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Tao Y, Li M, Gao H, Sun Y, Zhang F, Wu J, Liang H, He L, Gong M, Niu J, Miao Y. The hospitalization burden of inflammatory bowel disease in a southwestern highland region of China: a territory-wide study from 2015 to 2020. Front Med (Lausanne) 2024; 11:1410714. [PMID: 38912335 PMCID: PMC11190343 DOI: 10.3389/fmed.2024.1410714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 05/23/2024] [Indexed: 06/25/2024] Open
Abstract
Background Yunnan, a southwest highland and newly industrialized region of China, has an unknown hospitalization burden of inflammatory bowel disease (IBD). The study was conducted to explore territorial hospitalization burden of IBD. Methods The formatted medical records of patients with IBD were collected from a territory-wide database in Yunnan Province, China, from 2015 to 2020. General characteristics of the study population were reported using descriptive statistics. To evaluate the length of stay, hospitalization costs, surgery, complications, and trends in patients with inflammatory bowel disease. The logistic regression analysis was established to explore the factors affecting the hospitalization costs. Results A total of 12,174 records from 8192 patients were included. The annual hospitalization cost of IBD in Yunnan Province increased significantly from 2015 to 2020. From 2015 to 2020, the regional hospitalization burden of IBD increased, but it represented a decline in cost per hospitalization (r = -0.024, P = 0.008) and the length of stay (r = -0.098, P < 0.001). Surgery rates for hospitalized patients with Crohn's disease (CD) did not decrease (r = -0.002, P = 0.932), and even increased for patients with ulcerative colitis (UC) (r = 0.03, P = 0.002). The costs per hospitalization were $ 827.49 (540.11-1295.50) for UC and $ 1057.03 (644.26-1888.78) for CD. Among the identifiable cost items during the period, drug costs accounted for the highest proportion, accounting for 33% and 37.30% in patients with UC and CD, respectively. Surgical intervention [OR 4.87 (3.75-6.31), P < 0.001], comorbidities [OR 1.72 (1.52-1.94), P < 0.001], complications [OR 1.53 (1.32-1.78), P < 0.001], and endoscopy [OR 2.06 (1.86-2.28), P < 0.001] were predictor of high hospitalization costs. Conclusion The increasing burden of IBD is noteworthy a newly industrialized region of China. Interventions targeting surgery, complications, and comorbidities may be effective means of controlling the increasing hospitalization costs of IBD in the regions.
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Affiliation(s)
- Yan Tao
- Department of Gastroenterology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Yunnan Province Clinical Research Center for Digestive Diseases, Kunming, Yunnan, China
| | - Maojuan Li
- Department of Gastroenterology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Yunnan Province Clinical Research Center for Digestive Diseases, Kunming, Yunnan, China
| | - Huabin Gao
- Yunnan Evaluation Center for Medical Service and Administration, Kunming, Yunnan, China;
| | - Yang Sun
- Department of Gastroenterology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Yunnan Province Clinical Research Center for Digestive Diseases, Kunming, Yunnan, China
| | - Fengrui Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Yunnan Province Clinical Research Center for Digestive Diseases, Kunming, Yunnan, China
| | - Jing Wu
- Department of Gastroenterology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Yunnan Province Clinical Research Center for Digestive Diseases, Kunming, Yunnan, China
| | - Hao Liang
- Department of Gastroenterology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Yunnan Province Clinical Research Center for Digestive Diseases, Kunming, Yunnan, China
| | - Liping He
- School of Public Health, Kunming Medical University, Kunming, Yunnan, China
| | - Min Gong
- Department of Gastroenterology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Yunnan Province Clinical Research Center for Digestive Diseases, Kunming, Yunnan, China
| | - Junkun Niu
- Department of Gastroenterology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Yunnan Province Clinical Research Center for Digestive Diseases, Kunming, Yunnan, China
| | - Yinglei Miao
- Department of Gastroenterology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Yunnan Province Clinical Research Center for Digestive Diseases, Kunming, Yunnan, China
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Factors predicting statin prescribing for primary prevention: a historical cohort study. Br J Gen Pract 2021; 71:e219-e225. [PMID: 33558331 PMCID: PMC7888748 DOI: 10.3399/bjgp20x714065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/17/2020] [Indexed: 11/24/2022] Open
Abstract
Background Initiation of statins for the primary prevention of cardiovascular disease (CVD) should be based on CVD risk estimates, but their use is suboptimal. Aim To investigate the factors influencing statin prescribing when clinicians code and do not code estimated CVD risk (QRISK2). Design and setting A historical cohort of patients who had lipid tests in a database (IQVIA Medical Research Data) of UK primary care records. Method The cohort comprised 686 560 entries (lipid test results) between 2012 and 2016 from 383 416 statin-naive patients without previous CVD. Coded QRISK2 scores were extracted, with variables used in calculating QRISK2 and factors that might influence statin prescribing. If a QRISK2 score was not coded, it was calculated post hoc. The outcome was initiation of a statin within 60 days of the lipid test result. Results Of the entries, 146 693 (21.4%) had a coded QRISK2 score. Statins were initiated in 6.6% (95% confidence interval [CI] = 6.4% to 6.7%) of those with coded and 4.1% (95% CI = 4.0% to 4.1%) of uncoded QRISK2 (P<0.001). Statin initiations were consistent with National Institute for Health and Care Excellence guideline recommendations in 85.0% (95% CI = 84.2% to 85.8%) of coded and 44.2% (95% CI = 43.5% to 44.9%) of uncoded QRISK2 groups (P<0.001). When coded, QRISK2 score was the main predictor of statin initiation, but total cholesterol was the main predictor when a QRISK2 score was not coded. Conclusion When a QRISK2 score is coded, prescribing is more consistent with guidelines. With no QRISK2 score, prescribing is mainly based on total cholesterol. Using QRISK2 is associated with statin prescribing that is more likely to benefit patients. Promoting the routine CVD risk estimation is essential to optimise decision making.
