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Mwita JC, Godman B, Esterhuizen TM. Statin prescription among patients with type 2 diabetes in Botswana: findings and implications. BMC Endocr Disord 2020; 20:36. [PMID: 32151249 PMCID: PMC7063760 DOI: 10.1186/s12902-020-0516-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 02/27/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND There is evidence of statin benefit among patients with diabetes regardless of cholesterol levels or prior cardiovascular disease history. Despite the evidence, there is under-prescription of statins in clinical practice. This study aimed to assess statin prescriptions and associated factors among patients with type 2 diabetes in Botswana. METHODS The study was a secondary data analysis of 500 randomly selected type 2 diabetes patients at a specialised diabetes clinic at Gaborone, Botswana. We assessed the proportion of statin-eligible patients who are prescribed statins and evaluated the adjusted associations between various factors and statin prescriptions. RESULTS Overall, 477 (95.4%) participants were eligible for a statin prescription. Clinicians prescribed statins in 217 (45.5%) of eligible participants, and only one (4.4%) ineligible participant. The probability of a statin prescription was higher in participants with high baseline low-density lipoprotein cholesterol (risk ratio [RR]: 1.49; 95%CI: 1.17-1.89), increasing duration of diabetes (RR: 1.01; 95%CI 1.00-1.03) and the presence of chronic kidney disease (RR: 1.35; 95%CI: 1.06-1.74). CONCLUSION A large proportion with type 2 diabetes in Gaborone is not receiving statins. Clinicians did not consider most guideline-recommended indications for statin prescriptions. The findings call for improvement in diabetes quality of care by implementing evidence-based guideline recommendations.
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Affiliation(s)
- Julius Chacha Mwita
- Department of Internal Medicine, Faculty of Medicine, University of Botswana, Private Bag, 00713 Gaborone, Botswana
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Brian Godman
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, G4 0RE United Kingdom
- School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Tonya M. Esterhuizen
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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Lasso Regression for the Prediction of Intermediate Outcomes Related to Cardiovascular Disease Prevention Using the TRANSIT Quality Indicators. Med Care 2019; 57:63-72. [PMID: 30439793 DOI: 10.1097/mlr.0000000000001014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Cardiovascular disease morbidity and mortality are largely influenced by poor control of hypertension, dyslipidemia, and diabetes. Process indicators are essential to monitor the effectiveness of quality improvement strategies. However, process indicators should be validated by demonstrating their ability to predict desirable outcomes. The objective of this study is to identify an effective method for building prediction models and to assess the predictive validity of the TRANSIT indicators. METHODS On the basis of blood pressure readings and laboratory test results at baseline, the TRANSIT study population was divided into 3 overlapping subpopulations: uncontrolled hypertension, uncontrolled dyslipidemia, and uncontrolled diabetes. A classic statistical method, a sparse machine learning technique, and a hybrid method combining both were used to build prediction models for whether a patient reached therapeutic targets for hypertension, dyslipidemia, and diabetes. The final models' performance for predicting these intermediate outcomes was established using cross-validated area under the curves (cvAUC). RESULTS At baseline, 320, 247, and 303 patients were uncontrolled for hypertension, dyslipidemia, and diabetes, respectively. Among the 3 techniques used to predict reaching therapeutic targets, the hybrid method had a better discriminative capacity (cvAUCs=0.73 for hypertension, 0.64 for dyslipidemia, and 0.79 for diabetes) and succeeded in identifying indicators with a better capacity for predicting intermediate outcomes related to cardiovascular disease prevention. CONCLUSIONS Even though this study was conducted in a complex population of patients, a set of 5 process indicators were found to have good predictive validity based on the hybrid method.
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Khanji C, Bareil C, Hudon E, Goudreau J, Duhamel F, Lussier MT, Perreault S, Lalonde G, Turcotte A, Berbiche D, Martin É, Lévesque L, Gagnon MM, Lalonde L. Psychometric analysis of the TRANSIT quality indicators for cardiovascular disease prevention in primary care. Int J Qual Health Care 2018; 29:999-1005. [PMID: 29190350 DOI: 10.1093/intqhc/mzx145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2017] [Indexed: 01/20/2023] Open
Abstract
Objective To assess a selection of psychometric properties of the TRANSIT indicators. Design Using medical records, indicators were documented retrospectively during the 14 months preceding the end of the TRANSIT study. Setting Primary care in Quebec, Canada. Participants Indicators were documented in a random subsample (n = 123 patients) of the TRANSIT study population (n = 759). Interventions For every patient, the mean compliance to all indicators of a category (subscale score) and to the complete set of indicators (overall scale score) were established. To evaluate test-retest and inter-rater reliabilities, indicators were applied twice, two months apart, by the same evaluator and independently by different evaluators, respectively. To evaluate convergent validity, correlations between TRANSIT indicators, Burge et al. indicators and Institut national d'excellence en santé et en services sociaux (INESSS) indicators were examined. Main Outcome Measures Test-retest reliability, inter-rater reliability, and convergent validity. Results Test-retest reliability, as measured by intraclass correlation coefficients (ICCs) was equal to 0.99 (0.99-0.99) for the overall scale score while inter-rater reliability was equal to 0.95 (0.93-0.97) for the overall scale score. Convergent validity, as measured by Pearson's correlation coefficients, was equal to 0.77 (P < 0.001) for the overall scale score when the TRANSIT indicators were compared to Burge et al. indicators and to 0.82 (P < 0.001) for the overall scale score when the TRANSIT indicators were compared to INESSS indicators. Conclusions Reliability was excellent except for eleven indicators while convergent validity was strong except for domains related to the management of CVD risk factors.
