Prospective analysis of LDL-C goal achievement and self-reported medication adherence among statin users in primary care

Exploring barriers and facilitators of primary care physicians towards optimising statin therapy in patients with hyperlipidaemia in the very high-risk group: a qualitative study in Singapore

OBJECTIVES

To explore the perspectives of primary care physicians with regard to the barriers and facilitators towards optimising statin therapy in patients with hyperlipidaemia in the very high-risk group.

DESIGN

Qualitative descriptive study.

SETTING

Four polyclinics in a public primary care institution in Singapore.

PARTICIPANTS

Seven men and five women working as primary care physicians were recruited for in-depth interviews.

RESULTS

The major barriers to statin optimisation identified were patients' lack of knowledge and awareness, patients' fear of side effects, negative external influences on patients, poor doctor-patient relationship, time constraint during consultations, physicians' unfamiliarity with guidelines, low health literacy among the local population and lack of strong national policy. The major facilitators identified were patient education, providing continuity of care, improving electronic medical record systems' capabilities, physician education and public education.

CONCLUSION

We identified several important barriers and facilitators of statin therapy optimisation in this study. This information offers insights into the development of a multipronged approach to address barriers across different levels with the aim of optimising statin use, reducing cardiovascular events and improving patient outcomes.

Statin adherence in patients with high cardiovascular risk: a cross-sectional study

OBJECTIVES

Statin adherence is an essential problem although lifetime medication is recommended especially in patients with high cardiovascular risk. The importance of perceived risk as a predictor of adherence among cardiology patients has not been fully explored. This study aimed to test the importance of perceived risk as a predictor of statin adherence amongst hypercholesterolemic patients to identify predictors associated with poor adherence.

METHODS

This cross-sectional study was conducted at cardiology outpatient clinics of the University hospital in Ankara, Turkey. A total of 327 consecutive patients with high CV risk were recruited. Self-reported Morisky Green Levine Medication Adherence Scale was used to assess statin adherence.

RESULTS

Of the patients studied, 34.5% had concerns about side effects. Also, the mean age was 63.85 ± 11.29 years, 66.1% were men, 32.4% applied non-drug alternative therapies, 53.2% had a Mediterranean-style diet and 20.8% checked their lipid values irregularly. Participants reported 50.2% high, 30% moderate, and 19.9% low statin medication adherence. Low-density lipoprotein cholesterol (LDL-C), Total Cholesterol (TC), Triglyceride (TG) and high-density lipoprotein (HDL) control rates were 44.6%, 74.3%, 61.5% and 41.6%. On multiple logistic regression, concern about side effects was associated with a statistically significant quadruple elevation of odds of non-adherence. Also, being male, former smokers, not having complementary interventions, having regular visits, being educated for more than 5 years, having low depressive symptom scores, living in a rural, being never or former smokers, employee were significant predictors of high medication adherence scores.

CONCLUSION

Approximately half of the patients reported high medication adherence. Proper strategies to improve adherence would include patient education efforts focused on patients with concerns about side effects and those who are female, less educated, current smokers, interested in complementary interventions, have irregular follow-up visits, and have depressive symptoms. Brief medication adherence scales may facilitate the assessment of patients' adherence.

Patient-Reported Reasons for Switching or Discontinuing Statin Therapy: A Mixed Methods Study Using Social Media

Introduction

Statin discontinuation can have major negative health consequences. Studying the reasons for discontinuation can be challenging as traditional data collection methods have limitations. We propose an alternative approach using social media.

Methods

We used natural language processing and machine learning to extract mentions of discontinuation of statin therapy from an online health forum, WebMD (http://www.webmd.com). We then extracted data according to themes and identified key attributes of the people posting for themselves.

Results

We identified 2121 statin reviews that contained information on discontinuing at least one named statin. Sixty percent of people posting declared themselves as female and the most common age category was 55–64 years. Over half the people taking statins did so for < 6 months. By far the most common reason given (90%) was patient experience of adverse events, the most common of which were musculoskeletal and connective tissue disorders. The rank order of adverse events reported in WebMD was largely consistent with those reported to regulatory agencies in the US and UK. Data were available on age, sex, duration of statin use, and, in some instances, adverse event resolution and rechallenge. In some instances, details were presented on resolution of the adverse event and rechallenge.

Conclusion

Social media may provide data on the reasons for switching or discontinuation of a medication, as well as unique patient perspectives that may influence continuation of a medication. This information source may provide unique data for novel interventions to reduce medication discontinuation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40264-022-01212-0.

Would You Recommend a Statin to This Patient for Primary Prevention of Cardiovascular Disease? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Cardiovascular disease (CVD) is the leading cause of death in the United States. Hypercholesterolemia is a principal modifiable risk factor for the primary prevention of CVD. In addition to lifestyle modification, statins are an important tool to reduce risk for CVD in selected patients. A useful strategy to identify candidates for statins is to estimate the 10-year risk for CVD through the use of a validated risk calculator. Commonly used calculators include the Framingham risk score and the pooled cohort equation. Multiple randomized controlled trials have shown that statins reduce the risk for CVD in patients without known CVD. Two recent guidelines have proposed an approach to the use of statins in primary prevention of CVD. The American College of Cardiology/American Heart Association and the U.S. Department of Veterans Affairs guidelines form the basis for this discussion. The guidelines differ on the use of advanced testing to modify the 10-year CVD risk estimate and on the need for low-density lipoprotein cholesterol targets to establish the efficacy of statins. Advanced testing with coronary artery calcium measurement may be helpful for patients who are potentially eligible for statin therapy but who are uncertain if they wish to take a statin. In this paper, 2 experts, a preventive cardiologist and a general internist, discuss their approach to the use of statins for primary prevention of CVD and how they would apply the guidelines to an individual patient.

