Michel Gaudet

Determinants of discontinuation of new courses of antihypertensive medications.

Discontinuation of medication use constitutes a major barrier to adequate control of high blood pressure. We examined the effect of an array of potential predisposing, enabling and reinforcing factors on the discontinuation of newly prescribed antihypertensive medications. We conducted a prospective cohort study through a network of 173 pharmacies across Canada where were identified individuals newly prescribed an antihypertensive monotherapy. We interviewed participants by telephone four times to obtain information for a minimum duration of 18 months after entry into the cohort. We analyzed data using a multivariate proportional hazard model. Of 682 eligible participants, 43.3% had discontinued their initial medication at the end of the observation period. Individuals more likely to discontinue their initial medication were those who perceived side effects from this medication [Hazard Ratio (HR) = 1.91; 95% Confidence Interval (CI) 1.47-2.47). Individuals with medication insurance coverage were less likely to discontinue (HR = 0.74; 95% CI 0.55-0.99). Persistence with newly prescribed medications could be improved by selecting antihypertensive medications containing fewer side effects and by lifting economic barriers to drug treatment.

Non-compliance with drug treatment and reading difficulties with regard to prescription labelling among seniors

Background: The link between experiencing difficulties in reading or understanding and non-compliance with drug treatment among seniors is not clearly established. Objectives: We measured the effect of both difficulties in reading, as well as difficulties in understanding prescription labelling, on non-compliance with drug treatments among seniors. Since the use of a pill organizer prepared by a pharmacist may compensate for the problems in reading, we also checked the potential modifying effect of the use of a pill organizer on these two associations. Method: Data on non-compliance with drug treatment, comprehension of prescription labelling and on the factors potentially linked to non-compliance, were collected during face-to-face interviews with 325 seniors. Results: In all, 126 respondents (38.8%) were not able to read all the prescription labels and 218 (67.1%) did not fully understand all the information. 153 respondents were non-compliant with their drug treatment. After adjusting for sex, age, living alone or not, having had help with taking the medication, use of a pill organizer, having had sufficient funds to procure his medicine during the previous month, belief in the efficacy of his medication, perception of his state of health, satisfaction with physician-given and pharmacist-given information, as well as the complexity of the treatment, the two associations remained statistically non-significant. The use of a pill organizer was not a modifying factor. Conclusion: Our results did not demonstrate the existence, among seniors, of an association between non-compliance and difficulty in reading and understanding prescription labelling.

Tolerability of antihypertensive drugs in a community-based setting

BACKGROUND Outside the experimental environment of clinical trials, the tolerability of angiotensin-converting enzyme inhibitors (ACEIs), calcium channel blockers (CCBs), and the angiotensin II antagonist losartan has not been compared. OBJECTIVES The purpose of this study was to estimate, in current clinical practice, the 3-month cumulative incidence of side effects among first-time users of losartan, ACEIs, and CCBs for hypertension. METHODS We conducted a prospective cohort study through a network of 173 pharmacies across Canada to identify patients with hypertension who were newly prescribed monotherapy with losartan, an ACEI, or a CCB. Individuals were interviewed by telephone 3 times over a 3-month period to determine perceived side effects of the antihypertensive medication prescribed. Data were analyzed using a multivariate logistic regression model. RESULTS Among the 663 eligible individuals, the 3-month cumulative incidence of perceived side effects was 52.5% (42/80), 60.2% (222/369), and 69.6% (149/214) for those treated with losartan, an ACEI, and a CCB, respectively. After adjustment for sex, age, level of education, number of symptoms perceived the week before entering the study, prior use of antihypertensive drugs, current use of any other drug, drug insurance coverage, and duration of hypertension, the odds of reporting a side effect were significantly higher among patients treated with an ACEI (odds ratio [OR] = 1.78: 95% CI, 1.02-3.12) or a CCB (OR = 2.65; 95% CI, 1.47-4.78) compared with patients treated with losartan. CONCLUSIONS In a community-based setting, we observed that losartan is better tolerated than ACEIs and CCBs. Given that the occurrence of side effects may contribute to lower adherence to drug treatment, the low incidence of side effects associated with losartan makes it an attractive antihypertensive drug choice.

