Use Of Recommended Medications Research Articles

An audit & feedback intervention for improved anticoagulant use in patients with atrial fibrillation in primary care

BackgroundImproving use of anticoagulants in atrial fibrillation (AF) patients in primary care has proved challenging. Anticoagulants are often prescribed by primary care physicians in the long term. Suboptimal anticoagulant use may be partly due to physicians' non-prescribing. One potential way of targeting physician prescribing behavior is “audit & feedback”. The documented use of audit and feedback in research aimed at increasing use of anticoagulants in primary care is limited. The objective was to test if an audit & feedback intervention aimed at directors in primary care centers could increase the use of anticoagulants in patients with AF. MethodsDatabase generated quality reports with primary care center specific data on recommended medication use in their patients with previous stroke or atrial fibrillation were sent to intervention centers. Results94 centers received the intervention, 102 centers were controls. 31,477 patients in total were included. Use of anticoagulants in all primary care centers increased from 76% before to 82% after the intervention. Patients in intervention centers were more likely than patients in control centers to use anticoagulants after the intervention, adjusted odds ratio increasing slightly from 1.04 (95%, CI, 0.98–1.10) before to 1.08 (95% CI, 1.02–1.15) after the intervention. ConclusionsAn audit & feedback intervention with quality reports in primary care had only a small effect on anticoagulant use in patients with AF. A combined and more complex intervention may have a greater effect in improving anticoagulation use.

The impact of advanced nurse practitioners on patient outcomes in chronic kidney disease: A systematic review.

Management of individuals with chronic kidney disease (CKD) requires a collaborative approach. Nurses have diversified their skills to take on roles which have been traditionally physician-led. The impact of such roles, mainly that of the advanced nurse practitioner (ANP), has not been previously assessed using a systematic approach. The aim of this systematic review (SR) was to determine the impact of the addition of an ANP on patient outcomes in adults with CKD. A SR, following the guidance of PRISMA was undertaken. Population: adults with CKD. ANP. Databases searched included The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Embase and Medline. Outcome measures were blood pressure (BP), lipids, haemoglobin A1c (HbA1c), phosphate and parathormone (PTH) measures and recommended medication use. Four studies met the inclusion criteria. All possessed external validity and demonstrated low risk for random sequence generation and allocation concealment but were at high risk of performance bias and detection bias. The addition of an ANP resulted in the superior management of BP in all studies. Three studies reported improved control of low-density lipoprotein (LDL) and PTH. One study reported greater achievement of phosphate control. Glycaemic control was equal in both groups. All studies reported higher rates of recommended medication use. The addition of an ANP is superior or equal to the usual care models for the management of BP, LDL, PTH and glycaemic control in adults with CKD.

Adherence to Guidelines for Screening and Medication Use: Mortality and Onset of Major Macrovascular Complications in Elderly Persons With Diabetes Mellitus.

The objective of this study is to investigate relationships between adherence to recommended screening and medication use and severe macrovascular complications and all-cause mortality among persons aged above 68 years with diabetes mellitus (DM). Data came from a 5% Medicare claims sample of beneficiaries initially diagnosed with DM during 2006-2008; follow-up was up to 7 years. Adherence to screening guidelines led to reduced mortality-hazard ratio (HR) = 0.57, 95% confidence interval [CI] = [0.56, 0.58]; congestive heart failure [CHF], HR = 0.89, CI = [0.87, 0.91]; acute myocardial infarction [AMI], HR = 0.90, CI = [0.85, 0.95]; and stroke/transient ischemic attack [Stroke/TIA], HR = 0.92, CI = [0.87, 0.97]-during follow-up. Recommended medication use led to lower mortality: HR = 0.72, CI = [0.70, 0.73]; CHF, HR = 0.67, CI = [0.66, 0.69]; AMI, HR = 0.68, CI = [0.65, 0.71]; and Stroke/TIA, HR = 0.79, CI = [0.76, 0.83]. Elderly persons newly diagnosed with diabetes who adhered to recommended care experienced reduced risk of mortality and severe macrovascular complications.

Guideline recommended medication use among systolic heart failure patients in India: Insights from the American college of cardiology practice innovation and clinical excellence (PINNACLE)® India Registry

Guideline recommended medication use among systolic heart failure patients in India: Insights from the American college of cardiology practice innovation and clinical excellence (PINNACLE)® India Registry

Capsule Commentary on Fontil, et al. Physician Underutilization of Effective Medications for Resistant Hypertension at Office Visits in the United States: NAMCS 2006-2010

Resistant hypertension is defined as elevated blood pressure despite optimal or best-tolerated treatment with at least three antihypertensive agents (one of which is usually a diuretic). Compared to patients with controlled blood pressure, patients with resistant hypertension are 50 % more likely to experience adverse cardiovascular events over a 4-year period.1 The first management guideline for management of resistant hypertension was published by the American Heart Association (AHA) in 2008.2 Currently, there are several guidelines on treating resistant hypertension. Using data from the National Ambulatory Medical Care Survey, Fontil et al. described trends in physician (general/family practitioners, internists, cardiologists) use of recommended medications for resistant hypertension before and after the 2008 AHA guidelines.3 The authors found that use of recommended medications for resistant hypertension was low and remained low 2 years after guideline publication. Assuming that the contribution of pseudo-resistant hypertension to these results is limited (e.g., minimal white coat hypertension), these findings are unfortunately in line with previous studies that highlighted the limited impact of guideline publications.4 Fontil et al. discussed the use of treatment algorithms to encourage prescription of recommended medications including the importance of feedback to physicians regarding patterns of medication use. It is not clear whether it will be sufficient to swiftly improve the care of patients with resistant hypertension. Indeed, the clinical inertia of physicians not specialized in hypertension (an inertia due to several factors including misguided acceptance of elevated blood pressure and underestimation of cardiovascular disease risk)5 might remain a meaningful barrier to changing treatment of resistant hypertension even after the implementation of a treatment algorithm. An alternative would be to consider a “detect and redirect” approach. Non-specialist practitioners could be trained and helped (including by algorithms) to detect patients with resistant hypertension and then be guided to redirect them to physicians (including general internists) or to units/clinics specialized in the management of hypertension. In addition to improving the recommended medication use, this approach could also contribute to improving the investigation of resistant hypertension in general (e.g., diagnosis, secondary causes, target organ damage). Whether this would improve outcomes is worthy of future research.