The relationship between directly measured statin adherence, self-reported adherence measures and cholesterol levels in patients with coronary heart disease

BACKGROUND AND AIMS

We aimed to determine the relationship between statin adherence measured directly, and by self-report measures and serum cholesterol levels.

METHODS

Patients prescribed atorvastatin (N = 373) participated in a cross-sectional study 2-36 months after a coronary event. Self-reported adherence included statin adherence the past week, the 8-item Morisky medication adherence scale (MMAS-8), and the Gehi et al. adherence question. Atorvastatin was measured directly in spot blood plasma by a novel liquid chromatography tandem mass-spectrometry method discriminating adherence (0-1 doses omitted) and reduced adherence (≥2 doses omitted). Participants were unaware of the atorvastatin analyses at study participation.

RESULTS

Mean age was 63 (SD 9) years and 8% had reduced atorvastatin adherence according to the direct method. In patients classified with reduced adherence by the direct method, 40% reported reduced statin adherence, 32% reported reduced adherence with the MMAS-8 and 22% with the Gehi question. In those adherent by the direct method, 96% also reported high statin adherence, 95% reported high adherence on the MMAS-8 whereas 94% reported high adherence on the Gehi question. Cohen's kappa agreement score with the direct method was 0.4 for self-reported statin adherence, 0.3 for the Gehi question and 0.2 for the MMAS-8. Adherence determined by the direct method, self-reported statin adherence last week, and the Gehi question was inversely related to LDL-cholesterol levels with a p-value of <0.001, 0.001 and 0.004, respectively.

CONCLUSIONS

Plasma-statin measurements reveal reduced adherence with higher sensitivity than self-report measures, relate to cholesterol levels, and may prove to be a useful tool to improve lipid management.

Immigrants, Ethnicity, and Adherence to Secondary Cardiac Prevention Therapy: A Substudy of the ISLAND Trial

Background

The objective of this study was to evaluate adherence to guideline-recommended cardiac secondary prevention therapies by immigration and ethnicity.

Methods

We conducted a retrospective substudy of the Interventions Supporting Long-Term Adherence and Decreasing Cardiovascular Events (ISLAND) randomized controlled trial. A cohort of 1642 participants was analyzed. Patients were categorized based on their self-reported immigrant status as being Canadian or foreign born and based on their visual minority status (as European or a visual minority). We used logistic regression to examine associations between these patient characteristics of interest and patient adherence to statin medication 1 year after myocardial infarction (MI) and completion of cardiac rehabilitation, adjusting for age, sex, and comorbidities.

Results

The dataset included outcome data on 1049 (64%) Canadian-born patients and 593 (36%) immigrants. There were 347 (21%) who identified as a visual minority. We report a nonsignificant trend in statin adherence 1 year after MI favouring foreign-born participants compared with Canadian-born participants (odds ratio [OR], 1.26; 95% confidence interval [CI], 0.91-1.68). Visual minorities were found to have no significant difference in statin adherence 1 year after MI compared with participants of European ethnicity (OR, 1.04; 95% CI, 0.72-1.51). Neither immigration status (OR, 0.91; 95% CI, 0.72-1.15) nor visual minority status (OR, 0.97; 95% CI, 0.73-1.28) were associated with cardiac rehabilitation completion.

Conclusions

Our findings offer limited support that immigrants with > 10 years of Canadian residency exposure experience greater adherence to statins 1 year after MI. Further research is required to better inform our understanding of secondary prevention strategy among immigrant populations.

Cross-Cultural Adaptation and Lingual Validation of the Beliefs about Medicines Questionnaire (BMQ)-Specific for Cholesterol Lowering Drugs in the Visegrad Countries

The goal of this study was to translate the Beliefs about Medicines Questionnaire-Specific (BMQ-Specific) for cholesterol-lowering drugs, into the Hungarian, Slovak, Czech and Polish languages and test their reliability with statistical methods. For this purpose, Cronbach's alpha, confirmatory and exploratory factor analyses were conducted. The analyses included 235 Czech, 205 Hungarian, 200 Polish, and 200 Slovak respondents, all of whom were taking cholesterol-lowering drugs. The translations from English into the target languages were always done by two independent translators. As part of the validation process these translations were pilot tested and after the necessary alterations, they were translated back into English by a third translator. After the approval by the creator of the questionnaire, nationwide surveys were conducted in all four countries. The results of the confirmatory factor analysis were exceptionally good for the Czech and Slovak translations, while the Polish and Hungarian translations marginally crossed the predetermined thresholds. With the exception of a single Polish question, the results of the exploratory factor analysis were deemed acceptable. The translated versions of BMQ-Specific are reliable and valid tools to assess patients' beliefs about medication, especially medication adherence among patients taking cholesterol-lowering medication. A comparison between the four countries with this questionnaire is now possible.

Evidence to Support Inclusion of Pharmacogenetic Biomarkers in Randomised Controlled Trials

Pharmacogenetics and biomarkers are becoming normalised as important technologies to improve drug efficacy rates, reduce the incidence of adverse drug reactions, and make informed choices for targeted therapies. However, their wider clinical implementation has been limited by a lack of robust evidence. Suitable evidence is required before a biomarker's clinical use, and also before its use in a clinical trial. We have undertaken a review of five pharmacogenetic biomarker-guided randomised controlled trials (RCTs) and evaluated the evidence used by these trials to justify biomarker inclusion. We assessed and quantified the evidence cited in published rationale papers, or where these were not available, obtained protocols from trial authors. Very different levels of evidence were provided by the trials. We used these observations to write recommendations for future justifications of biomarker use in RCTs and encourage regulatory authorities to write clear guidelines.

