol-biosynthetic genes. Oral administration of DNJ imposed more profound modulation on gut microbiota in female mice than in male ones, as estimated by 16S rRNA metatranscriptomic analysis. DNJ markedly enriched Akkermansia and Clostridium group XIVa and promoted the production of indole-3-propionic acid (IPA) in a sexually dimorphic way. Importantly, IPA tightly associates with the antihyperlipidemic effect of DNJ and exhibited a potent lipid-lowering effect both in vitro and in vivo Together, our results have established a regulatory mechanism by which DNJ sex-specifically improves hyperlipidemia, offering an in-depth theoretical basis for therapeutic exploitation of DNJ as a sex-specific intervention against hyperlipidemia.IMPORTANCE Hyperlipidemia has been intensively focused on by researchers around the world owing to its major contribution to cardiovascular diseases. Various evidence reveals that women are more susceptible than male counterparts to dyslipidemia, making sex-dependent therapeutic strategies and drugs urgently needed. In the present work, we demonstrate that DNJ, the main active component of mulberry leaves, exerts an obvious female-preferential antihyperlipidemic effect through specifically enriching Akkermansia and Clostridium XIVa and elevating an active microbial metabolite, indole-3-propionic acid (IPA), in female mice. Moreover, we have corroborated the potent lipid-lowering efficacy of IPA both in vitro and in vivo These findings not only indicate a potential mechanism by which gut microbes and their metabolites confer the beneficial role of DNJ in ameliorating hyperlipidemia but also provide an in-depth theoretical basis for therapeutic exploitation of DNJ as a female-specific intervention against hyperlipidemia.
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Huebschmann AG, Huxley RR, Kohrt WM, Zeitler P, Regensteiner JG, Reusch JEB. Sex differences in the burden of type 2 diabetes and cardiovascular risk across the life course. Diabetologia 2019; 62:1761-1772. [PMID: 31451872 PMCID: PMC7008947 DOI: 10.1007/s00125-019-4939-5] [Citation(s) in RCA: 181] [Impact Index Per Article: 36.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 05/29/2019] [Indexed: 12/11/2022]
Abstract
By 2017 estimates, diabetes mellitus affects 425 million people globally; approximately 90-95% of these have type 2 diabetes. This narrative review highlights two domains of sex differences related to the burden of type 2 diabetes across the life span: sex differences in the prevalence and incidence of type 2 diabetes, and sex differences in the cardiovascular burden conferred by type 2 diabetes. In the presence of type 2 diabetes, the difference in the absolute rates of cardiovascular disease (CVD) between men and women lessens, albeit remaining higher in men. Large-scale observational studies suggest that type 2 diabetes confers 25-50% greater excess risk of incident CVD in women compared with men. Physiological and behavioural mechanisms that may underpin both the observed sex differences in the prevalence of type 2 diabetes and the associated cardiovascular burden are discussed in this review. Gender differences in social behavioural norms and disparities in provider-level treatment patterns are also highlighted, but not described in detail. We conclude by discussing research gaps in this area that are worthy of further investigation.
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Affiliation(s)
- Amy G Huebschmann
- Center for Women's Health Research, University of Colorado School of Medicine, MS C263, 12348 E. Montview Boulevard, Aurora, CO, 80045, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rachel R Huxley
- College of Science, Health and Engineering, La Trobe University, Melbourne, VIC, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Wendy M Kohrt
- Center for Women's Health Research, University of Colorado School of Medicine, MS C263, 12348 E. Montview Boulevard, Aurora, CO, 80045, USA
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Medicine, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Philip Zeitler
- Division of Pediatric Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Judith G Regensteiner
- Center for Women's Health Research, University of Colorado School of Medicine, MS C263, 12348 E. Montview Boulevard, Aurora, CO, 80045, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiology, University of Colorado School of Medicine (CU-SOM), Aurora, CO, USA
| | - Jane E B Reusch
- Center for Women's Health Research, University of Colorado School of Medicine, MS C263, 12348 E. Montview Boulevard, Aurora, CO, 80045, USA.
- Department of Medicine, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA.
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Aurora, CO, USA.
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Affiliation(s)
- Janet K. Han
- Division of Cardiology, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, CA (J.K.H., R.E.)
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles (J.K.H., K.E.W., R.E.)
| | - Elizabeth M. Yano
- Veterans Affairs Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, CA (E.M.Y.)
- Department of Health Policy and Management, University of California Los Angeles Fielding School of Public Health (E.M.Y.)
| | - Karol E. Watson
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles (J.K.H., K.E.W., R.E.)
| | - Ramin Ebrahimi
- Division of Cardiology, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, CA (J.K.H., R.E.)
