Antihypertensive medication prescribing in 27,822 elderly Canadians with diabetes over the past decade

A nationwide assessment of blood pressure control and the associated factors in Chinese type 2 diabetes mellitus patients

A subgroup analysis of the nationwide, cross-sectional 3B STUDY was performed to understand the current blood pressure (BP) control status and treatment patterns in Chinese diabetes patients as well as to identify factors associated with BP control. The demographic data, anthropometric parameters, and laboratory results were collected from 24 512 type 2 diabetes patients. The BP goal was a systolic BP <130 mm Hg and a diastolic BP <80 mm Hg regardless of a history of hypertension or current antihypertensive treatment. The overall prevalence of hypertension was 59.9% with geographical differences. Among the diabetes patients with hypertension, 76.9% received antihypertensive medicines. Calcium channel blockers (39.3%), angiotensin II receptor antagonists (26.6%), and then β-blockers (14.0%) or angiotensin-converting enzyme inhibitors (13.6%) were frequently used for BP control. Only 17.5% (n = 2658) of diabetes patients with hypertension reached the recommended target BP. Body mass index <24 kg/m² , urban resident, frequent physical activity, good adherence to medication, comorbidity with cardiovascular disease, achieving glycemic goal (HbA1c <7.0%), achieving lipid goal (low-density lipoprotein cholesterol <2.59 mmol/L) were independent factors that predicted achievement of target BP goal. On the contrary, comorbidity with chronic kidney disease predicted failure to achieve target BP goal. Patients who were treated in a cardiology department or lived in the North were more likely to achieve BP goals. A considerable proportion of diabetic patients failed to achieve guideline-recommended BP targets. More aggressive efforts should be made to overcome the diverse barriers and facilitate the optimization of diabetes management.

Impact of the Diabetes Canada Guideline Dissemination Strategy on the Prescription of Vascular Protective Medications: A Retrospective Cohort Study, 2010-2015

OBJECTIVE

The 2013 Diabetes Canada guidelines launched targeted dissemination tools and a simple assessment for vascular protection. We aimed to 1) examine changes associated with the launch of the 2013 guidelines and additional dissemination efforts in the rates of vascular protective medications prescribed in primary care for older patients with diabetes and 2) examine differences in the rates of prescriptions of vascular protective medications by patient and provider characteristics.

RESEARCH DESIGN AND METHODS

The study population included patients (≥40 years of age) from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) with type 2 diabetes and at least one clinic visit from April 2010 to December 2015. An interrupted time series analysis was used to assess the proportion of eligible patients prescribed a statin, ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB), or antiplatelet prescription in each quarter. Proton pump inhibitor (PPI) prescriptions were the reference control.

RESULTS

A dynamic cohort was used where participants were enrolled each quarter using a prespecified set of conditions (range 25,985-70,693 per quarter). There were no significant changes in statin (P = 0.43), ACEI/ARB (P = 0.42), antiplatelet (P = 0.39), or PPI (P = 0.16) prescriptions at baseline (guideline intervention). After guideline publication, there was a significant change in slope for statin (-0.52% per quarter, SE 0.15, P < 0.05), ACEI/ARB (-0.38% per quarter, SE 0.13, P < 0.05), and reference PPI (-0.18% per quarter, SE 0.05, P < 0.05) prescriptions.

CONCLUSIONS

There was a decrease in prescribing trends over time that was not specific to vascular protective medications. More effective knowledge translation strategies are needed to improve vascular protection in diabetes in order for patients to receive the most effective interventions.

Is cardiovascular risk reduction therapy effective in South Asian, Chinese and other patients with diabetes? A population-based cohort study from Canada

OBJECTIVES

Guidelines recommend ACE inhibitors (ACEi), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs) and diuretics in all patients with diabetes mellitus. However, the effectiveness of these agents in South Asian and Chinese populations is unknown. We sought to determine whether ACEi, ARB, CCB and diuretics are associated with reduced mortality in South Asian, Chinese and other patients with diabetes.

DESIGN

Population-based cohort study using administrative health databases.

SETTING

Province of British Columbia, Canada (2006-2013).