A Personalized Care Plan Is Positively Associated With Better Clinical Outcomes in the Care of Patients With Type 2 Diabetes: A Cross-Sectional Real-Life Study

OBJECTIVES

Our aim in this study was to determine whether the use of a personalized care plan is associated with better clinical outcomes of type 2 diabetes treatment in the real world.

METHODS

Quality of treatment was assessed using data from a yearly sample of patients with type 2 diabetes visiting primary care health centres in 2012-2016. Patients were divided into 3 groups as follows: 1) the patient has a copy of their personalized care plan, 2) the care plan exists in the patient record only or 3) the patient has no care plan. Data on smoking, laboratory tests, systolic blood pressure (sBP) and statin use were collected. We compared the outcomes between the 3 groups in terms of proportions of patients achieving the clinical targets recommended by international guidelines.

RESULTS

Evaluable data were available for 10,403 patients. Of these, 1,711 (16%) had a copy of their personalized care plan, and 3,623 (35%) had no care plan. Those patients who had a copy of their care plan were significantly more likely than those without to achieve the sBP target (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.29 to 1.51; p<0.001; adjusted for age and gender) and low-density lipoprotein target (OR, 1.46; 95% CI, 1.34 to 1.58; p<0.001), and to use statins (OR, 1.70; 95% CI, 1.57 to 1.85; p<0.001).

CONCLUSIONS

Patients who had a copy of their care plan had a better control of sBP and low-density lipoprotein, and were more likely to use statins than patients without a care plan.

Association of medication adherence and depression with the control of low-density lipoprotein cholesterol and blood pressure in patients at high cardiovascular risk

BACKGROUND

Many patients at high cardiovascular risk do not reach targets for low-density lipoprotein cholesterol (LDL-C) and blood pressure (BP). Depression is a frequent comorbidity in these patients and contributes to poor medication adherence.

OBJECTIVE

The aim of this study was to elucidate the associations between adherence to lipid-and BP-lowering drugs, the diagnosis of depression, and the control of LDL-C and BP.

PATIENTS AND METHODS

This study was conducted as multicenter, single-visit cross-sectional study in Germany. Adherence was assessed by the Morisky Medication Adherence Scale-8 (MMAS-8), and depression was assessed as documented in the patient chart.

RESULTS

A total of 3,188 ambulatory patients with hypercholesterolemia (39.8%), stable coronary artery disease (CAD; 7.4%), or both (52.9%) were included. Patients had a history of myocardial infarction (30.8%), diabetes (42.0%), were smokers (19.7%), and 16.1% had the investigator-reported diagnosis of depression. High or moderate adherence to lipid-lowering medication compared to low adherence was associated with lower LDL-C levels (105.5±38.3 vs 120.8±42.4 mg/dL) and lower BP (systolic BP 133.4±14.5 vs 137.9±13.9 mmHg, diastolic BP 78.3±9.6 vs 81.8±9.6 mmHg) and with a higher proportion of patients achieving the guideline-recommended LDL-C (16.9% vs 10.1%) and BP target (52.2% vs 40.8%, all comparisons P<0.0001). Adherence was worse in patients with depression. Correspondingly, patients with depression showed higher LDL-C levels, higher BP, and a lower probability of achieving the LDL-C and BP goal. Medication adherence correlated between BP- and lipid-lowering medications.

CONCLUSION

Self-reported medication adherence can be easily obtained in daily practice. A low adherence and the diagnosis of depression identify patients at risk for uncontrolled LDL-C and BP who likely benefit from intensified care.

Nonadherence to statins: individualized intervention strategies outside the pill box

Poor adherence to statin therapy is linked to significantly increased risk of cardiovascular events and death. Unfortunately, adherence to statins is far from optimal. This is an alarming concern for patients prescribed potentially life-saving cholesterol-lowering medication, especially for those at high risk of cardiovascular events. Research on statin adherence has only recently garnered broader attention; hence, major reasons unique to adherence to statin therapy need to be identified as well as suggestions for countermeasures. An integrated approach to minimizing barriers and enhancing facilitation at the levels of the patient, provider, and health system can help address adherence issues. Health care professionals including physicians, pharmacists, and nurses have an obligation to improve patient adherence, as routine care. In order to achieve sustained results, a multifaceted approach is indispensable.

Association Between Adherence to Statins, Illness Perception, Treatment Satisfaction, and Quality of Life among Lebanese patients

OBJECTIVES

The main objective of this study was to evaluate treatment adherence to statin and health-related quality of life (QOL) in Lebanese patients with dyslipidemia. Secondary objectives were to examine associations between treatment adherence, QOL, treatment satisfaction, and illness perception.

METHODS

This cross-sectional study, conducted in 20 community pharmacies from all districts of Lebanon between August 2016 and April 2017, enrolled 247 adult patients taking any statin.

