Health care utilization and the associated costs attributable to cardiovascular disease in Ireland: a cross-sectional study

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality and disability globally. We examined healthcare service utilization and costs attributable to CVD in Ireland in the period before the introduction of a major healthcare reform in 2016.

METHODS

Secondary analysis of data from 8 113 participants of the first wave of The Irish Longitudinal Study on Ageing. CVD was defined as having a self-reported doctor's diagnosis of myocardial infarction, angina, heart failure, stroke, atrial fibrillation or transient ischaemic attack. Participants self-reported the utilization of healthcare services in the year preceding the interview. Negative binomial regression with average marginal effects (AME) was used to estimate the incremental number of general practitioner (GP) and outpatient department (OPD) visits, accident and emergency department attendances and hospitalisations in population with CVD relative to population without CVD. We calculated the corresponding costs at individual and population levels, by gender and age groups.

RESULTS

The prevalence of CVD was 18.2% (95% CI: 17.3, 19.0) Participants with CVD reported higher utilization of all healthcare services. In adjusted models, having CVD was associated with incremental 1.19 (95% CI: 0.99, 1.39) GP and 0.79 (95% CI: 0.65, 0.93) OPD visits. There were twice as many incremental hospitalisations in males with CVD compared to females with CVD (AME (95% CI): 0.20 (0.16, 0.23) vs 0.10 (0.07, 0.14)). The incremental cost of healthcare service use in population with CVD was an estimated €352.2 million (95% CI: €272.8, €431.7), 93% of which was due to use of secondary care services.

CONCLUSION

We identified substantially increased use of healthcare services attributable to CVD in Ireland. Continued efforts aimed at CVD primary prevention and management are required.

Enhancing the clinical pharmacy service of a large teaching hospital: Development of a new clinical prioritisation tool

Background

The number and complexity of patients being admitted to hospitals is rising and some patients may not receive a full clinical pharmacy review or be reviewed as regularly as needed during their inpatient stay. This is a risk factor for medication errors. Clinical prioritisation identifies patients who are high-risk and most in need of a pharmacist review, targeting finite pharmacy resources to patients who will benefit the most.

Objectives

Assess and enhance clinical prioritisation within a hospital pharmacy department.

Methods

The study was conducted in a large urban academic teaching hospital. A cross-sectional survey of clinical pharmacists in the hospital was conducted to establish the patient clinical criteria they prioritise in their work. A clinical prioritisation tool was developed based on survey findings and was integrated into an existing electronic pharmacy care interface. A pre- and post-intervention study was conducted, consisting of data collection for five days pre- and five days post-implementation of the tool. Quantitative data were analysed using descriptive and inferential statistics. Qualitative data were analysed by thematic analysis.

Results

Of 39 eligible pharmacists, 37 (95%) responded to the survey. The top-rated prioritisation criteria, including medicines reconciliation tasks and high-risk medicines, helped to inform the content of the clinical prioritisation tool. Post-intervention, there were more Level 1 complex patients reviewed by pharmacists and fewer Level 3 stable patients compared to pre-intervention. Tool sensitivity ranged from 51 to 88%, depending on the experience of the pharmacist using the tool. High levels of satisfaction with clinical prioritisation were reported by those using the tool.

Conclusion

This newly developed clinical prioritisation tool has the potential to support pharmacists in identifying and reviewing patients in a more targeted manner than practice prior to tool development. Continued development and validation of the tool is essential, with a focus on developing a fully automated tool.

The impact of drug palatability on prescribing and dispensing of antibiotic formulations for paediatric patients: a cross-sectional survey of general practitioners and pharmacists

BACKGROUND

Palatability is a key element of paediatric acceptability for medicines. Many patient and drug factors are considered when choosing an antibiotic for a child. Pharmacists report that they receive questions about the palatability of oral liquid antibiotics for children. This study aimed to explore the experiences of GPs and pharmacists concerning palatability of oral liquid antibiotics for children.

METHODS

A questionnaire about the impact of palatability on the choice of antibiotic formulation for children was emailed to all community pharmacists in Ireland and to GPs and trainee GPs in the Cork region and posted on social media. Survey items were not compulsory; therefore, percentage responses were calculated based on the number of responses to that item. GP and pharmacist responses were analysed independently.

RESULTS

Responses were received from 244 participants (59 GPs, 185 pharmacists). Clinical guidelines and availability of supply were the most important factors considered when choosing an oral liquid antibiotic formulation for children by GP (79.7%) and pharmacist (66.5%) respondents respectively. Forty GP respondents (76.9%) reported ensuring adherence was the most common palatability-related reason leading to deviation from guidelines. Pharmacist respondents (52%) reported advising a parent/caregiver to manipulate the required antibiotic dose to improve acceptability. The least palatable oral liquid antibiotics reported were flucloxacillin (16% GPs, 18% pharmacists) and clarithromycin (17% of each profession).

CONCLUSION

This study identified palatability issues associated with oral liquid antibiotics for children reported by GPs and pharmacists. Pharmaceutical approaches to adapting oral liquid antibiotic formulations must be developed to improve palatability and thus paediatric acceptability.

Pharmacy students' experience of technology-enhanced learning during the COVID-19 pandemic

Background

With the advent of the COVID-19 pandemic, pharmacy students and educators experienced an abrupt shift as programmes that were previously taught exclusively in-person were then predominantly taught online. This sudden change provided little time for students to prepare for the new learning environment.

