Kari L. Olson

Medication nonadherence is associated with a broad range of adverse outcomes in patients with coronary artery disease

BACKGROUND Little is known about the effect of nonadherence among patients with coronary artery disease (CAD) on a broad spectrum of outcomes including cardiovascular mortality, cardiovascular hospitalizations, and revascularization procedures. METHODS This was a retrospective cohort study of 15,767 patients with CAD. Medication adherence was calculated as proportion of days covered for filled prescriptions of beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and statin medications. Multivariable Cox regression assessed the association between medication nonadherence as a time-varying covariate and a broad range of outcomes, adjusting for demographics and clinical characteristics. Median follow-up was 4.1 years. RESULTS Rates of medication nonadherence were 28.8% for beta-blockers, 21.6% for ACE inhibitors, and 26.0% for statins. In unadjusted analysis, nonadherence to each class of medication was associated with higher all-cause and cardiovascular mortality. In multivariable analysis, nonadherence remained significantly associated with increased all-cause mortality risk for beta-blockers (hazard ratio [HR] 1.50, 95% CI 1.33-1.71), ACE inhibitors (HR 1.74, 95% CI 1.52-1.98), and statins (HR 1.85, 95% CI 1.63-2.09). In addition, nonadherence remained significantly associated with higher risk of cardiovascular mortality for beta-blockers (HR 1.53, 95% CI 1.16-2.01), ACE inhibitors (HR 1.66, 95% CI 1.26-2.20), and statins (HR 1.62, 95% CI 1.124-2.13). The findings of increased risk associated with nonadherence were consistent for cardiovascular hospitalization and revascularization procedures. CONCLUSIONS Nonadherence to cardioprotective medications is common in clinical practice and associated with a broad range of adverse outcomes. These findings suggest that medication nonadherence should be a target for quality improvement interventions to maximize the outcomes of patients with CAD.

Importance of Therapy Intensification and Medication Nonadherence for Blood Pressure Control in Patients With Coronary Disease

BACKGROUND Despite the importance of blood pressure (BP) control in secondary prevention, a significant proportion of patients with coronary disease have uncontrolled BP. METHODS This retrospective cohort study of patients with coronary disease (N = 10 447) evaluated the impact of medication nonadherence and therapy intensification on reaching target BP goals. Medication adherence was calculated as the proportion of days covered for filled prescriptions of antihypertensive medications. Therapy intensification included dosage increase or increase in number of antihypertensive medications. The primary outcome was uncontrolled systolic BP (SBP) over time, using a latent class model that incorporated longitudinal SBP data and assigned patients to SBP trajectory groups. Multivariable regression evaluated the association between medication nonadherence (ie, proportion of days covered, <0.80) and therapy intensification with SBP control over time, with adjustment for demographics and clinical characteristics. RESULTS Three SBP trajectory groups were identified: (1) patients with BP that remained controlled (ie, SBP, <or=140 mm Hg) over time (n = 9114 [87.2%]); (2) patients with high BP that became controlled (n = 779 [7.5%]); and (3) patients with BP that remained high over time (n = 554 [5.3%]). In multivariable analyses, therapy intensification (odds ratio, 1.31; 95% confidence interval, 1.01-1.70) and medication nonadherence (odds ratio, 1.73; 95% confidence interval, 1.34-2.24) were associated with uncontrolled BP compared with high SBP that became controlled over time. CONCLUSIONS These findings suggest that medication nonadherence can help explain why BP levels remained elevated despite intensification of antihypertensive medications. Successful BP control is seen with a combination of intensification and adherence, suggesting that therapy intensification must be coupled with interventions to enhance medication adherence.

The triglyceride-lowering effects of a modest dose of docosahexaenoic acid alone versus in combination with low dose eicosapentaenoic acid in patients with coronary artery disease and elevated triglycerides.

Background: Hypertriglyceridemia is a risk factor for coronary artery disease (CAD). The American Heart Association recommends 1000 mg of omega-3 fatty acids, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), daily for cardioprotection and higher doses for triglyceride-lowering in patients with CAD. Methods: This was a prospective, randomized, double-blind study comparing DHA to DHA + EPA in patients with CAD and triglycerides greater than 200 mg/dL. Subjects were randomized to either 1000 mg of DHA or 1252 mg of DHA + EPA for eight weeks. Baseline and eight-week laboratories were drawn to assess changes in the fasting lipid profile. The primary objective was to evaluate the change in triglycerides between the two groups at eight weeks. Results: A total of 116 subjects were enrolled; 57 in the DHA group and 59 in the DHA + EPA group. Baseline characteristics were similar between groups. The mean age was 69.4 ± 9.1 years and 70.7% were male. Triglycerides decreased by an average of 21.8% in the DHA group (p < 0.001) and 18.3% in the DHA + EPA group (p < 0.001). The difference between groups was not significant. A greater proportion of subjects in the DHA group achieved triglyceride goal (less than 150 mg/dL) compared to the DHA + EPA group (24.6% versus 10.2%, p < 0.05). Conclusions: Our results indicate that the American Heart Association recommended cardioprotective dose of omega-3 fatty acids can also significantly lower triglycerides in patients with CAD. There do not appear to be significant differences in triglyceride-lowering between DHA only and DHA + EPA combination products when dosing is based on DHA.