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Ma TT, Wong ICK, Whittlesea C, Mackenzie IS, Man KKC, Lau W, Brauer R, Wei L. Initial cardiovascular treatment patterns during the first 90 days following an incident cardiovascular event. Br J Clin Pharmacol 2020; 87:1043-1055. [PMID: 32643191 DOI: 10.1111/bcp.14463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 11/30/2022] Open
Abstract
AIMS The aim of this study was to investigate the initial cardiovascular prescription patterns in patients after their first cardiovascular events, and to identify factors associated with cardiovascular polypharmacy. METHODS This was a cross-sectional study including patients aged ≥ 45 years with the first record of coronary heart disease (CHD) or stroke between 2007 and 2016 using The Health Improvement Network database. This study investigated the patterns of cardiovascular drugs prescribed during the first 90 days after the first cardiovascular events. Logistic regression was used to examine the association between patients' baseline characteristics and cardiovascular polypharmacy (≥5 cardiovascular drugs). RESULTS A total of 121,600 (59,843 CHD and 61,757 stroke) patients were included in the study. The mean age was 69.5 ± 11.9 years. The proportion of patients who were prescribed 0-1, 2-3, 4-5 drugs and ≥6 drugs were 11.0%, 29.8%, 38.6% and 20.5%, respectively. Factors associated with cardiovascular polypharmacy were sex (female: OR 0.74, 95% CI 0.72-0.76 vs male), age (75-84 years old: OR 0.50, 0.47-0.53 vs 45-54 years old), smoking status (current smoking: OR 1.29, 1.15-1.24 vs never), body mass index (obesity: OR 1.38, 1.34-1.43 vs normal), deprivation status (most deprived: OR 1.09, 1.04-1.14 vs least deprived) and Charlson comorbidity index (index ≥5: OR 1.25, 1.16-1.35 vs index 0). CONCLUSION Multiple cardiovascular drugs treatment was common in patients with CVD in the UK. High-risk factors of CVD were also associated with cardiovascular polypharmacy. Further studies are warranted to assess the impact of cardiovascular polypharmacy and its interaction on CVD recurrence and mortality.
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Affiliation(s)
- Tian-Tian Ma
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Ian C K Wong
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK.,Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Cate Whittlesea
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Isla S Mackenzie
- Medicines Monitoring Unit (MEMO Research) and Hypertension Research Centre, University of Dundee, Dundee, UK
| | - Kenneth K C Man
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Wallis Lau
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Ruth Brauer
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Li Wei
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
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van Eersel MEA, Visser ST, Joosten H, Gansevoort RT, Slaets JPJ, Izaks GJ. Pharmacological treatment of increased vascular risk and cognitive performance in middle-aged and old persons: six-year observational longitudinal study. BMC Neurol 2020; 20:242. [PMID: 32532237 PMCID: PMC7291556 DOI: 10.1186/s12883-020-01822-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 06/04/2020] [Indexed: 11/24/2022] Open
Abstract
Background Lowering vascular risk is associated with a decrease in the prevalence of cardiovascular disease and dementia. However, it is still unknown whether lowering of vascular risk with pharmacological treatment preserves cognitive performance in general. Therefore, we compared the change in cognitive performance in persons with and without treatment of vascular risk factors. Methods In this longitudinal observational study, 256 persons (mean age, 58 years) were treated for increased vascular risk during a mean follow-up period of 5.5 years (treatment group), whereas 1678 persons (mean age, 50 years) did not receive treatment (control group). Cognitive performance was three times measured during follow-up using the Ruff Figural Fluency Test (RFFT) and Visual Association Test (VAT), and calculated as the average of standardized RFFT and VAT score per participant. Because treatment allocation was nonrandomized, additional analyses were performed in demographic and vascular risk-matched samples and adjusted for propensity scores. Results In the treatment group, mean (SD) cognitive performance changed from − 0.30 (0.80) to − 0.23 (0.80) to 0.02 (0.87), and in control group, from 0.08 (0.77) to 0.24 (0.79) to 0.49 (0.74) at the first, second and third measurement, respectively (ptrend < 0.001). After adjustment for demographics and vascular risk, the change in cognitive performance during follow-up was not statistically significantly different between the treatment and control group: mean estimated difference, − 0.10 (95%CI − 0.21 to 0.01; p = 0.08). Similar results were found in matched samples and after adjustment for propensity score. Conclusion Change in cognitive performance during follow-up was similar in treated and untreated persons. This suggests that lowering vascular risk preserves cognitive performance.
