Teresa N. Harrison

Automated Outreach to Increase Primary Adherence to Cholesterol-Lowering Medications

BACKGROUND Primary nonadherence occurs when new prescriptions are not dispensed. Little is known about how to reduce primary nonadherence. We performed a randomized controlled trial to evaluate an automated system to decrease primary nonadherence to statins for lowering cholesterol. METHODS Adult members of Kaiser Permanente Southern California with no history of statin use within the past year who did not fill a statin prescription after 1 to 2 weeks were passively enrolled. The intervention group received automated telephone calls followed 1 week later by letters for continued nonadherence; the control group received no outreach. The primary outcome was a statin dispensed up to 2 weeks after delivery of the letter. Secondary outcomes included refills at intervals up to 1 year. Intervention effectiveness was determined by intent-to-treat analysis and Fisher exact test. Subgroups were examined using logistic regression. RESULTS There were 2606 participants in the intervention group and 2610 in the control group. Statins were dispensed to 42.3% of intervention participants and 26.0% of control participants (absolute difference, 16.3%; P < .001). The relative risk for the intervention vs control group was 1.63 (95% CI, 1.50-1.76). Intervention effectiveness varied slightly by age (P = .045) but was effective across all age strata. Differences in the frequency of statin dispensations persisted up to 1 year (P < .001). CONCLUSIONS The intervention was effective in reducing primary nonadherence to statin medications. Because of low marginal costs for outreach, this strategy appears feasible for reducing primary nonadherence. This approach may generalize well to other medications and chronic conditions.

Digoxin and Risk of Death in Adults With Atrial Fibrillation The ATRIA-CVRN Study

Background—Digoxin remains commonly used for rate control in atrial fibrillation, but limited data exist supporting this practice and some studies have shown an association with adverse outcomes. We examined the independent association between digoxin and risks of death and hospitalization in adults with incident atrial fibrillation and no heart failure. Methods and Results—We performed a retrospective cohort study of 14 787 age, sex, and high-dimensional propensity score-matched adults with incident atrial fibrillation and no previous heart failure or digoxin use in the AnTicoagulation and Risk factors In Atrial fibrillation-Cardiovascular Research Network (ATRIA-CVRN) study within Kaiser Permanente Northern and Southern California. We examined the independent association between newly initiated digoxin and the risks of death and hospitalization using extended Cox regression. During a median 1.17 (interquartile range, 0.49–1.97) years of follow-up among matched patients with atrial fibrillation, incident digoxin use was associated with higher rates of death (8.3 versus 4.9 per 100 person-years; P<0.001) and hospitalization (60.1 versus 37.2 per 100 person-years; P<0.001). Incident digoxin use was independently associated with a 71% higher risk of death (hazard ratio, 1.71; 95% confidence interval, 1.52–1.93) and a 63% higher risk of hospitalization (hazard ratio, 1.63; 95% confidence interval, 1.56–1.71). Results were consistent in subgroups of age and sex and when using intent-to-treat or on-treatment analytic approaches. Conclusions—In adults with atrial fibrillation, digoxin use was independently associated with higher risks of death and hospitalization. Given other available rate control options, digoxin should be used with caution in the management of atrial fibrillation.

Dietary Approaches to Prevent Hypertension

Elevated blood pressure arises from a combination of environmental and genetic factors and the interactions of these factors. A substantial body of evidence from animal studies, epidemiologic studies, meta-analyses, and randomized controlled trials has demonstrated that certain dietary patterns and individual dietary elements play a prominent role in the development of hypertension. Changes in diet can lower blood pressure, prevent the development of hypertension, and reduce the risk of hypertension-related complications. Dietary strategies for the prevention of hypertension include reducing sodium intake, limiting alcohol consumption, increasing potassium intake, and adopting an overall dietary pattern such as the DASH (Dietary Approaches to Stop Hypertension) diet or a Mediterranean diet. In order to reduce the burden of blood pressure-related complications, efforts that focus on environmental and individual behavioral changes that encourage and promote healthier food choices are warranted.

Psychometric Properties of the Osteoporosis-Specific Morisky Medication Adherence Scale in Postmenopausal Women with Osteoporosis Newly Treated with Bisphosphonates