A Pharmacist-Led, American Heart Association Heart360 Web-Enabled Home Blood Pressure Monitoring Program

Background—To determine whether a pharmacist-led, Heart360-enabled, home blood pressure monitoring (HBPM) intervention improves blood pressure (BP) control compared with usual care (UC). Methods and Results—This randomized, controlled trial was conducted in 10 Kaiser Permanente Colorado clinics. Overall, 348 patients with BP above recommended levels were randomized to the HBPM (n=175) or UC (n=173) groups. There were no statistically significant differences in baseline characteristics between the groups; however, there was a trend toward a higher baseline BP for the HBPM group compared with the UC group (148.8 versus 145.5 mm Hg for systolic BP; 89.6 versus 88.0 mm Hg for diastolic BP). At 6 months, the proportion of patients achieving BP goal was significantly higher in the HBPM group (54.1%) than in the UC group (35.4%; P<0.001). Compared with the UC group, the HBPM group experienced a −12.4-mm Hg larger (95% confidence interval, −16.3 to −8.6) reduction in systolic BP and a −5.7-mm Hg larger (95% confidence interval, −7.8 to −3.6) reduction in diastolic BP. The impact of the intervention on BP reduction was even larger for the subgroup of patients with diabetes mellitus or chronic kidney disease. The HBPM group had more e-mail and telephone contacts and greater medication regimen intensification. The proportion of patients reporting high satisfaction with hypertension care was significantly greater in the HBPM group (58%) than in the UC group (42%), P<0.001. Conclusions—A pharmacist-led, Heart360-supported, home BP monitoring intervention led to greater BP reductions, superior BP control, and higher patient satisfaction than UC. Clinical Trial Registration—URL: http://www.clinicaltrials.gov/ct2/show/NCT01162759. Unique identifier: NCT01162759.

Publication rates of abstracts presented by pharmacy residents at the Western States Conference

PURPOSE Investigators report the results of a study to determine the proportion of residency projects presented as abstracts at a regional residency conference that were subsequently published as full-length articles. SUMMARY Using every third item listed in the abstract booklets from the Western States Conference for the years 1995, 2000, and 2005, a search of MEDLINE and EMBASE for journal citations indicating publication of the corresponding residency projects was conducted; the searches covered a period including and extending five years beyond the year of abstract presentation at the conference. Of the total of 270 abstracts evaluated, 17 were expanded to full-length articles and published within the search time frame. The average time to publication (mean ± S.D.) was 24 ± 10 months. The publication rates associated with abstracts presented at the 1995, 2000, and 2005 conferences were 4.2%, 5.2%, and 8.2%, respectively. All published articles appeared in peer-reviewed journals, with more than half (54.2%) in pharmacy journals. The majority of residency projects published were retrospective and prospective cohort studies. In most cases (58.8%), the resident was listed as the first author of the published journal article. CONCLUSION The overall publication rate of abstracts presented at a regional residency conference in 1995, 2000, and 2005 was 6.3%, with an increase in the rate over those years.

Mortality Reduction Benefits of a Comprehensive Cardiac Care Program for Patients with Occlusive Coronary Artery Disease

Study Objective. To determine the effect of early and sustained enrollment in a comprehensive cardiac care (CCC) program on all‐cause mortality in patients with coronary artery disease (CAD).

Challenges to publishing pharmacy resident research projects from the perspectives of residency program directors and residents

Objective To identify barriers to completing and publishing pharmacy residency research projects from the perspective of program directors and former residents. Methods This was a cross-sectional survey of pharmacy residency program directors and former post-graduate year one and two residents. Directors of pharmacy residency programs whose residents present their projects at the Western States Conference (n=216) were invited to complete an online survey and asked to forward the survey to former residents of their program in 2009, 2010, or 2011. The survey focused on four broad areas: 1) demographic characteristics of the residency programs, directors, and residents; 2) perceived value of the research project; 3) perceived barriers with various stages of research; and 4) self-identified barriers to successful research project completion and publication. Results A total of 32 program directors and 98 residents completed the survey. The minority of programs offered formal residency research training. Both groups reported value in the research project as part of residency training. Significantly more directors reported obtaining institutional review board approval and working through the publication process as barriers to the research project (46.7% vs. 22.6% and 73.3% vs. 43.0%, respectively p<0.05) while residents were more likely to report collecting and analyzing the data as barriers (34.4% vs. 13.3% and 39.8% vs. 20.0%, respectively, p<0.05). Both groups self-identified time constraints and limitations in study design or quality of the study as barriers. However, while program directors also indicated lack of resident motivation (65.5%), residents reported lack of mentorship or program structural issues (43.3%). Conclusions Overall, while both groups found value in the residency research projects, there were barriers identified by both groups. The results of this study may provide areas of opportunity for improving the quality and publication rates of resident research projects.