Objectives

The study objective was to explore pharmacy students' experiences of technology-enhanced learning during the COVID-19 pandemic.

Methods

A cross-sectional survey was developed and distributed by email to all 3rd year (N = 76) and 4th year (N = 68) pharmacy students undertaking an MPharm programme in an Irish university.

Results

A total of 32 responses were collected, including 20 third year and 12 fourth year pharmacy students (response rates of 26.3% and 17.6%, respectively). The majority of respondents reported good or very good internet speed (71%) and stability (59%). Almost all were confident or very confident using Canvas (97%) prior to the onset of online learning. Respondents preferred engaging with other students in-person rather than online for coursework (68.8%) and learning new material (56.3%). Students favoured face-to-face delivery, with a recording of the session available online afterwards, for lectures (68.8%), workshops (50%) and tutorials (56.3%). Analysis of free-text comments indicates that respondents used recorded content to support exam revision and that a key drawback of online learning was social isolation.

Implications

Pharmacy students favoured a blended learning approach, with in-person learning being recorded to support study and revision. Students' experience of TEL during the pandemic should be considered in the development and ongoing review of pharmacy programmes.

Community Pharmacists' Attitude, Practice and Confidence in Supporting People with Diabetes in Japan and Ireland: A Cross-sectional Survey

Diabetes is a chronic disease requiring long-term management. Poorly controlled diabetes is associated with reduced quality of life and micro- and macro-vascular complications. Community pharmacists have a role in supporting people with diabetes to better address their condition and reduce their risk of diabetes-related illness. The purpose of this study was to examine and compare the attitudes, practices, and confidence of community pharmacists in Japan and Ireland on the care of people with diabetes. A cross-sectional survey of community pharmacists in Ireland (388 respondents) and Japan (144 respondents) was conducted to assess their attitudes, practices, confidence, and other characteristics linked to diabetes management. A Likert scale was utilized, with a range of strongly agree to strongly disagree. The study reported that Japanese pharmacists have lower levels of practice (p<0.004), confidence, trust by patients, job satisfaction, concern with patients, and knowledge (all p<0.001) regarding diabetes management than Irish pharmacists. Although there was no significant difference in the attitude of pharmacists in both countries, the results show almost similar attitudes toward diabetes management, indicating their willingness to support people with diabetes. These results demonstrated less confidence in diabetes management and less practice of diabetes management care among Japanese pharmacists than Irish pharmacists. The results can be used to identify pharmacist education needs and develop training programs in diabetes management for pharmacists in Japan and Ireland.

Factors influencing prescribing by critical care physicians to heart failure patients in Egypt: a cross-sectional survey

Background

Heart failure (HF) guideline-led prescribing improves patient outcomes; however, little is known about the factors influencing guideline-led prescribing in critical care settings. This study used a cross-sectional survey to assess the factors that influence physicians when prescribing to heart failure patients in a critical care setting in Egypt.

Results

The response rate was 54.8%. The international HF guidelines were the primary source of prescribing information for 84.2% of respondents. Staff were more familiar with the latest guideline recommendations than associate staff (86.7% vs 36.8%, p = 0.012) and considered patient’s perspectives more often (86.7% vs 26.3%, p = 0.036). Renal function was the clinical factor that most frequently influenced the prescribing of loop diuretics or renin–angiotensin–aldosterone system inhibitors. Pulmonary function influenced beta-blockers prescription. The most frequently cited barrier to guideline-led prescribing was the absence of locally drafted guidelines. A majority of prescribers agreed that implementation of clinical pharmacy services, physician education and electronic reminders may improve the implementation of guideline-led prescribing.

Conclusions

Although experienced physicians are familiar with and use international guidelines, physicians would welcome local guidance on HF prescribing and greater clinical pharmacist input.

Stakeholders' knowledge, attitudes and practices to pharmacovigilance and adverse drug reaction reporting in clinical trials: a mixed methods study

PURPOSE

The purpose of this study was to explore the knowledge, attitudes and practices of health professionals working in clinical trials, to pharmacovigilance and adverse drug reaction (ADR) reporting.

METHODS

A mixed methods study comprising an online questionnaire disseminated from September to November 2018, three semi-structured interviews and four focus groups. The qualitative components were conducted with a random sample of questionnaire participants who had provided their contact details (n = 24). The qualitative interviews were conducted at a location convenient to the participant's place of work between October and December 2018.

RESULTS

One hundred forty-eight participants completed the questionnaire. Study coordinators/project managers represented the largest group of participants ( 28.6%, n = 38). Poor knowledge or understanding of ADR reporting was the most frequently cited barrier to ADR reporting (75%, n = 93). The most common enabler to reporting was having a clear understanding of an ADR definition (85.7%, n = 108). Focus group and interview participants described having limited staff as a barrier to reporting an ADR. They welcomed the prospect of pharmacovigilance training and indicated that face-to-face training would be preferred to provision of online training.

CONCLUSION

This study highlights key factors that influence the reporting of ADRs in clinical trials. Although the findings are specifically related to the clinical trial environment in Ireland, they may provide a useful platform for optimising the future conduct of trials. This research suggests that ADR reporting may be improved through provision of enhanced pharmacovigilance training to clinical trial staff.

Knowledge of Adverse Drug Reaction Reporting and the Pharmacovigilance of Biological Medicines: A Survey of Healthcare Professionals in Ireland

Background

In Europe, changes to pharmacovigilance legislation, which include additional monitoring of medicines, aim to optimise adverse drug reaction (ADR) reporting systems. The legislation also makes provisions related to the traceability of biological medicines.