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Affiliation(s)
- Marlise E A van Eersel
- University Center for Geriatric Medicine, University of Groningen, University Medical Center Groningen, AA41, PO Box 30.001, 9700, RB, Groningen, The Netherlands.
| | - Sipke T Visser
- Department of Pharmacy, PharmacoTherapy, -Epidemiology and -Economics (PTE2), University of Groningen, Groningen, the Netherlands
| | - Hanneke Joosten
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ron T Gansevoort
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joris P J Slaets
- University Center for Geriatric Medicine, University of Groningen, University Medical Center Groningen, AA41, PO Box 30.001, 9700, RB, Groningen, The Netherlands
| | - Gerbrand J Izaks
- University Center for Geriatric Medicine, University of Groningen, University Medical Center Groningen, AA41, PO Box 30.001, 9700, RB, Groningen, The Netherlands
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Argollo M, Gilardi D, Peyrin-Biroulet C, Chabot JF, Peyrin-Biroulet L, Danese S. Comorbidities in inflammatory bowel disease: a call for action. Lancet Gastroenterol Hepatol 2019; 4:643-654. [PMID: 31171484 DOI: 10.1016/s2468-1253(19)30173-6] [Citation(s) in RCA: 113] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/17/2019] [Accepted: 03/18/2019] [Indexed: 02/06/2023]
Abstract
Inflammatory bowel disease (IBD) is a chronic systemic inflammatory condition. Previously, the focus has been on extraintestinal manifestations of IBD, including arthritis, psoriasis, and uveitis. Although comorbidities have long been the subject of intensive research in other chronic inflammatory diseases such as rheumatoid arthritis, the concept of comorbidities is only beginning to emerge in IBD. Several comorbid conditions have been proposed to be related to IBD, including cardiovascular disease, neuropsychological disorders, and metabolic syndrome. Recognition of these conditions and their treatment could lead to better management of IBD. This Review aims to explore current knowledge regarding classic and emerging comorbidities related to IBD.
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Affiliation(s)
- Marjorie Argollo
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Centre, Milan, Italy; Universidade Federal de São Paulo, São Paulo, Brazil
| | - Daniela Gilardi
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Centre, Milan, Italy
| | | | - Jean-Francois Chabot
- Department of Pneumology, Nancy University Hospital, Lorraine University, Nancy, France
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm U954, Nancy University Hospital, Lorraine University, Nancy, France
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Centre, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy.
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Laleman N, Henrard S, van den Akker M, Goderis G, Buntinx F, Van Pottelbergh G, Vaes B. Time trends in statin use and incidence of recurrent cardiovascular events in secondary prevention between 1999 and 2013: a registry-based study. BMC Cardiovasc Disord 2018; 18:209. [PMID: 30400778 PMCID: PMC6220501 DOI: 10.1186/s12872-018-0941-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 10/16/2018] [Indexed: 12/15/2022] Open
Abstract
Background The current study evaluated time trends of statin use and incidence of recurrent CVD in secondary prevention from 1999 to 2013 and investigated which factors were associated with statin use in secondary prevention. Methods Intego is a primary care registration network with 111 general practitioners working in 48 practices in Flanders, Belgium. This retrospective registry-based study included patients aged 50 years or older with a history of CVD. The time trends of statin use and incidence of recurrent CVD in secondary prevention were determined by using a joinpoint regression analysis. Multivariable mixed-effect logistic regression analysis was used to assess factors associated with statin use in patients in secondary prevention in 2013. Results The overall prevalence of statin use increased and showed two trends: a sharp increase from 1999 to 2005 (annual percentage change (APC) 25.4%) and a weaker increase from 2005 to 2013 (APC 3.7%). The average increase in statin use was the highest in patients aged 80 and older. Patients aged 70–79 years received the most statins. Men used more statins than women did, but both genders showed similar time trends. The incidence of CVD decreased by an average APC of 3.9%. There were no differences between men and women and between different age groups. A significant decrease was only observed in older patients without statins prescribed. In 2013, 61% of the patients in secondary prevention did not receive a statin. The absence of other secondary preventive medication was strongly associated with less statin use. Gender, age and comorbidity were associated with statin use to a lesser degree. Conclusions The prevalence of statin use in secondary prevention increased strongly from 1999 to 2013. Less than 50% of patients with a history of CVD received a statin in 2013. Especially patients who did not receive other secondary preventive medication were more likely to not receive a statin. Despite the strong increase in statin use, there was only a small decrease in the incidence of recurrent CVD, and this occurred mainly in older patients without statins prescribed.