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles (J.K.H., K.E.W., R.E.)
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Al-Salameh A, Chanson P, Bucher S, Ringa V, Becquemont L. Cardiovascular Disease in Type 2 Diabetes: A Review of Sex-Related Differences in Predisposition and Prevention. Mayo Clin Proc 2019; 94:287-308. [PMID: 30711127 DOI: 10.1016/j.mayocp.2018.08.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 07/24/2018] [Accepted: 08/06/2018] [Indexed: 12/31/2022]
Abstract
Type 2 diabetes mellitus is a major risk factor for cardiovascular disease. However, compiled data suggest that type 2 diabetes affects the risk of cardiovascular disease differentially according to sex. In recent years, large meta-analyses have confirmed that women with type 2 diabetes have a higher relative risk of incident coronary heart disease, fatal coronary heart disease, and stroke compared with their male counterparts. The reasons for these disparities are not completely elucidated. A greater burden of cardiometabolic risk in women was proposed as a partial explanation. Indeed, several studies suggest that women experience a larger deterioration in major cardiovascular risk factors and put on more weight than do men during their transition from normoglycemia to overt type 2 diabetes. This excess weight is associated with higher levels of biomarkers of endothelial dysfunction, inflammation, and procoagulant state. Moreover, sex differences in the prescription and use of some cardiovascular drugs may compound an "existing" disparity. We searched PubMed for articles published in English and French, by using the following terms: ("cardiovascular diseases") AND ("diabetes mellitus") AND ("sex disparity" OR "sex differences" OR "sex related differences" OR "sex-related differences" OR "sex disparities"). In this article, we review the available literature on the sex aspects of primary and secondary prevention of cardiovascular disease in people with type 2 diabetes, in the predisposition to cardiovascular disease in those people, and in the control of diabetes and associated cardiovascular risk factors.
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Affiliation(s)
- Abdallah Al-Salameh
- Centre de recherche en Epidémiologie et Santé des Populations (CESP), Université Paris-Sud, Université Paris-Saclay, INSERM, Villejuif, France; Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin-Bicêtre, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Centre de Recherche Clinique Paris-Sud, Le Kremlin-Bicêtre, France.
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin-Bicêtre, France; Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France; INSERM U1185, Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Sophie Bucher
- Centre de recherche en Epidémiologie et Santé des Populations (CESP), Université Paris-Sud, Université Paris-Saclay, INSERM, Villejuif, France; General Practice Department, Paris-Sud Faculty of Medicine, Paris-Sud University, Le Kremlin-Bicêtre, France
| | - Virginie Ringa
- Centre de recherche en Epidémiologie et Santé des Populations (CESP), Université Paris-Sud, Université Paris-Saclay, INSERM, Villejuif, France
| | - Laurent Becquemont
- Centre de recherche en Epidémiologie et Santé des Populations (CESP), Université Paris-Sud, Université Paris-Saclay, INSERM, Villejuif, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Centre de Recherche Clinique Paris-Sud, Le Kremlin-Bicêtre, France; Pharmacology Department, Paris-Sud Faculty of Medicine, Paris-Sud University, Le Kremlin-Bicêtre, France
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13
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Impact of Patient-Centered Medical Home Implementation on Diabetes Control in the Veterans Health Administration. J Gen Intern Med 2018; 33:1276-1282. [PMID: 29611089 PMCID: PMC6082213 DOI: 10.1007/s11606-018-4386-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 01/04/2018] [Accepted: 02/27/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Given its widespread dissemination across primary care, the Veterans Health Administration (VA) is an ideal setting to examine the impact of the patient-centered medical home (PCMH) on diabetes outcomes. OBJECTIVE To assess the impact of PCMH implementation on diabetes outcomes among patients receiving care in the Veterans Health Administration. DESIGN Retrospective cohort analysis and multilevel logistic regression. PATIENTS Twenty thousand eight hundred fifty-eight patients in one Midwest VA network who had a diabetes diagnosis in both 2009 and 2012 and who received primary care between October 1, 2008 and September 30, 2009. MAIN MEASURES Glycemic and lipid control using VA quality indicators [hemoglobin (Hb) A1c < 9%, low-density lipoprotein cholesterol (LDL-C) < 100 mg/dL]. KEY RESULTS Odds of glycemic control were lower in 2012 than 2009 (OR = 0.72, 95% CI = 0.67-0.77, p < 0.001), and this change in control over time varied by race (OR of the interaction between time and race = 1.18, 95% CI = 1.02-1.36, p = 0.028). While the disparity in glycemic control between white and black patients persisted post-PCMH, the magnitude of the disparity was smaller in 2012 compared to 2009 (2012: OR = 1.32, 95% CI = 1.18-1.47, p < 0.0001 and 2009: OR = 1.59, 95% CI = 1.39-1.82, p < 0.0001). Odds of lipid control did not significantly change between 2009 and 2012 and change did not vary by race and/or gender. CONCLUSIONS Although there were no significant improvements in odds of lipid control, and odds of glycemic control decreased following PCMH implementation, there was evidence of reduced racial disparities in glycemic control post-PCMH implementation.
