Treatment gap in the use of lipid-lowering drug therapy in diabetes: a population-based study

Pharmacist-led academic detailing improves statin therapy prescribing for Malaysian patients with type 2 diabetes: Quasi-experimental design

OBJECTIVE

Previous reports have highlighted the suboptimal utilization and prescription of statin therapy among patients with type 2 diabetes mellitus (T2DM) in the Malaysian clinical practice. This study aims to test the impact of a pharmacist-led academic detailing program on improving the overall statin therapy prescribing in Malaysian hospital and primary care settings.

METHODS

As a quasi-experimental design with a control group and pre-tests., we examined 1,598 medical records of T2DM subjects in six healthcare facilities in the state of Pahang, Malaysia. In all study sites, there was a pre and post-intervention assessment of the percentage of appropriate statin therapy prescribing that complied with the clinical guidelines with no potential safety issues. The intervention was an academic detailing program offered to the health care providers in three study sites, while the other three sites served as the control group. A comparison of the overall percentage of appropriate statin therapy prescribing before and after the academic detailing was performed in all intervention and control sites.

RESULTS

Overall, 797 medical records were examined in the pre-intervention phase, and 801 records were evaluated in the post-intervention phase. The academic detailing program was associated with a statistically significant difference in the proportion of appropriate statin therapy prescribing between the post-intervention phase compared to the pre-intervention phase (n = 246, 61.7% versus n = 188, 47.1%), p = 0.001. Whereas, the appropriate statin therapy prescribing in the control study sites experienced a modest change from 53.8% (214/398) to 56.7% (228/402), p = 0.220. The academic detailing showed significant increases in the proportions of appropriate statin therapy prescribing in both hospital and primary care settings.

CONCLUSIONS

The academic detailing program was found to be significantly associated with a positive impact on the overall statin therapy prescribing among patients with T2DM in Malaysian hospital and primary care settings.

An estimation of the long-term clinical and economic benefits of insulin lispro in Type 1 diabetes in the UK

AIMS

To determine the long-term health economic benefits associated with lispro vs. regular human insulin (RHI) in UK Type 1 diabetic (T1DM) patients using the previously published and validated CORE Diabetes Model.

METHODS

A literature review designed to capture clinical benefits associated with lispro and T1DM cohort characteristics specific to UK was undertaken. Clinical benefits were derived from a Cochrane meta-analysis. The estimated difference (weighted mean) in glycated haemoglobin (HbA(1c)) was -0.1% (95% confidence interval -0.2 to 0.0%) for lispro vs. RHI. Severe hypoglycaemia rates for lispro and RHI were 21.8 and 46.1 events per 100 patient years, respectively. Costs and disutilities were accounted for severe hypoglycaemia rates. All costs were accounted in 2007 poundUK from a National Health Service (NHS) perspective. Future costs and clinical benefits were discounted at 3.5% annually.

RESULTS

In the base-case analysis, lispro was projected to be dominant compared with RHI. Lispro was associated with improvements in quality-adjusted life expectancy (QALE) of approximately 0.10 quality-adjusted life years (QALYs) vs. RHI (7.60 vs. 7.50 QALYs). Lifetime direct medical costs per patient were lower with lispro treatment, pound70 576 vs. pound72 529. Severe hypoglycaemia rates were the key driver in terms of differences in QALE and lifetime costs. Sensitivity analyses with assumptions around time horizon, discounting rates and benefits in terms of glycaemic control or hypoglycaemic event rates revealed that lispro remained dominant.

CONCLUSIONS

Our findings suggest that lispro is likely to improve QALE, reduce frequency of diabetes-related complications and lifetime medical costs compared with RHI.

National improvements in low-density lipoprotein cholesterol management of individuals at high coronary risk: National Health and Nutrition Examination Survey, 1999 to 2002

BACKGROUND

This study sought to evaluate national levels of elevated low-density lipoprotein cholesterol (LDL-C) before and after publication of the Adult Treatment Panel III (ATP III). The ATP III guidelines intensified LDL-C targets and defined additional high-risk conditions. These recommendations are expected to have a noticeable impact on US cholesterol levels.

METHODS

Coronary heart disease (CHD) risk was determined per ATP III guidelines for US residents aged 20 to 79 years in the 1999 to 2000 and 2001 to 2002 surveys. For those at high risk, the LDL-C mean percentage <100 mg/dL and percentage > or =130 mg/dL, although not taking lipid-lowering therapy, were compared between the 2 surveys. In addition, subsets with and without CHD were evaluated.

RESULTS

Of all high-risk US residents, the mean LDL-C dropped from 129 mg/dL in 1999 to 2000 to 120 mg/dL in 2001 to 2002 (P = .003). Those <100 mg/dL increased from 23% to 32% (P = .003). Those > or =130 mg/dL and not on medication dropped from 36% to 27% (P = .001). Goal achievement and improvements were more favorable in the subset with CHD compared with those at high risk due to high-risk equivalent conditions.

CONCLUSIONS

The sharp increase in high-risk US residents at the goal and the drop in the untreated percentage of those above treatment threshold illustrate national improvements in the management of LDL-C for those at high coronary risk. High-risk subjects without CHD displayed less significant improvements, suggesting an opportunity for better recognition and management of these individuals.

Review of guidelines for bone mineral density testing and treatment of osteoporosis

Clinical practice guidelines (CPGs) are systematically developed statements intended to influence the behavior of health care providers and improve patient care. There are many CPGs with recommendations for selection of patients for bone mineral density testing and pharmacologic treatment of osteoporosis. Health care provider adherence rates for these CPGs are low. The multiplicity of osteoporosis CPGs directed to the same health care providers may play a role in their limited utilization in clinical practice. Similarities, differences, and conflicts in osteoporosis CPGs with wide distribution in the United States were examined. The analysis showed similarities as well as substantial variation in the patient populations addressed, inconsistency of some recommendations, differences in clinical risk factors identified, and sometimes limitations in clinical applications. If the number and diversity of osteoporosis CPGs is adversely affecting their use in clinical practice, then collaboration of stakeholder organizations to develop more consistent CPGs, in combination with systems-based approaches for their implementation, may improve patient care and reduce the burden of osteoporotic fractures.

Reducing cardiovascular disease in patients with diabetes mellitus

PURPOSE OF REVIEW

Patients with diabetes may be considered high-risk for management of cardiovascular risk factors not only because of increased rates of myocardial infarction but also because of a high prevalence of significant subclinical coronary artery disease and a poorer prognosis after myocardial infarction.

RECENT FINDINGS

Appropriate management of hypertension and hyperlipidemia has been shown unequivocally to reduce cardiovascular events. Benefit has been demonstrated with multiple antihypertensive agents; however, some studies suggest an advantage for angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. Most data for management of lipid disorders in diabetes have been obtained using statins; the value of combination lipid-lowering therapy remains to be validated.

SUMMARY

The role of glucose control in managing cardiovascular risk in patients with diabetes remains unclear. Epidemiologic studies suggest a strong relation between markers of glycemia and cardiovascular risk, even extending into the nondiabetic spectrum. Ongoing trials are evaluating novel strategies for reducing cardiovascular events in patients with diabetes.