Use Of Guideline-recommended Medications Research Articles

Trends in type 2 diabetes medication use and guideline adherence in Belgian primary care (2019–2023)

AimsTo assess the prevalence of atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and chronic kidney disease (CKD) among patients with type 2 diabetes (T2D) in Belgium. To analyze trends in medication use and adherence to guidelines from 2019 to 2023. MethodsWe conducted a retrospective cross-sectional analysis using data from the Intego primary care database, encompassing records from 431 general practitioners. We identified adults with T2D through diagnostic codes and glycated hemoglobin levels and analyzed subgroups with ASCVD, HF, and CKD for trends in medication use, particularly SGLT2 inhibitors (SGLT2-i) and GLP-1 receptor agonists (GLP-1). ResultsThe T2D population increased from 20,766 in 2019 to 21,764 in 2023. The prevalence of ASCVD, HF, and CKD among T2D patients slightly increased to 27 %, 6.7 %, and 23.7 % by 2023 (from 25.2 %, 4.9 % and 21.5 % respectively). Medication prescription trends showed a tripling of SGLT2-i and GLP-1 prescribing in the study period to 6.2 % and 11.5 % respectively. Despite these increases, only 7.5 % of eligible patients received these medications as of 2023. ConclusionThe study highlights a growing burden of ASCVD, HF, and CKD among T2D patients in Belgium and an increase in the use of guideline-recommended medications. However, there remains a substantial gap in the optimal use of these therapies, indicating a need for improved implementation of clinical guidelines in primary care.

GLP-1RA vs DPP-4i Use and Rates of Hyperkalemia and RAS Blockade Discontinuation in Type 2 Diabetes

Hyperkalemia is a common complication in people with type 2 diabetes (T2D) that may limit the use of guideline-recommended renin-angiotensin system inhibitors (RASis). Emerging evidence suggests that glucagon-like peptide-1 receptor agonists (GLP-1RAs) increase urinary potassium excretion, which may translate into reduced hyperkalemia risk. To compare rates of hyperkalemia and RASi persistence among new users of GLP-1RAs vs dipeptidyl peptidase-4 inhibitors (DPP-4is). This cohort study included all adults with T2D in the region of Stockholm, Sweden, who initiated GLP-1RA or DPP-4i treatment between January 1, 2008, and December 31, 2021. Analyses were conducted between October 1, 2023, and April 29, 2024. GLP-1RAs or DPP-4is. The primary study outcome was time to any hyperkalemia (potassium level >5.0 mEq/L) and moderate to severe (potassium level >5.5 mEq/L) hyperkalemia. Time to discontinuation of RASi use among individuals using RASis at baseline was assessed. Inverse probability of treatment weights served to balance more than 70 identified confounders. Marginal structure models were used to estimate per-protocol hazard ratios (HRs). A total of 33 280 individuals (13 633 using GLP-1RAs and 19 647 using DPP-4is; mean [SD] age, 63.7 [12.6] years; 19 853 [59.7%] male) were included. The median (IQR) time receiving treatment was 3.9 (1.0-10.9) months. Compared with DPP-4i use, GLP-1RA use was associated with a lower rate of any hyperkalemia (HR, 0.61; 95% CI, 0.50-0.76) and moderate to severe (HR, 0.52; 95% CI, 0.28-0.84) hyperkalemia. Of 21 751 participants who were using RASis, 1381 discontinued this therapy. The use of GLP-1RAs vs DPP-4is was associated with a lower rate of RASi discontinuation (HR, 0.89; 95% CI, 0.82-0.97). Results were consistent in intention-to-treat analyses and across strata of age, sex, cardiovascular comorbidity, and baseline kidney function. In this study of patients with T2D managed in routine clinical care, the use of GLP-1RAs was associated with lower rates of hyperkalemia and sustained RASi use compared with DPP-4i use. These findings suggest that GLP-1RA treatment may enable wider use of guideline-recommended medications and contribute to clinical outcomes in this population.