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Mapping the Gaps: Gender Differences in Preventive Cardiovascular Care among Managed Care Members in Four Metropolitan Areas. Womens Health Issues 2018; 28:446-455. [PMID: 29929865 DOI: 10.1016/j.whi.2018.04.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 03/21/2018] [Accepted: 04/20/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Prior research documents gender gaps in cardiovascular risk management, with women receiving poorer quality routine care on average, even in managed care systems. Although population health management tools and quality improvement efforts have led to better overall care quality and narrowing of racial/ethnic gaps for a variety of measures, we sought to quantify persistent gender gaps in cardiovascular risk management and to assess the performance of routinely used commercial population health management tools in helping systems narrow gender gaps. METHODS Using 2013 through 2014 claims and enrollment data from more than 1 million members of a large national health insurance plan, we assessed performance on seven evidence-based quality measures for the management of coronary artery disease and diabetes mellitus, a cardiac risk factor, across and within four metropolitan areas. We used logistic regression to adjust for region, demographics, and risk factors commonly tracked in population health management tools. FINDINGS Low-density lipoprotein (LDL) cholesterol control (LDL < 100 mg/dL) rates were 5 and 15 percentage points lower for women than men with diabetes mellitus (p < .0001), and coronary artery disease (p < .0001), respectively. Adjusted analyses showed women were more likely to have gaps in LDL control, with an odds ratio of 1.31 (95% confidence interval, 1.27-1.38) in diabetes mellitus and 1.88 (95% confidence interval, 1.65-2.10) in coronary artery disease. CONCLUSIONS Given our findings that gender gaps persist across both clinical and geographic variation, we identified additional steps health plans can take to reduce disparities. For measures where gaps have been consistently identified, we recommend that gender-stratified quality reporting and analysis be used to complement widely used algorithms to identify individuals with unmet needs for referral to population health and wellness behavior support programs.
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15
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Danan ER, Krebs EE, Ensrud K, Koeller E, MacDonald R, Velasquez T, Greer N, Wilt TJ. An Evidence Map of the Women Veterans' Health Research Literature (2008-2015). J Gen Intern Med 2017; 32:1359-1376. [PMID: 28913683 PMCID: PMC5698220 DOI: 10.1007/s11606-017-4152-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 06/08/2017] [Accepted: 07/27/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Women comprise a growing proportion of Veterans seeking care at Veterans Affairs (VA) healthcare facilities. VA initiatives have accelerated changes in services for female Veterans, yet the corresponding literature has not been systematically reviewed since 2008. In 2015, VA Women's Health Services and the VA Women's Health Research Network requested an updated literature review to facilitate policy and research planning. METHODS The Minneapolis VA Evidence-based Synthesis Program performed a systematic search of research related to female Veterans' health published from 2008 through 2015. We extracted study characteristics including healthcare topic, design, sample size and proportion female, research setting, and funding source. We created an evidence map by organizing and presenting results within and across healthcare topics, and describing patterns, strengths, and gaps. RESULTS We identified 2276 abstracts and assessed each for relevance. We excluded 1092 abstracts and reviewed 1184 full-text articles; 750 were excluded. Of 440 included articles, 208 (47%) were related to mental health, particularly post-traumatic stress disorder (71 articles), military sexual trauma (37 articles), and substance abuse (20 articles). The number of articles addressing VA priority topic areas increased over time, including reproductive health, healthcare organization and delivery, access and utilization, and post-deployment health. Three or fewer articles addressed each of the common chronic diseases: diabetes, hypertension, depression, or anxiety. Nearly 400 articles (90%) used an observational design. Eight articles (2%) described randomized trials. CONCLUSIONS Our evidence map summarizes patterns, progress, and growth in the female Veterans' health and healthcare literature. Observational studies in mental health make up the majority of research. A focus on primary care delivery over clinical topics in primary care and a lack of sex-specific results for studies that include men and women have contributed to research gaps in addressing common chronic diseases. Interventional research using randomized trials is needed.
