Persistence with estrogen therapy in a postmenopausal Medicaid population

Impact of a phone follow-up program on persistence with teriparatide or PTH(1-84) treatment

A follow-up program to help patients suffering from severe osteoporosis during their therapy with teriparatide or PTH(1-84) has been designed and performed. The objective of this study was to evaluate the 18-month persistence on these therapies in patients participating in the program. We enrolled 382 patients who started teriparatide or PTH(1-84) following this program and compared them with a historical cohort of 398 patients treated with the same therapies but who did not participate in any follow-up program. At the beginning of the therapy, nurses trained patients on self-injection. Patients received one phone call per week during the first month, then one phone call per month and per 3 months during the following 5 and 12 months, respectively. In every call, nurses helped patients to resolve any possible issues and collected adverse event information. The persistence rate of the group following the program was 85.6%, 8.2% higher than that of the group not following any program (77.4%). The log-rank test on persistence rates on therapy in patients enrolled and not enrolled in the program was performed; the difference was statistically significant (P = 0.006). Discontinuation in the follow-up program group occurred mainly at early stages of the treatment due to adverse events. Our results show that patients suffering from severe osteoporosis treated with teriparatide or PTH(1-84) and enrolled in a follow-up program have higher persistence rates than patients not following the program.

Clinical application of biochemical markers of bone turnover

With the ageing population in most countries, disorders of bone and mineral metabolism are becoming increasingly relevant to every day clinical practice. Consequently, the interest in, and the need for effective measures to be used in the screening, diagnosis and follow-up of such pathologies have markedly grown. Together with clinical and imaging techniques, biochemical tests play an important role in the assessment and differential diagnosis of metabolic bone disease. In recent years, the isolation and characterisation of cellular and extracellular components of the skeletal matrix have resulted in the development of molecular markers that are considered to reflect either bone formation or bone resorption. These biochemical indices are non-invasive, comparatively inexpensive and, when applied and interpreted correctly, helpful tools in the diagnostic and therapeutic assessment of metabolic bone disease. This review provides an overview of the current evidence regarding the clinical use of biochemical markers of bone remodelling in bone disease, with an emphasis on osteoporosis.

Hormone therapy use among postmenopausal French women before the publication of the Women's Health Initiative study: duration of use and factors associated with discontinuation

OBJECTIVE

Compliance with recent recommendations concerning hormone therapy (HT) requires that we understand the reasons why women receiving HT continue or stop their treatment. Our aim was to estimate the duration of HT use and analyze factors associated with its discontinuation during the period before the publication of articles challenging the safety of HT.

DESIGN

With data from 3 mail questionnaires--at inclusion (in 1990), 3 years, and 6 years--we estimated the cumulative treatment continuation rate by the actuarial method and used the Cox model to analyze the factors associated with discontinuation.

SETTING

French women participating in the GAZEL cohort of employees of the French national power and electricity company (Electricité de France-Gaz de France).

PATIENT(S)

One thousand eighty-three postmenopausal women who were ever-HT users.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Discontinuation of HT.

RESULT(S)

A total of 91.6% of women consulted gynecologists, and 88% continued treatment 5 years after they had begun it. Those reporting hot flashes as a reason for taking HT and those younger than 45 years old at menopause were less likely to stop HT, as were women reporting alcohol use.

CONCLUSION(S)

Our results demonstrate the importance of providing information to physicians, primarily gynecologists, to ensure appropriate treatment of symptoms for menopausal women, especially those younger than 45 years old, while bearing their long-term health in mind.

Determinants of adherence to osteoporosis treatment in clinical practice

INTRODUCTION

Poor adherence to prescribed treatments is widespread in clinical practice and this can lead to potentially life-threatening events. This problem is apparently very common for osteoporosis treatment but the causes of discontinuation and low compliance are complex and poorly defined.

METHODS

Global adherence to osteoporosis treatment was specifically addressed in a nation-wide survey carried out in 9851 postmenopausal women referred to 141 Italian centres for osteoporosis management for a follow-up assessment, at least one year after having been prescribed a treatment with one of the following drugs: calcium+/-vitamin D supplements alone (CaVitD), hormone replacement therapy (HRT), raloxifene 60 mg (RLX), intramuscular clodronate 100 mg/7-14 days (CLOD), risedronate 5 mg/day (RIS) and alendronate 10mg/daily (ALN10) or 70 mg once weekly (ALN OW).

