Kristijan H. Kahler

Results of a retrospective, observational pilot study using electronic medical records to assess the prevalence and characteristics of patients with resistant hypertension in an ambulatory care setting

BACKGROUND Resistant hypertension, or failure to attain blood pressure (BP) goals while treated with > or = 3 antihypertensives (including a diuretic), occurred in 15% to 18% of patients in prospective cohort trials. OBJECTIVES The aims of this work were to identify the prevalence of resistant hypertension in an ambulatory care setting and to describe the characteristics of patients with resistant hypertension. METHODS Adults with hypertension were retrospectively identified in a US electronic medical record from November 1, 2002, through November 30, 2005. Antihypertensive treatment and BP values were assessed to identify those with BP > or = 140/90 mm Hg (>130/80 mm Hg for those with diabetes mellitus or kidney disease). Patients treated with > or = 3 agents (including a thiazide) who had > or = 1 BP level above target were classified as having resistant hypertension. Baseline characteristics were compared between those with and those without resistant hypertension. RESULTS Of 29,474 study patients aged > or = 18 years, 21,460 (72.8%) had > or = 1 prescription order for an antihypertensive and 19,202 (65.1%) had a follow-up BP level above target. The analysis found that 2670 patients (9.1% overall or 12.4% of those who were treated) were classified as having resistant hypertension. Relative to those without resistant hypertension, a greater proportion of those with resistant hypertension were female (65.6% vs 60.5%), were older (66.2 vs 63.0 years), had a higher body mass index (31.6 vs 30.4 kg/m(2)), had higher baseline BP levels (148/81 vs 138/80 mm Hg), and had higher rates of diabetes mellitus (35.2% vs 20.1%) or kidney disease (4.9% vs 2.7%) than those without resistant hypertension (all comparisons, P < 0.001). CONCLUSIONS This retrospective, observational pilot study of usual community practice supports the findings from prospective trials that resistant hypertension is an important clinical problem. More effective management is needed to enable patients with, or at risk for, resistant hypertension to achieve BP goals.

Adherence and persistence associated with the pharmacologic treatment of osteoporosis in a managed care setting.

Background: The effectiveness of chronic therapies can be compromised by poor adherence and persistence. Materials and Methods: Investigators identified a continuously benefit-eligible cohort of women from a large, geographically diverse, national managed care plan who were newly diagnosed and treated for osteoporosis with alendronate, risedronate, or raloxifene. Drug utilization parameters were evaluated over a 12-month follow-up period for the study population. Adherence was assessed using a medication possession ratio calculated as total days of therapy for medication dispensed/365 days of study follow-up. Persistence was defined as continuous therapy on the same drug for each month over the entire study period. Adherence and persistence were also evaluated for all three study agents in women ≥65 years of age. Results: In the study cohort (N = 10,566), 12-month adherence/persistence rates were alendronate 61%/21%, risedronate 58%/19%, and raloxifene 54%/16%. Rates in women ≥65 years were similar to those in the entire study cohort. Weekly bisphosphonate users had slightly higher 12-month adherence (63% versus 54%, P < 0.05) and persistence (22% versus 19%, P = NS) rates than did daily users, independent of agent. Conclusion: Chronic oral-dosed osteoporosis therapies are associated with poor adherence and persistence, regardless of age or dosing regimen. Drug therapies and patient management approaches associated with improved adherence and persistence could improve the likelihood of achieving the therapeutic benefits observed in rigorously controlled clinical trials.

Patient Decision to Initiate Therapy for Osteoporosis: The Influence of Knowledge and Beliefs

BackgroundThere are effective treatments to prevent osteoporotic fractures, but these treatments are underutilized.ObjectiveTo evaluate the influence of patient characteristics, perceptions, knowledge and beliefs about osteoporosis on the decision to initiate osteoporotic treatment.ParticipantsWe identified female members of a managed care plan who had a dual energy x-ray absorptiometry (DXA) bone density test and fulfilled World Health Organization criteria for osteoporosis. Patients were excluded if they received osteoporotic medications in the prior 6 months.MeasurementsPatients were sent a questionnaire that included items assessing satisfaction with physician–patient communication, trust in the physician, osteoporosis knowledge and beliefs, beliefs about prescription medications, and perceptions of barriers to medication use. Administrative electronic health records were used to identify prescription drug use and health care utilization.ResultsTwo hundred and thirty-six women returned surveys and research authorization forms out of 465 contacted for participation. One hundred and thirty-five (57.2%) filled a prescription for an osteoporotic drug in the first 3 months after the DXA exam. The largest differences between initiators and non-initiators were in beliefs in the benefits of medications, and distrust of medications, with initiators believing more strongly in the benefits and effectiveness of medications (p < .001), and non-initiators reporting more distrust of medications (p < .001). Osteoporosis knowledge and the belief that osteoporosis is a serious disease were also related to therapy initiation in bivariate analysis.ConclusionsOnly 57% of patients initiated osteoporotic medication within 3 months of diagnosis. The decision to start osteoporosis treatment appeared to be related to a patient’s beliefs in the effectiveness of osteoporosis medications and distrust of medications.