Job strain and psychotropic drug use among white-collar workers

The main objective of this study was to measure the association between simultaneous exposure to high psychological demand and low decision latitude at work and the use of psychotropic drugs among white-collar workers. A second objective was to determine whether social support at work modified this association. A cross-sectional study was performed that included 2786 workers from the public sector in the Greater Quebec City area. A self-administered questionnaire was used in order to evaluate psychological demand, decision latitude and social support at work. Psychotropic drug use was measured over a period of 2 days. The prevalence of psychotropic drug use among the participants was found to be 3.9%, even though 20.5% were exposed to job strain. The association between job strain and psychotropic drug use, after adjustment for social support at work, age, gender, education, family income, employment status, occupation, stressful life events, cigarette smoking, alcohol consumption and physical activity, w...

Ambulatory use of olanzapine and risperidone: a population-based study on persistence and the use of concomitant therapy in the treatment of schizophrenia.

Objective: To assess treatment discontinuation and concomitant use of other antipsychotics among individuals initiated on olanzapine or risperidone for the treatment of schizophrenia. Method: Using data from the Quebec health insurance plan and the Quebec database for hospitalization, we conducted a population-based cohort study of patients for whom a first claim for olanzapine or risperidone was submitted between 1 January 1997 and 31 August 1999. Included were 6405 patients with schizophrenia whom we followed from the date of the first claim for olanzapine or risperidone either to discontinuation date, end of eligibility for the drug plan, 365 days, date of moving out of the province, or date of death. We used Cox regression models to compute hazards ratios (HRs) of having the treatment discontinued and logistic regression models to compute odds ratios (ORs) among persisting patients of having any concomitant antipsychotic prescription. All models were adjusted for age, sex, schizophrenia disorder, comorbidity, region, beneficiary type, substance use disorder, and prior hospitalization for mental illness. Results: Compared with risperidone users (n = 2718), discontinuation rates were lower for olanzapine users (n = 3687; HR = 0.79; 95%CI, 0.74 to 0.84). The odds of receiving any concomitant antipsychotic prescription did not differ statistically between olanzapine and risperidone users (OR 0.85; 95%CI, 0.71 to 1.01). Conclusions: The study results suggest that new users of olanzapine were less likely to discontinue their initial treatment than were new users of risperidone, although discontinuation was high in both groups. Among those who persisted, concomitant use of other antipsychotics did not differ between olanzapine users and risperidone users.

Lung Function in Advanced Age: Study of Ambulatory Subjects Aged over 75 Years

Spirometric parameters including forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1) and various parietal parameters (superior and inferior rib cage and abdominal maximal expansion amplitudes) were measured in 65 ambulatory subjects aged over 75 years. The population was divided into three age groups: group 1: 75-79; group 2; 80-84, group 3: 85 and older. A marked decrease in clinical and spirometric results was observed between groups 1 and 2, and 1 and 3, but there was no difference between groups 2 and 3. Such findings might be attributed to a survival effect. There was a high correlation between the parietal parameters and FVC and FEV1. In clinical practice, this simple parietal assessment may be of value in the identification of elderly subjects at risk of acute respiratory distress.