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Affiliation(s)
- Cynthia Khanji
- Primary Care Research Team, Centre de santé et de services sociaux de Laval, 1755 René-Laennec, Laval (Quebec), Canada H7M3L9.,Faculty of pharmacy, University of Montreal, 6128 City-Center Branch, Montreal (Quebec), Canada H3C3J7.,University of Montreal Hospital Research Centre (CRCHUM), 850 Saint-Denis Street, Montreal (Quebec), Canada H2X0A9
| | - Céline Bareil
- HEC Montréal, University of Montreal, 6128 City-Center Branch, Montreal (Quebec), CanadaH3C3J7
| | - Eveline Hudon
- Primary Care Research Team, Centre de santé et de services sociaux de Laval, 1755 René-Laennec, Laval (Quebec), Canada H7M3L9.,Faculty of medicine, University of Montreal, 6128 City-Center Branch, Montreal (Quebec), Canada H3C3J7
| | - Johanne Goudreau
- Primary Care Research Team, Centre de santé et de services sociaux de Laval, 1755 René-Laennec, Laval (Quebec), Canada H7M3L9.,Faculty of nursing, University of Montreal, 6128 City-Center Branch, Montreal (Quebec), Canada H3C3J7
| | - Fabie Duhamel
- Primary Care Research Team, Centre de santé et de services sociaux de Laval, 1755 René-Laennec, Laval (Quebec), Canada H7M3L9.,Faculty of nursing, University of Montreal, 6128 City-Center Branch, Montreal (Quebec), Canada H3C3J7
| | - Marie-Thérèse Lussier
- Primary Care Research Team, Centre de santé et de services sociaux de Laval, 1755 René-Laennec, Laval (Quebec), Canada H7M3L9.,Faculty of medicine, University of Montreal, 6128 City-Center Branch, Montreal (Quebec), Canada H3C3J7
| | - Sylvie Perreault
- Faculty of pharmacy, University of Montreal, 6128 City-Center Branch, Montreal (Quebec), Canada H3C3J7.,Sanofi Aventis Endowment Chair in Drug Utilization, 2905 Louis-R. Renaud Place, Laval (Quebec), Canada H7V0A3
| | - Gilles Lalonde
- Médi-Centre Chomedey, 610 Curé-Labelle Boulevard, Laval (Quebec), CanadaH7V2T7
| | - Alain Turcotte
- Department of Professional Services, Centre de santé et de services sociaux du Lac-des-Deux-Montagnes, 9100 Dumouchel Street, Mirabel (Quebec), CanadaJ7N5A1
| | - Djamal Berbiche
- Primary Care Research Team, Centre de santé et de services sociaux de Laval, 1755 René-Laennec, Laval (Quebec), Canada H7M3L9.,University of Montreal Hospital Research Centre (CRCHUM), 850 Saint-Denis Street, Montreal (Quebec), Canada H2X0A9
| | - Élisabeth Martin
- Primary Care Research Team, Centre de santé et de services sociaux de Laval, 1755 René-Laennec, Laval (Quebec), Canada H7M3L9.,University of Montreal Hospital Research Centre (CRCHUM), 850 Saint-Denis Street, Montreal (Quebec), Canada H2X0A9
| | - Lise Lévesque
- Primary Care Research Team, Centre de santé et de services sociaux de Laval, 1755 René-Laennec, Laval (Quebec), Canada H7M3L9.,University of Montreal Hospital Research Centre (CRCHUM), 850 Saint-Denis Street, Montreal (Quebec), Canada H2X0A9
| | - Marie-Mireille Gagnon
- Primary Care Research Team, Centre de santé et de services sociaux de Laval, 1755 René-Laennec, Laval (Quebec), Canada H7M3L9.,University of Montreal Hospital Research Centre (CRCHUM), 850 Saint-Denis Street, Montreal (Quebec), Canada H2X0A9
| | - Lyne Lalonde
- Primary Care Research Team, Centre de santé et de services sociaux de Laval, 1755 René-Laennec, Laval (Quebec), Canada H7M3L9.,Faculty of pharmacy, University of Montreal, 6128 City-Center Branch, Montreal (Quebec), Canada H3C3J7.,University of Montreal Hospital Research Centre (CRCHUM), 850 Saint-Denis Street, Montreal (Quebec), Canada H2X0A9.,Sanofi Aventis Endowment Chair in Ambulatory Pharmaceutical Care, 2905 Louis-R. Renaud Place, Laval (Quebec), Canada H7V0A3
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Alabousi M, Abdullah P, Alter DA, Booth GL, Hogg W, Ko DT, Manuel DG, Farkouh ME, Tu JV, Udell JA. Cardiovascular Risk Factor Management Performance in Canada and the United States: A Systematic Review. Can J Cardiol 2017; 33:393-404. [DOI: 10.1016/j.cjca.2016.07.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 07/03/2016] [Accepted: 07/06/2016] [Indexed: 01/13/2023] Open
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Sigmund AE, Fang Y, Chin M, Reynolds HR, Horwitz LI, Dweck E, Iturrate E. Postoperative Tachycardia: Clinically Meaningful or Benign Consequence of Orthopedic Surgery? Mayo Clin Proc 2017; 92:98-105. [PMID: 27890407 DOI: 10.1016/j.mayocp.2016.