Rates Of Medication Initiation Research Articles

Lessons Learned: Evaluation of Fracture Liaison Service Quality Improvement Efforts in a Large Academic Healthcare System.

The Fracture Liaison Service (FLS) care model, a care coordination program for patients experiencing a fragility fracture, is proven to improve management of patients with an osteoporotic fracture, but treatment initiation gaps persist. We describe the evolution of a centralized FLS within a university-based healthcare system, including impact of adding clinical pharmacist consultation, and describe circumstances surrounding continued care gaps. Cohort analysis of osteoporosis medication initiation before FLS, after initial implementation, and after addition of pharmacist consultation. Individuals aged 65 and older experiencing any fragility fracture between 7/1/16 and 3/31/22. A centralized team outreached eligible patients, ordered dual x-ray absorptiometry and laboratory tests as needed, and scheduled an osteoporosis-focused primary care appointment. Three years after FLS implementation, clinical pharmacist consultative review was added prior to the primary care visit. Initiation of osteoporosis pharmacologic therapy, completion of DXA, primary care follow-up rate, and description of circumstances where therapy was not initiated. Of 1204 new fractures between 7/1/16 and 3/31/22, 315 patients were enrolled in one of two FLS phases, and 89 eligible historical controls were identified. Medication initiation rates went from 22/89 (25%) pre-FLS to 201/428 (47%) after-FLS phase 1 [POST1] (p<0.001) and to 106/187 (57%) after FLS phase 2 (POST2), when clinical pharmacist consultation was added (p=0.03 versus POST1). DXA was completed in 56/89 (67%) of pre-FLS patients, 364/428 (85%) POST1 patients (p<0.001 versus pre), and 163/187 (87%) POST2 (p< 0.001 versus PRE, p=0.59 versus POST1).Of 375 patients who did not initiate osteoporosis medication, more in the combined post-FLS cohorts attended a follow-up primary care appointment (233/308, 76% attended, versus pre-FLS 41/67, 61%, p=0.016). An FLS including centralized outreach and care coordination significantly improved patient follow-up, DXA, and medication initiation. Addition of de-centralized pharmacist consultation further improved medication initiation rates.

Public drug insurance, moral hazard and children's use of mental health medication: Latent mental health risk-specific responses to lower out-of-pocket treatment costs.

Studies have shown that reducing out-of-pocket costs can lead to higher medication initiation rates in childhood. Whether the cost of such initiatives is inflated by moral hazard issues remains a question of concern. This paper looks to the implementation of a public drug insurance program in Québec, Canada, to investigate potential low-benefit consumption in children. Using a nationally representative longitudinal sample, we harness machine learning techniques to predict a child's risk of developing a mental health disorder. Using difference-in-differences analyses, we then assess the impact of the drug program on children's mental health medication uptake across the distribution of predicted mental health risk. Beyond showing that eliminating out-of-pocket costs led to a 3 percentage point increase in mental health drug uptake, we show that demand responses are concentrated in the top two deciles of risk for developing mental health disorders. These higher-risk children increase take-up of mental health drugs by 7-8 percentage points. We find even stronger effects for stimulants (8-11 percentage point increases among the highest risk children). Our results suggest that reductions in out-of-pocket costs could achieve better uptake of mental health medications, without inducing substantial low-benefit care among lower-risk children.

Outpatient Management of Guideline-Directed Medical Therapy for Heart Failure Using Telehealth: A Comparison of In-Office, Video, and Telephone Visits

BackgroundThere are limited data regarding the management of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) with virtual visits in comparison with in-office visits. We sought to compare the changes in GDMT (angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, angiotensin receptor neprilysin inhibitors, mineralocorticoid receptor antagonists, and sodium glucose cotransporter-2 inhibitors) and loop diuretics across visit types. Methods and ResultsThis study included 13,481 outpatient visits performed for 5439 unique patients with HFrEF between March 16, 2020, and March 15, 2021. The rates of initiation and discontinuation of GDMT were documented, and multivariable logistic regression was performed to test associations with outcomes between modes of visit. The rates of medication initiation were higher in office (11.7%) compared with video (9.6%) or telephone (7.2%) visits. In multivariable adjusted analysis, the initiation of at least 1 GDMT class was similar between in-office visits and video visits (adjusted odds ratio [OR] 0.97, 95% confidence interval [CI] 0.82–1.14, P = .703). Telephone visits were associated with less frequent initiation of at least 1 class of GDMT in comparison with in-office visits (adjusted OR 0.64, 95% CI 0.55–0.75; P < .001) and video visits (adjusted OR 0.67, 95% CI 0.55–0.81, P < .001). Despite similar rates of baseline loop diuretic use, patients seen with both video visits (adjusted OR 0.70, 95% CI 0.52–0.94, P = .018) and telephone visits (adjusted OR 0.64, 95% CI 0.49-0.83, P < .001) were less likely to have a loop diuretic initiated when compared with in-office visits. ConclusionsThe initiation of GDMT for HFrEF was similar between in-office and video visits and lower with telephone visits, whereas the initiation of a loop diuretic was less frequent in both types of virtual visits. These data suggest that video streaming capabilities should be encouraged for virtual visits.