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Affiliation(s)
- Elisheva R Danan
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA. .,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Erin E Krebs
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Kristine Ensrud
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Eva Koeller
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA
| | - Roderick MacDonald
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA
| | - Tina Velasquez
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA
| | - Nancy Greer
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA
| | - Timothy J Wilt
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
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16
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Goldstein KM, Stechuchak KM, Zullig LL, Oddone EZ, Olsen MK, McCant FA, Bastian LA, Batch BC, Bosworth HB. Impact of Gender on Satisfaction and Confidence in Cholesterol Control Among Veterans at Risk for Cardiovascular Disease. J Womens Health (Larchmt) 2017; 26:806-814. [PMID: 28192012 DOI: 10.1089/jwh.2016.5739] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Compared with men, women have poorer lipid control. Although potential causes of this disparity have been explored, it is unknown whether patient-centered factors such as satisfaction and confidence contribute. We evaluated (1) whether satisfaction with lipid control and confidence in ability to improve it vary by gender and (2) whether sociodemographic characteristics modify the association. MATERIALS AND METHODS We evaluated baseline survey responses from the Cardiovascular Intervention Improvement Telemedicine Study, including self-rated satisfaction with cholesterol levels and confidence in controlling cholesterol. Participants had poorly controlled hypertension and/or hypercholesterolemia. RESULTS A total of 428 veterans (15% women) participated. Compared with men, women had higher low-density lipoprotein values at 141.2 versus 121.7 mg/dL, respectively (p < 0.05), higher health literacy, and were less likely to have someone to help track their medications (all p < 0.05). In an adjusted model, women were less satisfied with their cholesterol levels than men with estimated mean scores of 4.3 versus 5.6 on a 1-10 Likert scale (p < 0.05). There was no significant difference in confidence by gender. Participants with support for tracking medications reported higher confidence levels than those without, estimated mean 7.8 versus 7.2 (p < 0.05). CONCLUSIONS Women veterans at high risk for cardiovascular disease were less satisfied with their lipid control than men; however, confidence in ability to improve lipid levels was similar. Veterans without someone to help to track medications were less confident, and women were less likely to have this type of social support. Lack of social support for medication tracking may be a factor in lingering gender-based disparities in hyperlipidemia.
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Affiliation(s)
- Karen M Goldstein
- 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina.,2 Division of General Internal Medicine, Department of Medicine, Duke University Medical Center , Durham, North Carolina
| | - Karen M Stechuchak
- 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina
| | - Leah L Zullig
- 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina.,2 Division of General Internal Medicine, Department of Medicine, Duke University Medical Center , Durham, North Carolina
| | - Eugene Z Oddone
- 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina.,2 Division of General Internal Medicine, Department of Medicine, Duke University Medical Center , Durham, North Carolina
| | - Maren K Olsen
- 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina.,3 Department of Biostatistics and Bioinformatics, Duke University Medical Center , Durham, North Carolina
| | - Felicia A McCant
- 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina
| | - Lori A Bastian
- 4 VA Connecticut Healthcare System , West Haven, Connecticut.,5 Department of Medicine, Yale University , New Haven, Connecticut
| | - Bryan C Batch
- 6 Division of Endocrinology, Department of Medicine, Duke University Medical Center , Durham, North Carolina
| | - Hayden B Bosworth
- 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina.,2 Division of General Internal Medicine, Department of Medicine, Duke University Medical Center , Durham, North Carolina.,7 School of Nursing, Duke University School of Medicine , Durham, North Carolina.,8 Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine , Durham, North Carolina
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18
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Lin X, Xu R, Fang L, Chen W, Hu D, Zhao S, Wang Y, Li J, Yan X. Factors influencing low-density lipoprotein cholesterol target achievement in primary care - Results from DYSIS China. Int J Cardiol 2016; 222:51-56. [PMID: 27454615 DOI: 10.1016/j.ijcard.2016.07.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 07/04/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Primary care facilities are the base for hypercholesterolemia treatment. However, data regarding the effectiveness of lipid management in primary care are lacking. METHODS AND RESULTS To evaluate lipid management in the primary care setting in China, we compared patients' characteristics and lipid management outcomes between 6100 outpatients treated at primary care versus 19,217 patients in non-primary settings using data from the DYSlipidemia International Study-China (DYSIS-CHINA). Compared to patients treated at non-primary hospitals, patients who received treatment at primary settings were younger, thinner, and were more likely to be female and to have a family history of premature CVD. Overall, 26.8% of very high-risk and 40.8% of high-risk patients achieved the LDL-C target with primary care treatment, whereas these target rates were 41.2% (p<0.001) and 58.6% (p<0.001), respectively, among patients treated at non-primary hospitals. High-dose statin therapy was underused in primary care patients compared to non-primary hospital patients (p<0.001). Logistic regression analysis showed that female gender, diabetes, and obesity were negative factors, whereas life-style modification and use of high-dose statin (40mg/d simvastatin equivalent) were favorable factors in predicting LDL-C target attainment in the primary care setting. CONCLUSION Sedentary life style, alcohol drinking, and use of suboptimal statin dosage are key factors that unfavorably affect the LDL-C target rate among patients treated at primary care facilities in China. Sufficient training for primary care physicians regarding proper statin use and support for the combined use of a statin with ezetimibe could promote LDL-C target attainment in primary care.