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/29/2016] [Accepted: 08/01/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine the clinical significance of tachycardia in the postoperative period. PATIENTS AND METHODS Individuals 18 years or older undergoing hip and knee arthroplasty were included in the study. Two data sets were collected from different time periods: development data set from January 1, 2011, through December 31, 2011, and validation data set from December 1, 2012, through September 1, 2014. We used the development data set to identify the optimal definition of tachycardia with the strongest association with the vascular composite outcome (pulmonary embolism and myocardial necrosis and infarction). The predictive value of this definition was assessed in the validation data set for each outcome of interest, pulmonary embolism, myocardial necrosis and infarction, and infection using multiple logistic regression to control for known risk factors. RESULTS In 1755 patients in the development data set, a maximum heart rate (HR) greater than 110 beats/min was found to be the best cutoff as a correlate of the composite vascular outcome. Of the 4621 patients who underwent arthroplasty in the validation data set, 40 (0.9%) had pulmonary embolism. The maximum HR greater than 110 beats/min had an odds ratio (OR) of 9.39 (95% CI, 4.67-18.87; sensitivity, 72.5%; specificity, 78.0%; positive predictive value, 2.8%; negative predictive value, 99.7%) for pulmonary embolism. Ninety-seven patients (2.1%) had myocardial necrosis (elevated troponin). The maximum HR greater than 110 beats/min had an OR of 4.71 (95% CI, 3.06-7.24; sensitivity, 47.4%; specificity, 78.1%; positive predictive value, 4.4%; negative predictive value, 98.6%) for this outcome. Thirteen (.3%) patients had myocardial infarction according to our predetermined definition, and the maximum HR greater than 110 beats/min had an OR of 1.72 (95% CI, 0.47-6.27). CONCLUSION Postoperative tachycardia within the first 4 days of surgery should not be dismissed as a postoperative variation in HR, but may precede clinically significant adverse outcomes.
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Affiliation(s)
- Alana E Sigmund
- Division of Perioperative Medicine, Hospital for Special Surgery, New York, NY.
| | - Yixin Fang
- Department of Mathematical Sciences, New Jersey Institute of Technology, Newark, NJ
| | - Matthew Chin
- NYU School of Medicine, NYU Langone Medical Center, New York, NY
| | - Harmony R Reynolds
- Division of Cardiology, Department of Medicine, Cardiovascular Clinical Research Center, NYU Langone Medical Center, New York, NY
| | - Leora I Horwitz
- Division of General Internal Medicine and Clinical Innovation, Department of Medicine, NYU School of Medicine, NYU Langone Medical Center, New York, NY; Division of Healthcare Delivery Science, Department of Population Health, NYU Langone Medical Center, New York, NY
| | - Ezra Dweck
- Division of Pulmonology and Critical Care, Department of Medicine, NYU Langone Medical Center, New York, NY
| | - Eduardo Iturrate
- Division of General Internal Medicine and Clinical Innovation, Department of Medicine, NYU School of Medicine, NYU Langone Medical Center, New York, NY
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Finnikin S, Ryan R, Marshall T. Cohort study investigating the relationship between cholesterol, cardiovascular risk score and the prescribing of statins in UK primary care: study protocol. BMJ Open 2016; 6:e013120. [PMID: 27856481 PMCID: PMC5128938 DOI: 10.1136/bmjopen-2016-013120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Risk scoring is an integral part of the prevention of cardiovascular disease (CVD) and should form the basis for the decision to offer medication to reduce cholesterol (statins). However, there is a suggestion in the literature that many patients are still initiated on statins based on raised cholesterol rather than a raised CVD risk. It is important, therefore, to investigate the role that lipid levels and CVD risks have in the decision to prescribe. This research will establish how cholesterol levels and CVD risk independently influence the prescribing of statins for the primary prevention of CVD in primary care. METHODS AND ANALYSIS The Health Improvement Network (THIN) is a database of coded primary care electronic patient records from over 500 UK general practices. From this resource, a historical cohort will be created of patients without a diagnosis of CVD, not currently receiving a prescription for statins and who had a lipid profile measured. A post hoc QRISK2 score will be calculated for these patients and they will be followed up for 60 days to establish whether they were subsequently prescribed a statin. Primary analysis will consist of predictive modelling using multivariate logistic regression with potential predictors including cholesterol level, calculated QRISK2 score, sociodemographic characteristic and comorbidities. Descriptive statistics will be used to identify trends in prescribing and further secondary analysis will explore what other factors may have influenced the prescribing of statins and the degree of interprescriber variability. ETHICS AND DISSEMINATION The THIN Data Collection Scheme was approved by the South-East Multicentre Research Ethics Committee in 2003. Individual studies using THIN require Scientific Review Committee approval. The original protocol for this study and a subsequent amendment have been approved (16THIN009A1). The results will be published in a peer review journal and presented at national and international conferences.