Objective

The objective of this study was to assess (i) knowledge and general experience of ADR reporting, (ii) knowledge, behaviours, and attitudes related to the pharmacovigilance of biologicals, and (iii) awareness of additional monitoring among healthcare professionals (HCPs) in Ireland.

Methods

Hospital doctors (n = 88), general practitioners (GPs) (n = 197), nurses (n = 104) and pharmacists (n = 309) completed an online questionnaire.

Results

There were differences in mean knowledge scores relating to ADR reporting and the pharmacovigilance of biologicals among the HCP groups. The majority of HCPs who use biological medicines in their practice generally record biologicals by brand name but practice behaviours relating to batch number recording differed between some professions. HCPs consider batch number recording to be valuable but also regard it as being more difficult than brand name recording. Most respondents were aware of the concept of additional monitoring but awareness rates differed between some groups. Among those who knew about additional monitoring, there was higher awareness of the inverted black triangle symbol among pharmacists (> 86.4%) compared with hospital doctors (35.1%), GPs (35.6%), and nurses (14.9%). Hospital pharmacists had more experience and knowledge of ADR reporting than other practising HCPs.

Conclusion

This study highlights the important role hospital pharmacists play in post-marketing surveillance. There is a need to increase pharmacovigilance awareness of biological medicines and improve systems to support their batch traceability.

Electronic supplementary material

The online version of this article (10.1007/s40259-018-0281-6) contains supplementary material, which is available to authorized users.

Regulation of biosimilar medicines and current perspectives on interchangeability and policy

Competition arising from the increasing availability of biosimilar medicines has resulted in healthcare savings and has provided greater patient access to high cost therapeutics in Europe. The biosimilar market in the USA is relatively new so the full impact of biosimilar availability remains to be seen. Educational initiatives relating to the use of biosimilar medicines are currently being undertaken by regulators, policy makers and industry. The debate on biosimilars has moved on from the appropriateness of the regulatory framework which governs their approval, to the practice of interchangeability. Interchangeability is an important issue for healthcare professionals but different definitions and regulatory frameworks exist in the USA and Europe. In the USA, an interchangeable biological product is a biosimilar which may be substituted by a pharmacist, subject to local State policies. The interchangeability of a biosimilar with its reference medicine will be evaluated by the United States Food and Drug Administration (FDA) in cases where approval as an 'interchangeable product' is sought. In contrast, the European Medicines Agency (EMA) does not assess or make recommendations on interchangeability, therefore, in Europe, interchangeability does not mean substitution but is generally physician-led or driven by national policy. This paper provides an overview of the regulation of biosimilar medicines. Challenges associated with the demonstration of interchangeability and practical considerations relating to switching are also discussed. Finally, we present policies that have been adopted to date in several European countries, the USA and Australia, which aim to promote the use of biosimilar medicines.

A tool for assessment of heart failure prescribing quality: A systematic review and meta-analysis

INTRODUCTION

Heart failure (HF) guidelines aim to standardise patient care. Internationally, prescribing practice in HF may deviate from guidelines and so a standardised tool is required to assess prescribing quality. A systematic review and meta-analysis were performed to identify a quantitative tool for measuring adherence to HF guidelines and its clinical implications.

METHODS

Eleven electronic databases were searched to include studies reporting a comprehensive tool for measuring adherence to prescribing guidelines in HF patients aged ≥18 years. Qualitative studies or studies measuring prescription rates alone were excluded. Study quality was assessed using the Good ReseArch for Comparative Effectiveness Checklist.

RESULTS

In total, 2455 studies were identified. Sixteen eligible full-text articles were included (n = 14 354 patients, mean age 69 ± 8 y). The Guideline Adherence Index (GAI), and its modified versions, was the most frequently cited tool (n = 13). Other tools identified were the Individualised Reconciled Evidence Recommendations, the Composite Heart Failure Performance, and the Heart Failure Scale. The meta-analysis included the GAI studies of good to high quality. The average GAI-3 was 62%. Compared to low GAI, high GAI patients had lower mortality rate (7.6% vs 33.9%) and lower rehospitalisation rates (23.5% vs 24.5%); both P ≤ .05. High GAI was associated with reduced risk of mortality (hazard ratio = 0.29, 95% confidence interval, 0.06-0.51) and rehospitalisation (hazard ratio = 0.64, 95% confidence interval, 0.41-1.00). No tool was used to improve prescribing quality.

CONCLUSION

The GAI is the most frequently used tool to assess guideline adherence in HF. High GAI is associated with improved HF outcomes.

Fine-mapping host genetic variation underlying outcomes to Mycobacterium bovis infection in dairy cows

BACKGROUND

Susceptibility to Mycobacterium bovis infection in cattle is governed in part by host genetics. However, cattle diagnosed as infected with M. bovis display varying signs of pathology. The variation in host response to infection could represent a continuum since time of exposure or distinct outcomes due to differing pathogen handling. The relationships between host genetics and variation in host response and pathological sequelae following M. bovis infection were explored by genotyping 1966 Holstein-Friesian dairy cows at 538,231 SNPs with three distinct phenotypes. These were: single intradermal cervical comparative tuberculin (SICCT) test positives with visible lesions (VLs), SICCT-positives with undetected visible lesions (NVLs) and matched controls SICCT-negative on multiple occasions.

