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Apple SJ, Clark R, Daich J, Gonzalez ML, Ostfeld RJ, Toth PP, Bittner V, Martin SS, Rana JS, Nasir K, Shapiro MD, Virani SS, Slipczuk L. Closing the Gaps in Care of Dyslipidemia: Revolutionizing Management with Digital Health and Innovative Care Models. Rev Cardiovasc Med 2023; 24:350. [PMID: 39077078 PMCID: PMC11272850 DOI: 10.31083/j.rcm2412350] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/23/2023] [Accepted: 10/18/2023] [Indexed: 07/31/2024] Open
Abstract
Although great progress has been made in the diagnostic and treatment options for dyslipidemias, unawareness, underdiagnosis and undertreatment of these disorders remain a significant global health concern. Growth in digital applications and newer models of care provide novel tools to improve the management of chronic conditions such as dyslipidemia. In this review, we discuss the evolving landscape of lipid management in the 21st century, current treatment gaps and possible solutions through digital health and new models of care. Our discussion begins with the history and development of value-based care and the national establishment of quality metrics for various chronic conditions. These concepts on the level of healthcare policy not only inform reimbursements but also define the standard of care. Next, we consider the advances in atherosclerotic cardiovascular disease risk score calculators as well as evolving imaging modalities. The impact and growth of digital health, ranging from telehealth visits to online platforms and mobile applications, will also be explored. We then evaluate the ways in which machine learning and artificial intelligence-driven algorithms are being utilized to address gaps in lipid management. From an organizational perspective, we trace the redesign of medical practices to incorporate a multidisciplinary team model of care, recognizing that atherosclerotic cardiovascular disease risk is multifaceted and requires a comprehensive approach. Finally, we anticipate the future of dyslipidemia management, assessing the many ways in which atherosclerotic cardiovascular disease burden can be reduced on a population-wide scale.
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Affiliation(s)
- Samuel J Apple
- Department of Medicine, New York City Health and Hospitals/Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Rachel Clark
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Jonathan Daich
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Macarena Lopez Gonzalez
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Robert J Ostfeld
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Peter P Toth
- CGH Medical Center, Sterling, IL, and Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 61081, USA
| | - Vera Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Seth S Martin
- Digital Health Lab, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Jamal S Rana
- Division of Cardiology, The Permanente Medical Group, Kaiser Permanente, Oakland, CA 94611, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Surgery, Houston, TX 77030, USA
| | - Michael D. Shapiro
- Center for Prevention of Cardiovascular Disease, Section on Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA
| | - Salim S Virani
- Office of the Vice Provost (Research), The Aga Khan University, 74800 Karachi, Pakistan
- Division of Cardiology, The Texas Heart Institute/Baylor College of Medicine, Houston, TX 77030, USA
| | - Leandro Slipczuk
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY 10467, USA
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Xu Z, Arnold M, Stevens D, Kaptoge S, Pennells L, Sweeting MJ, Barrett J, Di Angelantonio E, Wood AM. Prediction of Cardiovascular Disease Risk Accounting for Future Initiation of Statin Treatment. Am J Epidemiol 2021; 190:2000-2014. [PMID: 33595074 PMCID: PMC8485151 DOI: 10.1093/aje/kwab031] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 12/15/2022] Open
Abstract
Cardiovascular disease (CVD) risk-prediction models are used to identify high-risk individuals and guide statin initiation. However, these models are usually derived from individuals who might initiate statins during follow-up. We present a simple approach to address statin initiation to predict “statin-naive” CVD risk. We analyzed primary care data (2004–2017) from the UK Clinical Practice Research Datalink for 1,678,727 individuals (aged 40–85 years) without CVD or statin treatment history at study entry. We derived age- and sex-specific prediction models including conventional risk factors and a time-dependent effect of statin initiation constrained to 25% risk reduction (from trial results). We compared predictive performance and measures of public-health impact (e.g., number needed to screen to prevent 1 event) against models ignoring statin initiation. During a median follow-up of 8.9 years, 103,163 individuals developed CVD. In models accounting for (versus ignoring) statin initiation, 10-year CVD risk predictions were slightly higher; predictive performance was moderately improved. However, few individuals were reclassified to a high-risk threshold, resulting in negligible improvements in number needed to screen to prevent 1 event. In conclusion, incorporating statin effects from trial results into risk-prediction models enables statin-naive CVD risk estimation and provides moderate gains in predictive ability but had a limited impact on treatment decision-making under current guidelines in this population.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Angela M Wood
- Correspondence to Dr. Angela M. Wood, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge CB1 8RN, United Kingdom (e-mail: )
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Eastwood SV, Mathur R, Sattar N, Smeeth L, Bhaskaran K, Chaturvedi N. Ethnic differences in guideline-indicated statin initiation for people with type 2 diabetes in UK primary care, 2006-2019: A cohort study. PLoS Med 2021; 18:e1003672. [PMID: 34185782 PMCID: PMC8241069 DOI: 10.1371/journal.pmed.1003672] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/25/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Type 2 diabetes is 2-3 times more prevalent in people of South Asian and African/African Caribbean ethnicity than people of European ethnicity living in the UK. The former 2 groups also experience excess atherosclerotic cardiovascular disease (ASCVD) complications of diabetes. We aimed to study ethnic differences in statin initiation, a cornerstone of ASCVD primary prevention, for people with type 2 diabetes. METHODS AND FINDINGS Observational cohort study of UK primary care records, from 1 January 2006 to 30 June 2019. Data were studied from 27,511 (88%) people of European ethnicity, 2,386 (8%) people of South Asian ethnicity, and 1,142 (4%) people of African/African Caribbean ethnicity with incident type 2 diabetes, no previous ASCVD, and statin use