Racial/ethnic disparities in the use of medications for opioid use disorder (MOUD) and their effects on residential drug treatment outcomes in the US

BackgroundThis study examines racial/ethnic disparities in the use of medications for opioid use disorder (MOUD) in residential treatment and the influence of race/ethnicity on the association between MOUD use and treatment retention and completion. MethodsData were extracted from SAMHSA’s 2015–2017 Treatment Episode Dataset-Discharge (TEDS-D) datasets for adult opioid admissions/discharges to short-term (ST) (30 days or less) (N = 83,032) or long-term (LT) (> 30 days) residential treatment settings (N=61,626). Logistic regression estimated the likelihood of MOUD use among racial/ethnic groups and the moderation of race/ethnicity on the probability of treatment completion and retention, controlling for background factors. ResultsAfter adjusting for covariates, compared to Whites, MOUD use was less likely for Blacks in ST (OR = 0.728) and LT settings (OR = 0.725) and slightly less likely for Hispanics in ST settings (OR = 0.859) but slightly more likely for Hispanics in LT settings (OR = 1.107). In ST settings, compared to Whites, the positive effect of MOUD on retention was enhanced for Blacks (OR = 1.191) and Hispanics (OR = 1.234), and the positive effect on treatment completion was enhanced for Hispanics (OR = 1.144). In LT settings, the negative association between MOUD and treatment completion was enhanced for Hispanics (OR = 0.776). ConclusionsAccess to medications for opioid use disorder in short term residential treatment is particularly beneficial for Blacks and Hispanics, though adjusted models indicate they are less likely to receive it compared to Whites. Results are mixed for long-term residential treatment. Residential addiction treatment may represent an important setting for mitigating low rates of medication initiation and early discontinuation for minority patients.

Which patients are at risk for not receiving anti-osteoporosis treatment following hip fracture?: An ACS NSQIP analysis

BackgroundScreening and management of osteoporosis is often only considered by providers when patients present with multiple fragility fractures. The objective was to determine which patients are at risk for not receiving anti-osteoporotic medication and screening immediately following open reduction internal fixation (ORIF) for hip fracture. MethodsThe 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Hip Fracture Database was queried to identify patients ≥ 50 years old who underwent ORIF of femoral neck, intertrochanteric hip, and subtrochanteric hip fractures. Patients with concurrent polytrauma, malignancy, and other fragility fractures were excluded. Patients taking osteoporotic medications immediately prior to hospitalization were excluded to prevent an overlap in the screening and/or antiresorptive medication initiation rates. Multi-variate logistic regression was used to assess for factors associated with not receiving anti-osteoporotic medication immediately postoperatively. ResultsA total of 6179 patients were identified of whom 3304 (53.5%) were treated at a facility with a documented standardized hip fracture care program. Only 28.5% (N = 1766) patients received anti-osteoporosis medication immediately following ORIF. Independent factors associated with increased odds of not initiating bone protective medication were those without a standardized hip fracture care program (odds ratio [OR] 1.80 [1.58–2.06], P < 0.001), length of stay ≤ 5 days (odds ratio [OR] 1.47 [1.28–1.69], P < 0.001), patients waiting > 1 day until operation (odds ratio [OR] 1.35 [1.13–1.60], P = 0.001), patients requiring a mobility aid preoperatively (odds ratio [OR] 1.29 [1.13–1.47], P < 0.001), and patients who could not weight bear as tolerated (WBAT) on postoperative day 1 (POD 1) (odds ratio [OR] 1.25 [1.06–1.47], P = 0.008). ConclusionPatients starting anti-osteoporotic medication immediately following a hip fracture in the United States remains low (28.5%). Standardized hip fracture care programs have the greatest impact with regards to initiating anti-osteoporotic medication following hip fracture.