RESULTS

Overall 19.1% of the patients discontinued the prescribed drug before attending the bone mass re-evaluations, more than half of them within the first 6 months. The discontinuation rate was significantly different between the treatments. The medications most frequently interrupted within one year were CLOD (28.7%; p<0.01 versus any other treatment), while by far the least interrupted was ALN-OW (6.9%; p<0.001 versus any other treatment). The most frequent reasons for discontinuation were drug related side effects, insufficient motivation to treatment and fear of side effects. The prevalence of the reasons for discontinuation were different among treatments: safety concerns were very common for HRT, lack of motivation was the most common cause for CaVitD and CLOD, and drug related side effects for RIS, ALN and RLX. Persistence to treatment was significantly higher in patients with previous vertebral fractures, densitometric osteoporosis, on corticosteroid or anti-inflammatory treatments. A significantly increased risk of treatment interruption was found among patients on benzodiazepine or gastro-protective agents and in patients in whom a bone measurement was not readily available. The highest compliance to recommended dosing was observed with ALN OW and HRT (p<0.001 versus any other) and the lowest for CaVitD (p<0.01 versus any other). Poor treatment compliance (<50% drug taken) was significantly related to benzodiazepine and gastroprotective use, while a significantly better compliance was associated with recognized risk factors for osteoporosis: early menopause, low bone mass values values, previous vertebral fractures. The poorest adherence was observed when treatments were prescribed by General practitioners (GPs), and orthopaedic surgeons (p<0.01 versus global mean).

CONCLUSIONS

The results of this large survey of Italian osteoporotic women indicates that the most important determinant of both persistence and compliance to treatment is the type of drug prescribed with a definite advantage of ALN-OW. Treatment compliance is particularly poor for CaVitD and this emphasizes the need for new ways to supplement at least vitamin D. The main reasons for discontinuation are side effects and lack of motivation while the best treatment adherence was observed in patients with severe and well documented osteoporosis.

Persistence with teriparatide in patients with osteoporosis: the UK experience

INTRODUCTION

The objective of this paper was to determine the persistence with teriparatide at 12 months in all patients in the UK who were prescribed the treatment since its launch.

METHODS

Virtually all patients prescribed teriparatide in the UK receive treatment through Healthcare at Home, Basingstoke, UK. Data was obtained to assess the start date, discontinuation date and reason for discontinuation in all patients receiving teriparatide since its launch. Persistence was defined as the number of patients continuing treatment.

RESULTS

A total of 1,104 patients were included in the analysis. The median duration of use in all patients was 252 days. Of the 435 patients who were at least 12 months post-initiation of treatment, persistence was 87%. Forty-two patients (3.8%) had discontinued treatment due to adverse events.

CONCLUSIONS

This study demonstrates that persistence with teriparatide at 12 months is very high and is probably greater than that of existing oral therapies for osteoporosis. The reasons for the high persistence rates seen with teriparatide are likely to be multi-factorial. The high persistence rates should help to optimise the effectiveness of therapy in this group of high-risk patients.

Osteoporosis Medications Used by Older African–American Women: Effects of Socioeconomic Status and Psychosocial Factors

This study examined the effects of socioeconomic status, knowledge and Health Belief Model variables on ever use of hormone therapy and other osteoporosis medications among older African-American women. One-hundred and two African-American women, 60 years old or older, randomly selected from Registers of Voters and a list of participants in educational activities of a university hospital, were interviewed in their homes. Data collected concerned knowledge of osteoporosis, Health Belief Model variables, and cues to action such as history of hysterectomy, personal and family history of cancer, bone mineral density testing, and discussion with a physician about osteoporosis. Socioeconomic status indicators included years of education and household income. The average respondent age was 71.1 years; 47% were current or previous users (ever users) of hormone therapy, and 11% were ever users of other osteoporosis medications. Knowledge of osteoporosis, (odds ratio = 1.4), Hormone therapy benefits, (odds ratio = 1.63), a hysterectomy (odds ratio = 4.35), and a family history of cancer (odds ratio = 4.0) increased the odds of ever using hormone therapy. Perceptions of susceptibility (odds ratio = 3.5) and discussion with a physician about osteoporosis (odds ratio = 6.4) increased odds of ever using other osteoporosis medications. Socioeconomic status mediated the effects of knowledge of osteoporosis on ever using hormone therapy. Efforts to promote bone health to older African-American women should focus primary efforts to increasing perceptions of susceptibility to fracture and persuading physicians to initiate discussions about fracture prevention with African-American patients before a fracture occurs.