indicated by guidelines. Statin initiation rates were contrasted by ethnicity, and the number of ASCVD events that could be prevented by equalising prescribing rates across ethnic groups was estimated. Median time to statin initiation was 79, 109, and 84 days for people of European, South Asian, and African/African Caribbean ethnicity, respectively. People of African/African Caribbean ethnicity were a third less likely to receive guideline-indicated statins than European people (n/N [%]: 605/1,142 [53%] and 18,803/27,511 [68%], respectively; age- and gender-adjusted HR 0.67 [95% CI 0.60 to 0.76], p < 0.001). The HR attenuated marginally in a model adjusting for total cholesterol/high-density lipoprotein cholesterol ratio (0.77 [95% CI 0.69 to 0.85], p < 0.001), with no further diminution when deprivation, ASCVD risk factors, comorbidity, polypharmacy, and healthcare usage were accounted for (fully adjusted HR 0.76 [95% CI 0.68, 0.85], p < 0.001). People of South Asian ethnicity were 10% less likely to receive a statin than European people (1,489/2,386 [62%] and 18,803/27,511 [68%], respectively; fully adjusted HR 0.91 [95% CI 0.85 to 0.98], p = 0.008, adjusting for all covariates). We estimated that up to 12,600 ASCVD events could be prevented over the lifetimes of people currently affected by type 2 diabetes in the UK by equalising statin prescribing across ethnic groups. Limitations included incompleteness of recording of routinely collected data. CONCLUSIONS In this study we observed that people of African/African Caribbean ethnicity with type 2 diabetes were substantially less likely, and people of South Asian ethnicity marginally less likely, to receive guideline-indicated statins than people of European ethnicity, even after accounting for sociodemographics, healthcare usage, ASCVD risk factors, and comorbidity. Underuse of statins in people of African/African Caribbean or South Asian ethnicity with type 2 diabetes is a missed opportunity to prevent cardiovascular events.
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Affiliation(s)
| | - Rohini Mathur
- London School of Hygiene &Tropical Medicine, London, United Kingdom
| | | | - Liam Smeeth
- London School of Hygiene &Tropical Medicine, London, United Kingdom
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Abrantes C, Tonin FS, Reis-Pardal J, Castel-Branco M, Furtado C, Figueiredo IV, Fernandez-Llimos F. Implications of a defined daily dose fixed database for drug utilization research studies: The case of statins in Portugal. Br J Clin Pharmacol 2021; 87:3542-3549. [PMID: 33576512 DOI: 10.1111/bcp.14770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 12/31/2022] Open
Abstract
AIMS Given the discrepancies between PDDs (prescribed daily doses) and DDDs (defined daily doses), we aimed to assess the extent of error in the results of an 18-year population-level study on statin utilization in Portugal. METHODS The Portuguese regulatory agency provided data for the period 2000-2018 on statin dispensing (C10AA). The DDDs were gathered from the ATC/DDD database. DDDs were calculated by the DDD year-by-year approach (DDDYEAR ) and by the DDD last-year approach (DDDLAST ). PDDs were calculated according to the year-by-year approach (PDDYEAR ). Statin annual utilization rates per 1000 inhabitants per day were also calculated. Percent errors were calculated for PDDYEAR and DDDYEAR units. RESULTS The DDDYEAR approach revealed decreases in the consumption of atorvastatin, fluvastatin, lovastatin, pravastatin and simvastatin in 2009, when their DDD was modified. Conversely, the results from both DDDLAST and PDDYEAR approaches indicated gradual changes in the actual consumption of all statins in Portugal. Before 2009, atorvastatin, pravastatin and simvastatin utilization was greatly overestimated by DDDYEAR /1000 inhabitants/day. The average dose of lovastatin prescribed in the past 18 years (20 mg) was below the assigned DDDs during the study period, varying from 30 mg to 45 mg. Conversely, the PDD for fluvastatin was above the DDD values (ranging from 40 mg in 2000 to 70 mg in 2016). For atorvastatin, pravastatin and simvastatin, national PDDs were above the assigned DDD until the DDD modification in 2009. CONCLUSIONS A more dynamic system, based on national and annually updated DDDs, should be able to reduce discrepancies between DDDs and PDDs and the bias in utilization studies.
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Affiliation(s)
- Catarina Abrantes
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal
| | - Fernanda S Tonin
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, Brazil
| | | | - Margarida Castel-Branco
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal
| | - Claudia Furtado
- Health Technology Assessment Department, National Authority of Medicines and Health Products (INFARMED), Lisbon, Portugal
| | - Isabel V Figueiredo
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal
| | - Fernando Fernandez-Llimos
- Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
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Alameddine R, Seifeddine S, Ishak H, Antoun J. Improving statin prescription through the involvement of nurses in the provision of ASCVD score: a quality improvement initiative in primary care. Postgrad Med 2020; 132:479-484. [PMID: 32276565 DOI: 10.1080/00325481.2020.1755146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES This study compares two methods of providing CVD risk score on the percentage of appropriate statin therapy for primary prevention of CVD in family medicine clinics, according to the American Heart Association guidelines. METHODS Participants were non-diabetic patients aged 40 to 75 with a recently ordered low-density lipoprotein (LDL) level, not on statin therapy and free of CVD. The first intervention is passive with a display of the score on the EMR in the vital signs section and lasted for three months. The second intervention is collaborative where the nurses calculate the risk score and displayed it to the physician along with therapy recommendations. Electronic health records were reviewed to randomly select medical charts of eligible patients. RESULTS 162 charts were randomly selected out of 547 eligible charts and included in the analysis, including 60 charts for the baseline group. Among moderate-risk patients, the percentage of appropriate statin initiation was 0% at baseline and after intervention 1; yet it increased to (33.3% [7.5-70.1, 95% CI]) after intervention 2. Among high risk patients, percentage of appropriate statin initiation was 9.1% [0.1-41.3, 95% CI], 11.1% [1.4, 34.7, 95% CI] and 28.6% [8.4, 58.1, 95% CI] during baseline, intervention 1 and intervention 2, respectively. CONCLUSION The provision of the CVD risk score alone as clinical decision support is not enough to improve statin initiation for primary prevention. The nurse collaboration can improve guideline-concordant statin initiation.