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Affiliation(s)
- Samuel Finnikin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ronan Ryan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Tom Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Karmali KN, Lee JY, Brown T, Persell SD. Predictors of cholesterol treatment discussions and statin prescribing for primary cardiovascular disease prevention in community health centers. Prev Med 2016; 88:176-81. [PMID: 27090436 PMCID: PMC5040465 DOI: 10.1016/j.ypmed.2016.04.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 04/05/2016] [Accepted: 04/12/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although cholesterol guidelines emphasize cardiovascular disease (CVD) risk to guide primary prevention, predictors of statin use in practice are unknown. We aimed to identify factors associated with a cholesterol treatment discussion and statin prescribing in a high-risk population. METHODS We used data from a trial conducted among participants in community health centers without CVD or diabetes and a 10-year coronary heart disease (CHD) risk≥10%. Cholesterol treatment discussion was assessed at 6months and statin prescription at 1year. We used logistic regressions to identify factors associated with each outcome. RESULTS We analyzed 646 participants (89% male, mean age 60±9.5years). Cholesterol treatment discussion occurred in 19% and statin prescription in 12% of participants. Ten-year CHD risk was not associated with treatment discussion (OR 1.11 per 1 SD increase, 95% CI 0.91-1.33) but was associated with statin prescription (OR 1.41 per 1 SD increase, 95% CI 1.13-1.75) in unadjusted models. After adjusting for traditional CVD risk factors that contribute to CHD risk, low-density lipoprotein cholesterol (LDL-C) was independently associated with statin prescription (OR 1.82 per 1 SD increase, 95% CI 1.66-1.99). Antihypertensive medication use was independently associated with both cholesterol treatment discussion (OR 3.68, 95% CI 2.35-5.75) and statin prescription (OR 3.98, 95% CI 3.30-4.81). Other drivers of CVD risk (age, smoking, and systolic blood pressure) were not associated with statin use. CONCLUSIONS Single risk factor management strongly influences cholesterol treatment discussions and statin prescribing patterns. Interventions that promote risk-based statin utilization are needed. TRIAL REGISTRATION Clinicaltrials.gov.: NCT01610609.
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Affiliation(s)
- Kunal N Karmali
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States; Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Ji-Young Lee
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Tiffany Brown
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Stephen D Persell
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States; Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States.
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8
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Multimorbidity and Patient Safety Incidents in Primary Care: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0135947. [PMID: 26317435 PMCID: PMC4552710 DOI: 10.1371/journal.pone.0135947] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 07/29/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Multimorbidity is increasingly prevalent and represents a major challenge in primary care. Patients with multimorbidity are potentially more likely to experience safety incidents due to the complexity of their needs and frequency of their interactions with health services. However, rigorous syntheses of the link between patient safety incidents and multimorbidity are not available. This review examined the relationship between multimorbidity and patient safety incidents in primary care. METHODS We followed our published protocol (PROSPERO registration number: CRD42014007434). Medline, Embase and CINAHL were searched up to May 2015. Study design and quality were assessed. Odds ratios (OR) and 95% confidence intervals (95% CIs) were calculated for the associations between multimorbidity and two categories of patient safety outcomes: 'active patient safety incidents' (such as adverse drug events and medical complications) and 'precursors of safety incidents' (such as prescription errors, medication non-adherence, poor quality of care and diagnostic errors). Meta-analyses using random effects models were undertaken. RESULTS Eighty six relevant comparisons from 75 studies were included in the analysis. Meta-analysis demonstrated that physical-mental multimorbidity was associated with an increased risk for 'active patient safety incidents' (OR = 2.39, 95% CI = 1.40 to 3.38) and 'precursors of safety incidents' (OR = 1.69, 95% CI = 1.36 to 2.03). Physical multimorbidity was associated with an increased risk for active safety incidents (OR = 1.63, 95% CI = 1.45 to 1.80) but was not associated with precursors of safety incidents (OR = 1.02, 95% CI = 0.90 to 1.13). Statistical heterogeneity was high and the methodological quality of the studies was generally low. CONCLUSIONS The association between multimorbidity and patient safety is complex, and varies by type of multimorbidity and type of safety incident. Our analyses suggest that multimorbidity involving mental health may be a key driver of safety incidents, which has important implication for the design and targeting of interventions to improve safety. High quality studies examining the mechanisms of patient safety incidents in patients with multimorbidity are needed, with the goal of promoting effective service delivery and ameliorating threats to safety in this group of patients.