Compliance with drug therapies for the treatment and prevention of osteoporosis

OBJECTIVES

This study used paid claims data from real-world treatment settings to investigate the impact of hormone replacement therapy (HRT), bisphosphonate and raloxifene on patients with a recorded diagnosis of osteoporosis.

METHODS

Data from a large health insurer were used to identify 58,109 osteoporosis patients who initiated drug therapy for osteoporosis. Multivariate statistical models were developed for duration of therapy, compliance at 1 year, time to discontinuation or a change in therapy, health care costs and risk of fracture over 1 year.

RESULTS

One-year compliance rates were below 25% for all osteoporosis therapies. The mean unadjusted duration of continuous therapy was 221 days for raloxifene, 245 days for bisphosphonate, 262 for estrogen-only and 292 days for estrogen plus progestin. Raloxifene patients were consistently less compliant than estrogen-only patients after adjusting for differences in patient characteristics. Estrogen plus progestin patients were generally more compliant while bisphosphonate did not differentiate from estrogen-only. Compliance reduced the risk of hip fracture (o.r. = 0.382, P < 0.01) and vertebral fracture (o.r. = 0.601, P < 0.05). Compliant patients used fewer physicians services (-US dollars 56, P < 0.0001), hospital outpatient services (-US dollars 38, P < 0.05) and hospital care (-US dollars 155, P < 0.01). Bisphosphonate patients were twice as likely as estrogen-only patients to experience vertebral, Colles and other fractures and experienced higher health care costs (+US dollars 420, P < 0.01). The effectiveness of both raloxifene and bisphosphonate medications relative to estrogen-only improved significantly with the age of the patient.

CONCLUSIONS

Compliance with drug therapies for osteoporosis over 1 year is poor leaving patients at risk for fractures and higher health care costs.

Racial differences in lipid-lowering agent use in medicaid patients with cardiovascular disease

BACKGROUND

Racial differences in chronic cardiovascular disease (CVD) outcomes are well described, whereas less is known about the process of CVD preventive care and its potential contribution to disparate outcomes.

OBJECTIVE

The objective of this study was to examine the association between race and 1) prior use of a lipid-lowering agent (LLA), 2) LLA initiation, and 3) LLA discontinuation among individuals with an incident medical claim for CVD.

RESEARCH DESIGN

Retrospective claims analysis.

SUBJECTS

We studied continuously enrolled, fee-for-service Medicaid recipients <65 with a new medical claim for 1 of 15 CVD-related diagnoses or procedures from 1993 to 1998 (n = 14,833).

MEASURES

Pharmacy claims history reflecting previous, new, and ongoing LLA use were reviewed for the 24-month period around a new CVD claim. Multivariable logistic regression assessed the independent effect of minority status on new and ongoing LLA use controlling for clinical and demographic characteristics.

RESULTS

A total of 3924 (26.4%) individuals submitted LLA pharmacy claims. A total of 3668 of 4668 (78.6%) previous or new users obtained > or =1 refill. Minorities were less likely to have previously used LLA (adjusted odds ratio [AOR], 0.64; 95% confidence interval [CI], 0.58-0.70), to receive a new prescription (AOR, 0.62; 95% CI, 0.54-0.71), or to continue use, as evidenced by subsequent refill claims (AOR, 0.74; 95% CI, 0.62-0.87).

CONCLUSIONS

Publicly insured minorities with prescription coverage benefit less often from preventive care before or after a CVD diagnosis, resulting, in part, from providers' failure to initiate therapy and patients' failure to continue it. To reduce widening disparities in cardiovascular outcomes, strategies that target LLA underuse by minorities throughout the process of care are needed.

