Kathleen A. Foley

Treating early versus treating mild: timing of migraine prescription medications among patients with diagnosed migraine.

Introduction.—Although research suggests that early treatment of migraine headache when the pain is mild results in better outcomes for patients, many patients delay taking their acute‐migraine medication until their headaches are moderate or severe. Understanding when and why patients use their migraine medications is an important first step to improve migraine management.

Assessment of the clinical management of fragility fractures and implications for the new HEDIS osteoporosis measure.

Background: Rates of screening for and treatment of osteoporosis have been low, even among those with fractures who are at greatest risk for new fractures. Objective: The objective of this study was to examine trends in the clinical management of patients with fragility fractures to provide baseline data for future assessments of the impact of the new Health Plan Employer Data and Information Set (HEDIS) measure. Research Design: The MarketScan Medicare Supplemental and Coordination of Benefits (COB) database was used to examine adherence to the 2004 HEDIS guidelines by measuring the percent of women age 67 and older who were screened and/or treated after a fracture from 2000 through 2005. Clinical, demographic, and provider characteristics were assessed to determine the correlates of being screened and treated. Results: The overall unadjusted percent of women screened and treated remains low, with just 10.2% screened and 12.9% treated in 2005. Multivariate analyses, which controlled for fracture location, patient characteristics, physician specialty, and region indicated small, albeit statistically significant, increases in treatment and screening over time. Women fracturing in 2005 were 27% more likely to be screened and 15% more likely to receive treatment relative to those fracturing in the year 2000. Conclusions: Although our study found some improvements in the screening for and treatment of osteoporosis among Medicare beneficiaries with a fragility fracture from 2000 through 2005, the overall percent of women screened and/or treated remained low. These data provide a baseline for assessing the impact of the new HEDIS measure in the coming years.

Disparities in lipid management for African Americans and Caucasians with coronary artery disease: A national cross-sectional study

BackgroundIndividuals with coronary artery disease are at high risk for adverse health outcomes. This risk can be diminished by aggressive lipid management, but adherence to lipid management guidelines is far from ideal and substantial racial disparities in care have been reported. Lipid treatment and goal attainment information is not readily available for large patient populations seen in the fee-for-service setting. As a result, national programs to improve lipid management in this setting may focus on lipid testing as an indicator of lipid management. We describe the detection, treatment, and control of dyslipdemia for African Americans and Caucasians with coronary artery disease to evaluate whether public health programs focusing on lipid testing can eliminate racial disparities in lipid management.MethodsPhysicians and medical practices with high numbers of prescriptions for coronary artery disease medications were invited to participate in the Quality Assurance Program. Medical records were reviewed from a random sample of patients with coronary artery disease seen from 1995 through 1998. Data related to the detection, treatment, and control of dyslipidemia were abstracted from the medical record and evaluated in cross-sectional stratified and logistic regression analyses using generalized estimation equations.ResultsData from the medical records of 1,046 African Americans and 22,077 Caucasians seen in outpatient medical practices in 23 states were analyzed. African-American patients were younger, more likely to be women and to have diabetes, heart failure, and hypertension. The low density lipoprotein cholesterol (LDL-C) testing rate for Caucasian men was over 1.4 times higher than that for African-American women and about 1.3 times higher than that for African-American men. Almost 60% of tested Caucasian men and less than half of tested African Americans were prescribed lipid-lowering drugs. Tested and treated Caucasian men had the highest LDL-C goal attainment (35%) and African-American men the lowest (21%).ConclusionsAlthough increased lipid testing is clearly needed for African Americans, improvements in treatment and control are also necessary to eliminate racial disparities in lipid management. Disparities in treatment and goal attainment must be better understood and reflected in policy to improve the health of underserved populations.

The impact of physician attitudes and beliefs on treatment decisions: lipid therapy in high-risk patients.

Background:Despite clinical guidelines, many patients with hypercholesterolemia do not achieve treatment goals in clinical practice. Objectives:This study examined physician attitudes and beliefs about hyperlipidemia and whether they are associated with lipid treatment decisions. Methods:This was a cross-sectional study of 107 physicians who completed a validated survey of attitudes and beliefs about hyperlipidemia and provided treatment histories for 1187 statin-treated patients with coronary heart disease (CHD) or who were CHD risk-equivalent. Logistic regressions (using generalized estimating equation) estimated the impact of patient characteristics and physician attitudes and beliefs on whether a patient received increases in the statin dose. Results:Approximately 70% of the 843 patients who were not at low-density lipoprotein cholesterol goal (<100 mg/dL) with initial statin therapy received a dose increase, although only one-half attained goal. Controlling for patient characteristics, patients whose physicians believed “close enough to goal is good enough” had 47% lower odds of having a dose increase (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.34–0.82), whereas patients whose physicians believed “statins are effective” had almost twice the odds of having a dose increase (OR, 1.78; 95% CI, 1.05–3.00). Conclusions:Although the understanding of basic and clinical science remains fundamental, clinical guideline authors may want to consider the importance of physician attitudes and beliefs in determining translation of their guidelines into clinical practice.