PARTICIPANTS

Patients aged ≥35 years with incident diabetes.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was all-cause mortality for each medication class compared with untreated patients within each ethnicity. Treatment effect was assessed using inverse probability of treatment weighted Cox proportional hazards models. Medication adherence effect on mortality was also evaluated.

RESULTS

208 870 patients (13 755 South Asian, 22 871 Chinese, 172 244 other Canadian) were included. ACEi reduced mortality in other patients (HR=0.88, 0.84-0.91), but power was insufficient to evaluate for benefit in Chinese and South Asian patients. ARB and diuretics reduced mortality in Chinese (ARB HR=0.64, 0.50-0.82; diuretics HR=0.77, 0.62-0.96) and other patients (ARB HR=0.69, 0.64-0.74; diuretics HR=0.66, 0.63-0.69) compared with untreated patients. No mortality benefit was observed among South Asians for any drug class or for CCB among all ethnicities. Higher medication adherence was associated with lower mortality for other patients only (HR=0.79, 0.72-0.86).

CONCLUSIONS

Effectiveness of cardiovascular risk reduction therapy on mortality varies considerably by ethnicity. Further study is needed to evaluate the mortality benefit of antihypertensive agents in South Asians. Inclusion of these ethnic groups in future clinical trials is essential to examine for differential responses.

The long-term effects of stillbirth on women with and without gestational diabetes: a population-based cohort study

AIMS/HYPOTHESIS

The aim of this study was to estimate the incidence of type 2 diabetes (primary objective) and hospitalisation for cardiovascular events (secondary objective) in women with previous gestational diabetes mellitus (GDM) and in those with normal glucose tolerance (NGT) in pregnancy, and to evaluate the role of stillbirth in differentiating the risks.

METHODS

This was a population-based cohort study using administrative data and involving 12 local health authorities. Women with GDM (n = 3,851) during the index period from 2002 to 2010 were propensity matched with women with NGT (n = 11,553). Information was collected on type 2 diabetes development and hospitalisation for cardiovascular events.

RESULTS

During a median follow-up of 5.4 years, the incidence rate per 1,000 person-years of type 2 diabetes was 2.1 (95% CI 1.8, 2.5) in women without GDM and 54.0 (95% CI 50.2, 58.0) among women with GDM and pregnancy at term (incidence rate ratio [IRR] 26.9; 95% CI 22.1, 32.7 compared with NGT and pregnancy at term). A history of stillbirth increased the risk of type 2 diabetes development by about twofold, irrespective of GDM status. No significant interaction between stillbirth and GDM on type 2 diabetes risk was found. GDM was associated with a significantly higher risk of cardiovascular events compared with NGT (IRR 2.4; 95% CI 1.5, 3.8).

CONCLUSIONS/INTERPRETATION

Pregnancy complicated by GDM and ending in stillbirth represents an important contributory factor in determining type 2 diabetes development. Women with GDM are at a high risk of future cardiovascular events. Women with pregnancy complicated by GDM and stillbirth deserve careful follow-up.

Use of drugs related to the treatment of diabetes mellitus and other cardiovascular risk factors in the Spanish population. The Di@bet.es study

INTRODUCTION AND OBJECTIVES

To assess the patterns of use of 8 therapeutic drug groups for the treatment of diabetes mellitus and other cardiovascular risk factors, and to identify sociodemographic and health determinants of their use in the overall Spanish population.

METHODS

A representative sample of the Spanish population within the Di@bet.es study, a cross-sectional population-based survey, was included.

STUDY VARIABLES

sociodemographic, clinical, and lifestyle data; physical examination, and an oral glucose tolerance test in patients without known diabetes mellitus. Furthermore, patients were systematically queried about current medication use, and 8 pharmacotherapeutic groups were evaluated: lipid-lowering therapy, antihypertensives, oral hypoglycemic agents, insulin, thyroid hormone, uricosurics, psychoactive drugs, and nonsteroidal anti-inflammatory drugs.