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Affiliation(s)
- Reina Alameddine
- Department of Family Medicine, American University of Beirut , Beirut, Lebanon
| | - Suzan Seifeddine
- Department of Family Medicine, American University of Beirut , Beirut, Lebanon
| | - Hala Ishak
- Department of Family Medicine, American University of Beirut , Beirut, Lebanon
| | - Jumana Antoun
- Department of Family Medicine, American University of Beirut , Beirut, Lebanon
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Nanna MG, Navar AM, Wang TY, Li S, Virani SS, Li Z, Robinson JG, Roger VL, Wilson PWF, Goldberg AC, Koren A, Louie MJ, Peterson ED. Practice-level variation in statin use and low-density lipoprotein cholesterol control in the United States: Results from the Patient and Provider Assessment of Lipid Management (PALM) registry. Am Heart J 2019; 214:113-124. [PMID: 31202098 PMCID: PMC6639125 DOI: 10.1016/j.ahj.2019.05.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/14/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Adherence to guideline-recommended statin recommendations in the United States is suboptimal. Patients' likelihood to be treated according to guidelines may vary by the practice in which they are treated. METHODS Variation in the use of statin therapy in 5445 patients, with known or at high risk for atherosclerotic cardiovascular disease (ASCVD) and meeting a statin treatment indication, was examined across 74 US Patient and Provider Assessment of Lipid Management (PALM) Registry clinics. Multivariable generalized linear mixed modeling was used to determine the median odds ratio (MOR) for statin use and 2013 American College of Cardiology/American Heart Association guideline-recommended statin intensity by practice. MOR quantifies between-practice variation by comparing the odds of receiving guideline-recommended statin treatment in a patient from a randomly selected practice with a similar patient from another random practice. Risk-adjusted low-density lipoprotein cholesterol (LDL-C) control (<100 and <70 mg/dL) was compared among practice tertiles based on percentage of eligible patients receiving recommended statin intensity. RESULTS Among 74 practices (43.2% cardiology) comprised of 300 healthcare providers enrolling 5445 patients (56.2% with ASCVD), statin use at the guideline-recommended intensity at practices varied widely (12.7-71.4%; adjusted MOR 1.45, 95% confidence interval [CI] 1.35-1.64). Results were consistent when evaluated for any statin use overall (adjusted MOR 1.75, 95% CI 1.48-1.99) and when stratified by primary versus secondary prevention patients. Relative to practices with lowest or mid-tertile statin use of statins, highest tertile clinics were more frequently cardiology practices (68.0% vs 48.0% vs 12.5%, P < .001). Compared with lowest tertile clinics, patients at highest tertile clinics were more likely to achieve LDL-C <70 mg/dL (adjusted odds ratio [OR] 1.49, 95% CI 1.08-2.04) and <100 mg/dL (adjusted OR 1.78, 95% CI 1.41-2.25). CONCLUSIONS US clinics varied widely in their adherence to guideline recommendations for statin therapy, which contributed to significant differences in LDL-C levels.
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Affiliation(s)
- Michael G Nanna
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
| | - Ann Marie Navar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Shuang Li
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Zhuokai Li
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | - Peter W F Wilson
- Atlanta Veterans Affairs Medical Center and Emory Clinical Cardiovascular Research Institute, Atlanta, Georgia
| | | | | | | | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Cheng SF, Brown MM, Simister RJ, Richards T. Contemporary prevalence of carotid stenosis in patients presenting with ischaemic stroke. Br J Surg 2019; 106:872-878. [PMID: 30938840 DOI: 10.1002/bjs.11136] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/02/2018] [Accepted: 01/21/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Carotid stenosis is a common cause of ischaemic stroke and transient ischaemic attack (TIA). Despite rising recognition and centralization of stroke services there has been a decline in interventions for carotid stenosis in recent years. The aim of this study was to determine the current prevalence and management of carotid stenosis in the UK. METHODS This was a 1-year prospective observational study of consecutive patients presenting with ischaemic stroke, TIA or ischaemic retinal artery occlusion to a central London hyperacute stroke unit. Patients with significant carotid stenosis, defined as atherosclerotic narrowing of 50 per cent or greater, underwent multidisciplinary team (MDT) discussion to determine the cause of stroke/TIA and classify carotid stenosis as symptomatic or incidental. RESULTS In total, 2707 patients were seen; half had an ischaemic event and the majority had carotid imaging (1252 of 1444). Carotid stenosis of at least 50 per cent was seen in 238 (prevalence 19·0 (95 per cent c.i. 16·6 to 21·4) per cent). Patients with significant carotid stenosis were more likely to have hypertension, hypercholesterolaemia, diabetes and ischaemic heart disease. Carotid stenosis was deemed symptomatic in 99 patients (7·9 (6·3 to 9·5) per cent); of these, 17 had carotid occlusion, 17 were unfit for surgery and 58 patients were referred for carotid intervention. Among 139 patients with asymptomatic stenosis, 75 had carotid stenosis ipsilateral to the stroke but, after MDT discussion, the cause was deemed to be atrial fibrillation (32), small-vessel disease (15), another determined cause (5), or not determined owing to atypical imaging or clinical presentation. CONCLUSION Carotid stenosis is common, affecting one in five patients presenting with stroke or TIA. Careful MDT discussion may avoid unnecessary intervention and should be the standard of care.