Characteristics of patients initiating raloxifene compared to those initiating bisphosphonates

BackgroundBoth raloxifene and bisphosphonates are indicated for the prevention and treatment of postmenopausal osteoporosis, however these medications have different efficacy and safety profiles. It is plausible that physicians would prescribe these agents to optimize the benefit/risk profile for individual patients. The objective of this study was to compare demographic and clinical characteristics of patients initiating raloxifene with those of patients initiating bisphosphonates for the prevention and treatment of osteoporosis.MethodsThis study was conducted using a retrospective cohort design. Female beneficiaries (45 years and older) with at least one claim for raloxifene or a bisphosphonate in 2003 through 2005 and continuous enrollment in the previous 12 months and subsequent 6 months were identified using a collection of large national commercial, Medicare supplemental, and Medicaid administrative claims databases (MarketScan®). Patients were divided into two cohorts, a combined commercial/Medicare cohort and a Medicaid cohort. Within each cohort, characteristics (demographic, clinical, and resource utilization) of patients initiating raloxifene were compared to those of patients initiating bisphosphonate therapy. Group comparisons were made using chi-square tests for proportions of categorical measures and Wilcoxon rank-sum tests for continuous variables. Logistic regression was used to simultaneously examine factors independently associated with initiation of raloxifene versus a bisphosphonate.ResultsWithin both the commercial/Medicare and Medicaid cohorts, raloxifene patients were younger, had fewer comorbid conditions, and fewer pre-existing fractures than bisphosphonate patients. Raloxifene patients in both cohorts were less likely to have had a bone mineral density (BMD) screening in the previous year than were bisphosphonate patients, and were also more likely to have used estrogen or estrogen/progestin therapy in the previous 12 months. These differences remained statistically significant in the multivariate model.ConclusionIn this sample of patients enrolled in commercial, Medicare, and Medicaid plans, patients who initiated raloxifene treatment differed from those initiating bisphosphonates. Raloxifene patients were younger, had better overall health status and appeared to be less likely to have risk factors for new osteoporotic fractures than bisphosphonate patients. Differences in the clinical profiles of these agents may impact prescribing decisions. Investigators using observational data to make comparisons of treatment outcomes associated with these medications should take these important differences in patient characteristics into consideration.

Development and Validation of the Hyperlipidemia: Attitudes and Beliefs in Treatment (HABIT) Survey for Physicians

INTRODUCTION: Many patients treated with lipid-lowering medications in clinical practice do not achieve targeted National Cholesterol Education Program (NCEP) goals for low-density lipoprotein cholesterol (LDL-C), despite the proven efficacy of these medications. Understanding physician attitudes and beliefs about treating patients to goal may be useful in improving patient care and ensuring that all patients receive the benefits of treatments shown to be optimal in clinical trials.OBJECTIVE: To develop a theoretically based, and statistically reliable and valid survey instrument for measuring the attitudes and beliefs of physicians toward hyperlipidemia and its treatment, including treatment of patients to goal. To determine whether the attitudes measured were associated with physician intentions to treat patients to LDL-C goal.METHODS: We assessed the reliability of the instrument through an examination of the internal consistency and factor structure of the constructs. Validity was assessed through zero-order correlations among the constructs and the relationship between the constructs and an intent to treat to goal case study.RESULTS: Internal consistency scores for the 8 constructs ranged from 0.48 to 0.75. Factor loadings indicated that the individual items belonged to their respective constructs, as hypothesized. The predictive validity of the instrument was demonstrated by significant relationships between 5 of the 8 attitudinal constructs and an intent to treat to goal case study.CONCLUSIONS: The HABIT physician survey is the first validated instrument covering a broad set of attitudes about the treatment of hyperlipidemia that are both theoretically and empirically linked to physician intent to treat to NCEP LDL-C goal.

The Hyperlipidemia: Attitudes and Beliefs in Treatment (HABIT) survey for patients: results of a validation study.

Patient adherence with cholesterol-lowering medications is a crucial component in helping patients achieve lipid goals. Understanding patient attitudes and beliefs about hyperlipidemia and its pharmacological treatments may be useful in improving patient adherence with their treatment plan. The objectives of this study were to develop a theoretically based, statistically reliable, and valid survey instrument for measuring the attitudes and beliefs of patients towards hyperlipidemia and its treatments, and to determine whether the attitudes measured were associated with patient-reported medication adherence. We assessed the reliability of the instrument through an examination of the internal consistency and factor structure of 8 attitude constructs including attitudes about the effectiveness of medications and the quality of doctor-patient communication. Validity was assessed through correlations among the attitudes and the relationship between the attitudes and the number of medication adherence problems the patient experienced in the past month. Internal consistency scores for the 8 constructs ranged from .46 to .82. Factor loadings indicated that the individual items belonged to their respective constructs, as hypothesized. The validity of the instrument was demonstrated by significant relationships between 4 of the attitudinal constructs and self-reported medication adherence problems. This study provides preliminary evidence of the reliability and validity of the HABIT (Hyperlipidemia: Attitudes and Beliefs in Treatment) patient survey of attitudes about the treatment of hyperlipidemia.

Illness-associated productivity costs among women with employer-sponsored insurance and newly diagnosed breast cancer.

Objective: Determine lost work time and job attrition for incident breast cancer (BC). Methods: The cases were employed women, aged 18 to 64, with BC identified by a validated algorithm between 1999 and 2005, from claims (MarketScan) and attendance databases. Controls without cancer were matched 3:1 on age, comorbidity, and index year. Results: First-year mean disability days were 60 (cases, N = 880) versus 5 (controls, N = 2640) (P < 0.001). The first-year disability costs were

Effectiveness of statin titration on low-density lipoprotein cholesterol goal attainment in patients at high risk of atherogenic events

4900 for cases versus

Trends in Lipid Management Among Patients With Coronary Artery Disease Has diabetes received the attention it deserves

385 for controls (P < 0.001). In years 2 through 4, the disability days and associated costs were similar for the cases versus controls. After 4 years, 56.4% of cases were still enrolled in the employer-sponsored insurance programs compared to 6.5% of controls (P < 0.001). Conclusions: The lost work associated with BC is substantial in the first year after diagnosis. Employee retention is much higher for BC cases versus controls.