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Affiliation(s)
- Nele Laleman
- Department of Public Health and Primary Care, Universiteit Leuven (KU Leuven), Kapucijnenvoer 33, Blok J, 3000, Leuven, Belgium
| | - Séverine Henrard
- Department of Public Health and Primary Care, Universiteit Leuven (KU Leuven), Kapucijnenvoer 33, Blok J, 3000, Leuven, Belgium.,Institute of Health and Society, Université catholique de Louvain (UCL), Brussels, Belgium
| | - Marjan van den Akker
- Department of Public Health and Primary Care, Universiteit Leuven (KU Leuven), Kapucijnenvoer 33, Blok J, 3000, Leuven, Belgium.,Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Geert Goderis
- Department of Public Health and Primary Care, Universiteit Leuven (KU Leuven), Kapucijnenvoer 33, Blok J, 3000, Leuven, Belgium
| | - Frank Buntinx
- Department of Public Health and Primary Care, Universiteit Leuven (KU Leuven), Kapucijnenvoer 33, Blok J, 3000, Leuven, Belgium.,Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Gijs Van Pottelbergh
- Department of Public Health and Primary Care, Universiteit Leuven (KU Leuven), Kapucijnenvoer 33, Blok J, 3000, Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, Universiteit Leuven (KU Leuven), Kapucijnenvoer 33, Blok J, 3000, Leuven, Belgium. .,Institute of Health and Society, Université catholique de Louvain (UCL), Brussels, Belgium.
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Cho YY, Sidorenkov G, Denig P. Role of Patient and Practice Characteristics in Variance of Treatment Quality in Type 2 Diabetes between General Practices. PLoS One 2016; 11:e0166012. [PMID: 27806107 PMCID: PMC5091743 DOI: 10.1371/journal.pone.0166012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 10/21/2016] [Indexed: 11/18/2022] Open
Abstract
Background Accounting for justifiable variance is important for fair comparisons of treatment quality. The variance between general practices in treatment quality of type 2 diabetes (T2DM) patients may be attributed to the underlying patient population and practice characteristics. The objective of this study is to describe the between practice differences in treatment, and identify patient and practice level characteristics that may explain these differences. Methods The data of 24,607 T2DM patients from 183 general practices in the Netherlands were used. Treatment variance was assessed in a cross-sectional manner for: glucose-lowering drugs/metformin, lipid-lowering drugs/statins, blood pressure-lowering drugs/ACE-inhibitor or ARB. Patient characteristics tested were age, gender, diabetes duration, comorbidity, comedication. Practice characteristics were number of T2DM patients, practice type, diabetes assistant available. Multilevel logistic regression was used to examine the between practice variance in treatment and the effect of characteristics on this variance. Results Treatment rates varied considerably between practices (IQR 9.5–13.9). The variance at practice level was 7.5% for glucose-lowering drugs, 3.6% for metformin, 3.1% for lipid-lowering drugs, 10.3% for statins, 8.6% for blood pressure-lowering drugs, and 3.9% for ACE-inhibitor/ARB. Patient and practice characteristics explained 19.0%, 7.5%, 20%, 6%, 9.9%, and 13.4% of the variance respectively. Age, multiple chronic drugs, and ≥3 glucose-lowering drugs were the most relevant patient characteristics. Number of T2DM patients per practice was the most relevant practice characteristic. Discussion Considerable differences exist between practices in treatment rates. Patients’ age was identified as characteristic that may account for justifiable differences in especially lipid-lowering treatment. Other patient or practice characteristics either do not explain or do not justify the differences.
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Affiliation(s)
- Yeon Young Cho
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Epidemiology, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Grigory Sidorenkov
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- * E-mail:
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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8
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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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9
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Barfoed BL, Paulsen MS, Christensen PM, Halvorsen PA, Jarbøl DE, Larsen ML, Munch MR, Søndergaard J, Nielsen JB. Associations between patients' adherence and GPs' attitudes towards risk, statin therapy and management of non-adherence--a survey and register-based study. Fam Pract 2016; 33:140-7. [PMID: 26936208 DOI: 10.1093/fampra/cmw005] [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] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Previous studies suggest that doctors' personal lifestyle, risk taking personality and beliefs about risk reducing therapies may affect their clinical decision-making. Whether such factors are further associated with patients' adherence with medication is largely unknown. OBJECTIVE To estimate associations between GPs' attitudes towards risk, statin therapy and management of non-adherence and their patients' adherence, and to identify subgroups of GPs with poor patient adherence. METHODS All Danish GPs were invited to participate in an online survey. We asked whether they regarded statin treatment as important, how they managed non-adherence and whether non-adherence annoyed them. The Jackson Personality Inventory-revised was used to measure risk attitude. The GPs' responses were linked to register data on their patients' redeemed statin prescriptions. Mixed effect logistic regression was used to estimate associations between patient adherence and GPs' attitudes. Adherence was estimated by the proportion of days covered in a 1-year period using an 80% cut-off. RESULTS We received responses from 1398 GPs (42.2%) who initiated statin therapy in 12 192 patients during the study period. In total 6590 (54.1%) of these patients were adherent. Patients who had GPs rarely assessing their treatment adherence were less likely to be adherent than those who had GPs assessing their patients' treatment adherence now and then, odds ratio (OR) 0.86 [confidence interval (CI) 0.77-0.96]. No other associations were found between patients' adherence and GPs' attitudes. CONCLUSIONS Our findings suggest that GPs' attitudes to risk, statin therapy or management of non-adherence are not significantly associated with their patients' adherence.