Comparison of Diabetes Medications Used by Adults With Commercial Insurance vs Medicare Advantage, 2016 to 2019

Glucagonlike peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT2i), and dipeptidyl peptidase-4 inhibitors (DPP-4i) are associated with low rates of hypoglycemia, and postmarketing trials of GLP-1RA and SGLT2i demonstrated that these medications improved cardiovascular and kidney outcomes. To compare trends in initiation of treatment with GLP-1RA, SGLT2i, and DPP-4i by older adults with type 2 diabetes insured by Medicare Advantage vs commercial health plans. This retrospective cohort study used administrative claims data from a deidentified database of commercially insured and Medicare Advantage beneficiaries. Adults aged 58 to 66 years with type 2 diabetes who filled any medication prescription to lower glucose levels from January 1, 2016, to December 31, 2019, were compared between groups. Enrollment in a Medicare Advantage or commercial health insurance plan. The odds of initiating GLP-1RA, SGLT2i, and DPP-4i treatment were examined for Medicare Advantage vs commercial insurance beneficiaries using 3 separate logistic regression models adjusted for year and demographic and clinical factors. These models were used to calculate adjusted annual rates of medication initiation by health plan. A total of 382 574 adults with pharmacologically treated type 2 diabetes (52.9% men; mean [SD] age, 62.4 [2.7] years) were identified, including 172 180 Medicare Advantage and 210 394 commercial beneficiaries. From 2016 to 2019, adjusted rates of initiation of GLP-1RA, SGLT2i, and DPP-4i treatment increased among all beneficiaries, from 2.14% to 20.02% for GLP-1RA among commercial insurance beneficiaries and from 1.50% to 11.44% among Medicare Advantage beneficiaries; from 2.74% to 18.15% for SGLT2i among commercial insurance beneficiaries and from 1.57% to 8.51% among Medicare Advantage beneficiaries; and from 3.30% to 11.71% for DPP-4i among commercial insurance beneficiaries and from 2.44% to 7.68% among Medicare Advantage beneficiaries. Initiation rates for all 3 drug classes were consistently lower among Medicare Advantage than among commercial insurance beneficiaries. Within each calendar year, the odds of initiating GLP-1RA treatment ranged from 0.28 (95% CI, 0.26-0.29) to 0.70 (95% CI, 0.65-0.75) for Medicare Advantage and commercial insurance beneficiaries, respectively; SGLT2i, from 0.21 (95% CI, 0.20-0.22) to 0.57 (95% CI, 0.53-0.61), respectively; and DPP-4i, from 0.37 (95% CI, 0.34-0.39) to 0.73 (95% CI, 0.69-0.78), respectively (P < .001 for all). The odds of starting GLP-1RA and SGLT2i increased with income; for an income of $200 000 and higher vs less than $40 000, the odds ratio for GLP-1RA was 1.23 (95% CI, 1.15-1.32) and for SGLT2i was 1.16 (95% CI, 1.09-1.24). These findings suggest that Medicare Advantage beneficiaries may be less likely than commercially insured beneficiaries to be treated with newer medications to lower glucose levels, with greater disparities among lower-income patients. Better understanding of nonclinical factors contributing to treatment decisions and efforts to promote greater equity in diabetes management appear to be needed.

Patients 80 + have similar medication initiation rates to those aged 50-79 in Ontario FLS.

In 39 FLS fracture clinics across Ontario, Canada, fracture prevention coordinators identified, assessed, and facilitated the referral of eligible patients for bone densitometry, fracture risk assessment, and implementation of pharmacotherapy in patients classified as high risk for future fracture. Variables assessed at baseline included age, sex, marital status, living location, fracture location, history of previous fracture, parent's history of hip fracture, history of falls, and fracture risk status. At 6months, bone active medication initiation was assessed in patients classified as high risk for future fracture. The Chi-square test of independence was used to compare medication initiation rates between patients 80 + and those 50-79years old. Our sample size consisted of 808 patients aged 50-79years and 346 aged 80 + years. After accounting for fracture risk status, there was no statistically significant difference in medication initiation rates of patients 50-79 and 80 + years old (76.9% versus 73.7%, p = 0.251). A systematic approach to identifying patients at high risk for future fracture and tailoring treatment recommendations to these patients appeared to eliminate differences in treatment initiation rates based on older age.