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Affiliation(s)
- S F Cheng
- Division of Surgery and Interventional Science, University College London, London, UK
| | - M M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, UK
| | - R J Simister
- University College London Hospitals NHS Foundation Trust, London, UK
| | - T Richards
- Division of Surgery and Interventional Science, University College London, London, UK
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Qadi O, Marshall T, Adderley N, Bem D. Patients' and health professionals' attitudes and perceptions towards the initiation of preventive drugs for primary prevention of cardiovascular disease: protocol for a systematic review of qualitative studies. BMJ Open 2019; 9:e025587. [PMID: 30975677 PMCID: PMC6500290 DOI: 10.1136/bmjopen-2018-025587] [Citation(s) in RCA: 2] [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] [Received: 07/24/2018] [Revised: 03/05/2019] [Accepted: 03/07/2019] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Lipid-lowering drugs and antihypertensive agents can be prescribed for the primary prevention of cardiovascular disease. In some cases, patients eligible for primary prevention of cardiovascular disease according to the European guidelines are not always started on preventive drugs. Existing research explores the attitudes of health professionals and patients towards cardiovascular preventive drugs but does not always differentiate between the attitudes towards drug initiation for primary or secondary prevention. We aim to systematically review qualitative studies assessing health professionals' and patients' attitudes and perceptions towards drug initiation for primary prevention of cardiovascular disease. METHODS AND ANALYSIS MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, CINAHL, Applied Social Sciences Index and Abstracts, Conference Proceedings Citation Index (Web of Science), Healthcare Management Information Consortium, and Open Grey will be searched without restrictions on date or language of publication. Searches will be limited to studies of qualitative design, standalone or in the context of a mixed-method design, focusing on cardiovascular drug initiation for primary prevention. The primary outcome is the attitudes of health professionals and patients towards drug initiation for primary prevention of cardiovascular disease. Two reviewers will independently carry out the study selection, data extraction and quality assessment. The Critical Appraisal Skills Programme Qualitative Research Checklist will be used to assess the quality of included studies. The findings will be analysed using Thomas and Harden's thematic synthesis approach. ETHICS AND DISSEMINATION This systematic review does not require ethical approval as primary data will not be collected. The results of the study will be published in a peer-reviewed journal and presented at relevant conferences. PROSPERO REGISTRATION NUMBER CRD42018095346.
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Affiliation(s)
- Olla Qadi
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
| | - Tom Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
| | - Nicola Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
| | - Danai Bem
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
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McDowell RD, Bennett K, Moriarty F, Clarke S, Barry M, Fahey T. Prescriber Variation in Relation to Prescribing Trends within the Preferred Drugs Initiative in Ireland (2012-2015): An Interrupted Time-Series Study Using Latent Curve Models. Med Decis Making 2019; 39:278-293. [PMID: 30741086 DOI: 10.1177/0272989x18818165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To examine the impact of the Preferred Drugs Initiative (PDI), an Irish health policy aimed at reducing prescribing variation. DESIGN Interrupted time series spanning 2012 to 2015. SETTING Health Service Executive pharmacy claims data for General Medical Services (GMS) patients, approximately 40% of the Irish population. PARTICIPANTS Prescribers issuing preferred drug group items to GMS adults before and after PDI guidelines. PRIMARY OUTCOME The percentage coverage of PDI medications within each drug class per calendar quarter per prescriber. METHODS Latent curve models with structured residuals (LCM-SRs) were used to model coverage of the preferred drugs over time. The number of GMS adults receiving medication and the percentage who were 65 years and older at the start of the study were included as covariates. RESULTS In the quarter following PDI guidelines, coverage of the preferred drugs increased most in absolute terms for proton pump inhibitors (PPIs) (1.50% [SE 0.15], P < 0.001) and selective and norepinephrine reuptake inhibitors (SNRIs) (1.17% [SE 0.26], P < 0.001). Variation between prescribers remained relatively unchanged and increased for urology medications. Prescribers who increased coverage of the preferred PPI also increased coverage of the preferred statin immediately following guidelines (correlation 0.47 [SE 0.13], P < 0.001). Where guidelines were disseminated simultaneously, coverage of one preferred drug did not significantly predict coverage of the other preferred drug in the next calendar quarter. Prescribing of preferred drugs was not moderated by prescriber-level factors. CONCLUSIONS Modest changes in prescribing of the preferred drugs have been observed over the course of the PDI. However, the guidelines have had little impact in reducing variation between prescribers. Further strategies may be necessary to reduce variation in clinical practice and enhance patient care.
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Affiliation(s)
- Ronald D McDowell
- Health Research Board (HRB) Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland Medical School, Dublin 2, Ireland.,Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - Kathleen Bennett
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Frank Moriarty
- Health Research Board (HRB) Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland Medical School, Dublin 2, Ireland
| | - Sarah Clarke
- Health Service Executive Medicines Management Programme, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland
| | - Michael Barry
- National Centre for Pharmacoeconomics, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland
| | - Tom Fahey
- Health Research Board (HRB) Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland Medical School, Dublin 2, Ireland
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Abstract
The evaluation of the real-life benefits and risks of statins in population is a major pharmacoepidemiological issue, given their widespread use for cardiovascular prevention. The purpose of this review was not to be exhaustive but to show the contributions of pharmacoepidemiology for various aspects of the evaluation of statins such as real-life drug use, effectiveness and risk. Statins are among the most used drugs in the world, but recent data show a slight decrease in use. Actual statin users are older, and have more comorbidities than those studied in clinical trials, but this does not seem to compromise their effectiveness, unlike the compliance issues that are common with these drugs. Beyond the known adverse reactions of statins from the clinical trials, risks of statins can be varied and sometimes difficult to evaluate, considering the ubiquity of cholesterol throughout the body, from drug or endogenous molecule metabolism to the construction of cell membranes or cell activities.
