The association between achieving low-density lipoprotein cholesterol (LDL-C) goal and statin treatment in an employee population

A Risk Model to Predict Statin Non-Adherence Following an Acute Coronary Syndrome

BACKGROUND

Patients at risk of statin non-adherence are often not identified during hospital admission with an acute coronary syndrome (ACS).

METHODS

In 19,942 patients hospitalised for ACS, statin dispensing was determined from the national pharmaceutical dispensing database. A risk score for non-adherence was developed from a multivariable Poisson regression model of associations between risk factors and the statin Medication Possession Ratio (MPR) <0.8 6-18 months after hospital discharge.

RESULTS

Statin MPR was <0.8 in 4,736 (24%) patients. MPR <0.8 was more likely in patients with a history of cardiovascular disease (CVD) (RR 3.79, CI 95% 3.42-4.20) and those without known CVD (RR 2.25, 95% CI 2.04-2.48) who were not taking a statin on ACS admission, compared to patients with low density lipoprotein (LDL) cholesterol <2 mmol/L who were on a statin. For patients taking a statin on admission, higher LDL was associated with MPR <0.8 (≥3 versus <2 mmol/L, RR 1.96, 95%CI 1.72-2.24). Other independent risk factors for MPR <0.8 were age <45 years, female, disadvantaged ethnic groups, and no coronary revascularisation during the ACS admission. The risk score, which included nine variables, had a C-statistic of 0.67. MPR was <0.8 in 12% of 5,348 patients with a score ≤5 (lowest quartile) and 45% of 5,858 patients with a score ≥11 (highest quartile).

CONCLUSION

A risk score generated from routinely collected data predicts statin non-adherence in patients hospitalised with ACS. This may be used to target inpatient and outpatient interventions to improve medication adherence.

Adherence to Statin Therapy and Attainment of LDL Cholesterol Goal Among Patients with Type 2 Diabetes and Dyslipidemia

BACKGROUND

Statins are widely utilized antidyslipidemics with a proven track record of safety and efficacy. However, the efficacy of these therapeutic agents hinges on patients' adherence to their prescribed statins.

OBJECTIVE

The primary objectives of this study were to examine the relationship between adherence to prescribed statins and its impact on the low-density lipoprotein (LDL) level, and to explore the factors that influence patient adherence to statins among patients with diabetes and dyslipidemia.

METHODS

This was a retrospective, cross-sectional study using the electronic health records data of adults (≥18 years) with type 2 diabetes and dyslipidemia visiting outpatient clinics at a university-affiliated tertiary care center. Adherence to statin therapy was estimated using the proportion of days covered (PDC). Patients with diabetes were considered adherent to statins if they had a PDC of ≥80%. Treatment success was considered if the LDL level of < 2.6 mmol/L.

RESULTS

Out of 10,226 of patients with diabetes, 1532 met the inclusion criteria and were included in the study. Seventy-nine percent of the patients with diabetes were on atorvastatin and 21% were on simvastatin. The vast majority of the patients with diabetes (77%) were considered adherent and about 42% achieved LDL-cholesterol goal < 2.6 mmol/L. No association between adherence to statin therapy and LDL goal attainment was observed. Women had lower odds of being adherent to statin therapy (AOR=0.66, 95% CI: 0.49-0.87) compared to men. Further, young adults (18-44 years) had lower odds of being adherent to statin therapy (AOR=0.58, 95% CI: 0.32-0.97) compared to older adults (age>65 years).

CONCLUSION

The findings of this study highlight the need to examine the impact of adherence to statins on healthcare services utilization due to different complications of uncontrolled dyslipidemia.

Effect of Patient Care Coordination on Hospital Encounters and Related Costs

Given high costs of hospital encounters, providers have increasingly turned to patient-centered health care programs to improve cost-effectiveness and population health for patients with high needs. Yet, evidence is mixed about program effectiveness. This pre-post comparative analysis assessed whether the number of hospital encounters and related costs decreased for patients who received care coordination services funded through Texas's 1115(a) Medicaid waiver incentive-based payment model, under which providers created new programs to improve care quality, population health, and cost-effectiveness. This study compared hospital records for patients who were frequent emergency department users at 4 urban safety net hospitals in Texas and state data for hospital encounters for the calendar years 2013 through 2015. The study included 9061 patients who frequently used emergency departments: 4117 patients who received waiver-funded care coordination services at 2 hospitals and 4944 patients who received usual care at 2 comparison hospitals. Regression models compared changes in patients' hospital use and length of stay for the 2 groups. Patients receiving waiver-funded care coordination had a 19% lower probability of hospitalization after receiving care coordination relative to patients who received usual care, for a mean savings of approximately $1500 per year per patient. Receiving care coordination was not associated with a change in length of stay. Care coordination developed by hospitals to meet the needs of their most vulnerable patients can reduce their use of hospital resources through better preventive care. These findings bolster the business case for care coordination, which may help ensure service continuation.