RESULTS

The mean age of the participants was 52.63 ± 11.92 years (57.5% males); the mean duration of treatment with a statin was 59.72 months. A significant association was found between adherence and marital status ( P < .0001), educational level ( P = .001), cigarette smoking ( P < .0001), and alcohol drinking ( P < .0001). A negative but significant correlation was found between the adherence score and the duration of dyslipidemia ( r = -0.199). A significant but negative correlation was also found between the side effect score and age ( r = -0.137). The monthly salary, the marital status, the educational level, smoking cigarettes or waterpipes, and drinking alcohol were all associated with the Illness Perception Questionnaire scores ( P < 0.0001 for all variables). Secondary level of education (β = 13.43), smoking more than 3 waterpipes per week (β = 14.06), global satisfaction score (β = 0.32), convenience score (β = 0.29), and effectiveness score (β = 0.27) would significantly increase the adherence score. Smoking more than 15 cigarettes per day (β = -11.15) and a divorced status (β = -14.81) would however significantly decrease the adherence score. Significant associations were found between the illness perception score, the QOL domains, and the satisfaction domains ( P < .05 for all variables).

CONCLUSION

This study showed that global satisfaction with treatment, convenience, and effectiveness are important factors that increase treatment adherence. Patient adherence results in patient satisfaction and improved QOL and is an important criterion for achieving desired therapeutic outcomes.

Motivational Interviewing and Medication Review in Coronary Heart Disease (MIMeRiC): Protocol for a Randomized Controlled Trial Investigating Effects on Clinical Outcomes, Adherence, and Quality of Life

BACKGROUND

Preventive treatment goals for blood pressure and cholesterol levels continue to be unmet for many coronary patients. The effect of drug treatment depends on both its appropriateness and the patients' adherence to the treatment regimen. There is a need for adherence interventions that have a measurable effect on clinical outcomes.

OBJECTIVE

This study aims to evaluate the effects on treatment goals of an intervention designed to improve patient adherence and treatment quality in secondary prevention of coronary heart disease. A protocol for the prespecified process evaluation of the trial is published separately.

METHODS

The Motivational Interviewing and Medication Review in Coronary heart disease (MIMeRiC) trial is a prospective, randomized, outcomes-blinded trial designed to compare individualized follow-up by a clinical pharmacist using motivational interviewing (MI) and medication review with standard follow-up. Patients were randomized to 2 groups after stratification according to their beliefs about medicines. After standard follow-up at the cardiology clinic, patients in the intervention group are seen individually by a clinical pharmacist 2 to 5 times as required over 7 months, at the clinic. The pharmacist reviews each patient's medication and uses MI to manage any problems with prescribing and adherence. The primary study outcome is the proportion of patients who have reached the treatment goal for low-density lipoprotein cholesterol by 12 months after discharge. Secondary outcomes are the effects on patient adherence, systolic blood pressure, disease-specific quality of life, and health care use.

RESULTS

The protocol for this study was approved by the Regional Ethics Committee, Linköping, in 2013. Enrollment started in October 2013 and ended in December 2016 when 417 patients had been included. Follow-up data collection will conclude in March 2018. Publication of the primary and secondary outcome results from the MIMeRiC trial is anticipated in 2019.

CONCLUSIONS

The MIMeRiC trial will assess the effectiveness of an intervention involving medication reviews and individualized support. The results will inform the continued development of support for this large group of patients who use preventive medicines for lifelong treatment. The design of this adherence intervention is based on a theoretical framework and is the first trial of an intervention that uses beliefs about medicines to individualize the intervention protocol.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02102503; https://clinicaltrials.gov/ct2/show/NCT02102503 (Archived by WebCite at http://www.webcitation.org/6x7iUDohy).

Patient-reported adherence to statin therapy, barriers to adherence, and perceptions of cardiovascular risk

BACKGROUND

Patient reports of their adherence behaviors, concerns about statins, and perceptions of atherosclerotic cardiovascular disease (ASCVD) risk could inform approaches for improving adherence to statin therapy. We examined these factors and their associations with adherence.

METHODS

We conducted telephone interviews among a stratified random sample of adults receiving statins within an integrated delivery system (N = 730, 81% response rate) in 2010. We sampled equal numbers of individuals in three clinical risk categories: those with 1) coronary artery disease; 2) diabetes or other ASCVD diagnosis; and 3) no diabetes or ASCVD diagnoses. We assessed 15 potential concerns about and barriers to taking statins, and perceived risk of having a heart attack in the next 10 years (0-10 scale). We calculated the proportion of days covered (PDC) by statins in the last 12 months using dispensing data and used multivariate logistic regression to examine the characteristics associated with non-adherence (PDC<80%). Analyses were weighted for sampling proportions.

RESULTS

Sixty-one percent of patients with PDC<50% reported not filling a new prescription, splitting or skipping statins, or stopping refilling statins in the last 12 months vs. 15% of those with PDC≥80% (p<0.05). The most commonly reported concerns about statins were preferring to lower cholesterol with lifestyle changes (66%), disliking medications in general (59%), and liver or kidney problems (31%); having trouble remembering to take statins (9%) was the most common reason for taking less than prescribed. In multivariate analyses, clinical risk categories were not significantly associated with odds of non-adherence; however, those with higher perceived risk of heart attack were less likely to be non-adherent.

CONCLUSIONS

Patient-reported medication-taking behaviors were correlated with statin PDC and those with lower perceived cardiovascular risk were less likely to be adherent. These findings highlight the importance of eliciting from and educating patients on their adherence behaviors and ASCVD risks.

Achievement of LDL Cholesterol Goal and Adherence to Statin by Diabetes Patients in Kelantan

BACKGROUND

Statins are a class of potent drugs that can be used to reduce cholesterol, especially low-density lipoprotein cholesterol (LDL-C). However, their effectiveness is limited if adherence to treatment is poor. The objectives of the study are to estimate the proportion of diabetic patient who has achieved LDL-C goal and to determine the association of LDL-C achievement with socio demographic factors and statin therapy adherence.