An assessment of cholesterol goal attainment in patients with chronic kidney disease

BACKGROUND Patients with chronic kidney disease (CKD) are at significant risk for cardiovascular disease (CVD). The National Kidney Foundation developed clinical practice guidelines (Kidney Disease Outcomes Quality Initiative) for targeting low-density lipoprotein cholesterol (LDL-C) goals. OBJECTIVE This study evaluated the extent to which these guidelines were adhered to among patients with CKD and to examine factors associated with the attainment of LDL-C goals. METHODS In this cross-sectional study we evaluated patients with a glomerular filtration rate of 15 to 59 mL/min per 1.73 m². Patients with previous CVD, who were receiving dialysis, or were post kidney transplant were excluded. Administrative databases were used to determine the percentage of patients with a fasting lipid profile performed within the previous year, the percentage who attained a LDL-C goal less than 100 mg/dL, and to determine lipid-lowering medications prescribed. Logistic regression analysis was used to identify factors associated with LDL-C goal attainment. RESULTS Of the 4541 patients evaluated, 3157 (69.5%) had a fasting lipid profile performed within the previous year. Overall, 60.8% attained a LDL-C less than 100 mg/dL. Among patients at goal, 72.2% were taking lipid-lowering therapy compared with 37.9% of those not at goal (P < .01). Characteristics independently associated with LDL-C goal attainment were increasing age, male gender, increasing chronic disease score, history of diabetes, and statin use. CONCLUSION Although most patients were screened and attained LDL-C goal, there was room for improvement. Statin use was independently associated with LDL-C goal attainment. Future prospective studies should focus on evaluating clinical outcomes of lipid-lowering interventions within the CKD population.

Self-reported inhaler use in patients with chronic obstructive pulmonary disease.

COPD is a common disease which is increasing in prevalence. The proportion of patients who vary their inhaler use from what is prescribed and the reasons for variance are largely unknown. The objective of this study was to determine the extent of and reported reasons for patient-reported variance in the use of inhalers prescribed for COPD. A 17-item survey was mailed to 600 ambulatory patients with spirometry-defined COPD. The survey included questions about inhaler use and reasons for using inhalers differently than prescribed. Survey responses were compared between patients reporting no variance vs. variance from prescribed instructions. Logistic regression was used to determine predictors for variance. The response rate was 45.8% (48.7% male; mean age: 73+/-8 years). Forty percent of respondents were not using inhalers as prescribed. The most common reasons were: feeling the inhalers did not help breathing (20%), forgetting to use inhalers (19%) and cost (15%). Higher education level, home oxygen use and prescriptions for ipratropium were predictors for inhaler variance. The impact of inhaler variance on morbidity of COPD should be evaluated.

Relationship between haemoglobin A1C values and recurrent cardiac events: A retrospective, longitudinal cohort study.

AbstractObjective: This study set out to analyse the impact of baseline glycosylated haemoglobin A1c (HbA1c) values on the incidence of recurrent cardiac events in patients prescribed optimal secondary prevention medications and receiving aggressive cardiac risk factor management. Methods: This was a retrospective study conducted at Kaiser Permanente Colorado and included adults followed by a clinical pharmacy specialist-managed cardiac risk service (CPCRS) with an incident cardiac event and an HbA1c value measured within 1 year prior or 60 days after the incident cardiac event was identified. Cox proportional hazards models were constructed to assess the relationship between HbA1c levels and recurrent cardiac events (assessed as continuous and categorical measures) after adjustment for potential confounding variables. Results: Of 5663 patients identified within an incident cardiac event between January 1999 and March 2005, 1270 (22.4%) patients had a baseline HbA1c value recorded. Of these 1270 patients, 215 (16.9%) had a recurrent cardiac event. Compared with the ‘no recurrent event’ cohort, the ‘recurrent event’ cohort were younger, less likely to have undergone an initial coronary artery bypass graft, and more likely to have undergone percutaneous coronary intervention with or without stent. The recurrent event cohort was also less likely to have purchased an HMG-CoA reductase inhibitor (‘statin’) [p = 0.043] at the time of the incident cardiac event. There was no significant difference in mean baseline HbA1c value between the cohorts. There were also no significant differences between the cohorts when categorized by baseline HbA1c <7% as referent compared with ≥7% to <8%, ≥8% to <9%, ≥9 to <10%, and ≥10%. Moreover, there was no significant difference between cohorts when HbA1c values <7% were compared with values >7% in the unadjusted analysis. Results remained non-significant after adjustment for sex, incident cardiac event type, baseline age, β-blocker use, statin use and hyperlipidaemia. Conclusion: The results of this study suggest that an abnormal HbA1c is not predictive of recurrent cardiac events among patients with cardiovascular disease when other cardiovascular risk factors are being aggressively treated and appropriate secondary prevention medications are being taken. However, larger studies are warranted to validate these findings