A systematic review to assess adherence and persistence with statins

OBJECTIVE

To identify and assess studies published over a 10 year period up to February 2016 which measure adherence or persistence with statins, to summarize their methods, strengths and weaknesses and to summarize evidence linking statin adherence/persistence with risk of cardiovascular events.

METHODS

Electronic databases and abstracts from four major cardiovascular disease conferences were searched from January 2005 to February 2016. The study selection process was performed by two reviewers working independently. Studies were included if they reported data regarding patient adherence or persistence with statins in adults with primary hypercholesterolemia, using any type of study design or length of follow-up. One reviewer extracted the study data and assessed study quality, which was checked by a second reviewer independently. Given the heterogeneity between the included studies a narrative critique and summary is presented.

RESULTS

We report on 84 real world studies which aimed to assess adherence or persistence with statins. The majority of studies concluded that good adherence/persistence was associated with reduction in cardiovascular events and mortality. In two studies high intensity statin regimens were associated with poorer patient adherence when compared to low intensity statins. Adherence and persistence with statin therapy also has an impact on hospitalization costs and other cardiovascular disease (CVD) related costs.

CONCLUSIONS

Adherence and persistence are associated with a reduction in CVD events and mortality. There was limited evidence to suggest that high intensity statin regimens are associated with poorer treatment adherence when compared to lower intensity regimens. Hence, more robust studies are required to establish this association. As recommended by the 2013 ACC/AHA, 2016 ESC and several other clinical guidelines, clinicians and pharmacy managers should regularly monitor statin therapy adherence.

The Protective Effect of Antioxidants Consumption on Diabetes and Vascular Complications

Obesity and diabetes is generally accompanied by a chronic state of oxidative stress, disequilibrium in the redox balance, implicated in the development and progression of complications such as micro- and macro-angiopathies. Disorders in the inner layer of blood vessels, the endothelium, play an early and critical role in the development of these complications. Blunted endothelium-dependent relaxation and/or contractions are quietly associated to oxidative stress. Thus, preserving endothelial function and oxidative stress seems to be an optimization strategy in the prevention of vascular complications associated with diabetes. Diet is a major lifestyle factor that can greatly influence the incidence and the progression of type 2 diabetes and cardiovascular complications. The notion that foods not only provide basic nutrition but can also prevent diseases and ensure good health and longevity is now attained greater prominence. Some dietary and lifestyle modifications associated to antioxidative supply could be an effective prophylactic means to fight against oxidative stress in diabesity and complications. A significant benefit of phytochemicals (polyphenols in wine, grape, teas), vitamins (ascorbate, tocopherol), minerals (selenium, magnesium), and fruits and vegetables in foods is thought to be capable of scavenging free radicals, lowering the incidence of chronic diseases. In this review, we discuss the role of oxidative stress in diabetes and complications, highlight the endothelial dysfunction, and examine the impact of antioxidant foods, plants, fruits, and vegetables, currently used medication with antioxidant properties, in relation to the development and progression of diabetes and cardiovascular complications.

Effect of an educational program in primary care: the case of lipid control in cardio-cerebrovascular prevention

Lowering blood cholesterol levels reduces the risk of coronary heart disease. However, the effect of interventions depends on the patients' adherence to treatment. Primary care plays an important role in the detection, treatment and monitoring of disease, therefore different educational programs (EP) have been implemented to improve disease management in general practice. The present study is aimed to assess whether a general practitioner auditing and feedback EP may improve dyslipidaemia management in a primary care setting and to evaluate patients' adherence to prescribed lipid-lowering treatment. The quality of cardiovascular and cerebrovascular disease prevention before and after the implementation of an EP offered to 25 general practitioners (GPs), was evaluated. Clinical and prescription data on patients receiving at least one lipid-lowering treatment was collected. To evaluate the quality of the healthcare service provided, clinical and biochemical outcomes, and drug-utilization, process indicators were set up. Adherence was evaluated before and after the EP as the "Medication Possession Ratio" (MPR). A correlation analysis was carried out to estimate the effect of the MPR in achieving pre-defined clinical end-points. Prescription data for lipid-lowering drugs was collected in a sample of 839 patients. While no differences in the achievement of blood lipid targets were observed, a slight but significant improvement of the MPR was registered after the EP (MPR >0.8=64.2% vs 60.6%, p=0.0426). Moreover, high levels of statin adherence were associated with the achievement of total blood cholesterol target (OR=3.3 for MPR >0.8 vs MPR <0.5, 95% CI:1.7-6.7) or LDL therapeutic goal (OR=3.3 for MPR >0.8 vs MPR <0.5, 95% CI:1.5-7.2). The EP partially improved the defined clinical targets; probably, a more patient-based approach could be more appropriate to achieve the defined target. Further studies are needed to identify how healthcare services can be improved.