What Do Québec Children Eat During Their First Six Months

Study objectives were to describe the introduction of foods and beverages and the use of vitamin and/or mineral supplements among infants aged six months, and to identify factors associated with following Québec recommendations on introducing foods and beverages. Study subjects were primiparous women interviewed by phone when their infants were approximately six months old. Data were gathered on foods and beverages offered to infants, the age at which these were introduced, and supplements. The use of each food, beverage, and supplement was evaluated according to recommendations. Mean age at which foods were introduced and proportions of women who followed recommendations were calculated. Multivariate logistic regression models were used to identify the factors associated with following recommendations. Results indicated that among the 1,937 interviewed mothers, 212 (10.9%) exclusively breast-fed their infants before age four months, 1,073 (55.4%) breast-fed their infants at birth but gave them formula or foods before age four months, and 652 (33.7%) formula-fed their infants at birth. Factors associated with adherence to recommendations were breast-feeding exclusively, being older than 30 years, an annual family income of at least 60,000 dollars, and being a non-smoker. Few mothers followed all the recommendations.Study objectives were to describe the introduction of foods and beverages and the use of vitamin and/or mineral supplements among infants aged six months, and to identify factors associated with following Quebec recommendations on introducing foods and beverages. Study subjects were primiparous women interviewed by phone when their infants were approximately six months old. Data were gathered on foods and beverages offered to infants, the age at which these were introduced, and supplements. The use of each food, beverage, and supplement was evaluated according to recommendations. Mean age at which foods were introduced and proportions of women who followed recommendations were calculated. Multivariate logistic regression models were used to identify the factors associated with following recommendations. Results indicated that among the 1,937 interviewed mothers, 212 (10.9%) exclusively breast-fed their infants before age four months, 1,073 (55.4%) breast-fed their infants at birth but gave them formula or...

Back to the Future: The European Academy for the Medicine of Ageing Revisited

It was around a decade ago that several heads of geriatric departments (Group of European Professors in Medical Gerontology [1, 2]) envisioned the need for younger colleagues to get an adequate postgraduate training in geriatrics under the auspices of an international faculty. This ‘nucleus group’ consisted of E. Beregi, S. Duursma, J. Grimley Evans, J.P. Michel, A. Ruiz-Torres, H.B. Stähelin and B. Steen. The product of these discussions was the inauguration of the ‘European Academy for the Medicine of Ageing’ (EAMA) [3, 4]. The importance of training an ample future geriatric faculty has certainly not diminished since then. Indeed, the cross-talk and the delineation of specific tasks between internists and geriatricians is still a question of debate [5, 6]. One of the major tasks from the beginning was the creation of a network of past and present students. Meanwhile, three courses (each course lasting for 4 weeks spread over a 2-year period) have been completed and the fourth one has just started, in January 2001. Besides a devoted faculty, two ‘critical success factors’ seem to make up the success of the EAMA: (1) the unique site in Sion (Switzerland) in the well-equipped ‘Institut Universitaire Kurt Bösch’ where the courses are held, and (2) the generous support of the Novartis Foundation for Gerontological Research, which enables the recruitment of highclass international teachers. ‘Flashback’ to the Third Course

Appropriateness of Omeprazole Prescribing in Quebec’s Senior Population

BACKGROUND Prescribing omeprazole for the treatment of digestive disorders accounts for an important part of the costs in Quebecs drug benefit plan. In July 1993, the Quebec drug program listed omeprazole, with restriction, in its formulary. On January 1, 1994, this restriction was lifted; since then, omeprazole has been listed in the regular provincial formulary. OBJECTIVE To describe the appropriateness of initial omeprazole prescribing in the ambulatory senior population of Quebec in the 27 months after being listed without restriction. SUBJECTS AND METHODS A retrospective population-based cohort study was performed using prescription and medical services claims databases of the Quebec drug program. Data were extracted for elderly patients who received their first omeprazole prescription between July 1, 1994 and March 31, 1996. RESULTS Among the 47,140 first-time users of omeprazole identified, 7516 (15.9%) had had an endoscopy in the previous six months, 2308 (4.9%) were given an antimicrobial agent and omeprazole simultaneously, and 22,730 (48.2%) received omeprazole after prior use of an H2 receptor antagonist (H2RA) or a prokinetic drug. A total of 26,525 (56.3%) first-time users were prescribed omeprazole based on at least one of the three criteria listed above. Among these users, 729 (2.8%) received an H2RA concurrently with omeprazole. Altogether, 25,796 (54.7%) first-time users received omeprazole appropriately. CONCLUSIONS Although reimbursement for omeprazole prescriptions has not been restricted in Quebec since January 1, 1994, it was prescribed appropriately for elderly patients in the majority of cases studied.