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Affiliation(s)
- Xue Lin
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - RuiYi Xu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ligang Fang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wei Chen
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Dayi Hu
- Department of Cardiology, Peking University People's Hospital, No.11, Xi Zhi Men Nan Da Jie, Xicheng District, Beijing 100044, China
| | - Shuiping Zhao
- Department of Cardiology, Second Xiangya Hospital, Central South University, No.139, People Street (M.), Changsha 410011, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No. 6, Tiantan Xi Li, Dongcheng District, Beijing 100050, China
| | - Jihu Li
- MSD China Holding Co., Ltd., No. 1601, Nanjing Rd.(W), JingAn District, Shanghai 20004, China
| | - Xiaowei Yan
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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Zhang H, Plutzky J, Shubina M, Turchin A. Drivers of the Sex Disparity in Statin Therapy in Patients with Coronary Artery Disease: A Cohort Study. PLoS One 2016; 11:e0155228. [PMID: 27148965 PMCID: PMC4858152 DOI: 10.1371/journal.pone.0155228] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 04/26/2016] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Women are less likely to be prescribed statins than men. Existing reports explain only a fraction of this difference. We conducted a study to identify factors that account for sex differences in statin therapy among patients with coronary artery disease (CAD). METHODS AND RESULTS We retrospectively studied 24,338 patients with CAD who were followed for at least a year between 2000 and 2011 at two academic medical centers. Women (9,006 / 37% of study patients) were less likely to either have initiated statin therapy (81.9% women vs. 87.7% men) or to have persistent statin therapy at the end of follow-up (67.0% women vs. 71.4% men). Women were older (72.9 vs. 68.4 years), less likely to have ever smoked (49.8% vs. 65.6%), less likely to have been evaluated by a cardiologist (57.5% vs. 64.5%) and more likely to have reported an adverse reaction to a statin (27.1% vs. 21.7%) (p < 0.0001 for all). In multivariable analysis, patients with history of smoking (OR 1.094; p 0.017), younger age (OR 1.013 / year), cardiologist evaluation (OR 1.337) and no reported adverse reactions to statins (OR 1.410) were more likely (p < 0.0001 for all) to have persistent statin therapy. Together, these four factors accounted for 90.4% of the sex disparity in persistent statin therapy. CONCLUSIONS Several specific factors appear to underlie divergent statin therapy in women vs. men. Identifying such drivers may facilitate programmatic interventions and stimulate further research to overcome sex differences in applying proven interventions for cardiovascular risk reduction.