Association between statin adherence and cholesterol level reduction from baseline in a veteran population

STUDY OBJECTIVE

To investigate the association between statin adherence and changes in lipid panel outcomes from baseline in a veteran population.

DESIGN

Retrospective cohort study using multiple linear regression models.

SETTING

Veterans Affairs health care system within the Veterans Integrated Service Network 22, a network of Veterans Affairs facilities in the southwest region of the United States that includes Los Angeles, San Diego, Loma Linda, and Long Beach, California, and Las Vegas, Nevada, with an enrollment of approximately 1.4 million veterans.

PATIENTS

A total of 5365 patients who were new statin users between December 1, 2006, and November 30, 2007; 2674 patients were in the adherent group and 2691 were in the nonadherent group.

MEASUREMENTS AND MAIN RESULTS

Adherence was determined by the medication possession ratio. Patients were categorized as adherent if the medication possession ratio at follow-up was 0.80 or more. Adherent patients exhibited significant differences in baseline demographic and clinical characteristics than nonadherent patients in our study sample. Baseline laboratory values for adherent patients were significantly lower for low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), non-high-density lipoprotein cholesterol (non-HDL), and total cholesterol levels. The primary outcome was change in LDL level from baseline at 12 months. Secondary outcomes were changes in non-HDL and total cholesterol levels from baseline at 12 months. Independent variables controlled for in the multiple linear regression included age, sex, body mass index, race-ethnicity, baseline lipid panel (LDL, HDL, total cholesterol, and triglycerides), statin copayment status, income quintile (according to ZIP code median household income), baseline medication count, statin prescribed, and comorbidities. Multiple linear regression revealed that adherent patients demonstrated significantly greater reductions in LDL of 20.98 mg/dl versus nonadherent patients (p<0.0001). Adherent patients similarly demonstrated larger reductions of 24.31 mg/dl in non-HDL and 24.06 mg/dl in total cholesterol versus nonadherent patients (p<0.0001 for both comparisons).

CONCLUSION

Patients adherent to statin therapy had significant associations with clinically relevant reductions in LDL, non-HDL, and total cholesterol from baseline at 12 months compared with nonadherent patients when controlling for potential confounders. Adherence to statin therapy may have important consequences in decreasing clinical outcomes such as myocardial infarctions, strokes, and mortality due to large reductions in lipid panel outcomes from baseline at 12 months.

The burden and management of dyslipidemia: practical issues

The objective of this study is to describe briefly the burden of dyslipidemia, and to discuss and present strategies for health professionals to improve dyslipidemia management, based on a review of selected literature focusing on interventions for dyslipidemia treatment adherence. Despite the availability of effective lifestyle and pharmaceutical therapies for dyslipidemias, they continue to present a significant economic burden in the United States. Adherence to evidence-based guidelines for the treatment of dyslipidemias is unsatisfactory. The reasons for medication nonadherence are complex and specific to each patient. The lack of progress in achieving optimal lipid targets is caused by many factors: patient (medication adherence, cost of medication, literacy), medication (adverse effects, complexity of regimen), provider (lack of adherence to evidence-based practice guidelines, poor communication), and the US healthcare system (being focused on acute care rather than prevention, lack of continuity of care, general lack of use of an electronic health record). Combined interventions that target each part of the system have been effective in improving treatment adherence and achieving lipid goals. Patients, providers, pharmacists, and employers all play a role in management of dyslipidemia. No single approach will solve the complex issue of improving dyslipidemia management. The required lifestyle changes are known and effective medications are available. The challenge is for all interested parties-including nurses, nurse practitioners, doctors, pharmacists, other health care professionals, employers, and health plans-to help patients achieve behavioral changes.

Systematic care management: a comprehensive approach to catastrophic injury management applied to a catastrophic burn injury population--clinical, utilization, economic, and outcome data in support of the model

The new standard for successful burn care encompasses both patient survival and the burn patient's long-term quality of life. To provide optimal long-term recovery from catastrophic injuries, including catastrophic burns, an outcome-based model using a new technology called systematic care management (SCM) has been developed. SCM provides a highly organized system of management throughout the spectrum of care that provides access to outcome data, consistent oversight, broader access to expert providers, appropriate allocation of resources, and greater understanding of total costs. Data from a population of 209 workers' compensation catastrophic burn cases with a mean TBSA of 27.9% who were managed under the SCM model of care were analyzed. The data include treatment type, cost, return to work, and outcomes achieved. Mean duration of management to achieve all guaranteed outcomes was 20 months. Of the 209 injured workers, 152 (72.7%) achieved sufficient recovery to be released to return to work, of which 97 (46.8%) were both released and competitively employed. Assessment of 10 domains of functional independence indicated that 47.2% of injured workers required total assistance at initiation of SCM. However, at termination of SCM, 84% of those injured workers were fully independent in the 10 functional activities. When compared with other burn research outcome data, the results support the value of the SCM model of care.