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Affiliation(s)
- Benedicte L Barfoed
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark,
| | - Maja S Paulsen
- Danish Quality Unit of General Practice, Odense, Denmark
| | | | - Peder A Halvorsen
- Department of Community Medicine, University of Tromsø, The Arctic University of Norway, Tromsø, Norway and
| | - Dorte E Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Mogens L Larsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Maria R Munch
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper B Nielsen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Schilling C, Mortimer D, Dalziel K, Heeley E, Chalmers J, Clarke P. Using Classification and Regression Trees (CART) to Identify Prescribing Thresholds for Cardiovascular Disease. PHARMACOECONOMICS 2016; 34:195-205. [PMID: 26578402 DOI: 10.1007/s40273-015-0342-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND AND OBJECTIVE Many guidelines for clinical decisions are hierarchical and nonlinear. Evaluating if these guidelines are used in practice requires methods that can identify such structures and thresholds. Classification and regression trees (CART) were used to analyse prescribing patterns of Australian general practitioners (GPs) for the primary prevention of cardiovascular disease (CVD). Our aim was to identify if GPs use absolute risk (AR) guidelines in favour of individual risk factors to inform their prescribing decisions of lipid-lowering medications. METHODS We employed administrative prescribing information that is linked to patient-level data from a clinical assessment and patient survey (the AusHeart Study), and assessed prescribing of lipid-lowering medications over a 12-month period for patients (n = 1903) who were not using such medications prior to recruitment. CART models were developed to explain prescribing practice. Out-of-sample performance was evaluated using receiver operating characteristic (ROC) curves, and optimised via pruning. RESULTS We found that individual risk factors (low-density lipoprotein, diabetes, triglycerides and a history of CVD), GP-estimated rather than Framingham AR, and sociodemographic factors (household income, education) were the predominant drivers of GP prescribing. However, sociodemographic factors and some individual risk factors (triglycerides and CVD history) only become relevant for patients with a particular profile of other risk factors. The ROC area under the curve was 0.63 (95% confidence interval [CI] 0.60-0.64). CONCLUSIONS There is little evidence that AR guidelines recommended by the National Heart Foundation and National Vascular Disease Prevention Alliance, or conditional individual risk eligibility guidelines from the Pharmaceutical Benefits Scheme, are adopted in prescribing practice. The hierarchy of conditional relationships between risk factors and socioeconomic factors identified by CART provides new insights into prescribing decisions. Overall, CART is a useful addition to the analyst's toolkit when investigating healthcare decisions.
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Affiliation(s)
- Chris Schilling
- Centre for Health Policy, School of Population and Global Health, University of Melbourne, Melbourne, VIC, 3051, Australia.
| | - Duncan Mortimer
- Centre for Health Economics, Monash Business School, Monash University, Melbourne, VIC, 3800, Australia
| | - Kim Dalziel
- Centre for Health Policy, School of Population and Global Health, University of Melbourne, Melbourne, VIC, 3051, Australia
| | - Emma Heeley
- The George Institute for Global Health, The University of Sydney and the Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia
| | - John Chalmers
- The George Institute for Global Health, The University of Sydney and the Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia
| | - Philip Clarke
- Centre for Health Policy, School of Population and Global Health, University of Melbourne, Melbourne, VIC, 3051, Australia
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11
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Primdahl J, Ferreira RJO, Garcia-Diaz S, Ndosi M, Palmer D, van Eijk-Hustings Y. Nurses' Role in Cardiovascular Risk Assessment and Management in People with Inflammatory Arthritis: A European Perspective. Musculoskeletal Care 2015; 14:133-51. [PMID: 26549188 DOI: 10.1002/msc.1121] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Cardiovascular risk (CVR) assessment and management in patients with inflammatory arthritis (IA) is recommended but European nurses' involvement in this role has not been well studied. AIM The aim of the present study was to explore European nurses' role in assessing and managing CVR, in order to suggest topics for practice development and research in this area regarding persons with IA. METHODS We searched Embase, Cinahl, Cochrane, PsycInfo and PubMed databases and included European articles from the past ten years if they described how nurses assess and/or manage CVR. In addition to the systematic review, we provided case studies from five different countries to illustrate national guidelines and nurses' role regarding CVR assessment and management in patients with IA. RESULTS Thirty-three articles were included. We found that trained nurses were undertaking CVR assessment and management in different settings and groups of patients. The assessments include blood pressure, body mass index, waist circumference, glucose and lipid-profile, adherence to medication and behavioural risk factors (unhealthy diet, physical inactivity, alcohol and smoking). Different tools were used to calculate patients' risk. Risk management differed from brief advice to long-term follow-up. Nurses tended to take a holistic and individually tailored approach. Clinical examples of inclusion of rheumatology nurses in these tasks were scarce. CONCLUSION Nurses undertake CVR assessment, communication and management in different types of patients. This is considered to be a highly relevant task for rheumatology nursing, especially in patients with IA. Further studies are needed to assess patients' perspective, effectiveness and cost-effectiveness of nurse-led CVR. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Jette Primdahl
- King Christian X's Hospital for Rheumatic Diseases, Graasten, Denmark. .,Institute for Regional Health Research, University of Southern Denmark, Odense, Denmark and Hospital of Southern Jutland, Aabenraa, Denmark.