RESULTS

Regional heritability mapping identified three loci associated with the NVL phenotype on chromosomes 17, 22 and 23, distinct to the region on chromosome 13 associated with the VL phenotype. The region on chromosome 23 was at genome-wide significance and candidate genes overlapping the mapped window included members of the bovine leukocyte antigen class IIb region, a complex known for its role in immunity and disease resistance. Chromosome heritability analysis attributed variance to six and thirteen chromosomes for the VL and NVL phenotypes, respectively, and four of these chromosomes were found to explain a proportion of the phenotypic variation for both the VL and NVL phenotype. By grouping the M. bovis outcomes (VLs and NVLs) variance was attributed to nine chromosomes. When contrasting the two M. bovis infection outcomes (VLs vs NVLs) nine chromosomes were found to harbour heritable variation. Regardless of the case phenotype under investigation, chromosome heritability did not exceed 8% indicating that the genetic control of bTB resistance consists of variants of small to moderate effect situated across many chromosomes of the bovine genome.

CONCLUSIONS

These findings suggest the host genetics of M. bovis infection outcomes is governed by distinct and overlapping genetic variants. Thus, variation in the pathology of M. bovis infected cattle may be partly genetically determined and indicative of different host responses or pathogen handling. There may be at least three distinct outcomes following M. bovis exposure in dairy cattle: resistance to infection, infection resulting in pathology or no detectable pathology.

Intrauterine insemination-No more Mr. N.I.C.E. guy?

OBJECTIVE

To determine the per cycle chance of a live birth and to identify factors that may support a more individualised application of IUI in view of National Institute for Health and Care Excellence (NICE) updated guideline on fertility 2013.

STUDY DESIGN

A retrospective, cohort study of 851 couples (1688 cycles) with unexplained, mild endometriosis, one patent Fallopian tube (with ovulation occurring in the corresponding ovary), mild male factor or ovulatory dysfunction, who initiated their first cycle of IUI/COH during the study period 2009-2013 and completed up to 3 cycles. Exclusion criteria included donor sperm and diminished ovarian reserve. Success factors and probabilities were determined based on live birth rates.

RESULTS

Mean age was 33.8±3.3years and mean duration of subfertility was 2.28±1.47years. Independent associates of successful outcome factors were lower age (AOR 0.93; 95%CI 0.89-0.98, p=0.007) and multiparity (AOR 1.72; 95%CI 1.17-2.52). Live-birth rates declined independently of other factors from 15.3% (n=130/851) in cycle 1-7.0% (n=19/273) in cycle 3 (AOR 0.76; 95%CI, 0.62-0.93, p=0.008). Per cycle probabilities of live birth ranged from 21.4% to 5.1% dependent on age, cycle number and previous parity. The unadjusted cumulative pregnancy rate for live birth per cycle started, over three cycles, was 34.9% with a multiple live birth rate per cycle started of 5.4%. The associates of live birth amongst those with unexplained sub-fertility only (n=632, first cycle attempt) were also analysed, yielding similar results.

CONCLUSIONS

IUI/COH is a simple treatment that produces good live birth rates, especially in younger patients and/or those with previous parity. More than 90% of total live births with IUI/COH is achieved during the first two cycles. As a retrospective, observational study, there is no comparator group and therefore we cannot comment on the relative efficacy of up to three IUI cycles over expectant management in a similar cohort. Our study suggests that probabilities of success can be used to individualise treatment decisions and that there is merit in continuing to offer IUI before resorting to IVF for certain patients.

Cost-effectiveness of natriuretic peptide-based screening and collaborative care: a report from the STOP-HF (St Vincent's Screening TO Prevent Heart Failure) study

AIMS

Prevention of cardiovascular disease and heart failure (HF) in a cost-effective manner is a public health goal. This work aims to assess the cost-effectiveness of the St Vincent's Screening TO Prevent Heart Failure (STOP-HF) intervention.

METHODS AND RESULTS

This is a substudy of 1054 participants with cardiovascular risk factors [median age 65.8 years, interquartile range (IQR) 57.8:72.4, with 4.3 years, IQR 3.4:5.2, follow-up]. Annual natriuretic peptide-based screening was performed, with collaborative cardiovascular care between specialist physicians and general practitioners provided to patients with BNP levels >50 pg/mL. Analysis of cost per case prevented and cost-effectiveness per quality-adjusted life year (QALY) gained was performed. The primary clinical endpoint of LV dysfunction (LVD) with or without HF was reduced in intervention patients [odds ratio (OR) 0.60; 95% confidence interval (CI) 0.38-0.94; P = 0.026]. There were 157 deaths and/or emergency hospitalizations for major adverse cardiac events (MACE) in the control group vs. 102 in the intervention group (OR 0.68; 95% CI 0.49-0.93; P = 0.01). The cost per case of LVD/HF prevented was €9683 (sensitivity range -€843 to €20 210), whereas the cost per MACE prevented was €3471 (sensitivity range -€302 to €7245). Cardiovascular hospitalization savings offset increased outpatient and primary care costs. The cost per QALY gain was €1104 and the intervention has an 88% probability of being cost-effective at a willingness to pay threshold of €30 000.

CONCLUSION

Among patients with cardiovascular risk factors, natriuretic peptide-based screening and collaborative care reduced LVD, HF, and MACE, and has a high probability of being cost-effective.

TRIAL REGISTRATION

NCT00921960.