Does the route of administration for estrogen hormone therapy impact the risk of venous thromboembolism? Estradiol transdermal system versus oral estrogen-only hormone therapy.

Objective:The aim of this study was to quantify the magnitude of risk reduction for venous thromboembolism events associated with an estradiol transdermal system relative to oral estrogen-only hormone therapy agents. Methods:A claims analysis was conducted using the Thomson Reuters MarketScan database from January 2002 to October 2009. Participants 35 years or older who were newly using an estradiol transdermal system or an oral estrogen-only hormone therapy with two or more dispensings were analyzed. Venous thromboembolism was defined as one or more diagnosis codes for deep vein thrombosis or pulmonary embolism. Cohorts of estradiol transdermal system and oral estrogen-only hormone therapy were matched 1:1 based on both exact factor and propensity score matching, and an incidence rate ratio was used to compare the rates of venous thromboembolism between the matched cohorts. Remaining baseline imbalances from matching were included as covariates in multivariate adjustments. Results:Among the matched estradiol transdermal system and oral estrogen-only hormone therapy users (27,018 women in each group), the mean age of the cohorts was 48.9 years; in each cohort, 6,044 (22.4%) and 1,788 (6.6%) participants had a hysterectomy and an oophorectomy at baseline, respectively. A total of 115 estradiol transdermal system users developed venous thromboembolism, compared with 164 women in the estrogen-only hormone therapy cohort (unadjusted incidence rate ratio, 0.72; 95% CI, 0.57-0.91; P = 0.006). After adjustment for confounding factors, the incidence of venous thromboembolism remained significantly lower for estradiol transdermal system users than for estrogen-only hormone therapy users. Conclusions:This large population-based study suggests that participants receiving an estradiol transdermal system have a significantly lower incidence of venous thromboembolism than do participants receiving oral estrogen-only hormone therapy.

Evaluation of compliance and health care utilization in patients treated with single pill vs. free combination antihypertensives.

Abstract Objectives: To compare compliance/persistence, health care resource utilization, and costs associated with single-pill combination (SPC) vs. free-combination (FC) therapies among adult hypertension patients at the national and state level. Combination therapies with angiotensin receptor blocker (ARB) + calcium channel blocker, ARB + hydrochlorothiazide, and angiotensin-converting enzyme inhibitor + hydrochlorothiazide were evaluated. Methods: Patients initiated on SPC or FC were identified in the MarketScan Database (2006–2008). Multivariate regression models were used to compare the health care outcomes of SPC vs. FC use during the 6-month study period. National- and state-level outcomes were analyzed and reported. Compliance was measured by medication possession ratio (MPR), and persistence was assessed based on treatment discontinuation (i.e., a lapse in therapy exceeding 30 days). Utilization and cost outcomes included frequencies of inpatient and emergency room (ER) visits and changes in health care costs from baseline. Results: Adjusting for baseline characteristics, SPC patients (N = 382,476) demonstrated significantly higher MPR than FC patients (N = 197,375) (difference = 11.6%; 95% confidence interval [CI]: 11.4%, 11.7%). SPC patients had fewer all-cause hospitalizations (adjusted incidence rate ratio [IRR] = 0.77; 95% CI: 0.75, 0.79) and ER visits (adjusted IRR = 0.87; 95% CI: 0.86, 0.89) than FC patients. Results for cardiovascular-related utilization were similar to all-cause results. Compared to FC, SPC patients showed significantly greater reductions post-therapy initiation in all-cause medical costs by −

Inhaled corticosteroid use in patients with chronic obstructive pulmonary disease and the risk of pneumonia: a retrospective claims data analysis.

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Cardiovascular morbidity, heart rates and use of antimuscarinics in patients with overactive bladder

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A Questionnaire to Assess the Relevance and Credibility of Observational Studies to Inform Health Care Decision Making: An ISPOR-AMCP-NPC Good Practice Task Force Report

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Disease-modifying drug initiation patterns in commercially insured multiple sclerosis patients: a retrospective cohort study

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Cost Effectiveness of Management of Mild-to-Moderate Atopic Dermatitis with 1% Pimecrolimus Cream in Children and Adolescents 2–17 Years of Age

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