Background: Poor adherence to oral osteoporosis medications is common. Strategies for improving adherence begin with identification of the problem. The 8-item Morisky Medication Adherence Scale for self-reported adherence to antihypertensive medications was modified for assessing adherence to oral osteoporosis medications. An evaluation of the measurement properties of the Osteoporosis-Specific Morisky Medication Adherence Scale (OS-MMAS) was needed. Objective: To examine the psychometric properties of the OS-MMAS in women with postmenopausal osteoporosis. Methods: Five hundred women aged 55 years and older with osteoporosis who were newly prescribed daily or weekly oral bisphosphonates between May 15, 2010, and August 15, 2010, were randomly selected from Kaiser Permanente Southern California, a large integrated health care delivery system, and mailed a self-administered survey that included the 8-item OS-MMAS, Self-Efficacy for Appropriate Medication Use Scale (SEAMS), Beliefs about Medicines Questionnaire (BMQ), Treatment Satisfaction Questionnaire for Medication (TSQM), Gastrointestinal Symptom Rating Scale (GSRS), and 12-item Short-Form Health Survey (SF-12v2). OS-MMAS scores can range from 0 to 8, with higher scores indicating better medication adherence. Internal consistency reliability was evaluated using Cronbach α coefficient. Test-retest reliability was assessed using intraclass correlation coefficients (ICCs) in a subset of 102 participants. Construct validity was assessed using confirmatory (actor analysis and correlations between OS-MMAS and related measures. Results: Of 197 participants, 150 reported that they were still taking their bisphosphonate at the time of the survey and completed the OS-MMAS. Overall, 30.7%, 32.7%, and 36.7% had tow, medium, and high OS-MMAS scores (<6, 6 to <8, and 8, respectively). Cronbach α was 0.82 and the ICC was 0.77. Convergent validity was supported by significant correlations with SEAMS, BMQ necessity, and TSQM scores. In confirmatory factor analysis, a single-factor scale was supported. Conclusions: The OS-MMAS showed strong psychometric properties with good reliability and construct validity and may provide a valuable assessment of self-reported medication adherence in women newly prescribed oral osteoporosis medications.

Hypertensive disorders first identified in pregnancy increase risk for incident prehypertension and hypertension in the year after delivery.

Background: Hypertensive disorders in pregnancy, including preeclampsia/eclampsia (PE/E) are associated with long-term cardiovascular disease risk. However, little is known about the effect of these conditions on risk for prehypertension (preHTN) or hypertension (HTN) in the early years after delivery. Methods: The cohort consisted of women who had prenatal care and delivered a live singleton neonate at Kaiser Permanente Bellflower Medical Center in 2005–2010. Women with prepregnancy HTN or preHTN were excluded from analysis. Multivariable robust Poisson regression models were used to assess associations between any hypertensive disorder or PE/E and development of preHTN/HTN in the year after delivery, adjusted for maternal age, race/ethnicity, parity, smoking, prepregnancy weight status, gestational weight gain, gestational diabetes, and gestational age. Results: Among 5960 women who were normotensive prior to pregnancy, 358 (6.0%) developed a hypertensive disorder in pregnancy, of whom 215 (60.1%) had PE/E. Overall, 63 (1.1%) developed HTN and 902 (15.1%) preHTN in the year after delivery. After accounting for all potential confounders, women with a hypertensive disorder in pregnancy and those with PE/E were 2.36 (95% confidence interval: 1.97–2.83) and 2.48 (95% confidence interval: 1.99–3.11) times as likely, respectively, to develop preHTN/HTN in the year after delivery as those without pregnancy-related HTN. Results were similar with and without adjustment for gestational diabetes. Conclusion: Our findings highlight the need for prospective studies aimed at determining whether early postpartum screening and improved follow-up of women with hypertensive disorders first identified in pregnancy may prevent future cardiovascular disease.

Prehypertension prior to or during early pregnancy is associated with increased risk for hypertensive disorders in pregnancy and gestational diabetes.

Objective: To examine whether and to what extent pre/early-pregnancy blood pressure (BP) in the prehypertensive range contributes to the development of hypertensive disorders in pregnancy and gestational diabetes mellitus (GDM). Methods: The cohort consisted of women who had their prenatal care and delivered a live singleton neonate at the Kaiser Permanente Bellflower Medical Center during 2005–2010. Women with prepregnancy hypertension (HTN) were excluded from the analysis. Among the remaining women, pre/early-pregnancy prehypertension (preHTN) was defined as two consecutive elevated BPs (SBP ≥ 120 or DBP ≥ 80) at separate ambulatory visits in the period from 1 year prior to pregnancy through the first trimester. Hypertensive disorders of pregnancy, including pre-eclampsia/eclampsia (PE/E), were identified by ICD-9 diagnoses. Mid-pregnancy 75-g oral glucose tolerance tests were used to identify GDM. Multivariable logistic and robust Poisson regression was used to test the association between preHTN and each outcome, adjusted for potential confounders. Results: Among 7802 women with at least two BP measures prior to or early in pregnancy, 2156 (27.6%) had preHTN. Overall, 653 (8.4%) developed a hypertensive disorder of pregnancy, 373 (4.8%) had PE/E, and 1877 (24.1%) developed GDM. After covariate adjustment, women with preHTN were 2.65 [95% confidence interval (CI) 2.22–3.16], 2.17 (95% CI 1.72–2.73), and 1.20 (95% CI 1.09–1.33) times as likely to develop any hypertensive disorder, PE/E, and GDM, respectively, compared to normotensive women. Conclusion: Prospective studies aimed at evaluating whether women with preHTN detected prior to or early in pregnancy may benefit from more intensive screening and/or interventions to prevent hypertensive disorders in pregnancy and GDM are needed.