The St Vincent's potentially inappropriate medicines study: development of a disease-specific consensus list and its evaluation in ambulatory heart failure care

AIMS

Heart failure (HF) patients may be at risk of prescription of potentially inappropriate medicines (PIMs) yet no disease-specific list is available to assess PIM use in this population. A Consensus Potentially Inappropriate Medicines in Heart Failure (PIMHF) list was developed, assessed, and compared with an established, general tool in an ambulatory HF population.

METHODS AND RESULTS

The Consensus PIMHF list was compiled using modified Delphi methodology with a multidisciplinary team. The list consisted of 11 items. The medication profile of 350 patients was assessed. The association of a Consensus PIMHF item use over a median follow-up period of 1.8 (interquartile range 1.3-2.1) years with the primary endpoint of death, acute hospitalization, or unscheduled outpatient visit was examined. Fifty-one patients (14.6%) were prescribed ≥1 Consensus PIMHF item. In univariable analysis, patients prescribed ≥1 Consensus PIMHF item were 58% more likely to experience the primary endpoint than those with none [95% confidence interval (CI) 1.02-2.45]. When adjusted for age, sex, and HF severity, this difference remained [hazard ratio (HR) 1.88, 95% CI 1.16-3.06] and these associations were in contrast to the use of a more general tool (HR 1.24, 95% CI 0.83-1.84). However, when further adjusted to include co-morbidity score and polypharmacy, there was no association with outcome using either tool (HR 1.40, 95% CI 0.83-2.38; HR 1.05, 95% CI 0.69-1.60, respectively).

CONCLUSION

The Consensus PIMHF list provides the first HF-specific medicines review tool. These results provide some support for more disease-specific tools with limited lists of PIMs to rationalize medicines management in HF. However, more prospective work on the application of these tools in practice is needed.

Aspirin Use in Heart Failure

Background—

Aspirin use in heart failure (HF) is controversial. The drug has proven benefit in comorbidities associated with HF; however, retrospective analysis of angiotensin-converting enzyme inhibitor trials and prospective comparisons with warfarin have shown increased risk of morbidity with aspirin use. This study aims to evaluate the association of low-dose aspirin with mortality and morbidity risk in a large community-based cohort.

Methods and Results—

This was a retrospective cohort study of patients attending an HF disease management program. Aspirin use at baseline and its association with mortality and HF hospitalization in the population was examined. Of 1476 patients (mean age, 70.4±12.4 years; 63% men), 892 (60.4%) were prescribed aspirin. Low-dose aspirin (75 mg/d) was prescribed to 828 (92.8%) patients. Median follow-up time was 2.6 (0.8–4.5) years. During the follow-up period, 464 (31.4%) patients died. In adjusted analysis, low-dose aspirin use was associated with reduced mortality risk compared with nonaspirin use (hazard ratio=0.58; 95% confidence interval, 0.46–0.74), and this was confirmed by a propensity-matched subgroup analysis. Low-dose aspirin use was associated with reduced risk of HF hospitalization compared with nonaspirin use in the total population (adjusted hazard ratio=0.70; 95% confidence interval, 0.54–0.90). In adjusted analysis, there was no difference in mortality or HF hospitalization between high-dose aspirin users (>75 mg/d) and nonaspirin users.

Conclusions—

In this study, low-dose aspirin therapy was associated with a significant reduction in mortality and morbidity risk during long-term follow-up. These results suggest that low-dose aspirin may have a continuing role in secondary prevention in HF and underline the need for more trials of low-dose aspirin use in HF.

Natriuretic peptide-based screening and collaborative care for heart failure: the STOP-HF randomized trial

IMPORTANCE

Prevention strategies for heart failure are needed.

OBJECTIVE

To determine the efficacy of a screening program using brain-type natriuretic peptide (BNP) and collaborative care in an at-risk population in reducing newly diagnosed heart failure and prevalence of significant left ventricular (LV) systolic and/or diastolic dysfunction.

DESIGN, SETTING, AND PARTICIPANTS

The St Vincent's Screening to Prevent Heart Failure Study, a parallel-group randomized trial involving 1374 participants with cardiovascular risk factors (mean age, 64.8 [SD, 10.2] years) recruited from 39 primary care practices in Ireland between January 2005 and December 2009 and followed up until December 2011 (mean follow-up, 4.2 [SD, 1.2] years).

INTERVENTION

Patients were randomly assigned to receive usual primary care (control condition; n=677) or screening with BNP testing (n=697). Intervention-group participants with BNP levels of 50 pg/mL or higher underwent echocardiography and collaborative care between their primary care physician and specialist cardiovascular service.

MAIN OUTCOMES AND MEASURES

The primary end point was prevalence of asymptomatic LV dysfunction with or without newly diagnosed heart failure. Secondary end points included emergency hospitalization for arrhythmia, transient ischemic attack, stroke, myocardial infarction, peripheral or pulmonary thrombosis/embolus, or heart failure.