Association of Osteoporosis Medication Use After Hip Fracture With Prevention of Subsequent Nonvertebral Fractures

Osteoporosis medication treatment is recommended after hip fracture, yet contemporary estimates of rates of initiation and clinical benefit in the patient population receiving routine care are not well documented. To report osteoporosis treatment initiation rates between January 1, 2004, and September 30, 2015, and to estimate the risk reduction in subsequent nonvertebral fractures associated with treatment initiation in patients with hip fracture. In this cohort study, data from a commercial insurance claims database from the United States were analyzed. Patients 50 years and older who had a hip fracture and were not receiving treatment with osteoporosis medications before their fracture were included. Prescription dispensing of an osteoporosis medication within 180 days of a hip fracture hospitalization. Each initiation episode was matched with 10 nonuse episodes on person-time after the index hip fracture event to preclude immortal time bias and followed up for the outcome of nonvertebral fracture until change in exposure or a censoring event. An instrumental variable analysis using 2-stage residual inclusion method was conducted using calendar year, specialist access, geographical variation in prescribing patterns, and hospital preference. Among 97 169 patients with a hip fracture identified, the mean (SD) age was 80.2 (10.8) years, and 64 164 (66.0%) were women. A continuous decline over the study years was observed in osteoporosis medication initiation rates from 9.8% (95% CI, 9.0%-10.6%) in 2004 to 3.3% (95% CI, 2.9%-3.8%) in 2015. In the effectiveness analyses, the hospital preference instrumental variable had a stronger association with treatment (pseudo R2 = 0.20) than the other 3 instrumental variables (specialist access: pseudo R2 = 0.04; calendar year: pseudo R2 = 0.05; and geographic variation: pseudo R2 = 0.07). Instrumental variable analysis with hospital preference suggested a rate difference of 4.2 events (95% CI, 1.1-7.3) per 100 person-years in subsequent fractures associated with osteoporosis treatment initiation compared with nonuse in an additive hazard model. Low rates of osteoporosis treatment initiation after a hip fracture in recent years were observed. Clinically meaningful reduction in subsequent nonvertebral fracture rates associated with treatment suggests that improving prescriber adherence to guidelines and patient adherence to prescribed regimens may result in notable public health benefit.

Medication Management Patterns Among Medicare Beneficiaries With COPD Initiating Nebulized Arformoterol Treatment