METHODS

This is a cross-sectional study involving 234 patients with type 2 diabetes mellitus (T2DM) and dyslipidaemia attending an outpatient clinic in a hospital in Kelantan. Interviews and self-administered questionnaires were used to determine their sociodemographic and clinical characteristics. Adherence to therapy was assessed using the Medication Compliance Questionnaire (MCQ). The associations between the achievement of LDL targets and sociodemographic/clinical factors, including adherence, were analysed with simple logistic regression.

RESULTS

About 37.6% of patients achieved their LDL-C target. The percentage of patients who adhered to statin use was 98.3%, and 20.5% of these patients reported full adherence. There was no significant association between achievement of LDL-C targets with adherence or any other sociodemographic factors, such as age, gender and educational or economic status (all P-value < 0.05).

CONCLUSION

Despite a high level of adherence, the majority of patients failed to achieve LDL-C targets. More concerted efforts are needed to improve this.

Lipid-lowering treatment modifications among patients with hyperlipidemia and a prior cardiovascular event: a US retrospective cohort study

BACKGROUND

Numerous studies demonstrate that, even with use of statins, many patients are unable to meet their LDL-C goals. This study examined modifications to statin and/or ezetimibe therapy among patients with hyperlipidemia and prior history of cardiovascular (CV) events in a US commercially insured population.

METHODS

Adults (age ≥18 years) initiating statins and/or ezetimibe between 1 January 2007 and 31 December 2008 were identified from HealthCore Integrated Research Database. The index date was the initiation date of statins and/or ezetimibe. All patients had ≥1 medical claims related to myocardial infarction, unstable angina, ischemic stroke, transient ischemic attack, coronary artery bypass graft, or percutaneous coronary intervention within 12 months prior to the index date. Treatment modifications to statins and/or ezetimibe initiated on the index date (index therapy) included permanent discontinuation of any lipid lowering therapy (LLT), rechallenge, switching, subtraction, augmentation, and dose changes.

RESULTS

Among 17,902 patients, around 90% initiated with statin monotherapy, followed by statin and ezetimibe combination (3.0%: 18-64 years; 3.8%: ≥65 years). Ten percent or less initiated on high intensity statins. Most common treatment modifications were rechallenging index therapy (25.2%: 18-64 years, 27.0%: ≥65 years), switching (27.5%: 18-64 years, 24.6%: ≥65 years), and permanent discontinuation of any LLT (18.6%: 18-64 years, 21.0%: ≥65 years). Only 10% of patients in both groups underwent dose escalation.

CONCLUSIONS

Real-world evidence indicates that few high-risk patients initiate therapy with high-intensity statins. More than 50% of patients underwent a rechallenge or switching. Despite high CVD risk profile, approximately 20% of patients permanently discontinued any LLT. Key limitations: Pharmacy claims do not provide information on whether patients who had a pharmacy fill actually took the medication as prescribed. It is unknown whether rechallenge was a simple delay in filling a prescription or an actual rechallenge of their index therapy. Reasons for treatment discontinuations or modifications were unavailable in claims data.

Insurance, self-reported medication adherence and LDL cholesterol: The REasons for Geographic And Racial Differences in Stroke study

BACKGROUND

Lack of health insurance may adversely impact medication adherence and the control of cardiovascular risk factors. We examined if the association between insurance and LDL-C is due to self-reported low medication adherence.

METHODS

This cross-sectional study included 8685 black and white men and women aged 45 and older who participated in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort and used statins. Medication adherence was assessed using the 4-item Morisky Medication Adherence Scale (MMAS-4). Mean differences in LDL-C between participants with and without insurance were calculated using generalized linear models before and after adjustment for MMAS-4. Subgroups stratified by age, annual household income, diabetes, and CHD were compared. Separately, individual MMAS-4 questions were examined for mediation effects.

RESULTS

After multivariable adjustment but without MMAS-4, LDL-C was 2.5mg/dL (95% CI -0.6, 5.6) higher among uninsured versus insured participants. After further adjustment for MMAS-4, LDL-C was 2.6mg/dL (95% CI -0.5, 5.6) higher. Stratified analyses produced similar results. No mediating effect was observed when each MMAS-4 question was examined separately.

CONCLUSION

High medication adherence does not mediate the association between having health insurance and lower LDL-C.

Increasing the Detection of Familial Hypercholesterolaemia Using General Practice Electronic Databases

BACKGROUND

Familial hypercholesterolaemia (FH) is a common autosomal co-dominant condition that causes premature cardiovascular disease. Awareness of FH is poor and only 10-15% of the affected population is identified. Electronic health records provide an opportunity to increase detection and awareness in general practice OBJECTIVE: To determine whether a simple electronic extraction tool can increase detection of FH in general practice.

METHOD

An extraction tool applied to general practice electronic health records (EHR) to screen for FH, total cholesterol and low density lipoprotein cholesterol (LDL-c) levels in association with entered diagnostic criteria and demographic data in five general practices.

RESULTS

Of 157,290 active patients examined, 0.7% (n=1081) had an LDL-c>5.0 mmol/L representing 1 in 146 of active patients. An additional 0.8% (n=1276) patients were at possible risk of FH. Of those with an LDL-c>5.0 mmol/L 43.7% of patients had no record of being prescribed statins. Twenty patients (0.013%) had a clinical diagnosis of FH entered in the EHR.