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Affiliation(s)
- Julien Bezin
- Inserm, UMR 1219, Bordeaux population health research center, team pharmacoepidemiology, université Bordeaux, 33076 Bordeaux, France.
| | - Nicholas Moore
- Inserm CIC1401, Inserm CR1219, Bordeaux PharmacoEpi, université et CHU de Bordeaux, 33076 Bordeaux, France
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Ferrières J, Lautsch D, Gitt AK, De Ferrari G, Toplak H, Elisaf M, Drexel H, Horack M, Baxter C, Ambegaonkar B, Brudi P, Toth PP. Body mass index impacts the choice of lipid-lowering treatment with no correlation to blood cholesterol - Findings from 52 916 patients in the Dyslipidemia International Study (DYSIS). Diabetes Obes Metab 2018; 20:2670-2674. [PMID: 29888459 PMCID: PMC6220851 DOI: 10.1111/dom.13415] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 06/04/2018] [Accepted: 06/08/2018] [Indexed: 11/28/2022]
Abstract
A high body mass index (BMI) is associated with increased cardiovascular risk. We sought to identify whether BMI influences the choice of lipid-lowering treatment in a large, real-world cohort of 52 916 patients treated with statins. The Dyslipidemia International Study (DYSIS) is a cross-sectional, observational, multicentre study in statin-treated patients ≥45 years of age from 30 countries; 1.1% were underweight (BMI < 18.5 kg/m2 ), 33.1% had normal weight (BMI 18.5-24.9 kg/m2 ), 41.5% were overweight (BMI 25-29.9 kg/m2 ), 17.1% had class I obesity (BMI 30.0-34.9 kg/m2 ), 5.0% had class II obesity (BMI 35-39.9 kg/m2 ), and 2.1% had class III obesity (≥40 kg/m2 ). BMI correlated with high-density lipoprotein cholesterol (HDL-C) and triglycerides (Spearman's ρ: -0.147 and 0.170, respectively; P < 0.0001 for both); however, there was no correlation with low-density lipoprotein cholesterol (LDL-C; ρ: 0.003; P = 0.51). Statin intensity increased with increasing BMI (ρ: 0.13; P < 0.001), an association that held after adjustment for comorbidities (OR: 2.4; 95% CI: 2.0-3.0) on BMI ≥ 30 kg/m2 for atorvastatin equivalent ≥40 mg/d.
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Affiliation(s)
- Jean Ferrières
- Department of CardiologyToulouse Rangueil University HospitalToulouseFrance
- Department of Epidemiology and Public HealthUMR INSERM 1027, Toulouse University School of MedicineToulouseFrance
| | | | - Anselm K. Gitt
- Herzzentrum LudwigshafenLudwigshafenGermany
- Stiftung Institut für HerzinfarktforschungLudwigshafenGermany
| | - Gaetano De Ferrari
- Department of CardiologyIRCCS Fondazione Policlinico San Matteo, and University of PaviaPaviaItaly
| | - Hermann Toplak
- Lipid Clinic, Department of MedicineMedical University of GrazGrazAustria
| | - Moses Elisaf
- School of MedicineUniversity of IoanninaIoanninaGreece
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT)FeldkirchAustria
- Department of Medicine and CardiologyPrivate University of the Principality of LiechtensteinTriesenLiechtenstein
- Department of Medicine Division of CardiologyDrexel University College of MedicinePhiladelphiaPennsylvania
| | - Martin Horack
- Stiftung Institut für HerzinfarktforschungLudwigshafenGermany
| | | | | | | | - Peter P. Toth
- CGH Medical CenterSterlingIllinois
- Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins University School of MedicineBaltimoreMaryland
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12
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Riaz R, Merchant AZ, Ul Haq MS, Nasir SAR, Rizvi Y, Khan JA, Zakaria SM, Jawed H, Hamid K, Zehra NUA, Ahmed M, Ali HA, Fatima K. Statins everyday versus alternate days: Is there a difference in myalgia rates? Indian Heart J 2018; 70:492-496. [PMID: 30170642 PMCID: PMC6116713 DOI: 10.1016/j.ihj.2017.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 09/30/2017] [Accepted: 10/31/2017] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Statins are widely used drugs, known to cause myalgia, leading to high discontinuation rates. The objective of our study was to determine the frequency of myalgia in patients on everyday-dose (EDD) regimen with those on alternate-day dose (ADD) regimen. METHODS This cross sectional study was conducted in a tertiary care hospital of Pakistan. A sample size of 400 patients between the age of 40-70 years, taking simvastatin 40mg for at least 6 months or more were selected. Patients with prior musculoskeletal or neuromuscular complains, and family history of muscular disorders were excluded. Subjects were evaluated for myalgia via a self-administered questionnaire, and those complaining of myalgia were then evaluated for serum vitamin D levels. Data was analyzed through SPSS 16.0 and compared using chi square test. RESULTS The overall prevalence of myalgia was 7% (28/400). Frequency of myalgia in patients taking simvastatin everyday (n=20, 10%) was significantly higher compared to those taking it every alternate day (n=8, 4%) (p=0.02). There was no significant difference between the time of onset, nature, severity, type, or location of myalgia between the 2 groups. The most common cited triggering factor for pain was physical exercise. Of the patients experiencing myalgia, 13 (6.5%) from the EDD group and 6 (3%) from the ADD group had low levels of vitamin D. CONCLUSIONS ADD regime was better tolerated by the patients than EDD regime. Alternate day therapy, with or without vitamin D supplementation, may be used by the physicians for troublesome muscular complains.