RESULTS

Sixty-six percent of the Spanish population was taking at least one medication. Therapeutic drug use was associated with age, independently of the higher prevalence of diabetes mellitus, hypertension, or hyperlipidemia in older patients. Sex disparities were found in the use of lipid-lowering agents, allopurinol, levothyroxine, nonsteroidal anti-inflammatory drugs, and psychoactive drugs. Use of psychoactive drugs was related to education level, work status, physical activity, smoking, and alcohol consumption. Almost 30% of patients with diabetes mellitus were taking 6 or more medications daily. Diabetes mellitus was associated with greater use of antihypertensives, lipid-lowering agents, and nonsteroidal anti-inflammatory drugs.

CONCLUSIONS

Age and sex are the most important factors determining therapeutic drug use. Lifestyle patterns and sociocultural factors have an impact only on psychoactive drug use. Diabetes mellitus is associated with greater use of antihypertensives, lipid-lowering agents, and nonsteroidal anti-inflammatory drugs.

From pharmaco-therapy to pharmaco-prevention: trends in prescribing to older adults in Ontario, Canada, 1997-2006

Background

The developed world is undergoing a demographic transition with greater numbers of older adults and higher rates of chronic disease. Most elder care is now provided by primary care physicians, who prescribe the majority of medications taken by these patients. Despite these significant trends, little is known about population-level prescribing patterns to primary care patients aged 65+.

Methods

We conducted a population-based retrospective cohort study to examine 10-year prescribing trends among family physicians providing care to patients aged 65+ in Ontario, Canada.

Results

Both crude number of prescription claims and prescription rates (i.e., claims per person) increased dramatically over the 10-year study period. The greatest change was in prescribing patterns for females aged 85+. Dramatic increases were observed in the prescribing of preventive medications, such as those to prevent osteoporosis (+2,347%) and lipid-lowering agents (+697%). And lastly, the number of unique classes of medications prescribed to older persons has increased, with the proportion of older patients prescribed more than 10 classes of medications almost tripling during the study period.

Conclusions

Prescribing to older adults by family physicians increased substantially during the study period. This raises important concerns regarding quality of care, patient safety, and cost sustainability. It is evident that further research is urgently needed on the health outcomes (both beneficial and harmful) associated with these dramatic increases in prescribing rates.

Diminishing efficacy of combination therapy, response-heterogeneity, and treatment intolerance limit the attainability of tight risk factor control in patients with diabetes

OBJECTIVE

To evaluate the attainability of tight risk factor control targets for three diabetes risk factors and to assess the degree of polypharmacy required.

DATA SOURCES/STUDY SETTING

National Health and Nutrition Examination Survey-III.

STUDY DESIGN

We simulated a strategy of "treating to targets," exposing subjects to a battery of treatments until low-density lipoprotein (LDL)-cholesterol (100 mg/dL), hemoglobin A1c (7 percent), and blood pressure (130/80 mm Hg) targets were achieved or until all treatments had been exhausted. Regimens included five statins of increasing potency, four A1c-lowering therapies, and eight steps of antihypertensive therapy.

DATA COLLECTION/EXTRACTION METHODS

We selected parameter estimates from placebo-controlled trials and meta-analyses.

PRINCIPAL FINDINGS

Under ideal efficacy conditions, 77, 64, and 58 percent of subjects achieved the LDL, A1c, and blood pressure targets, respectively. Successful control depended highly on a subject's baseline number of treatments. Using the least favorable assumptions of treatment tolerance, success rates were 11-17 percentage points lower. Approximately 57 percent of subjects required five or more medication classes.

CONCLUSIONS

A significant proportion of people with diabetes will fail to achieve targets despite using high doses of multiple, conventional treatments. These findings raise concerns about the feasibility and polypharmacy burden needed for tight risk factor control, and the use of measures of tight control to assess the quality of care for diabetes.

The effect of selected patient's characteristics on the choice of antihypertensive medication in the elderly in Slovakia

PURPOSE

The aim of the present study was to determine which patient-related characteristics influence the selection of the antihypertensive drug class in elderly patients in Slovakia.

METHODS

The sample for our study (n = 401) was selected from 1045 patients admitted to the Department of Internal Medicine of a general hospital during the period of 1 December 2003-31 March 2005. Patients aged 65 or more with documented arterial hypertension and treated with at least one antihypertensive drug were enrolled in our retrospective study. Specific socio-demographic and clinical characteristics as well as cardiovascular comorbid conditions were evaluated as potential factors that could have influenced the choice of antihypertensive drug class.