| | - Ricardo J O Ferreira
- Centro Hospitalar e Universitário de Coimbra, EPE, Coimbra, Portugal.,Health Sciences Research Unit: Nursing (UICISA:E), Coimbra, Portugal
| | - Silvia Garcia-Diaz
- Moises Broggi Hospital, Consorci Sanitari Integral CSI, Barcelona, Spain
| | - Mwidimi Ndosi
- School of Healthcare, University of Leeds, Leeds, UK
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12
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Chang KCM, Soljak M, Lee JT, Woringer M, Johnston D, Khunti K, Majeed A, Millett C. Coverage of a national cardiovascular risk assessment and management programme (NHS Health Check): Retrospective database study. Prev Med 2015; 78:1-8. [PMID: 26051202 DOI: 10.1016/j.ypmed.2015.05.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 05/29/2015] [Accepted: 05/30/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine coverage of NHS Health Check, a national cardiovascular risk assessment programme in England, in the first four years after implementation, and to examine prevalence of high cardiovascular disease (CVD) risk and uptake of statins in high risk patients. METHOD Study sample was 95,571 patients in England aged 40-74years continuously registered with 509 practices in the Clinical Practice Research Datalink between April 2009 and March 2013. Multilevel logistic regression models were used to assess predictors of Health Check attendance; elevated CVD risk factors and statin prescribing among attendees. RESULTS Programme coverage was 21.4% over four years, with large variations between practices (0%-72.7%) and regions (9.4%-30.7%). Coverage was higher in older patients (adjusted odds ratio 2.88, 95% confidence interval 2.49-3.31 for patients 70-74years) and in patients with a family history of premature coronary heart disease (2.37, 2.22-2.53), but lower in Black Africans (0.75, 0.61-0.92) and Chinese (0.68, 0.47-0.96) compared with White British. Coverage was similar in patients living in deprived and affluent areas. Prevalence of high CVD risk (QRISK2≥20%) among attendees was 4.6%. One third (33.6%) of attendees at high risk were prescribed a statin after Health Checks. CONCLUSIONS Coverage of the programme and statin prescribing in high risk individuals was low. Coverage was similar in deprived and affluent groups but lower in some ethnic minority groups, possibly widening inequalities. These findings raise a question about whether recommendations by WHO to develop CVD risk assessment programmes internationally will deliver anticipated health benefits.
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Affiliation(s)
- Kiara Chu-Mei Chang
- Department of Primary Care and Public Health, Imperial College London, W6 8RP London, UK.