CONCLUSIONS

Patients at high risk of FH can be identified by a simple electronic screening method in general practice. Clinical data entry is variable in general practice. Targeted screening enables clinical assessment of patients at risk of cardiovascular disease and using the DLCNS will enable primary care to increase identification of FH. Approximately one in five patients extracted using this method, are likely to have phenotypically probable FH, making it a useful screening tool.

The OPTIMIZE trial: Rationale and design of a randomized controlled trial of motivational enhancement therapy to improve adherence to statin medication

BACKGROUND

Statins are a class of medications that are particularly effective for lowering cholesterol and reducing cardiovascular morbidity and mortality. Despite a range of benefits, non-adherence to statin medication is prevalent with 50% to 75% of patients failing to adhere to treatment within the first 2-years. A previous review on interventions to improve adherence to cholesterol lowering medication concluded that rigorous trials were needed with emphasis on the patient's perspective and shared decision making. Motivational interviewing (MInt) is a promising patient-centered approach for improving adherence in patients with chronic diseases. This manuscript describes the rational and design of a randomized controlled trial (RCT) testing the efficacy of MInt in improving adherence to statin medication.

METHODS

Patients filling their first statin prescription will be recruited to complete a 6-month observation run-in period (phase-1) after which medication possession ratio (MPR) will be assessed. Patients meeting criteria for non-adherence (MPR≤60%) will be invited to participate in the trial. 336 non-adherent new statin users will undergo a fasting lipid panel, complete baseline questionnaires, and be randomly allocated to receive four sessions of adherence education delivered using MInt (EdMInt) or to an education control (EC) delivered at 3-month intervals. Final assessments will occur 12-months after the first EdMInt or EC session. The primary outcome is change in MPR adherence to statin medication from baseline to 12-months. Secondary outcomes include within-patient change in self-reported medication adherence, stage of change and self-efficacy for medication adherence, motivation to adhere to statin medication, and lipid profile.

Low-density lipoprotein cholesterol of less than 70 mg/dL is associated with fewer cardiovascular events in acute coronary syndrome patients: a real-life cohort in Thailand

BACKGROUND

Elevated low-density lipoprotein cholesterol (LDL-C) is associated with an increased risk of cardiovascular disease or mortality; however, the LDL-C goal for therapy in acute coronary syndrome (ACS) patients is controversial and varies among guidelines. This study aimed to assess the effect of reaching an LDL-C goal of <70 mg/dL (<1.8 mmol/L) on first composite cardiovascular outcomes in routine clinical practice in Thailand.

METHODS

A retrospective cohort study was conducted using medical charts and the electronic hospital database of patients diagnosed with ACS and treated with statins at a tertiary care hospital in Thailand between 2009 and 2012. After admission, patients were followed from the date of LDL-C goal assessment until the first event of composite cardiovascular outcomes (nonfatal ACS, nonfatal stroke, or all-cause death). Cox proportional hazard models adjusted for potential confounders were used.

RESULTS

Of 405 patients, mean age was 65 years (60% males). Twenty-seven percent of the patients attained an LDL-C goal of <70 mg/dL, 38% had LDL-C between 70 and 99 mg/dL, and 35% had LDL-C ≥100 mg/dL. Forty-six patients experienced a composite cardiovascular outcome. Compared with patients with an LDL-C ≥100 mg/dL, patients achieving an LDL-C of <70 mg/dL were associated with a reduced composite cardiovascular outcome (adjusted hazard ratio [HR]=0.42; 95% confidence interval [CI]=0.18-0.95; P-value=0.037), but patients with an LDL-C between 70 and 99 mg/dL had a lower composite cardiovascular outcome, which was not statistically significant (adjusted HR=0.73; 95% CI=0.37-1.42; P-value=0.354).

CONCLUSION

ACS patients who received statins and achieved an LDL-C of <70 mg/dL had significantly fewer composite cardiovascular outcomes, confirming "the lower the better" and the benefit of treating to LDL-C target in ACS patient management.

Statin therapy in patients with acute coronary syndrome: low-density lipoprotein cholesterol goal attainment and effect of statin potency

Background

Elevated low-density lipoprotein cholesterol (LDL-C) is associated with an increased risk of coronary artery disease. Current guidelines recommend an LDL-C target of <70 mg/dL (<1.8 mmol/L) for acute coronary syndrome (ACS) patients, and the first-line treatment to lower lipids is statin therapy. Despite current guidelines and the efficacious lipid-lowering agents available, about half of patients at very high risk, including ACS patients, fail to achieve their LDL-C goal. This study assessed LDL-C goal attainment according to use of high and low potency statins in routine practice in Thailand.

Methods

A retrospective cohort study was performed by retrieving data from medical records and the electronic hospital database for a tertiary care hospital in Thailand between 2009 and 2011. Included were ACS patients treated with statins at baseline and with follow-up of LDL-C levels. Patients were divided into high or low potency statin users, and the proportion reaching the LDL-C goal of <70 mg/dL was determined. A Cox proportional hazard model was applied to determine the relationship between statin potency and LDL-C goal attainment. Propensity score adjustment was used to control for confounding by indication.

Results

Of 396 ACS patients (60% males, mean age 64.3±11.6 years), 229 (58%) were treated with high potency statins and 167 (42%) with low potency statins. A quarter reached their target LDL-C goal (25% for patients on high potency statins and 23% on low potency statins). High potency statins were not associated with increased LDL-C goal attainment (adjusted hazards ratio 1.22, 95% confidence interval 0.79–1.88; P=0.363).