Nonadherence and Osteoporosis Treatment Preferences of Older Women: A Qualitative Study

BACKGROUND

Physicians must have an understanding of patients' medication beliefs in order to enhance medication adherence. To increase understanding, this study examined how beliefs about medication and four osteoporosis treatments influenced treatment selection and adherence.

METHODS

Six focus groups, three with 28 African Americans and one with 11 non-Hispanic white women, were conducted in English. Two groups with 16 Hispanics were conducted in Spanish. The convenience sample was recruited from senior centers and housing in lower socioeconomic geographic areas. The average age was 74.8 +/- 1.1 years.

RESULTS

Adherence was associated with recognition of the serious consequences of nonadherence, realization of the beneficial effects, and the belief that medicines are not harmful. Doubts about physicians' competence to prescribe appropriate drugs were also revealed. Women who thought they were unlikely to fracture or perceived fracture outcomes as not severe chose no treatment. If they identified a need, they weighed benefits against the attendant risks to find the best alternative among the affordable options. Price considerations eliminated raloxifene and alendronate. Consideration of side effects eliminated estrogen and raloxifene. Calcium was viewed as a low-cost, low-risk alternative. Those who could afford alendronate and who viewed its side effects as preventable preferred it. Benefit and risk assessments may have been biased by fear of cancer and thromboembolic events.

CONCLUSIONS

Women's beliefs about necessity of treatment, medication safety, cost of treatment, and treatment goals appear critical to osteoporosis treatment selection and adherence.

Clinical correlates of estrogen replacement therapy use and duration of use among medicaid recipients

Estrogen replacement therapy (ERT) is used not only for the short-term control of menopausal symptoms but long-term for disease prevention. This study examined the influence of selected clinical conditions on the use of ERT and the duration of ERT use among women enrolled in a state Medicaid program. We identified 60,531 women, aged >/=45 years, who were enrolled in Maryland Medicaid continuously for at least 2 of 3 years. ERT use was determined through prescription claims submitted for reimbursement. The presence or risk of selected clinical conditions (e.g., osteoporosis, heart disease, estrogen-sensitive cancers) was determined by screening Medicaid claims files for related diagnoses, procedures, or prescription claims. Multiple logistic regression was used to model ERT use, and proportional hazards regression was used to model duration of use. Fourteen percent of these women filled an ERT prescription, with use varying by age, race, and place of residence. Oral dosage forms were the most popular (80.8%), followed by vaginal cream or ring (22.2%), and transdermal patch (7.3%). In adjusted models, osteoporosis, heart disease, hypertension, hyperlipidemia, diabetes, ovarian cancer, and thromboembolic disease were positively associated and dementia and breast cancer were negatively associated with ERT use. None of these medical conditions predicted the duration of estrogen therapy. Use of ERT was very low among these women despite coverage of prescription medications, and the presence of clinical indications had no influence on the length of therapy among these women despite known benefits for long-term preventive therapy.

Assessing NSAID prescription use as a predisposing factor for gastroesophageal reflux disease in a Medicaid population

PURPOSE

The purpose of the study was to determine the incidence of GERD associated with prescription NSAID consumption.

METHODS

All Georgia Medicaid patients > 25 years of age and continuously eligible for 1996, 1997, and 1998 were included in the study. Patients were excluded if they received a GERD diagnoses during 1996 and 1997. Patients were observed in 1998 and classified into GERD and control cohorts. Comorbidities, demographics, and NSAID prescription consumption were retained and modeled with logistic regression.

RESULTS

The absolute risk of developing GERD without previous NSAID consumption was 0.38. The absolute risk of developing GERD for those patients who consumed one or more NSAID prescriptions during 1996 and 1997 was 0.80. Thus, the relative risk of GERD for NSAID patients was 2.11. GERD was significantly associated with one or more NSAID prescriptions (OR = 1.82), age (OR = 1.05 for 5 year range), gender (OR = 1.31 for females), asthma (OR = 3.24), obesity (OR = 2.77), hiatal hernia (OR = 4.17), tobacco use (OR = 2.56), and alcohol (OR = 1.83). The initial NSAID prescription was responsible for the greatest marginal increase in GERD.

CONCLUSIONS

Our study suggests that NSAIDs are associated with GERD especially for females, alcohol and tobacco users, and patients with asthma, hiatal hernia, or obesity.