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Rohrer JE, Doganer YC, Merry SP, Angstman KB, Erickson JL, Furst JW. Low-density lipoprotein-cholesterol (LDL-C) greater than 100 mg/dL as a quality indicator: locating risk in person, place and time. J Eval Clin Pract 2015; 21:735-9. [PMID: 25988919 DOI: 10.1111/jep.12378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2015] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Achieving control over elevated lipid parameters, particularly low-density lipoprotein (LDL)-cholesterol, is an acknowledged quality indicator in primary care. The Centers for Disease Control and Prevention (CDC)'s model for investigation of outbreaks (person-place-time) can be applied to the analysis of quality indicators. METHODS A sample of 322 family medicine patients for whom lipid levels were ordered was extracted. LDL > 100 mg/dL was cross-tabulated by personal characteristics [age group, gender, body mass index (BMI), diagnoses], month (time) and ordering department (place). RESULTS Age (except one age category), gender, time and location were not related to LDL > 100 mg/dL after adjustment for covariates. All levels of BMI above normal elevated the risk of LDL > 100 mg/dL [BMI 25-29.9: odds ratio (OR) = 3.41, confidence interval (CI) = 1.61-7.23, P = 0.0014; BMI 30-34.9: OR = 2.93, CI = 1.28-6.70, P = 0.0109; BMI ≥ 35: OR = 2.75, CI = 1.19-6.37, P = 0.0181]. Patients with coronary artery disease (CAD) and diabetes mellitus (DM) were at reduced risk for LDL > 100 mg/dL (CAD: OR = 0.47, CI = 0.24-0.91, P = 0.0254; DM: OR = 0.28, CI = 0.14-0.55, P = 0.0002). CONCLUSION An outbreak investigation model is useful for analysing variations in this quality indicator. Patients with higher BMI and those not diagnosed with CAD or DM type I/II may be considered for intensified lipid lowering using quality improvement efforts. These might include counselling for lifestyle changes or medication therapy depending upon their calculated cardiac risk.
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Affiliation(s)
- James E Rohrer
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yusuf C Doganer
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephen P Merry
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kurt B Angstman
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob L Erickson
- Sports Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Joseph W Furst
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
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Vinker S, Bitterman H, Comaneshter D, Cohen AD. Physicians' behavior following changes in LDL cholesterol target goals. Isr J Health Policy Res 2015; 4:20. [PMID: 26034577 PMCID: PMC4450467 DOI: 10.1186/s13584-015-0016-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 03/26/2015] [Indexed: 11/12/2022] Open
Abstract
Background In 01/2011 Clalit Health Services (CHS), changed the LDL-Cholesterol target definitions in its quality indicators program, from a universal target to values stratified by risk assessment based on ATP III criteria. The objective of this study is to evaluate the effect of this change on achievement of LDL-C targets and on physicians’ prescriptions of statins. Study Design: A descriptive study based on administrative dataset 06/2010-06/2012. Methods Setting: CHS, The largest health maintenance organization in Israel that insures above 4,000,000 beneficiaries. Patients: Patients who had been in the same risk group throughout the study period. Measurements: Attainment of targets for LDL-C and purchases of statins prior to, and following, implementation of the guidelines in the CHS quality indicators program. Results 433,662 patients remained in the same risk groups throughout the study period; 55.8% were women; the average age was 53.0 ± 10.3 years; 63.9%, 13.4%, and 22.7% were at low, medium, and high risk respectively. After implementation, the proportion of patients reaching LDL-C targets increased in all risk groups: from 58.6% to 61.6%, from 55.1% to 61.1%, and from 44.5% to 49.0%, in low, medium, and high risk groups respectively (p < 0.001). The proportion of patients treated with potent statins increased in all risk groups; from 3.4% to 5.6%, from 6.7% to 10.3%, and from 14.5% to 20.3% respectively (p < 0.001). Conclusion The risk stratification approach as a basis for the quality indicators program was implemented and better achievement of target LDL-C levels ensued. We suggest that implementation of quality indicators that are consistent with the current literature can lead to improvements that exceeds temporal trends.
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Affiliation(s)
- Shlomo Vinker
- Chief Physician Office, Central Headquarter, Clalit Health Services, Tel Aviv, Israel ; Department of Family Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Bitterman
- Chief Physician Office, Central Headquarter, Clalit Health Services, Tel Aviv, Israel
| | - Doron Comaneshter
- Chief Physician Office, Central Headquarter, Clalit Health Services, Tel Aviv, Israel
| | - Arnon D Cohen
- Chief Physician Office, Central Headquarter, Clalit Health Services, Tel Aviv, Israel ; Siaal Family Medicine and Primary Care Research Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Doganer YC, Rohrer JE, Angstman KB, Merry SP, Erickson JL. Variations in lipid screening frequency in family medicine patients with cardiovascular risk factors. J Eval Clin Pract 2015; 21:215-20. [PMID: 25394299 DOI: 10.1111/jep.12290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2014] [Indexed: 11/27/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES This study was undertaken to assess the frequency of lipid screening in comparison with the United States Preventive Services Task Force guideline in a sample of family medicine patients. In addition, we sought to determine the association between testing frequency and achievement of lipid targets. METHODS A random sample was extracted from 271 patients from among all patients cared for in our Department of Family Medicine for whom lipid screening was ordered from March to September 2012 and who had ≥2 well-defined cardiovascular risk factors. Lipid testing frequency was classified in three ways: semi-annual or less often (0-12 tests over 6 years), annual or less often (0-6 tests), or biennial (0-3 tests). RESULTS Multiple logistic regression analysis revealed that the predictors of lipid screening more often than semi-annually were age ≥60 years [odds ratio (OR) = 3.7] and diabetes mellitus (DM) (OR = 30.6). Predictors of screening more often than annually were DM (OR = 4.3), hypertension (OR = 2.1), family history of premature coronary artery disease (OR = 5.6) and statin treatment (OR = 3.5). Lipid goal attainment was not associated with testing frequency except with regard to low-density lipoprotein levels (P = 0.043, P < 0.001, P = 0.005, by semi-annual, annual and biennial, respectively) and total cholesterol levels (P = 0.015, P = 0.025 by semi-annual and annual, respectively). CONCLUSIONS Questionable high frequency of lipid testing was detected even when the more conservative approach of annual monitoring was assumed. Frequency of testing was not associated with goal attainment for most parameters. Physicians should request the lipid testing based on overall risk assessment and person variability in accordance with published guidelines.