RESULTS

A total of 263 patients (41.6%) in the intervention group had at least 1 BNP reading of 50 pg/mL or higher. The intervention group underwent more cardiovascular investigations (control, 496 per 1000 patient-years vs intervention, 850 per 1000 patient-years; incidence rate ratio, 1.71; 95% CI, 1.61-1.83; P<.001) and received more renin-angiotensin-aldosterone system-based therapy at follow-up (control, 49.6%; intervention, 56.5%; P=.01). The primary end point of LV dysfunction with or without heart failure was met in 59 (8.7%) of 677 in the control group and 37 (5.3%) of 697 in the intervention group (odds ratio [OR], 0.55; 95% CI, 0.37-0.82; P = .003). Asymptomatic LV dysfunction was found in 45 (6.6%) of 677 control-group patients and 30 (4.3%) of 697 intervention-group patients (OR, 0.57; 95% CI, 0.37-0.88; P = .01). Heart failure occurred in 14 (2.1%) of 677 control-group patients and 7 (1.0%) of 697 intervention-group patients (OR, 0.48; 95% CI, 0.20-1.20; P = .12). The incidence rates of emergency hospitalization for major cardiovascular events were 40.4 per 1000 patient-years in the control group vs 22.3 per 1000 patient-years in the intervention group (incidence rate ratio, 0.60; 95% CI, 0.45-0.81; P = .002).

CONCLUSION AND RELEVANCE

Among patients at risk of heart failure, BNP-based screening and collaborative care reduced the combined rates of LV systolic dysfunction, diastolic dysfunction, and heart failure.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00921960.

Are beta2-agonists responsible for increased mortality in heart failure?

AIMS

Previous large-scale, retrospective studies have shown increased mortality in heart failure (HF) patients using β2-agonists (B2As). We further examined the relationship between B2A use and mortality in a well-characterized population by adjusting for natriuretic peptide levels as a measure of HF severity.

METHODS AND RESULTS

This was a retrospective cohort study of patients attending an HF Disease Management Programme with mean follow-up of 2.9 ± 2.4 years. Chart review confirmed B2A use, dose and duration of use, and documented pulmonary function evaluation. The primary endpoint was the effect of B2A use compared with no B2A use on mortality using unadjusted and adjusted Kaplan-Meier survival curves. Data were available for 1294 patients (age 70.6 ± 11.5 years) of whom 64% were male and 22.2% were taking B2As. β2-Agonist users were older, more likely to be male, to have smoked, to have chronic obstructive pulmonary disease (COPD) and asthma, and less likely to take beta-blockers. Multivariable associates of mortality included: B-type natriuretic peptide (BNP), coronary artery disease, age, and beta-blocker use. Unadjusted mortality rates for B2A users were found to be significantly higher than non-B2A users [hazard ratio (HR) 1.304, 95% confidence interval (CI) 1.030-1.652, P= 0.028]. However, when adjusted for age, sex, medication, co-morbidity, smoking, COPD, and BNP differences, overall mortality rates were similar [HR 1.043, 95% CI (0.771-1.412), P= 0.783].

CONCLUSION

Unlike previous reports, this retrospective evaluation of B2A therapy in HF patients shows no relationship with long-term mortality when adjusted for population differences including BNP.  Large, prospective studies are required to define the risk/benefit ratio of B2As in patients with heart failure.

Prospective analysis of LDL-C goal achievement and self-reported medication adherence among statin users in primary care

BACKGROUND

Improvements in the control of LDL-C levels have occurred in the past decade due to the introduction of increasingly potent statins, such as atorvastatin and rosuvastatin. Many patients, however, do not achieve their LDL-C goals, which presents a practical dilemma for clinicians and highlights the need to identify adherence problems in a clinically relevant manner.

OBJECTIVE

The purpose of this study was to evaluate the relationship between LDL-C goal achievement and both medication adherence and beliefs assessed using structured questioning.

METHODS

All patients were aged ≥40 years and participated in the cardiovascular risk factor management program STOP-HF (St. Vincent's Screening To Prevent Heart Failure study). One hundred and eighty-five participants who had been prescribed statins, split between those who achieved and those who did not achieve LDL-C goal, were randomly selected for a prospective study examining the relationship between adherence, assessed by the Morisky Medication Adherence Scale (MMAS), and LDL-C goal achievement. Patients' beliefs about medicines were assessed using the Beliefs about Medicines Questionnaire-General (BMQ-G). Main outcome measures were predictors of LDL-C goal achievement and medication adherence and predictors of adherence among patients using the MMAS.

RESULTS

The average age of the selected patients was 64.9 (9.9) years; 45% were male, 46% had hypertension, 17.5% had coronary artery disease, and 10% had diabetes. Questionnaires were answered by 119 patients, 71 of whom (59.7%) were goal achievers. LDL-C goal achievers were more likely to respond to the questionnaires than nonachievers (76.8% vs 52.7%; P = 0.002). Fifty-eight respondents (48.7%) reported that they were not fully adherent to medication and in multivariable analysis were twice as likely to miss LDL-C goal compared with those who were adherent. Approximately 25% of patients who reported nonadherence were intentionally so. Patients' beliefs about medicines were a significant predictor of self-reported adherence but not of LDL-C goal achievement.

CONCLUSIONS

Medication nonadherence may be responsible for failure to achieve goal in many patients who are prescribed statins. In routine clinical care, the structured MMAS questionnaire may provide clinicians with an effective tool to assess medication nonadherence in the context of statin therapy failure. STOP-HF ClinicalTrials.gov identifier: NCT00921960.

