Abstract
BackgroundCardiovascular disease is a leading cause of death in older people, and the impact of being exposed or not exposed to preventive cardiovascular medicines is accordingly high. Underutilization of beneficial drugs is common, but prevalence estimates differ across settings, knowledge on predictors is limited, and clinical consequences are rarely investigated.MethodsUsing data from a prospective population-based cohort study, we assessed the prevalence, determinants, and outcomes of medication underuse based on cardiovascular criteria from Screening Tool To Alert to Right Treatment (START).ResultsMedication underuse was present in 69.1% of 1454 included participants (mean age 71.1 ± 6.1 years) and was significantly associated with frailty (odds ratio: 2.11 [95% confidence interval: 1.24–3.63]), body mass index (1.03 [1.01–1.07] per kg/m2), and inversely with the number of prescribed drugs (0.84 [0.79–0.88] per drug). Using this information for adjustment in a follow-up evaluation (mean follow-up time 2.24 years) on cardiovascular and competing outcomes, we found no association of medication underuse with cardiovascular events (fatal and non-fatal) (hazard ratio: 1.00 [0.65–1.56]), but observed a significant association of medication underuse with competing deaths from non-cardiovascular causes (2.52 [1.01–6.30]).ConclusionMedication underuse was associated with frailty and adverse non-cardiovascular clinical outcomes. This may suggest that cardiovascular drugs were withheld because of serious co-morbidity or that concurrent illness can preclude benefit from cardiovascular prevention. In the latter case, adapted prescribing criteria should be developed and evaluated in those patients.
Highlights
The predominant risks of a population with continuously increasing life expectancy include the simultaneous use of multiple medications [1], the associated risk of adverse drug reactions [2, 3], the growing complexity of medication schedules[4], and difficulty to follow the instructions and administer the drugs correctly [5, 6]
Medication underuse was present in 69.1% of 1454 included participants and was significantly associated with frailty, body mass index (1.03 [1.01–1.07] per kg/m2), and inversely with the number of prescribed drugs (0.84 [0.79–0.88] per drug)
Using this information for adjustment in a follow-up evaluation on cardiovascular and competing outcomes, we found no association of medication underuse with cardiovascular events, but observed a significant association of medication underuse with competing deaths from non-cardiovascular causes (2.52 [1.01–6.30])
Summary
The predominant risks of a population with continuously increasing life expectancy include the simultaneous use of multiple medications [1], the associated risk of adverse drug reactions [2, 3], the growing complexity of medication schedules[4], and difficulty to follow the instructions and administer the drugs correctly (non-adherence) [5, 6]. Underuse is frequent and well documented for many drug classes [7] including statins, antihypertensive agents, beta-blockers, antiplatelet agents, or drug combinations in the secondary prevention of cardiovascular events Because those drugs that are not prescribed and not taken by the patient cannot be pharmacologically active, the prognosis of diseases is expectedly worse and poor in patients with the highest risk for an event. Evidence for clinical consequences of medication underuse is scarce and methodological restraints preclude causality assessment, among them a cross-sectional study design [17], insufficient sample size in prospective investigations [18], or restrictions of the used data source [15] This situation prompted us to address the topic in a prospective population-based cohort. Underutilization of beneficial drugs is common, but prevalence estimates differ across settings, knowledge on predictors is limited, and clinical consequences are rarely investigated.
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