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Affiliation(s)
- Ramsha Riaz
- Dow Medical College, Dow university of Health Sciences, Karachi, Pakistan
| | | | | | | | - Yusra Rizvi
- Dow Medical College, Dow university of Health Sciences, Karachi, Pakistan.
| | | | | | - Hassaan Jawed
- Dow Medical College, Dow university of Health Sciences, Karachi, Pakistan
| | - Khizar Hamid
- Dow Medical College, Dow university of Health Sciences, Karachi, Pakistan
| | - Noor-Ul-Ain Zehra
- Dow Medical College, Dow university of Health Sciences, Karachi, Pakistan
| | - Madiha Ahmed
- Dow Medical College, Dow university of Health Sciences, Karachi, Pakistan
| | - Hussain Asif Ali
- Dow Medical College, Dow university of Health Sciences, Karachi, Pakistan
| | - Kaneez Fatima
- Dow Medical College, Dow university of Health Sciences, Karachi, Pakistan
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13
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Asthana S, Moon G, Gibson A, Bailey T, Hewson P, Dibben C. Inequity in cardiovascular care in the English National Health Service (NHS): a scoping review of the literature. HEALTH & SOCIAL CARE IN THE COMMUNITY 2018; 26:259-272. [PMID: 27747961 DOI: 10.1111/hsc.12384] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/11/2016] [Indexed: 06/06/2023]
Abstract
There is a general understanding that socioeconomically disadvantaged people are also disadvantaged with respect to their access to NHS care. Insofar as considerable NHS funding has been targeted at deprived areas, it is important to better understand whether and why socioeconomic variations in access and utilisation exist. Exploring this question with reference to cardiovascular care, our aims were to synthesise and evaluate evidence relating to access to and/or use of English NHS services around (i) different points on the care pathway (i.e. presentation, primary management and specialist management) and (ii) different dimensions of inequality (socioeconomic, age- and gender-related, ethnic or geographical). Restricting our search period from 2004 to 2016, we were concerned to examine whether, compared to earlier research, there has been a change in the focus of research examining inequalities in cardiac care and whether the pro-rich bias reported in the late 1990s and early 2000s still applies today. We conducted a scoping study drawing on Arksey & O'Malley's framework. A total of 174 studies were included in the review and appraised for methodological quality. Although, in the past decade, there has been a shift in research focus away from gender and age inequalities in access/use and towards socioeconomic status and ethnicity, evidence that deprived people are less likely to access and use cardiovascular care is very contradictory. Patterns of use appear to vary by ethnicity; South Asian populations enjoying higher access, black populations lower. By contrast, female gender and older age are consistently associated with inequity in cardiovascular care. The degree of geographical variation in access/use is also striking. Finally, evidence of inequality increases with stage on the care pathway, which may indicate that barriers to access arise from the way in which health professionals are adjudicating health needs rather than a failure to seek help in the first place.
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Affiliation(s)
- Sheena Asthana
- School of Government, University of Plymouth, Plymouth, UK
| | - Graham Moon
- School of Geography and the Environment, University of Southampton, Southampton, UK
| | - Alex Gibson
- School of Government, University of Plymouth, Plymouth, UK
| | - Trevor Bailey
- Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Paul Hewson
- School of Computing and Mathematics, University of Plymouth, Plymouth, UK
| | - Chris Dibben
- School of Geosciences, University of Edinburgh, Edinburgh, UK
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14
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Brown F, Singer A, Katz A, Konrad G. Statin-prescribing trends for primary and secondary prevention of cardiovascular disease. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2017; 63:e495-e503. [PMID: 29138175 PMCID: PMC5685466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To determine the proportion of patients receiving statins for primary or secondary prevention of cardiovascular disease (CVD), as well as to describe lipid-screening trends. DESIGN Retrospective chart review using the Manitoba Primary Care Research Network repository. SETTING Manitoba. PARTICIPANTS A total of 149 262 patients. MAIN OUTCOME MEASURES Proportion of patients who were taking statins for primary or secondary prevention of cardiovascular disease (CVD), who did not have evidence of CVD recorded in their charts, and who underwent lipid screening; distribution of statins among age groups; and the proportion of patients eligible for lipid screening when the age cutoffs of the 2012 and 2016 Canadian Cardiovascular Society guidelines were applied. RESULTS Of the 149 262 patients, 139 025 (93%) did not have CVD recorded in their electronic medical records and made up the primary prevention group; of these 139 025 patients, 5955 (4%) were taking statins. Also in the primary prevention group, 14 814 (11%) patients were 75 years of age and older; of these patients, 1374 (9%) were taking statins. A total of 10 237 of the 149 262 (7%) patients had CVD recorded in their charts (secondary prevention group); 3013 (29%) of these patients were taking statins. When the 2016 Canadian Cardiovascular Society guidelines age cutoffs were applied, 56% of patients (83 119 of 149 262) were eligible for lipid screening, and 31% (26 024 of 83 119) of them had evidence of screening in the past 5 years. Of the total population of those aged 75 and older, 28% (5597 of 20 188) had undergone lipid screening. Of the total population taking statins, 28% (2481 of 8968) had undergone lipid testing while taking statins. CONCLUSION In Manitoba, less than 5% of the primary prevention population and less than 30% of the secondary prevention population had received repeat statin prescriptions from their primary care providers. This represents a possible practice gap that warrants future research, as statins offer considerable morbidity and mortality benefits in these patients.