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Affiliation(s)
- Yusuf C Doganer
- Department of Family Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
The purpose of this article is to update the primary care community on the evidence and guidelines for cardiovascular disease screening in a general-risk adult population, with the goal of assisting clinicians in developing an evidence-based approach toward screening. This article discusses global risk assessment and screening strategies, including blood pressure, lipids, C-reactive protein, homocysteine, coronary artery calcium score, carotid intima-media thickness, ultrasound of the abdominal aorta, and electrocardiography.
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Affiliation(s)
- Margaret L Wallace
- Department of Family Medicine, University of Wisconsin, 1100 Delaplaine Court, Madison, WI 53715, USA.
| | - Jason A Ricco
- Department of Family Medicine, University of Wisconsin, 1100 Delaplaine Court, Madison, WI 53715, USA
| | - Bruce Barrett
- Department of Family Medicine, University of Wisconsin, 1100 Delaplaine Court, Madison, WI 53715, USA
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Khatana SAM, Jiang L, Wu WC. A comprehensive analysis of dyslipidaemia management in a large health care system. J Eval Clin Pract 2014; 20:81-7. [PMID: 24118549 DOI: 10.1111/jep.12082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2013] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Dyslipidaemia is a cardiovascular risk factor, and national screening and treatment guidelines have been established, but achievement of these remains inadequate. Multidisciplinary approaches, such as the chronic care model, have been applied to other chronic diseases and likely would be applicable to the management of dyslipidaemia. We therefore aimed to comprehensively study the different components of a multidisciplinary management approach to dyslipidaemia in a large health care system for patients at a high risk for cardiovascular events. METHODS All patients at a Veterans Affairs Medical Center in the United States over 3 years with diabetes and/or coronary artery disease were included. Various clinical and demographic variables were collected and achievement of national cholesterol goals was determined. Univariate and multivariate analyses were conducted to determine the association of different health care variables with improved patient cholesterol guideline achievement. RESULTS There were 3559 patients in the study population and 51.0% had achieved national cholesterol goals. Multivariate analyses showed that patients who had achieved goals were more likely to have attended cardiology clinic [odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.3-2.01] and nutrition clinic (OR = 1.3, 95% CI = 1.04-1.7) and were more likely to have primary care providers who were nurse practitioners (OR = 1.6, 95% CI = 1.2-2.0), practicing full-time (OR = 1.8, 95% CI = 1.5-2.1) and at the main hospital-based clinics (OR = 1.5, 95% CI = 1.3-1.9). CONCLUSIONS Our study identifies different components of a multidisciplinary approach to management of dyslipidaemia that are efficacious and these results may help guide future investment in this area.
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Affiliation(s)
- Sameed Ahmed Mustafa Khatana
- Research Enhancement Award Program at the Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
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Lugomirski P, Guo H, Boom NK, Donovan LR, Ko DT, Tu JV. Quality of Diabetes and Hyperlipidemia Screening Before a First Myocardial Infarction. Can J Cardiol 2013; 29:1382-7. [DOI: 10.1016/j.cjca.2013.03.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Revised: 03/14/2013] [Accepted: 03/15/2013] [Indexed: 12/19/2022] Open
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Wu J, Zhu S, Yao GL, Mohammed MA, Marshall T. Patient factors influencing the prescribing of lipid lowering drugs for primary prevention of cardiovascular disease in UK general practice: a national retrospective cohort study. PLoS One 2013; 8:e67611. [PMID: 23922649 PMCID: PMC3724846 DOI: 10.1371/journal.pone.0067611] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 05/24/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Guidelines indicate eligibility for lipid lowering drugs, but it is not known to what extent GPs' follow guidelines in routine clinical practice or whether additional clinical factors systematically influence their prescribing decisions. METHODS A retrospective cohort analysis was undertaken using electronic primary care records from 421 UK general practices. At baseline (May 2008) patients were aged 30 to 74 years, free from cardiovascular disease and not taking lipid lowering drugs. The outcome was prescription of a lipid lowering drug within the next two years. The proportions of eligible and ineligible patients prescribed lipid lowering drugs were reported and multivariable logistic regression models were used to investigate associations between age, sex, cardiovascular risk factors and prescribing. RESULTS Of 365,718 patients with complete data, 13.8% (50,558) were prescribed lipid lowering drugs: 28.5% (21,101/74,137) of those eligible and 10.1% (29,457/291,581) of those ineligible. Only 41.7% (21,101/50,558) of those prescribed lipid lowering drugs were eligible. In multivariable analysis prescribing was most strongly associated with increasing age (OR for age ≥ 65 years 4.21; 95% CI 4.05-4.39); diabetes (OR 4.49; 95% CI 4.35-4.64); total cholesterol level ≥ 7 mmol/L (OR 2.20; 95% CI 2.12-2.29); and ≥ 4 blood pressure measurements in the past year (OR 4.24; 95% CI 4.06-4.42). The predictors were similar in eligible and ineligible patients. CONCLUSIONS Most lipid lowering drugs for primary prevention are prescribed to ineligible patients. There is underuse of lipid lowering drugs in eligible patients.