Conclusion

There was no significant effect of high potency statins on LDL-C goal attainment. Moreover, this study showed low LDL-C goal attainment for patients on either low or high potency statins. The reasons for the low LDL-C goal attainment rate warrants further investigation.

Effectiveness of a combined strategy to improve therapeutic compliance and degree of control among patients with hypercholesterolaemia: a randomised clinical trial

BACKGROUND

In subjects with hypercholesterolaemia, cholesterol values remain above guideline levels. One of the limiting factors to the achievement of goals in such patients is therapeutic non-adherence. The aim of this study is to assess the effectiveness of an intervention designed to improve control of hypercholesterolaemic patients, consisting of a combined strategy that would include the delivery of printed information, treatment-compliance check cards and the dispatch of text messages as complementary measures in support of the intervention at the general practitioner's practice.

METHODS/DESIGN

A randomised, parallel-group clinical trial will be conducted at the family medicine outpatient facilities of eight health centres in three of Spain's Autonomous Regions (Comunidades Autónomas), covering a total of 358 subjects aged 18 years or over with diagnosis of hypercholesterolaemia. Patients in the intervention group will be supplied with printed material with information on the disease and its management, mobile-telephone text messages with guideline summaries, reminders of forthcoming appointments and/or arrangements for making new appointments in the event of non-attendance, and self-report cards to check compliance with recommendations. Both groups -intervention and control- will receive routine recommendations from their physicians in accordance with current European clinical practice guidelines for hypercholesterolaemia and cardiovascular risk management. As regards the measurements to be made, the main variable is the proportion of subjects who attain the low density lipoprotein cholesterol levels set as a target across a follow-up period of 24 months. The secondary variables are as follows: adherence to recommendations on lifestyle and adherence to drug treatment; variation in lipid profiles and cardiovascular risk levels; appearance of cardiovascular events; physical activity; food consumption; smoking habit; anthropometric measures; blood pressure; health problems; use of hypolipidaemic agents; socio-demographic data; beliefs and expectations about preventive recommendations; and degree of satisfaction with the combined strategy.

DISCUSSION

Should this intervention prove effective, a recommendation could be issued on the application of this combined strategy to subjects with hypercholesterolaemia. It is a simple, relatively inexpensive intervention.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02314663.

[Adherence to statin treatment and associated factors in female users from the Unified Health System (SUS)]

OBJECTIVE

To identify the adherence rate of a statin treatment and possible related factors in female users from the Unified Health System.

METHOD

Seventy-one women were evaluated (64.2 ± 11.0 years) regarding the socio-economic level, comorbidities, current medications, level of physical activity, self-report of muscular pain, adherence to the medical prescription, body composition and biochemical profile. The data were analyzed as frequencies, Chi-Squared test, and Mann Whitney test (p<0.05).

RESULTS

15.5% of women did not adhere to the medical prescription for the statin treatment, whose had less comorbidities (p=0.01), consumed less quantities of medications (p=0.00), and tended to be younger (p=0.06). Those patients also presented higher values of lipid profile (CT: p=0.01; LDL-c: p=0.02). Musculoskeletal complains were not associated to the adherence rate to the medication.

CONCLUSION

The associated factors to adherence of dyslipidemic women to statin medical prescription were age, quantity of comorbidities and quantity of current medication.

Self-reported adherence by MARS-CZ reflects LDL cholesterol goal achievement among statin users: validation study in the Czech Republic

RATIONALE, AIMS AND OBJECTIVES

Measuring self-reported adherence may contribute to minimizing the risk of therapy failure. Hence, the main aim of the study was to assess the psychometric properties of the Czech version of Medication Adherence Report Scale (MARS-CZ) and its appropriateness for use in long-term statin therapy where goal levels of low-density lipoprotein cholesterol (LDL-c) should be achieved.

METHODS

Anonymous structured interview was performed to determine self-reported adherence by MARS-CZ in outpatients chronically treated with statins. At the same time, medication records were reviewed for inclusion of patients into groups of those who achieved and do not achieved LDL-c goal according to cardiovascular risk level. Reliability and validity of MARS-CZ were tested as well as the relationship between adherence and LDL-c goal achievement was examined.

RESULTS

A total of 136 (86.6%) patients completed the interview; mean age was 66.1 years; 49.3% were male. The mean score of MARS-CZ was 24.4 and showed positive skewing. Satisfactory internal consistency (Cronbach's α=0.54), strong test-retest reliability (r=0.83, P<0.001; intra-class correlation=0.63, 95% confidence interval: 0.35-0.81) and positive correlation with eight-item Morisky Medication Adherence Scale (r=0.62, P<0.001) were indicated. Low validity values were found between MARS-CZ and 12-item Short Form Health Survey mental and physical subscales. MARS-CZ score significantly correlated with LDL-c goal achievement (P<0.05) when all patients who achieved LDL-c goal (35%) reported high adherence to statin. MARS-CZ score also correlated with cardiovascular risk level and doctor's judgments on adjusting treatment targets for each patient.

CONCLUSION

This study proved MARS-CZ as an acceptable self-reported adherence measure. In routine clinical practice, MARS-CZ could be helpful to reveal medication non-adherence before the alteration of drug regimen and thereby contributing to enhancement of statin therapy management.

Understanding patients' adherence-related beliefs about medicines prescribed for long-term conditions: a meta-analytic review of the Necessity-Concerns Framework

BACKGROUND

Patients' beliefs about treatment influence treatment engagement and adherence. The Necessity-Concerns Framework postulates that adherence is influenced by implicit judgements of personal need for the treatment (necessity beliefs) and concerns about the potential adverse consequences of taking it.