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Affiliation(s)
- Huabing Zhang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jorge Plutzky
- Harvard Medical School, Boston, Massachusetts, United States of America
- Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Maria Shubina
- Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Alexander Turchin
- Harvard Medical School, Boston, Massachusetts, United States of America
- Brigham and Women's Hospital, Boston, Massachusetts, United States of America
- Harvard Clinical Research Institute, Boston, Massachusetts, United States of America
- * E-mail:
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Gupta R, Sharma M, Goyal NK, Bansal P, Lodha S, Sharma KK. Gender differences in 7 years trends in cholesterol lipoproteins and lipids in India: Insights from a hospital database. Indian J Endocrinol Metab 2016; 20:211-218. [PMID: 27042418 PMCID: PMC4792023 DOI: 10.4103/2230-8210.176362] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To determine gender differences and secular trends in total, low-density lipoprotein (LDL) and high DL (HDL) cholesterol and triglycerides using a large hospital database in India. METHODS All blood lipid tests evaluated from July 2007 to December 2014 were analyzed. Details of gender and age were available. Statin therapy was obtained at two separate periods. Trends were calculated using linear regression and Mantel-Haenszel X(2). RESULTS Data of 67395 subjects (men 49,904, women 17,491) aged 51 ± 12 years were analyzed. Mean levels (mg/dl) were total cholesterol 174.7 ± 45, LDL cholesterol 110.7 ± 38, non-HDL cholesterol 132.1 ± 44.8, HDL cholesterol 44.1 ± 10, triglycerides 140.8 ± 99, and total: HDL cholesterol 4.44 ± 1.5. Various dyslipidemias in men/women were total cholesterol ≥200 mg/dl 25.4/36.4%, LDL cholesterol ≥130 mg/dl 28.1/35.0% and ≥100 mg/dl 54.4/66.4%, non-HDL cholesterol ≥160 mg/dl 25.5/29.6%, HDL cholesterol <40/50 mg/dl 54.4/64.4%, and triglycerides ≥150 mg/dl 34.0/26.8%. Cholesterol lipoproteins declined over 7 years with greater decline in men versus women for cholesterol (Blinear regression = -0.82 vs. -0.33, LDL cholesterol (-1.01 vs. -0.65), non-HDL cholesterol (-0.88 vs. -0.52), and total: HDL cholesterol (-0.02 vs. -0.01). In men versus women there was greater decline in prevalence of hypercholesterolemia (X(2) trend 74.5 vs. 1.60), LDL cholesterol ≥130 mg/dl (X(2) trend 415.5 vs. 25.0) and ≥100 mg/dl (X(2) trend 501.5 vs. 237.4), non-HDL cholesterol (X(2) trend 77.4 vs. 6.85), total: HDL cholesterol (X(2) trend 212.7 vs. 10.5) and high triglycerides (X(2) trend 10.8 vs. 6.15) (P < 0.01). Use of statins was in 2.6% (36/1405) in 2008 and 9.0% (228/2527) in 2014 (P < 0.01). Statin use was significantly lower in women (5.8%) than men (10.3%). CONCLUSIONS In a large hospital - database we observed greater hypercholesterolemia and low HDL cholesterol in women. Mean levels and prevalence of high total, LDL, non-HDL and total: HDL cholesterol declined over 7 years. A lower decline was observed in women. This was associated with lower use of statins.
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Affiliation(s)
- Rajeev Gupta
- Department of Internal Medicine, Fortis Escorts Hospital, Jaipur, Rajasthan, India
| | - Madhawi Sharma
- Department of Laboratory Medicine, Fortis Escorts Hospital, Jaipur, Rajasthan, India
| | - Neeraj Krishna Goyal
- Department of Laboratory Medicine, Fortis Escorts Hospital, Jaipur, Rajasthan, India
| | - Preeti Bansal
- Department of Laboratory Medicine, Fortis Escorts Hospital, Jaipur, Rajasthan, India
| | - Sailesh Lodha
- Department of Endocrinology, Fortis Escorts Hospital, Jaipur, Rajasthan, India
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Regensteiner JG, Golden S, Huebschmann AG, Barrett-Connor E, Chang AY, Chyun D, Fox CS, Kim C, Mehta N, Reckelhoff JF, Reusch JEB, Rexrode KM, Sumner AE, Welty FK, Wenger NK, Anton B. Sex Differences in the Cardiovascular Consequences of Diabetes Mellitus: A Scientific Statement From the American Heart Association. Circulation 2015; 132:2424-47. [PMID: 26644329 DOI: 10.1161/cir.0000000000000343] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
Reports from recent studies suggest that diabetes confers a higher risk of cardiovascular disease in women compared to men. Larger studies, including meta-analyses, report that women with diabetes have a 44 % greater risk of incident coronary heart disease and a 27 % greater risk of incident stroke compared to men with diabetes. In this article, we summarize results from longitudinal studies that examine sex differences in risk factors for and rates of macrovascular complications from diabetes. We also discuss possible mechanisms for increased cardiovascular risk associated with diabetes in women compared to men, including the clustering of hypertension, obesity, and elevated triglycerides, the possible contribution of hormonal differences, and sex differences in the prescription of and adherence to pharmacologic treatment. In conclusion, diabetes is associated with a slightly higher risk of cardiovascular disease in women compared to men. Future studies should further explore the reasons underlying imperfect use of medications that lower cardiovascular risk in both women and men with diabetes.