| | - Michael Soljak
- Department of Primary Care and Public Health, Imperial College London, W6 8RP London, UK
| | - John Tayu Lee
- Department of Primary Care and Public Health, Imperial College London, W6 8RP London, UK
| | - Maria Woringer
- Department of Primary Care and Public Health, Imperial College London, W6 8RP London, UK
| | - Desmond Johnston
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Imperial College London, London W2 1PG, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester LE5 4PW, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, W6 8RP London, UK
| | - Christopher Millett
- Department of Primary Care and Public Health, Imperial College London, W6 8RP London, UK
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13
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Klemenc-Ketis Z, Terbovc A, Gomiscek B, Kersnik J. Role of nurse practitioners in reducing cardiovascular risk factors: a retrospective cohort study. J Clin Nurs 2015; 24:3077-83. [DOI: 10.1111/jocn.12889] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Zalika Klemenc-Ketis
- Department of Family Medicine; Medical Faculty; University of Maribor; Maribor Slovenia
- Department of Family Medicine; Medical Faculty; University of Ljubljana; Ljubljana Slovenia
| | - Alenka Terbovc
- Zdravstveni dom Kranj; Osnovno zdravstvo Gorenjske; Kranj Slovenia
| | - Bostjan Gomiscek
- Faculty of Business; University of Wollongong in Dubai; Dubai UAE
- Faculty of Organizational Sciences; University of Maribor; Kranj Slovenia
| | - Janko Kersnik
- Department of Family Medicine; Medical Faculty; University of Maribor; Maribor Slovenia
- Department of Family Medicine; Medical Faculty; University of Ljubljana; Ljubljana Slovenia
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14
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Dougados M, Soubrier M, Perrodeau E, Gossec L, Fayet F, Gilson M, Cerato MH, Pouplin S, Flipo RM, Chabrefy L, Mouterde G, Euller-Ziegler L, Schaeverbeke T, Fautrel B, Saraux A, Chary-Valckenaere I, Chales G, Dernis E, Richette P, Mariette X, Berenbaum F, Sibilia J, Ravaud P. Impact of a nurse-led programme on comorbidity management and impact of a patient self-assessment of disease activity on the management of rheumatoid arthritis: results of a prospective, multicentre, randomised, controlled trial (COMEDRA). Ann Rheum Dis 2014; 74:1725-33. [PMID: 24872377 PMCID: PMC4552897 DOI: 10.1136/annrheumdis-2013-204733] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 04/16/2014] [Indexed: 01/26/2023]
Abstract
Objectives Rheumatoid arthritis (RA) patients are at an increased risk of developing comorbid conditions. A close monitoring of the disease targeting a status of low disease activity is associated with a better outcome. The aim of this trial was to evaluate the impact of a nurse-led programme on comorbidities and the impact of patient self-assessment of disease activity on the management of RA. Methods We enrolled 970 patients (mean age 58 years, 79% women) in a prospective, randomised, controlled, open-label, 6-month trial. In the comorbidity group (n=482), the nurse checked comorbidities and sent the programme results to the attending physicians. In the self-assessment group (n=488), the nurse taught the patient how to calculate his/her Disease Activity Score which had to be reported on a booklet to be shared with the treating rheumatologist. The number of measures taken for comorbidities and the percentage of patients recording a change (initiation, switch or increased dose) in disease-modifying antirheumatic drugs (DMARDs) in the 6 months follow-up period of the study defined the outcomes of the trial. Results The number of measures taken per patient was statistically higher in the comorbidity group: 4.54±2.08 versus 2.65±1.57 (p<0.001); incidence rate ratio: 1.78 (1.61–1.96) and DMARD therapy was changed more frequently in the self-assessment group: 17.2% versus 10.9% (OR=1.70 (1.17; 2.49), p=0.006). Conclusions This study demonstrates the short-term benefit of a nurse-led programme on RA comorbidity management and the impact of patient self-assessment of disease activity on RA treatment intensification. Trial registration number NCT #01315652.
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Affiliation(s)
- Maxime Dougados
- Rhumatologie B, Cochin Hospital, Paris, France; rené Descartes University INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, France
| | - Martin Soubrier
- Department of Rheumatology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Elodie Perrodeau
- Department of Epidemiology, INSERM U738, APHP, Hôtel-Dieu Hospital, Paris, France
| | - Laure Gossec
- Rheumatology Department, UPMC, Univ Paris 06, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Françoise Fayet
- Department of Rheumatology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Mélanie Gilson
- Department of Rheumatology, CHU Sud Hospital, Grenoble, France
| | | | - Sophie Pouplin
- Department of Rheumatology, Bois-Guillaume CHU, Rouen, France
| | - René-Marc Flipo
- Department of Rheumatology, CHU Roger Salengro Hospital, University of Lille 2, Lille, France
| | | | - Gael Mouterde
- Department of Rheumatology, Lapeyronie Hospital, Montpellier, France
| | | | | | - Bruno Fautrel
- Department of Rheumatology, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Alain Saraux
- Department of Rheumatology, and EA2216, CHU Brest, Université de Bretagne Occidentale, France
| | | | - Gérard Chales
- Medecine Faculty, Department of Rheumatology, South Hospital, Rennes 1 University, Rennes, France
| | | | - Pascal Richette
- Université Paris Diderot, UFR médicale, Paris , France; APHP Hôpital Lariboisiére, Fédération de Rhumatologie, Paris, France
| | - Xavier Mariette
- Department of Rheumatology, APHP, Bicêtre Hospital, Le Kremlin-Bicetre, France
| | - Francis Berenbaum
- Department of Rheumatology, Univ Paris 06 and INSERM UMRS_938, DHU i2B, APHP Saint- Antoine Hospital, Paris, France
| | - Jean Sibilia
- Department of Rheumatology, Hautepierre CHU, Fédération de médecine translationnelle, UMR INSERM 1109, Strasbourg, France
| | - Philippe Ravaud
- Department of Epidemiology, APHP, Bichat Hospital, Paris, France
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15