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Affiliation(s)
- Jianhua Wu
- Centre for Environmental and Preventive Medicine, Barts and The London School of Medicine and Dentistry, University of London, London, United Kingdom
| | - Shihua Zhu
- School of Public Health and Population Science, University of Birmingham, Birmingham, United Kingdom
| | - Guiqing Lily Yao
- Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
| | - Mohammed A. Mohammed
- School of Public Health and Population Science, University of Birmingham, Birmingham, United Kingdom
| | - Tom Marshall
- School of Public Health and Population Science, University of Birmingham, Birmingham, United Kingdom
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Lalonde L, Tsuyuki RT, Landry E, Taylor J. Results of a national survey on OTC medicines, Part 2: Do pharmacists support switching prescription agents to over-the-counter status? Can Pharm J (Ott) 2013; 145:73-76.e1. [PMID: 23509506 DOI: 10.3821/145.2.cpj73] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Lalonde L, Goudreau J, Hudon É, Lussier MT, Duhamel F, Bélanger D, Lévesque L, Martin É. Priorities for action to improve cardiovascular preventive care of patients with multimorbid conditions in primary care--a participatory action research project. Fam Pract 2012; 29:733-41. [PMID: 22379187 DOI: 10.1093/fampra/cms021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) prevention in patients with multimorbid conditions is not always optimal in primary care (PC). Interactive collaborative processes involving PC community are recommended to develop new models of care and to successfully reshape clinical practices. OBJECTIVE To identify challenges and priorities for action in PC to improve CVD prevention among patients with multimorbid conditions. METHODS Physicians (n = 6), nurses (n = 6), community pharmacists (n = 6), other health professionals (n = 6), patients (n = 6) and family members (n = 6), decision makers (n = 6) and researchers (n = 6) took part in a 1-day workshop. Using the Chronic Care Model (CCM) as a framework, participants in focus groups and nominal groups identified the challenges and priorities for action. RESULTS Providing appropriate support to lifestyle change in patients and implementing collaborative practices are challenging. Priorities for action relate to three CCM domains: (i) improve the clinical information system by providing computerized tools for interprofessional and interinstitutional communication, (ii) improve the organization of health care and delivery system design by enhancing interprofessional collaboration, especially with nurses and pharmacists, and creating care teams that include a case manager and (iii) improve self-management support by giving patients access to nutritionists, to personalized health care plans including lifestyle recommendations and to other resources (community resources, websites). CONCLUSIONS To optimize CVD prevention, PC actors recommend focussing mainly on three CCM domains. Electronic medical records, collaborative practices and self-management support are perceived as pivotal aspects of successful PC prevention programme. Developing and implementing such models are challenging and will require the mobilization of the whole PC community.
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Affiliation(s)
- Lyne Lalonde
- Équipe de recherche en soins de première ligne, Centre de santé et de services sociaux de Laval, Laval, Quebec, Canada.
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Rodrigues CJDO, Ribeiro HF, Ribeiro AB, Zanella MT, Batista MC. Cholesterol goal attainment in hypertensive patients: the impact of metabolic syndrome components. Metab Syndr Relat Disord 2012; 10:195-201. [PMID: 22313142 DOI: 10.1089/met.2011.0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hypertension and dyslipidemia are potentially modifiable cardiovascular risk factors. METHODS We studied hypertensive outpatients regarding goal attainment in controlling dyslipidemia, according to individual cardiovascular risk profile, following the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines. Factors of goal attainment for low-density lipoprotein cholesterol (LDL-C) were determined. RESULTS Of the 1,202 patients, this study included 886 (73.8% female, 59.9±11.1 years) with available data to determine cardiovascular risk. Overall, 544 (61.4%) had LDL-C within the goal. Individuals with inappropriate LDL-C were older, had higher systolic blood pressure (SBP), and were more likely to have metabolic syndrome, diabetes, and cardiovascular disease (CVD) and were less likely to show a controlled blood pressure. There was a progressive worsening of LDL-C control as the number of components of metabolic syndrome increased. There was also a progressive increase in the percentage of patients with inappropriate LDL-C with the increase in cardiovascular risk. In a logistic regression model including LDL-C inadequacy as a dependent variable, only age, diabetes, and CVD were predictors of inappropriate LDL-C. Moreover, even with correction for demographic and clinical variables, the inappropriate LDL-C was an independent predictor of CVD. CONCLUSIONS The control of dyslipidemia in hypertensive patients is far from ideal and results are even worse in individuals with CVD.