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Affiliation(s)
- Amanda Lyon
- Department of Medicine, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Elizabeth A Jackson
- Department of Medicine, Division of Cardiovascular Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48106, USA.
| | - Rita R Kalyani
- Department of Medicine, Johns Hopkins University, 1830 E Monument St # 333, Baltimore, MD, 21287, USA.
| | - Dhananjay Vaidya
- Department of Medicine, Johns Hopkins University, 1830 E Monument St # 333, Baltimore, MD, 21287, USA.
| | - Catherine Kim
- Departments of Medicine, Obstetrics & Gynecology, and Epidemiology, University of Michigan, 2800 Plymouth Road, Building 16, Room 430W, Ann Arbor, MI, 48109, USA.
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Goldstein KM, Melnyk SD, Zullig LL, Stechuchak KM, Oddone E, Bastian LA, Rakley S, Olsen MK, Bosworth HB. Heart matters: Gender and racial differences cardiovascular disease risk factor control among veterans. Womens Health Issues 2015; 24:477-83. [PMID: 25213741 DOI: 10.1016/j.whi.2014.05.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 05/29/2014] [Accepted: 05/29/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the leading cause of mortality for U.S. women. Racial minorities are a particularly vulnerable population. The increasing female veteran population has an higher prevalence of certain cardiovascular risk factors compared with non-veteran women; however, little is known about gender and racial differences in cardiovascular risk factor control among veterans. METHODS We used analysis of variance, adjusting for age, to compare gender and racial differences in three risk factors that predispose to CVD (diabetes, hypertension, and hyperlipidemia) in a cohort of high-risk veterans eligible for enrollment in a clinical trial, including 23,955 men and 1,010 women. FINDINGS Low-density lipoprotein (LDL) values were higher in women veterans than men with age-adjusted estimated mean values of 111.7 versus 97.6 mg/dL (p < .01). Blood pressures (BPs) were higher among African-American than White female veterans with age-adjusted estimated mean systolic BPs of 136.3 versus 133.5 mmHg, respectively (p < .01), and diastolic BPs of 82.4 versus 78.9 mmHg (p < .01). African-American veterans with diabetes had worse BP, LDL values, and hemoglobin A1c levels, although the differences were only significant among men. CONCLUSIONS Female veterans have higher LDL cholesterol levels than male veterans and African-American veterans have higher BP, LDL cholesterol, and A1c levels than Whites after adjusting for age. Further examination of CVD gender and racial disparities in this population may help to develop targeted treatments and strategies applicable to the general population.
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Affiliation(s)
- Karen M Goldstein
- Center of Excellence for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina; Ambulatory Care Services, Durham Veterans Affairs Medical Center, Durham, North Carolina; Division of General Internal Medicine, Duke University, Durham, North Carolina.
| | - S Dee Melnyk
- Center of Excellence for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina; Ambulatory Care Services, Durham Veterans Affairs Medical Center, Durham, North Carolina; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Leah L Zullig
- Center of Excellence for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina; Department of Health Policy and Management, University of North Carolina, Chapel Hill, North Carolina
| | - Karen M Stechuchak
- Center of Excellence for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Eugene Oddone
- Center of Excellence for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina; Ambulatory Care Services, Durham Veterans Affairs Medical Center, Durham, North Carolina; Division of General Internal Medicine, Duke University, Durham, North Carolina
| | - Lori A Bastian
- VA Connecticut Healthcare System, Newington, Connecticut; University of Connecticut Health Center, Farmington, Connecticut
| | - Susan Rakley
- Ambulatory Care Services, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Maren K Olsen
- Center of Excellence for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Hayden B Bosworth
- Center of Excellence for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina; Division of General Internal Medicine, Duke University, Durham, North Carolina; Departments of Psychiatry and School of Nursing, Duke University, Durham, North Carolina
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24
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Gaisenok O, Martsevich S, Tripkosh S, Lukina Y. Analysis of lipid-lowering therapy and factors affecting regularity of statin intake in patients with cardiovascular disease enrolled in the PROFILE registry. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.repce.2014.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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25
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Analysis of lipid-lowering therapy and factors affecting regularity of statin intake in patients with cardiovascular disease enrolled in the PROFILE registry. Rev Port Cardiol 2015; 34:111-6. [DOI: 10.1016/j.repc.2014.08.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 08/16/2014] [Indexed: 11/23/2022] Open
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26