Insulin, lipid profiles and measures of fatness in Taiwanese women in relation to duration of residence in Australia

This study investigated the relationships between measures of fatness and blood insulin and lipids in Taiwanese females living in Taiwan (n=97) or Australia (n=100), and examined the effect of length of residence in Australia on these relationships. Fasting glucose and lipids were determined by Reflotron and fasting insulin using Microparticle Enzyme Immunoassay; insulin resistance (IR) was identified by HOMA. There were no significant inter-country differences in crude plasma insulin or HOMA-IR between Taiwan and Australia (51.7+/-42.2 vs. 45.0+/-29.0 pmol/L and 1.43+/-1.21 vs. 1.29+/-1.00, respectively, all p> 0.05), but when insulin and HOMA-IR were adjusted for waist circumference, they were greater in Taiwan (45.7+/-1.6 vs. 38.0+/-1.6 pmol/L and 1.26+/-1.59 vs. 1.13+/-1.59, respectively, all p< 0.05). Subjects living in Australia greater than 5 years had higher insulin and HOMA-IR values than those with less than 5 years residence (50.0+/-32.3 vs. 32.4+/-10.5 pmol/L and 1.45+/-1.00 vs. 0.90+/-0.28, respectively, all p< 0.01), even after adjustment for all measures of fatness. Subjects in Australia > 5 years have 6 (CI, 1.3-27.9) times the risk of having insulin > 50 pmol/L; the increased risk being confined to generally and/or centrally obese women. Measures of central obesity and general obesity were positively associated with HOMA-IR in both countries (r = 0.23, p< 0.05 and 0.27 p< 0.01, Taiwan, 0.43 and 0.43, both p< 0.01, Australia). Taiwanese females living in Australia initially appear to have a more favorable state of IR than those in Taiwan, but insulin resistance is associated with length of residence in Australia, particularly among the obese.

Change in diet and body mass index in Taiwanese women with length of residence in Australia

The purpose of this cross-sectional study was to examine and compare anthropometric measurements and dietary intake of Taiwanese Chinese females living in Taiwan and Australia, including any effect of length of Australian residence. Height, weight, waist and hip circumference and percent total body fat were measured and dietary intake estimated using a 7-day record. Participants were Taiwanese females without systemic disease (100 from Sydney metropolitan area, Australia, 97 from Ping-Tung County, Taiwan). Subjects in Australia had similar body mass index (weight-kg/height-m(2)) and percent total body fat but higher waist and hip circumference than those in Taiwan (22.9+/-3.0 vs. 22.8+/-3.1 kg/m(2), p >0.05; 31.4+/-5.8 vs. 31.0+/-6.2 %, p >0.05; 76.2+/-7.5 vs. 72.1+/-7.3 cm, p =0.0001; 97.3+/-6.2 vs. 93.3+/-6.2 cm, p =0.0001, respectively), significance unaffected by age adjustment. Total energy intake was higher in Australia (2367+/-574 vs. 1878+/-575 Kcal) as was the caloric adjusted intake of carbohydrate and saturated fat, measured as grams (342.8+/-91.5 vs. 264.9+/-91.0 g; 30.7+/-9.1 vs. 23.0+/-9.1 g) or as percentage of caloric adjusted intake (57.3+/-1.4 vs. 55.6+/-2.3 %; 12.1+/-0.7 vs. 11.2+/-1.1 %), all p<0.001, respectively. There was a trend for anthropometric measures to increase in subjects who had lived in Australia greater than 5 years, and they also have 14 times the odds of having a waist circumference greater than 80 cm compared to those living in Australia less than 5 years (95% CI, 1.84, 112.0). The increase in waist circumference and higher energy and saturated fat intake associated with length of residence in Australia for Taiwanese females suggests an increased risk of cardiovascular disease and diabetes.

Associations with Vitamin D deficiency in "at risk" Australians

In a study of 185 elderly living in assisted care and 192 frail aged living in the community in the Sydney metropolitan area, nursing home residents were found to be at a 3-fold and hostel dwellers at a 2-fold risk of Vitamin D [25(OH)D] deficiency (<25 nmol/L) compared to self care residents. Middle Eastern people were found to be at 4-fold risk and Vietnamese a 3-fold risk of deficiency compared to their Australian counterparts. In recently arrived Chinese immigrants, Vitamin D deficiency, was found in 28%, and marginal levels (<37 nmol/L) in 60%, compared to the 34 and 76% found in our nursing home population, and 25 and 57% in hostel care residents. Of the Middle Eastern elderly, 58% were deficient and 83% marginal; although only 18% of Vietnamese were deficient, 68% had marginal Vitamin D status. Other factors associated with Vitamin D deficiency were mobility and sun exposure in assisted care, and low dietary Vitamin D and calcium intake, reduced exercise levels and high % body fat levels in the immigrant groups.

An investigation of health behavior change in Vietnamese-born individuals living in Sydney, Australia

OBJECTIVE

The purpose of this study was to look at rates of acculturation among Vietnamese immigrants, with particular emphasis on health behaviors.

DESIGN

A volunteer sample was surveyed.

SETTING/PARTICIPANTS

The participants were drawn from inner and western Sydney, Australia. Participants were asked for their perception of their English fluency as a measure of likely exposure to health promotion advertising and their food, social, exercise, drinking, and smoking habits.

RESULTS

It was found that the longer the Vietnamese immigrants participants had lived in Australia, the less likely they were to smoke; in fact, the smoking rate of this population is as low as that of the Australian population as a whole. However the immigrants did not change their low rate of alcohol consumption. In addition, the Vietnamese who had lived longer in Australia significantly increased their daily exercise and started to eat more take-away foods.

CONCLUSIONS

With respect to health promotion, these changes are mixed: smoking has decreased, but half the group had begun eating take-away foods; this factor, if combined with a lack of exercise, is likely to lead to obesity.