SESSION TITLE: COPD: Lessons for the Real-World Management of Disease SESSION TYPE: Original Investigation Slide PRESENTED ON: Tuesday, October 31, 2017 at 02:45 PM - 04:15 PM PURPOSE: Global guidelines recommend the use of long-acting bronchodilators (LABD) as maintenance therapy for patients with COPD. However, little is known about the treatment and management patterns associated with initiating nebulized LABD therapy such as arformoterol. This study examined these treatment patterns among Medicare beneficiaries with COPD prior to and after initiating arformoterol. METHODS: Medicare administrative data from 2010-2014 were used to identify beneficiaries with ≥2 COPD outpatient visits within 30 days apart or with ≥1 COPD-related hospitalization(s) (i.e., ICD-9 codes 491.xx, 492.xx, and 496). Patients continuously enrolled in Medicare parts A, B, and D for the entire study period that initiated arformoterol were identified after excluding deaths. The use of the four following COPD medication classes 90-days prior to (pre-period) and after initiation of arformoterol (post-period) were examined: (a) LAMA/LABA: long-acting muscarinic antagonists (LAMAs) and inhaled long-acting beta2 agonists (LABAs) including fixed dose LABA+inhaled corticosteroid (ICS) combinations; (b) ICS/Neb ICS: ICS and nebulized corticosteroids (neb-CS); (c) methylxanthines, and d) other that included medications such as short-acting bronchodilators (SABD), oral corticosteroids and antibiotics. Rates of medication initiation, treatment continuation and discontinuation within these classes were determined based on refill patterns in the post-period. Sociodemographic and clinical characteristics (e.g., comorbidities) were also examined. Descriptive statistics were used to examine means, frequencies, and proportions. All analyses were preformed using SAS Enterprise Guide 7.1. RESULTS: A total of 11,886 nebulized arformoterol users were identified for the analysis. A substantial proportion of the patient cohort was 75 years or older (42%) and dually eligible for Medicaid (37%). Overall, 5,542 (46%) beneficiaries had received no LABD maintenance treatment 90 days prior to initiating arformoterol. Instead, they were being treated with a nebulized (50%) or an inhaled (37%) SABD, a systemic CS (46%), and many were on antibiotics (37%). In the post-period, 58% of beneficiaries received dual-therapy (LABA/ICS/Neb ICS [52%] or LAMA/LAMA [6%]), 21% received triple-therapy (LABA/LAMA/ICS/Neb CS), and 20% received monotherapy (only arformoterol). Nearly 41% of beneficiaries dropped ≥1 classes of medications they were taking prior to initiating arformoterol in the post-period. The largest decrease (-23%) was seen in CS use. CONCLUSIONS: The results suggest that nearly half of beneficiaries with COPD are not being treated with recommended LABD maintenance therapy. Among arformoterol users, dual therapy with a CS was highly prevalent. About 1 in 5 beneficiaries received either triple therapy or monotherapy. CLINICAL IMPLICATIONS: Evaluating the drivers associated with over reliance on SABD in lieu of recommended LABD maintenance treatment for appropriate patients, examining the triggers for initiating arformoterol, and linking arformoterol monotherapy v. combination therapy to outcomes are warranted. These analyses could help advance clinical decision-making for patients with COPD, particularly for those who have a history of exacerbations and hospitalizations. DISCLOSURE: Bartolome Celli: Consultant fee, speaker bureau, advisory committee, etc.: Advance Health Solutions, LLC, University grant monies: Astra Zeneca, Consultant fee, speaker bureau, advisory committee, etc.: Glaxo Smith Kline, Consultant fee, speaker bureau, advisory committee, etc.: Boehringer-Ingelheim, Consultant fee, speaker bureau, advisory committee, etc.: Astra Zeneca, Consultant fee, speaker bureau, advisory committee, etc.: Novartis, Consultant fee, speaker bureau, advisory committee, etc.: Pulmonix Maryam Navaie: Consultant fee, speaker bureau, advisory committee, etc.: Sunovion Pharmaceuticals Inc., Employee: Advance Health Solutions, LLC Vaidyanathan Ganapathy: Employee: Sunovion Pharmaceuticals, Inc. Zhun Xu: Grant monies (from industry related sources): Advance Health Solutions, LLC Soojin Cho-Reyes: Consultant fee, speaker bureau, advisory committee, etc.: Advance Health Solutions, LLC Todd Gilmer: Grant monies (from industry related sources): Advance Health Solutions, LLC No Product/Research Disclosure Information

Antihypertensive Medication Initiation Among Young Adults with Regular Primary Care Use

Young adults with hypertension have the lowest prevalence of controlled blood pressure compared to middle-aged and older adults. Uncontrolled hypertension, even among young adults, increases future cardiovascular event risk. However, antihypertensive medication initiation is poorly understood among young adults and may be an important intervention point for this group. The purpose of this study was to compare rates and predictors of antihypertensive medication initiation between young adults and middle-aged and older adults with incident hypertension and regular primary care contact. A retrospective analysis Adults ≥ 18 years old (n = 10,022) with incident hypertension and no prior antihypertensive prescription, who received primary care at a large, Midwestern, academic practice from 2008-2011. The primary outcome was time from date of meeting hypertension criteria to antihypertensive medication initiation, or blood pressure normalization without medication. Kaplan-Meier analysis was used to estimate the probability of antihypertensive medication initiation over time. Cox proportional-hazard models (HR; 95% CI) were fit to identify predictors of delays in medication initiation, with a subsequent subpopulation analysis for young adults (18-39 years old). After a mean follow-up of 20 (±13) months, 34% of 18-39 year-olds with hypertension met the endpoint, compared to 44% of 40-59 year-olds and 56% of ≥ 60 year-olds. Adjusting for patient and provider factors, 18-39 year-olds had a 44% slower rate of medication initiation (HR 0.56; 0.47-0.67) than ≥ 60 year-olds. Among young adults, males, patients with mild hypertension, and White patients had a slower rate of medication initiation. Young adults with Medicaid and more clinic visits had faster rates. Even with regular primary care contact and continued elevated blood pressure, young adults had slower rates of antihypertensive medication initiation than middle-aged and older adults. Interventions are needed to address multifactorial barriers contributing to poor hypertension control among young adults.