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Billimek J, Malik S, Sorkin DH, Schmalbach P, Ngo-Metzger Q, Greenfield S, Kaplan SH. Understanding disparities in lipid management among patients with type 2 diabetes: gender differences in medication nonadherence after treatment intensification. Womens Health Issues 2015; 25:6-12. [PMID: 25442365 PMCID: PMC4275363 DOI: 10.1016/j.whi.2014.09.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 09/07/2014] [Accepted: 09/10/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Gender differences in dyslipidemia are widely documented, but the contributors to these differences are not well understood. This study examines whether differences in quality of care, intensity of lipid-lowering medication regimen, and medication adherence can explain this disparity. METHODS Secondary analysis of medical records data and questionnaires collected from adult patients with type 2 diabetes (n = 1,369) from seven outpatient clinics affiliated with an academic medical center as part of the Reducing Racial Disparities in Diabetes: Coached Care (R2D2C2) study. Primary outcome was low-density lipoprotein (LDL) cholesterol. FINDINGS Women had higher LDL cholesterol levels than men (mean [SD], 101.2 [35.2] vs. 92.3 [33.0] mg/dL; p < .001), but were no less likely to receive recommended processes of diabetes care, to attain targets for glycemic control and blood pressure, or to be on intensive medication regimens. More women than men reported medication nonadherence related to cost (32.7% vs. 24.2%; p = .040) and related to side effects (47.2% vs. 36.8%; p = .024). For all patients, regimen intensity (p < .05) and nonadherence related to side effects (p < .01) were each associated with higher LDL cholesterol levels. The addition of a new lipid-lowering agent was associated with subsequent nonadherence related to side effects for women (p < .001), but not for men (p = .45; test for interaction p = .048). CONCLUSIONS Despite comparable quality of diabetes care and regimen intensity for lipid management, women with diabetes experienced poorer lipid control than men. Medication nonadherence seemed to be a major contributor to dyslipidemia, particularly for women because of side effects associated with intensifying the lipid-lowering regimen.
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Affiliation(s)
- John Billimek
- Health Policy Research Institute, School of Medicine, University of California, Irvine, California; Department of Medicine, School of Medicine, University of California, Irvine, California.
| | - Shaista Malik
- Division of Cardiology, Department of Medicine, School of Medicine, University of California, Irvine, California
| | - Dara H Sorkin
- Health Policy Research Institute, School of Medicine, University of California, Irvine, California; Department of Medicine, School of Medicine, University of California, Irvine, California
| | - Priel Schmalbach
- School of Social Ecology, University of California, Irvine, California; School of Medicine, University of California, Irvine, California
| | - Quyen Ngo-Metzger
- Health Policy Research Institute, School of Medicine, University of California, Irvine, California; Department of Medicine, School of Medicine, University of California, Irvine, California
| | - Sheldon Greenfield
- Health Policy Research Institute, School of Medicine, University of California, Irvine, California; Department of Medicine, School of Medicine, University of California, Irvine, California
| | - Sherrie H Kaplan
- Health Policy Research Institute, School of Medicine, University of California, Irvine, California; Department of Medicine, School of Medicine, University of California, Irvine, California
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27
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Bielawski MP, Goldstein KM, Mattocks KM, Bean-Mayberry B, Yano EM, Bastian LA. Improving care of chronic conditions for women veterans: identifying opportunities for comparative effectiveness research. J Comp Eff Res 2014; 3:155-66. [PMID: 24645689 DOI: 10.2217/cer.14.4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This article aims to critically analyze research focused on the findings for five chronic conditions: chronic pain, diabetes, cardiovascular disease, HIV and cancer among women veterans to identify opportunities for comparative effectiveness research. We provide a descriptive analysis from the relevant articles in prior systematic reviews. In order to identify potential gaps in research for these specific conditions, we also conducted a literature search to highlight studies focusing on women veterans published since the last systematic review. While the scientific knowledge base has grown for these chronic conditions among women veterans, the vast majority of the published literature remains descriptive and/or observational, with only a few studies examining gender differences and even fewer clinical trials. There is a need to conduct comparative effectiveness research on chronic conditions among women veterans to improve health and healthcare.
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Affiliation(s)
- Mark P Bielawski
- Center of Excellence, VA Connecticut Healthcare System, Newington, CT, USA
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28
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Bastian LA, Bosworth HB, Washington DL, Yano EM. Setting the stage: Research to inform interventions, practice and policy to improve women veterans' health and health care. J Gen Intern Med 2013; 28 Suppl 2:S491-4. [PMID: 23807053 PMCID: PMC3695276 DOI: 10.1007/s11606-013-2470-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Lori A. Bastian
- />VA Connecticut Healthcare System, University of Connecticut Health Center, 555 Willard Avenue, Newington, CT 06011 USA
| | | | - Donna L. Washington
- />VA Greater Los Angeles Healthcare System, UCLA School of Medicine, Los Angeles, CA USA
| | - Elizabeth M. Yano
- />VA Greater Los Angeles Healthcare System, UCLA School of Public Health, Los Angeles, CA USA
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