Cardiovascular medication in relation to renal function after coronary artery bypass surgery

Guidelines for recommended medication use for the secondary prevention of coronary heart disease are exceedingly important in patients with chronic kidney disease. Despite a high risk for recurrent cardiovascular events, these patients are less likely to use evidence-based recommended medications. The objective of the current study was to analyze the association between renal function and guideline-recommended drug therapy in patients with coronary heart disease. In this nationwide population-based cohort study, we included 12,332 patients with established coronary heart disease who underwent primary isolated coronary artery bypass grafting in Sweden between 2005 and 2008. Medication use was retrieved from the national Prescribed Drug Register. During the first year after coronary surgery, 94% of patients had at least two dispensed prescriptions for an antiplatelet agent, 68% for an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker, 92% for a beta-blocker, and 93% for a statin. Only 57% of all patients had prescriptions for all four medication classes. Reduced renal function (estimated glomerular filtration rate (eGFR) of 30 to 45 mL/min per 1.73 m(2) and <30 mL/min per 1.73 m(2)) was significantly associated with a lower use of all four medication classes (adjusted risk ratio 0.89, 95% confidence interval 0.82 to 0.98; and adjusted risk ratio 0.75, 95% confidence interval 0.62 to 0.90, respectively) as compared to normal renal function (eGFR >60 mL/min per 1.73 m(2)). In patients with established coronary heart disease, moderate to severe renal dysfunction was associated with significantly lower use of guideline-recommend medications as compared to normal renal function.

Factors Associated with Non-Adherence to Three Hypertension Self-Management Behaviors: Preliminary Data for a New Instrument

Clinicians have difficulty in identifying patients that are unlikely to adhere to hypertension self-management. Identifying non-adherence is essential to addressing suboptimal blood pressure control and high costs. 1) To identify risk factors associated with non-adherence to three key self-management behaviors in patients with hypertension: proper medication use, diet, and exercise; 2) To evaluate the extent to which an instrument designed to identify the number of risk factors present for non-adherence to each of the three hypertension self-management behaviors would be associated with self-management non-adherence and blood pressure. Cross-sectional analysis of randomized trial data. Six hundred and thirty-six primary care patients with hypertension. 1) Demographic, socioeconomic, psychosocial, and health belief-related factors; 2) measures of self-reported adherence to recommended medication use, diet recommendations, and exercise recommendations, all collected at baseline assessment; 3) systolic blood pressure (SBP) and diastolic blood pressure (DBP). We identified patient factors associated with measures of non-adherence to medications, diet, and exercise in hypertension. We then combined risk factors associated with ≥1 adherence measure into an instrument that generated three composite variables (medication, diet, and exercise composites), reflecting the number of risk factors present for non-adherence to the corresponding self-management behavior. These composite variables identified subgroups with higher likelihood of medication non-adherence, difficulty following diet recommendations, and difficulty following exercise recommendations. Composite variable levels representing the highest number of self-management non-adherence risk factors were associated with higher SBP and DBP. We identified factors associated with measures of non-adherence to recommended medication use, diet, and exercise in hypertension. We then developed an instrument that was associated with non-adherence to these self-management behaviors, as well as with blood pressure. With further study, this instrument has potential to improve identification of non-adherent patients with hypertension.

Prescription drug benefits and use of guideline recommended medications by elderly Medicare beneficiaries with diabetes mellitus.

To determine whether prescription drug benefits are associated with the use of guideline recommended medications by older persons with type 2 diabetes mellitus (DM). Cross-sectional study. A national sample of Medicare beneficiaries with DM aged 65 and older and an indication for angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II-receptor blocker (ARB) use or high risk of coronary heart disease (hypertension or current smoking) who participated in the 2003 Medicare Current Beneficiary Survey. Prescription drug coverage was measured according to self-report and verified according to insurance claims. Outcome variables were use of an ACEI or an ARB (ACEI/ARB) or a statin or use of an ACEI/ARB and a statin. Survey-weighted multinomial logistic regression was used to identify the independent effect of drug coverage on one of two categories of recommended medication use (ACEI/ARB or statin or ACEI/ARB and statin) compared with the reference category of none after controlling for sociodemographic characteristics and health status. The final study sample was 1,181 (weighted N=4.0 million). Overall, 23% had no drug coverage, 16% Medicaid coverage, 43% employer coverage, 9% Medigap coverage, and 9% Department of Veterans Affairs (VA) or state-sponsored low-income coverage. Overall, 33% received a statin and an ACEI/ARB, 44% only an ACEI/ARB or a statin, and 23% neither. After adjustment, VA and state-sponsored drug benefits were most strongly associated with combined ACEI/ARB and statin use (relative risk ratio (RRR)=4.83, 95% confidence interval (CI)=2.24-10.4)), followed by employer-sponsored coverage (RRR=2.60, 95% CI=1.67-4.03)). Prescription drug benefits from VA and state-sponsored drug programs are strongly associated with use of recommended medications by older adults with DM.