Abstract 351: Predictors of Delays to Antihypertensive Medication Initiation Among Young Adults with Regular Primary Care Use

Background: In the U.S., young adults (18-39 years old) continue to have low rates of hypertension control (38%) compared to middle-aged and older adults (54%). Although lifestyle modification counseling is a critical step in hypertension treatment, antihypertensive medication initiation is crucial for young adults who remain hypertensive, especially with Stage 2 hypertension (≥160/100 mmHg). However, young adults have low rates of antihypertensive medication initiation and the factors driving delays in medication initiation among young adults who are regular users of primary care are not well understood. The purpose of this study is to compare the rates of antihypertensive medication initiation among age groups and determine predictors of delays in antihypertensive medication initiation among young adults. Methods: This is a retrospective analysis of 14,974 patients, ≥18 years old, receiving regular primary care in a large, Midwestern, academic group practice from 2008 - 2011. Patients were included upon meeting JNC7 clinical criteria for Stage 1 (≥140-159/90-99 mmHg) or Stage 2 hypertension and followed up to 4 years. Patients with a previous antihypertensive prescription were excluded. Cox proportional hazard models (HR; 95% CI) stratified by hypertension stage, were fit overall and separately for young adults 18-39 years old to identify predictors of delays in antihypertensive medication initiation. Results: After 4 years, 51% overall (4,149 of 8,125) were prescribed antihypertensive medication and 69% (1,650 of 2,403) among those with Stage 2 hypertension; 43% of hypertensive young adults (18-39 yrs; 846 of 1,988) were prescribed medication, 62% (339 of 547) among those with Stage 2. Among age groups, 43% of 18-39 year olds (846 of 1,988) received antihypertensive treatment within 4 years, compared to 53% (40-59 yrs; 2,223 of 4,216) and 56% (≥60 yrs; 1,080 of 1,921). Adjusting for patient factors, blood pressure lability (i.e., intermittently normal blood pressures), and provider factors, adults 18-24 years old had a 50% slower rate of medication initiation (HR 0.5; 0.4-0.7) than ≥60 year olds. Adults 25-31 years (HR 0.6; 0.5-0.7) and 32-39 years (HR 0.8; 0.7-0.9) also had slower rates of medication initiation. When analyses were limited to young adults, higher urgent care use, White race, labile blood pressures, and non-English primary language were associated with slower rates of medication initiation. Young adults with diabetes, Medicaid and more specialty visits had faster rates. Conclusions: There are delays in antihypertensive medication initiation for young adults with multifactorial causes. Addressing poor hypertension control rates among young adults should target key factors related to delays, while continuing lifestyle modification counseling.

A population-based analysis of the post-fracture care gap 1996–2008: the situation is not improving

The post-fracture care gap has not narrowed in recent years. Following an initial improvement, rates of medication initiation have actually declined. The current study characterizes temporal changes in post-fracture bone mineral density (BMD) testing or osteoporosis treatment initiation from 1996/1997 to 2007/2008. A population-based administrative data repository for Manitoba, Canada was accessed to identify non-traumatic fractures in individuals aged 50 years and older. Outcomes included BMD testing or dispensation of an osteoporosis medication in the 12 months following the fracture. Thirty thousand nine hundred and twenty (30,920) fracture events met the inclusion criteria; 15,670 affected major osteoporotic fracture sites. Based on either BMD testing or treatment initiation, intervention rates reached a maximum of only 15.5% in 2003/2004, compared with 6.3% in 1996/1997, and 13.2% in 2007/2008 (p-for-trend < 0.001). Post-fracture BMD testing increased from 0.7% in 1996/1997 to 8.9% 2007/2008 (p-for-trend < 0.001). Osteoporosis medication use increased from 6.1% in 1996/1997 to 12.3% in 2001/2002 and then progressively declined to 5.9% by 2007/2008 (p-for-trend = 0.025). Similar trends were observed when only major osteoporotic fractures were included. The initiation of BMD testing or medication varied according to age, gender, geographic region, and income. Despite increased attention to gaps in osteoporosis management post-fracture in the last 10 years, the situation has not improved: in 2007/20008, fewer than 20% of untreated individuals with a low-trauma fracture received intervention. Novel strategies are required to disseminate and implement best practices at the point of care to reduce the risk of recurrent fractures.