RESULTS

The most frequently prescribed antihypertensive drugs were angiotensin-converting enzyme (ACE) inhibitors and diuretics (61.8% and 60.1% of patients, respectively). Patients aged >/= 85 years had lower probability of ACE inhibitors prescription (OR = 0.49). Females had higher chance of calcium channel blockers use (OR = 3.84) and lower odds of diuretics administration (OR = 0.50). In patients living alone, ACE inhibitors were preferred (OR = 2.16). The use of diuretics was more frequent in polymorbid patients (OR = 1.95). Immobile patients had lower chance of being prescribed beta-blockers and calcium channel blockers (OR = 0.25 and OR = 0.39, respectively).

CONCLUSION

The present study revealed that the selection of the antihypertensive drug class in elderly patients is influenced not only by comorbid conditions present but also by socio-demographic and clinical characteristics, such as age, sex, living alone, polymorbidity and immobilization. These characteristics reflect the doctor's perception of risk from pharmacotherapy of hypertension in elderly patients.

The darkening cloud of diabetes: do trends in cardiovascular risk management provide a silver lining?

OBJECTIVE

We aimed to evaluate the changes in cardiovascular-related health care utilization (drug therapies, hospitalizations) and mortality for the diabetic population during a 9-year period in Saskatchewan, Canada.

RESEARCH DESIGN AND METHODS

We identified annual diabetes prevalence rates for people aged >or=30 years between 1993 and 2001 from the administrative databases of Saskatchewan Health. Annual rates of evidence-based drug therapies (antihypertensives, ACE inhibitors, beta-blockers, calcium channel blockers, 3-hydroxy-3-metaglutaryl coenzyme A reductase inhibitors [statins]), hospitalizations for cerebrovascular and cardiac events, and all-cause mortality were estimated. Rates were direct age and sex standardized using the 2001 Canadian population, and trends over time were assessed using Joinpoint regression.

RESULTS

From 1993 to 2001, diabetes prevalence increased 34% (4.7-6.5%, P < 0.001) with the highest rates in men and those aged >or=65 years. The rate of increase in diabetes prevalence appeared to slow in those aged <65 years (P < 0.01 for trend). Significant increased use of evidence-based drug therapies was observed (41% increase in antihypertensive agents, 97% increase in ACE inhibitors, 223% increase in statin therapies; all P < 0.05 for trend). During this period, both cerebrovascular and cardiac-related hospitalizations declined by 36% (9.5 vs. 6.1 per 1,000) and 19% (38.0 vs. 30.6 per 1,000) (P < 0.05 for trends), respectively, with similar reductions regardless of sex. No change in all-cause mortality was observed (17.7 vs. 17.8 deaths per 1,000; P > 0.05).

CONCLUSIONS

During our period of study, there was an increase in the utilization of evidenced-based drug therapies in people with diabetes and reductions in cardiovascular-related hospitalizations. Despite this, we observed no change in all-cause mortality.

Canadian Hypertension Education Program: the evolution of hypertension management guidelines in Canada

The Canadian Hypertension Education Program (CHEP) is a unique Canadian initiative to improve awareness, treatment and control of hypertension through the education of health care professionals. It is the culmination of an over 30-year effort in the development of hypertension management recommendations in Canada. Important transitions in this evolution included adoption of a consensus approach, rigorous evidence grading, enhanced dissemination strategies, recommendation consolidation, sophisticated adjudication procedures, an annual process and the 'branding' of the effort as a distinct entity. CHEP is composed of expert health care 'volunteers', organized via steering, executive and central review committees, in conjunction with three task forces: the Recommendations Task Force, the Implementation Task Force and the Outcomes Research Task Force. CHEP espouses philosophies that strengthen effectiveness and cohesion: multiple partnerships, stakeholders, supporters and multidisciplinary participants ensure that key messages are disseminated with great impact to broad audiences. Over the past 10 years, there have been unprecedented advances in the treatment of hypertension and the reduction of related diseases in Canada. CHEP, a likely contributor, is being increasingly viewed as an international model for knowledge translation.