A randomized controlled trial of an automated telephone intervention to improve blood pressure control.

The objective of this study was to evaluate the effectiveness of a telephonic outreach program to improve blood pressure (BP) control among patients with hypertension. The authors identified adults 18 years and older with uncontrolled BP within the previous 12 months. Patients received either an automated telephone call advising them to have a walk‐in BP check (n=31,619) or usual care (n=33,154). The primary outcome was BP control at 4 weeks. Significantly more patients who received the intervention achieved BP control compared with the usual care group (32.5% vs 23.7%; P<.0001). Patients in the intervention arm with cardiovascular disease, chronic kidney disease, or diabetes mellitus achieved better BP control. Older age, female sex, and having a household income above the median were associated with BP control. When designing quality‐improvement interventions to increase BP control rates, health care organizations should consider utilizing an automated telephone outreach campaign.

Health-related quality of life outcomes from a contemporary prostate cancer registry in a large diverse population

To assess the health‐related quality of life (HRQoL) of patients with prostate cancer up to 24 months after treatment in a contemporary large diverse population.

The Utility of Ambulatory Blood Pressure Monitoring for Diagnosing White Coat Hypertension in Older Adults

The beneficial effect of antihypertensive medication on reducing the risk of cardiovascular disease (CVD) events is supported by data from randomized controlled trials of older adults with hypertension. However, in clinical practice, overtreatment of hypertension in older adults may lead to side effects and an increased risk of falls. The diagnosis and treatment of hypertension is primarily based on blood pressure measurements obtained in the clinic setting. Ambulatory blood pressure monitoring (ABPM) complements clinic blood pressure by measuring blood pressure in the out-of-clinic setting. ABPM can be used to identify white coat hypertension, defined as elevated clinic blood pressure and non-elevated ambulatory blood pressure. White coat hypertension is common in older adults but does not appear to be associated with an increased risk of CVD events among this population. Herein, we review the current literature on ABPM in the diagnoses of white coat hypertension in older adults, including its potential role in preventing overtreatment.

Association of Burden of Atrial Fibrillation With Risk of Ischemic Stroke in Adults With Paroxysmal Atrial Fibrillation: The KP-RHYTHM Study

Importance Atrial fibrillation is a potent risk factor for stroke, but whether the burden of atrial fibrillation in patients with paroxysmal atrial fibrillation independently influences the risk of thromboembolism remains controversial. Objective To determine if the burden of atrial fibrillation characterized using noninvasive, continuous ambulatory monitoring is associated with the risk of ischemic stroke or arterial thromboembolism in adults with paroxysmal atrial fibrillation. Design, Setting, and Participants This retrospective cohort study conducted from October 2011 and October 2016 at 2 large integrated health care delivery systems used an extended continuous cardiac monitoring system to identify adults who were found to have paroxysmal atrial fibrillation on 14-day continuous ambulatory electrocardiographic monitoring. Exposures The burden of atrial fibrillation was defined as the percentage of analyzable wear time in atrial fibrillation or flutter during the up to 14-day monitoring period. Main Outcomes and Measures Ischemic stroke and other arterial thromboembolic events occurring while patients were not taking anticoagulation were identified through November 2016 using electronic medical records and were validated by manual review. We evaluated the association of the burden of atrial fibrillation with thromboembolism while not taking anticoagulation after adjusting for the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) or CHA2DS2-VASc stroke risk scores. Results Among 1965 adults with paroxysmal atrial fibrillation, the mean (SD) age was 69 (11.8) years, 880 (45%) were women, 496 (25%) were persons of color, the median ATRIA stroke risk score was 4 (interquartile range [IQR], 2-7), and the median CHA2DS2-VASc score was 3 (IQR, 1-4). The median burden of atrial fibrillation was 4.4% (IQR ,1.1%-17.23%). Patients with a higher burden of atrial fibrillation were less likely to be women or of Hispanic ethnicity, but had more prior cardioversion attempts compared with those who had a lower burden. After adjusting for either ATRIA or CHA2DS2-VASc stroke risk scores, the highest tertile of atrial fibrillation burden (≥11.4%) was associated with a more than 3-fold higher adjusted rate of thromboembolism while not taking anticoagulants (adjusted hazard ratios, 3.13 [95% CI, 1.50-6.56] and 3.16 [95% CI, 1.51-6.62], respectively) compared with the combined lower 2 tertiles of atrial fibrillation burden. Results were consistent across demographic and clinical subgroups. Conclusions and Relevance A greater burden of atrial fibrillation is associated with a higher risk of ischemic stroke independent of known stroke risk factors in adults with paroxysmal atrial fibrillation.