Pharmacotherapy of Alcohol Use Disorders in the Veterans Health Administration

Pharmacotherapy of Alcohol Use Disorders in the Veterans Health Administration

Pharmacotherapy of Alcohol Use Disorders in the Veterans Health Administration

Acamprosate, oral and long-acting injectable naltrexone, and disulfiram are approved for treatment of alcohol dependence. Their availability and consideration of their use in treatment are now standards of high-quality care. This study determined rates of medication initiation among Veterans Health Administration (VHA) patients. VHA pharmacy and administrative data were used to identify patients with alcohol use disorder diagnoses in fiscal years (FY) 2006 and 2007 and the proportion (nationally and by facility) who received each medication. Patient characteristics associated with receipt were also examined. Among more than a quarter-million patients with alcohol use disorder diagnoses, the percentage receiving any of the medications increased from 2.8% in FY 2006 to 3.0% in FY 2007. Receipt of these medications was more likely among patients who received specialty addiction care, those with alcohol dependence (compared with abuse), those younger than 55 years, and females. In the patient subgroups examined, the largest proportion to receive any of the medications was 11.6%. Across 128 VHA facilities, rates of use among patients in the sample who had received past-year specialty addiction treatment ranged from 0% to 20.5%; rates ranged from 0% to 4.3% among those with no specialty treatment. Patient preferences and medical contraindications could not be determined from the data. Findings suggest the need to better understand systemwide variation in use of these medications and their use as a rough proxy for availability and consideration of pharmacotherapy--a standard of care with strong organizational support.

Medication Adherence Among Adolescents in a School‐Based Health Center

School-based health centers are an integral part of the health care delivery system for low-income children. Medication adherence for these patients may be challenging because the student is often responsible for bringing home the prescription and receiving the instructions. This study assesses medication fill, initiation, and adherence rates among adolescents in a school-based health center to identify major barriers to medication compliance. Students enrolled in a school-based health center, >or=10 years old, able to read and write English, and whose parent had provided consent for participation, were eligible for the study. Eligible students who received a prescription from the health center were invited to return to the clinic a week later to complete a questionnaire (with verbal assent). Primary outcome measures included medication fill rates, medication initiation rates, medication adherence rates, and reasons for nonadherence. Eighty-one students completed the questionnaire: 45 students (55.6%) filled their prescription. Of the students who filled their prescriptions, 75.6% reported always taking their medication at the appropriate time, 22.2% reported sometimes forgetting to take their medication, and 2.2% reported never taking the medication. However, many discrepancies were found between reported medication-taking behavior and the instructions provided to the student. Medication fill, initiation, and adherence rates among students receiving prescriptions for medications in school-based health centers are suboptimal. Interventions that address key identified barriers need to be developed and evaluated in order to achieve optimal fill and adherence rates.

A randomized, controlled trial of panic disorder treatment initiation in an emergency department chest pain center

Study Objective: We examine the effect of a protocol for panic disorder recognition and treatment initiation on medication initiation rates and medication continuation rates at 1- and 3-month follow-up. Methods: Enrolled participants, all at low to moderate risk for acute coronary syndrome, completed a 6-hour emergency department chest pain evaluation and panic disorder screen. Participants who had results positive for panic disorder completed the Panic Disorder Module of the Structured Clinical Interview (SCID) for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) by the research psychiatrist and the treating emergency physician, each blinded to the other's rating. Participants with panic disorder were randomized to either paroxetine initiation at 20 mg/d for 1 month or usual care with telephone follow-up at 3 months. Results: Fifty (32%) of 156 enrolled participants met criteria for panic disorder. All 25 (100%) participants in the paroxetine group initiated treatment, compared with 6 (24%) in the usual care group initiating any form of treatment (P =.006, relative risk [RR] 2.58, 95% confidence interval [CI] 1.20 to 5.58). Fourteen (56%) participants continued paroxetine treatment for at least 1 month, and at 3 months, 9 (36%) continued on some antipanic medication, compared with 2 (8%) for the usual care group (P =.05, RR 3.57, 95% CI 0.84 to 15.8). Conclusion: Panic disorder is common and severe in this sample of patients with chest pain. A screening measure and a brief (5-minute) structured interview allowed emergency physicians with no extra training to reliably diagnose panic disorder and initiate pharmacologic treatment. [Wulsin L, Liu T, Storrow A, Evans S, Dewan N, Hamilton C. A randomized, controlled trial of panic disorder treatment initiation in an emergency department chest pain center. Ann Emerg Med. February 2002;39:139-143.]