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Meta-Analysis of Statin Effects in Women Versus Men. J Am Coll Cardiol 2012; 59:572-82. [DOI: 10.1016/j.jacc.2011.09.067] [Citation(s) in RCA: 178] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Revised: 07/22/2011] [Accepted: 09/20/2011] [Indexed: 11/24/2022]
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Wang Z, Klipfell E, Bennett BJ, Koeth R, Levison BS, Dugar B, Feldstein AE, Britt EB, Fu X, Chung YM, Wu Y, Schauer P, Smith JD, Allayee H, Tang WHW, DiDonato JA, Lusis AJ, Hazen SL. Gut flora metabolism of phosphatidylcholine promotes cardiovascular disease. Nature 2011; 472:57-63. [PMID: 21475195 PMCID: PMC3086762 DOI: 10.1038/nature09922] [Citation(s) in RCA: 3692] [Impact Index Per Article: 284.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Accepted: 02/09/2011] [Indexed: 02/06/2023]
Abstract
Metabolomics studies hold promise for discovery of pathways linked to disease processes. Cardiovascular disease (CVD) represents the leading cause of death and morbidity worldwide. A metabolomics approach was used to generate unbiased small molecule metabolic profiles in plasma that predict risk for CVD. Three metabolites of the dietary lipid phosphatidylcholine, namely choline, trimethylamine N-oxide (TMAO), and betaine, were identified and then shown to predict risk for CVD in an independent large clinical cohort. Dietary supplementation of mice with choline, TMAO or betaine promoted up-regulation of multiple macrophage scavenger receptors linked to atherosclerosis, and supplementation with choline or TMAO promoted atherosclerosis. Studies using germ-free mice confirmed a critical role for dietary choline and gut flora in TMAO production, augmented macrophage cholesterol accumulation and foam cell formation. Suppression of intestinal microflora in atherosclerosis-prone mice inhibited dietary choline-enhanced atherosclerosis. Genetic variations controlling expression of flavin monooxygenases (FMOs), an enzymatic source of TMAO, segregated with atherosclerosis in hyperlipidemic mice. Discovery of a relationship between gut flora-dependent metabolism of dietary phosphatidylcholine and CVD pathogenesis provides opportunities for development of both novel diagnostic tests and therapeutic approaches for atherosclerotic heart disease.
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Affiliation(s)
- Zeneng Wang
- Department of Cell Biology, Cleveland Clinic, Cleveland, Ohio 44195, USA
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Berg C, Petersenn S, Lahner H, Herrmann BL, Buchfelder M, Droste M, Stalla GK, Strasburger CJ, Roggenbuck U, Lehmann N, Moebus S, Jöckel KH, Möhlenkamp S, Erbel R, Saller B, Mann K. Cardiovascular risk factors in patients with uncontrolled and long-term acromegaly: comparison with matched data from the general population and the effect of disease control. J Clin Endocrinol Metab 2010; 95:3648-56. [PMID: 20463098 DOI: 10.1210/jc.2009-2570] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
CONTEXT Data on cardiovascular risk in acromegaly are scanty and lack a clear correlation to epidemiological data. OBJECTIVE Our aim was an evaluation of cardiovascular risk factors in patients with active acromegaly, a calculation of the Framingham risk score (FRS) compared with age- and gender-matched controls of the general population, and an evaluation of the effect of IGF-I normalization. DESIGN AND SETTING We conducted a retrospective, comparative study at a university referral center. PATIENTS A total of 133 patients with acromegaly (65 men, aged 45-74 yr) from the German Pegvisomant Observational Study were matched to 665 controls from the general population. MAIN OUTCOME MEASURES Risk factors were measured at baseline and after 12 months of treatment with pegvisomant (n=62). RESULTS Patients with acromegaly had increased prevalence of hypertension, mean systolic and diastolic blood pressure (BP), history of diabetes mellitus and glycosylated hemoglobin (all P<0.001) and decreased high-density lipoprotein, low-density lipoprotein, and total cholesterol (all P<0.001). FRS was significantly higher in patients with acromegaly compared with controls (P<0.001). At 12 months, systolic BP (P=0.04) and glycosylated hemoglobin (P=0.02) as well as FRS (P=0.005) decreased significantly. IGF-I was normalized in 62% (41 of 62). In these patients, glucose and systolic and diastolic BP was significantly lower than in partially controlled patients. SUMMARY We found an increased prevalence of cardiovascular risk factors in acromegalic patients compared with controls. Control of acromegaly led to a significant decrease of FRS, implying a reduced risk for coronary heart disease. This was most significant in those patients who completely normalized their IGF-I levels. CONCLUSION Disease control is important to reduce the likelihood for development of coronary heart disease.
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Affiliation(s)
- Christian Berg
- Department of Endocrinology, Institute for Medical Informatics, Biometry, and Epidemiology, West-German Heart Centre Essen, University Hospital of Essen, University of Duisburg-Essen, Department of Endocrinology, Hufelandstrasse 55, 45122 Essen, Germany.
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