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Affiliation(s)
- Felicity Brown
- Practising physician at Seven Oaks Emergency Department in Winnipeg, Man.
| | - Alexander Singer
- Director of the Manitoba Primary Care Research Network and Assistant Professor in the Department of Family Medicine at the University of Manitoba
| | - Alan Katz
- Director of the Manitoba Centre for Health Policy and Professor in the Department of Community Health Sciences and the Department of Family Medicine at the University of Manitoba
| | - Gerald Konrad
- Unit Director at the Family Medical Centre Teaching Unit and Associate Professor in the Department of Family Medicine at the University of Manitoba
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15
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Schroff P, Gamboa CM, Durant RW, Oikeh A, Richman JS, Safford MM. Vulnerabilities to Health Disparities and Statin Use in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study. J Am Heart Assoc 2017; 6:e005449. [PMID: 28847913 PMCID: PMC5634251 DOI: 10.1161/jaha.116.005449] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 06/15/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Statins may be underutilized in certain vulnerable populations, but the effect of cumulative vulnerabilities within 1 individual is not well described. We sought to determine the likelihood of receiving statins with an increasing number of vulnerabilities in an individual, after controlling for factors known to influence health services utilization. METHODS AND RESULTS We identified 18 216 participants from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study who had a statin indication or who were taking statins, as verified by pill bottle review. Statin use was assessed with respect to 5 major vulnerability domains alone and in combination: older age, black race, female sex, high area-level poverty, and lack of health insurance. The study included 5286 white men, 4180 black men, 2791 white women, and 4194 black women; 5.6% of the sample had no vulnerabilities, 20.6% had 1 vulnerability, 29.2% had 2 vulnerabilities, 27.3% had 3 vulnerabilities, and 17.3% had 4 or 5 vulnerabilities. All race-sex groups were less likely than white men to use statins; prevalence of use was 0.80 in black women with reference to white men (P<0.0001). In both unadjusted and adjusted models, as the number of vulnerabilities increased, statin use steadily decreased. After adjusting for factors that influence health services utilization, compared with those without any vulnerabilities, statin use prevalence was 0.91, 0.83, 0.74 and 0.68 (P<0.0001) in those with 1, 2, 3, and 4 or 5 vulnerabilities, respectively. CONCLUSIONS Participants with more simultaneously occurring vulnerabilities experienced the greatest disparities in statin use. Black women and those without health insurance were at particularly high risk of underutilization.
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Affiliation(s)
| | - Christopher M Gamboa
- University of Alabama at Birmingham, AL
- Weill Cornell Medical College, New York, NY
| | | | | | | | - Monika M Safford
- University of Alabama at Birmingham, AL
- Weill Cornell Medical College, New York, NY
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16
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Kim G, Jang SY, Han E, Lee YH, Park SY, Nam CM, Kang ES. Effect of statin on hepatocellular carcinoma in patients with type 2 diabetes: A nationwide nested case-control study. Int J Cancer 2016; 140:798-806. [PMID: 27861855 DOI: 10.1002/ijc.30506] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 11/02/2016] [Indexed: 12/23/2022]
Abstract
Relationship on new statin use and the risk of hepatocellular carcinoma (HCC) in patients with incident type 2 diabetes mellitus (T2DM), who might be at the risk of developing HCC, is uncertained. A nationwide population-based nested case-control study was conducted within the National Health Insurance Service National Sample Cohort 2002-2013 in Korea. Newly prescribed statin after newly diagnosed T2DM was defined as statin use. Controls were matched to case patients on age, sex, follow-up time, and the date of diabetes diagnosis at a five-to-one ratio. Odds ratios (ORs) for associations of statin use with HCC were calculated using conditional logistic regression. After at least a 5-year HCC-free period, there were 229 incident HCC cases and 1,145 matched controls from 47,738 patients with incident diabetes. Of these 229 incident HCC cases, 27 (11.8%) were statin users, whereas 378 (33.0%) were statin users among 1,145 controls. Statin use was associated with a reduced risk of HCC development (adjusted OR [AOR]= 0.36, 95% confidence interval [CI] 0.22-0.60) after adjustment for chronic viral hepatitis, liver cirrhosis, alcoholic liver disease, previous cancer, aspirin use, insulin use, sulfonylurea use, metformin use, thiazolidinedione use, history of chronic obstructive pulmonary disease, Charlson comorbidity score, household income level, and residential area. Risk reduction was accentuated with an increase of cumulative defined daily doses (cDDD) compared with non-users (AORs 0.53, 0.36, 0.32, and 0.26 in ≤60, 60-180, 181-365, and >365cDDD, respectively; P for trend <0.0001). The risk reduction was apparent in the presence of liver disease (AOR = 0.27, 95% CI 0.14-0.50), including heterogeneous groups of clinical diagnosis of liver disease, but not significant in the absence of liver disease (AOR = 0.64, 95% CI 0.32-1.29). Among patients with new onset T2DM, statin use before HCC diagnosis may have a beneficial inhibitory effect on HCC development in a dose-dependent manner, especially in individuals with liver disease.
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Affiliation(s)
- Gyuri Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Graduate School, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Suk-Yong Jang
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eugene Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Graduate School, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong-Ho Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Graduate School, Yonsei University College of Medicine, Seoul, Republic of Korea.,Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Se-Young Park
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chung Mo Nam
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Seok Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Graduate School, Yonsei University College of Medicine, Seoul, Republic of Korea.,Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea
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17
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Kim G, Lee YH, Kang ES, Cha BS, Lee HC, Lee BW. Characteristics Predictive for a Successful Switch from Insulin Analogue Therapy to Oral Hypoglycemic Agents in Patients with Type 2 Diabetes. Yonsei Med J 2016; 57:1395-403. [PMID: 27593867 PMCID: PMC5011271 DOI: 10.3349/ymj.2016.57.6.1395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/09/2016] [Accepted: 03/14/2016] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The objective of this study was to investigate clinical and laboratory parameters that could predict which patients could maintain adequate glycemic control after switching from initial insulin therapy to oral hypoglycemic agents (OHAs) among patients with type 2 diabetes (T2D). MATERIALS AND METHODS We recruited 275 patients with T2D who had been registered in 3 cohorts of initiated insulin therapy and followed up for 33 months. The participants were divided into 2 groups according to whether they switched from insulin to OHAs (Group I) or not (Group II), and Group I was further classified into 2 sub-groups: maintenance on OHAs (Group IA) or resumption of insulin (Group IB). RESULTS Of 275 patients with insulin initiation, 63% switched to OHAs (Group I) and 37% continued insulin (Group II). Of these, 44% were in Group IA and 19% in Group IB. The lowest tertile of baseline postprandial C-peptide-to-glucose ratio (PCGR), higher insulin dose at switching to OHAs, and higher HbA1c level at 6 months after switching to OHAs were all associated with OHA failure (Group IB; p=0.001, 0.046, and 0.014, respectively). The lowest tertile of PCGR was associated with ultimate use of insulin (Group IB and Group II; p=0.029). CONCLUSION Higher baseline level of PCGR and lower HbA1c levels at 6 months after switching to OHAs may be strong predictors for the successful maintenance of OHAs after switching from insulin therapy in Korean patients with T2D.