OBJECTIVE

To assess the utility of the NCF in explaining nonadherence to prescribed medicines.

DATA SOURCES

We searched EMBASE, Medline, PsycInfo, CDSR/DARE/CCT and CINAHL from January 1999 to April 2013 and handsearched reference sections from relevant articles.

STUDY ELIGIBILITY CRITERIA

Studies using the Beliefs about Medicines Questionnaire (BMQ) to examine perceptions of personal necessity for medication and concerns about potential adverse effects, in relation to a measure of adherence to medication.

PARTICIPANTS

Patients with long-term conditions.

STUDY APPRAISAL AND SYNTHESIS METHODS

Systematic review and meta-analysis of methodological quality was assessed by two independent reviewers. We pooled odds ratios for adherence using random effects models.

RESULTS

We identified 3777 studies, of which 94 (N = 25,072) fulfilled the inclusion criteria. Across studies, higher adherence was associated with stronger perceptions of necessity of treatment, OR = 1.742, 95% CI [1.569, 1.934], p<0.0001, and fewer Concerns about treatment, OR = 0.504, 95% CI: [0.450, 0.564], p<0.0001. These relationships remained significant when data were stratified by study size, the country in which the research was conducted and the type of adherence measure used.

LIMITATIONS

Few prospective longitudinal studies using objective adherence measures were identified.

CONCLUSIONS

The Necessity-Concerns Framework is a useful conceptual model for understanding patients' perspectives on prescribed medicines. Taking account of patients' necessity beliefs and concerns could enhance the quality of prescribing by helping clinicians to engage patients in treatment decisions and support optimal adherence to appropriate prescriptions.

Determinants of lipid goal achievement in patients on extended-release nicotinic acid/laropiprant in primary care clinical practice

OBJECTIVES

To establish determinants of lipid goal attainment in primary care patients, with particular focus on participation in a disease management programme (DMP) on diabetes mellitus (DM) and/or coronary heart disease (CHD), with real-world practical relevance.

METHODS

The present analysis was based on an observational study in 2359 patients with dyslipidaemia or hypercholesterolaemia that were treated with nicotinic acid 1000 mg/laropiprant 20 mg (Tredaptive) one or two tablets daily. Subgroups were formed by DMP participation (DMP vs. no DMP). A stepwise logistic regression model with backward selection of variables was applied to investigate factors influencing the probability of reaching lipid goals. Follow-up was 23 ± 7 weeks.

RESULTS

Low density lipoprotein cholesterol (LDL-C) <100 mg/dl was achieved by 30.8% in DMP versus 26.8% (no DMP), high density lipoprotein (HDL-C) >40/50 mg/dl in 61.3% versus 66.1%, and triglycerides (TG) <150 mg/dl in 28.9% versus 31.7%. On multivariate analysis, age, sex, concomitant high-risk cardiovascular disease, or participation in a DMP appeared to have inconsistent effects on reaching LDL-C, HDL-C and TG goals. Likelihood to reach the LDL-C goal tended to be higher in males, in patients outside DMP, and in patients with DM or CHD, and those treated with 1 tablet (versus 2 tablets) extended release nicotinic acid 1000 mg/laropiprant 20 mg. The likelihood of reaching the HDL-C goal was higher in males and in patients without DM or DM+CHD (no effect of DMP). The likelihood of reaching the TG goals was higher in females, in patients outside DMP, and in patients with DM and/or CHD. Limitations include potential bias due to study design, physician and patient selection, and missing values at follow-up.

CONCLUSION

DMP participation was not associated with overall improved lipid goal attainment. Physicians cannot predict the magnitude of effects of newly initiated lipid modifying therapy based on baseline characteristics of their patients.

Delayed educational reminders for long-term medication adherence in ST-elevation myocardial infarction (DERLA-STEMI): protocol for a pragmatic, cluster-randomized controlled trial

Background

Despite evidence-based recommendations supporting long-term use of cardiac medications in patients post ST-elevation myocardial infarction, adherence is known to decline over time. Discontinuation of cardiac medications in such patients is associated with increased mortality.

Methods/design

This is a pragmatic, cluster-randomized controlled trial with blinded outcome assessment and embedded qualitative process evaluation. Patients from one health region in Ontario, Canada who undergo a coronary angiogram during their admission for ST-elevation myocardial infarction and who survive their initial hospitalization will be included. Allocation of eligible patients to intervention or usual care will take place within one week after the angiogram using a computer-generated random sequence. To avoid treatment contamination, patients treated by the same family physician will be allocated to the same study arm. The intervention consists of recurrent, personalized, paper-based educational messages and reminders sent via post on behalf of the interventional cardiologist to the patient, family physician, and pharmacist urging long-term adherence to secondary prevention medications. The primary outcome is the proportion of patients who report in a phone interview taking all relevant classes of cardiac medications at twelve months. Secondary outcomes to be measured at three and twelve months include proportions of patients who report: actively taking each cardiac medication class of interest (item-by-item); stopping medications due to side effects; taking one or two or three medication classes concurrently; a perfect Morisky Medication Adherence Score for cardiac medication compliance; and having a discussion with their family physician about long-term adherence to cardiac medications. Self-reported measures of adherence will be validated using administrative data for prescriptions filled.

Discussion

This intervention is designed to be easily generalizable. If effective, it could be implemented broadly. If it does not change medication utilization, the process evaluation will offer insights regarding how such an intervention could be optimized in future.

Trial registration

Clinicaltrials.gov NCT01325116