Body Fat Distribution and Total Body Fat as Risk Factors for Microalbuminuria in the Obese

BACKGROUND/AIM

Despite evidence linking type of obesity with subsequent organ malfunction, such a link with renal malfunction has not been widely researched. The aim of this study was to investigate percentage of total body fat (%TBF), and body fat distribution in relation to the renal function in overweight/obese subjects.

METHODS

Body mass index (BMI), waist-to-hip ratio (WHR), TBF (by bioelectric impedance), and albumin excretion rate (AER) were determined in 77 subjects: 48 overweight/obese (BMI > or =27.8 for men and > or =27.3 for women) and 29 controls (BMI <27.8 for men and <27.3 for women). Obese subjects were subdivided into those (n = 33) with central fat distribution (WHR > or =0.81 for women and > or =0.92 for men) and those (n = 15) with peripheral fat distribution (WHR <0.81 for women and <0.92 for men).

RESULTS

Obesity, irrespective of type, was significantly related to increased AER. Furthermore, in subjects who did not differ in %TBF, the age-adjusted relative risk of abnormal AER was 18 times greater in centrally obese subjects as compared with controls, while only four times greater in peripherally obese subjects.

CONCLUSION

A significant difference in risk of renal malfunction was observed in individuals having the same %TBF, but differing in the distribution of this fat, with a central fat pattern being the greater risk.

Smoking and lipid cardiovascular risk factors in Vietnamese refugees in Australia

BACKGROUND

The effects of smoking and sex on lipid risk factors for cardiovascular disease were examined among Vietnamese people newly arrived in Australia.

METHODS

Immigrants recruited through Refugee Screening had anthropometric data recorded and blood collected to measure total cholesterol (TC), high-density lipoprotein cholesterol (HDL), and triglyceride (TG) by Reflotron; apolipoprotein A-1 (apo A-1) and apolipoprotein B-100 (apo B) by immunoturbidimetric analyses (Turbitimer); and lipoprotein (a) (LP (a)) by ELISA. A questionnaire determined behavioral variables known to influence cardiovascular risk and Statview, Minitab, and SPSS were employed for data analysis.

RESULTS

Lipoprotein profiles of men (n = 242) and women (n = 159) were compared. Crude TC and apo B were similar; HDL, apo A-1, and LP (a) were higher in women, TG was higher in men. After adjustment (age, BMI, WHR, years of smoking, and drinks per week), only apo A-1 and LP (a), were higher in women. "At risk" levels of TC or apo B did not differ by gender; risk of low apo A-1 was higher among men. Smokers had a significant risk (crude and adjusted) of low HDL, low apo A-1, and high LP (a). The sex difference in HDL was removed by a single adjustment for smoking; male smokers had higher LP (a) than male nonsmokers.

CONCLUSION

Male and female Vietnamese immigrants had similar adjusted lipid profiles. Smoking had a marked detrimental effect on lipids.

Leptin and total cholesterol are predictors of weight gain in pre-pubertal children

OBJECTIVE

The aim of this study was to identify specifically which biochemical indices predict excessive weight gain over time in a cohort of pre-pubertal children.

SUBJECTS

Fifty nine healthy pre-pubertal children (age: 6.3-9.8y).

MEASUREMENTS

Children were defined anthropometrically and biochemically at baseline. Height and weight measurements were then repeated after six (n=52) and 12 months (n=37).

RESULTS

Weight change after six months (defined by a change in body mass index (BMI) z-score from baseline) demonstrated no correlation with fasting plasma levels of leptin, insulin, insulin:glucose (IG) ratio, cholesterol, triglyceride or high density lipoprotein (HDL) cholesterol. However, after 12 months there was a significant negative correlation between BMI z-score change and initial plasma leptin (r=-0.35, P=0.048) and this relationship strengthened when adjusted for body fat (from bio-electrical impedance; r=-0.46, P=0.009). In addition, there was a significant positive relationship between plasma total cholesterol and BMI z score change (r=0.38, P=0.03) and this relationship remained unchanged when adjusted for body fat. No relationship was observed between weight change after 12 months and plasma levels of insulin, IG ratio, HDL cholesterol or triglyceride.

CONCLUSION

Plasma leptin and total cholesterol were found to be predictive of weight gain over 12 months in a cohort of pre-pubertal children. These two potential predictors can be readily measured in clinical practice and these findings may represent a method of defining the 'at risk of obesity' state in childhood.

Body mass index and body fat distribution in newly-arrived Vietnamese refugees in Sydney, Australia

Body mass index (BMI), body fat distribution and some behavioural variables were examined in an ethnic Vietnamese population newly arrived in Australia. The age range was 23 to 74 years for males (n = 246, mean = 38.8) and 24 to 66 for females (n = 165, mean = 36.4). Mean BMI was 20.62 +/- 2.65 (male) and 21.25 +/- 3.16 (female). Waist-to-hip ratio (WHR) was 0.844 (males) v 0.802 (females), p < 0.0001: waist was 73.7 cm (males) v 71.7 cm (females), (p = 0.007). Male smoking was 69%, female, 1%; the BMI of male non-smokers was higher than that of smokers 21.22 v 20.35 (p = 0.0017). Exercise patterns, diet or alcohol intake did not appear to affect BMI. The mean BMI of this refugee Vietnamese population is low by comparison with the Australian population. Vietnamese females although of lower mean BMI, have higher WHR than Australian females.