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Jansen J, Bonner C, McKinn S, Irwig L, Glasziou P, Doust J, Teixeira-Pinto A, Hayen A, Turner R, McCaffery K. General practitioners' use of absolute risk versus individual risk factors in cardiovascular disease prevention: an experimental study. BMJ Open 2014; 4:e004812. [PMID: 24833688 PMCID: PMC4025465 DOI: 10.1136/bmjopen-2014-004812] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 04/14/2014] [Accepted: 04/22/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To understand general practitioners' (GPs) use of individual risk factors (blood pressure and cholesterol levels) versus absolute risk in cardiovascular disease (CVD) risk management decision-making. DESIGN Randomised experiment. Absolute risk, systolic blood pressure (SBP), cholesterol ratio (total cholesterol/high-density lipoprotein (TC/HDL)) and age were systematically varied in hypothetical cases. High absolute risk was defined as 5-year risk of a cardiovascular event >15%, high blood pressure levels varied between SBP 147 and 179 mm Hg and high cholesterol (TC/HDL ratio) between 6.5 and 7.2 mmol/L. SETTING 4 GP conferences in Australia. PARTICIPANTS 144 Australian GPs. OUTCOMES GPs indicated whether they would prescribe cholesterol and/or blood pressure lowering medication. Analyses involved logistic regression. RESULTS For patients with high blood pressure: 93% (95% CI 86% to 96%) of high absolute risk patients and 83% (95% CI 76% to 88%) of lower absolute risk patients were prescribed blood pressure medication. Conversely, 30% (95% CI 25% to 36%) of lower blood pressure patients were prescribed blood pressure medication if absolute risk was high and 4% (95% CI 3% to 5%) if lower. 69% of high cholesterol/high absolute risk patients were prescribed cholesterol medication (95% CI 61% to 77%) versus 34% of high cholesterol/lower absolute risk patients (95% CI 28% to 41%). 36% of patients with lower cholesterol (95% CI 30% to 43%) were prescribed cholesterol medication if absolute risk was high versus 10% if lower (95% CI 8% to 13%). CONCLUSIONS GPs' decision-making was more consistent with the management of individual risk factors than an absolute risk approach, especially when prescribing blood pressure medication. The results suggest medical treatment of lower risk patients (5-year risk of CVD event <15%) with mildly elevated blood pressure or cholesterol levels is likely to occur even when an absolute risk assessment is specifically provided. The results indicate a need for improving uptake of absolute risk guidelines and GP understanding of the rationale for using absolute risk.
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Affiliation(s)
- Jesse Jansen
- Screening and Test Evaluation Program (STEP), School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology & Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
| | - Carissa Bonner
- Screening and Test Evaluation Program (STEP), School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology & Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
| | - Shannon McKinn
- Screening and Test Evaluation Program (STEP), School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology & Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
| | - Les Irwig
- Screening and Test Evaluation Program (STEP), School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Paul Glasziou
- Screening and Test Evaluation Program (STEP), School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Research in Evidence Based Practice Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Jenny Doust
- Screening and Test Evaluation Program (STEP), School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Research in Evidence Based Practice Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Armando Teixeira-Pinto
- Screening and Test Evaluation Program (STEP), School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew Hayen
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Robin Turner
- Screening and Test Evaluation Program (STEP), School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- Screening and Test Evaluation Program (STEP), School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology & Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
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16
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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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Mohammed MA, Marshall T, Gill P. The effect of chance variability in blood pressure readings on the decision making of general practitioners: an internet-based case vignette study. PLoS One 2012; 7:e46556. [PMID: 23133591 PMCID: PMC3487729 DOI: 10.1371/journal.pone.0046556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Accepted: 08/31/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Guidelines for the management of blood pressure (BP) in primary care generally suggest that decisions be made on the basis of specific threshold values (e.g. BP 140/90 mmHg); but this fails to adequately accommodate a common cause of variation--the play of chance. OBJECTIVE To determine the impact of chance variability in BP readings on the clinical decision making of general practitioners (GPs) regarding anti-hypertensive treatment and cardiovascular risk management. METHOD We used an internet based study design, where 109 GPs were assigned to manage one of eight case vignettes (guidelines would recommend treatment for only one of the eight) and presented with blood pressure readings that were randomly selected from an underlying population. RESULTS Seventeen (15.6%, 17/109) GPs consulted the vignette for whom treatment was recommended, but only 7/17 (41.2%) GPs prescribed treatment, whereas 14/92 (15.2%) GPs prescribed medication to the other vignettes. When deciding to follow-up a vignette GPs were influenced by threshold values for systolic and diastolic BP, but not by the overall cardiovascular risk. If the first reading was a low BP (systolic <140, diastolic <90) GPs were highly likely to discharge the vignette and follow-up a high BP reading (diastolic >90 or systolic BP≥140). Similar factors predicted the decision to prescribe a drug, although the vignette's cardiovascular risk (>20%) was now statistically significant (p = 0.03). CONCLUSIONS GP decision making, whilst generally consistent with guidelines, appears to be compromised by chance variation leading to under and over treatment. Interventions to adequately accommodate chance variability into clinical decision making are required.
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Affiliation(s)
- Mohammed A. Mohammed
- Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Tom Marshall
- Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
- * E-mail:
| | - Paramjit Gill
- Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
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