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Affiliation(s)
- Gyuri Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Graduate School, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Ho Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Graduate School, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Seok Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Graduate School, Yonsei University College of Medicine, Seoul, Korea
| | - Bong Soo Cha
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Graduate School, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Chul Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Graduate School, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Wan Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Graduate School, Yonsei University College of Medicine, Seoul, Korea.
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18
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Robson JC, Kiran A, Maskell J, Hutchings A, Arden N, Dasgupta B, Hamilton W, Emin A, Culliford D, Luqmani R. Which Patients with Giant Cell Arteritis Will Develop Cardiovascular or Cerebrovascular Disease? A Clinical Practice Research Datalink Study. J Rheumatol 2016; 43:1085-92. [DOI: 10.3899/jrheum.151024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2016] [Indexed: 02/07/2023]
Abstract
Objective.To evaluate the risk of cerebrovascular disease and cardiovascular disease (CVD) in patients with giant cell arteritis (GCA), and to identify predictors.Methods.The UK Clinical Practice Research Datalink 1991–2010 was used for a parallel cohort study of 5827 patients with GCA and 37,090 age-, sex-, and location-matched controls. A multivariable competing risk model (non-cerebrovascular/CV-related death as the competing risk) determined the relative risk [subhazard ratio (SHR)] between patients with GCA compared with background controls for cerebrovascular disease, CVD, or either. Each cohort (GCA and controls) was then analyzed individually using the same multivariable model, with age and sex now present, to identify predictors of CVD or cerebrovascular disease.Results.Patients with GCA, compared with controls, had an increased risk SHR (95% CI) of cerebrovascular disease (1.45, 1.31–1.60), CVD (1.49, 1.37–1.62), or either (1.47, 1.37–1.57). In the GCA cohort, predictors of “cerebrovascular disease or CVD” included increasing age, > 80 years versus < 65 years (1.98, 1.62–2.42), male sex (1.20, 1.05–1.38), and socioeconomic status, most deprived quintile versus least deprived (1.34, 1.01–1.78). These predictors were also present within the non-GCA cohort.Conclusion.Patients with GCA are more likely to develop cerebrovascular disease or CVD than age-, sex-, and location-matched controls. In common with the non-GCA cohort, patients who are older, male, and from the most deprived compared with least deprived areas have a higher risk of cerebrovascular disease or CVD. Further work is needed to understand how this risk may be mediated by specific behavioral, social, and economic factors.
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19
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Asthana S, Gibson A, Bailey T, Moon G, Hewson P, Dibben C. Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BackgroundA strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.ObjectivesTo generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.DesignCross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).ResultsThe utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.ConclusionsWe found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Sheena Asthana
- School of Government, University of Plymouth, Plymouth, UK
| | - Alex Gibson
- School of Government, University of Plymouth, Plymouth, UK
| | - Trevor Bailey
- College of Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Graham Moon
- School of Geography and the Environment, University of Southampton, Southampton, UK
| | - Paul Hewson
- School of Computing and Mathematics, University of Plymouth, Plymouth, UK
| | - Chris Dibben
- School of Geosciences, University of Edinburgh, Edinburgh, UK
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20
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Severity of obesity and management of hypertension, hypercholesterolaemia and smoking in primary care: population-based cohort study. J Hum Hypertens 2015; 30:40-5. [PMID: 25810065 PMCID: PMC5399150 DOI: 10.1038/jhh.2015.23] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 02/11/2015] [Accepted: 02/17/2015] [Indexed: 01/20/2023]
Abstract
Obesity and obesity-associated cardiovascular risk are increasing worldwide. This study aimed to determine how different levels of obesity are associated with the management of smoking, hypertension and hypercholesterolaemia in primary care. We conducted a cohort study of adults aged 30–100 years in England, sampled from the primary care electronic health records in the Clinical Practice Research Datalink. Prevalence, treatment and control were estimated for each risk factor by body mass index (BMI) category. Adjusted odds ratios (AOR) were estimated, allowing for age, gender, comorbidity and socioeconomic status, with normal weight as reference category. Data were analysed for 247 653 patients including 153 308 (62%) with BMI recorded, of whom 46 149 (30%) were obese. Participants were classified into simple (29 257), severe (11 059) and morbid obesity (5833) categories. Smoking declined with the increasing BMI category, but smoking cessation treatment increased. Age-standardised hypertension prevalence was twice as high in morbid obesity (men 78.6% women 66.0%) compared with normal weight (men 37.3% women 29.4%). Hypertension treatment was more frequent (AOR 1.75, 1.59–1.92) but hypertension control less frequent (AOR 0.63, 0.59–0.69) in morbid obesity, with similar findings for severe obesity. Hypercholesterolaemia was more frequent in morbid obesity (men 48.2% women 36.3%) than normal weight (men 25.0% women 20.0%). Lipid lowering therapy was more frequent in morbid obesity (AOR 1.83, 1.61–2.07) as was cholesterol control (AOR 1.19, 1.06–1.34). Increasing obesity category is associated with elevated risks from hypertension and hypercholesterolaemia. Inadequate hypertension control in obesity emerges as an important target for future interventions.
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