Evaluating the Use of Guideline-Recommended Medications and Potentially Inappropriate Medications among Outpatients with Heart Failure

Evaluating the Use of Guideline-Recommended Medications and Potentially Inappropriate Medications among Outpatients with Heart Failure

Randomized controlled trial of a clinical decision support system for painful polyneuropathy.

Despite the existence of guidelines, painful neuropathy is often inappropriately treated. We sought to determine the effectiveness of a clinical decision support system on guideline-recommended medication use. We randomized neurology providers, stratified by subspecialty, to a best practice alert (BPA) linked to a Smartset or a BPA alone when seeing patients with neuropathy. The primary outcome was the proportion of patients with uncontrolled nerve pain prescribed a guideline-recommended medication. Generalized estimating equations were used to assess effectiveness. Seventy-five neurology providers (intervention 38, control 37) treated 2697 patients with neuropathy (intervention 1026, control 671). Providers did not acknowledge the BPA in 1928 (71.5%) visits. Only four of eight intervention arm neurologists who treated patients with uncontrolled nerve pain opened the Smartset. The intervention was not associated with guideline-recommended medication use (odds ratio 0.52, 0.18-1.48; intervention 52%, control 54.8%). Our intervention did not improve prescribing practices for painful neuropathy. Physicians typically ignored the BPAs/Smartset; therefore, future studies should mandate their use or employ alternate strategies.

Psychological distress and medication use for secondary prevention of cardiovascular events: Evidence from a large-scale population-based cohort study

ObjectiveCardiac patients with psychological distress have a poorer prognosis than patients without distress, potentially reflecting differences in preventive care. We aimed to examine distress-related variation in guideline-recommended medication use for secondary prevention of cardiovascular disease (CVD). MethodsBaseline questionnaire data from the 45 and Up Study (collected 2006–2009) were linked to hospitalisation, pharmaceutical dispensing and death records (to exclude those who died). Among participants hospitalised with myocardial infarction, angina, stroke/transient ischaemic attack in the six years before the questionnaire, Modified Poisson regression was used to estimate relative risks (RR) for distress (Kessler 10 scores: low[10- < 12], mild[12- < 16], moderate[16- < 22] and high[22–50]) and use of both blood pressure- and lipid-lowering medications, and use of neither medication in the three months following the questionnaire, adjusting for sociodemographic and health characteristics. ResultsAmong 7598 participants, 34.0% had low, 35.4% mild, 18.3% moderate and 12.3% high psychological distress. Around two-thirds (63.4%) were using both medications and the proportion declined with increasing levels of distress: RRs were 1.01(95%CI:0.97–1.05), 0.95(0.90–1.00) and 0.91(0.86–0.97) for mild, moderate and high compared to low distress, respectively (p(trend) = 0.001). The proportion using neither medication was 9.1% and increased with increasing distress: RRs for mild, moderate and high compared to low distress were 0.99(0.82–1.19), 1.30(1.06–1.59) and 1.60(1.28–1.98), respectively (p(trend) < 0.001). ConclusionPatients with psychological distress may need more support to optimise their use of secondary CVD prevention medications. Increasing the use of these medications for distressed patients may improve prognosis for patients with distress and improve population-level secondary prevention of CVD more broadly.

Longitudinal pattern of pain medication utilization in peripheral neuropathy patients.

We aimed to investigate the pattern and utilization of neuropathic pain medications in peripheral neuropathy patients. Using a privately insured, health care claims database from 2001 to 2014, we identified a retrospective cohort of incident peripheral neuropathy patients (validated ICD-9 definition) after excluding other chronic pain conditions. Outcome measures included opioid prescriptions, chronic opioid therapy (greater than or equal to 90 days of continuous supply), guideline-recommended medications for painful peripheral neuropathy (serotonin reuptake inhibitors, tricyclic antidepressants, and gabapentinoids), and pain specialists (neurologists, physiatrists, and anesthesiologists). Multivariable logistic regression was used to evaluate associations of patient-level factors with these outcomes. The peripheral neuropathy population included 14,426 individuals with a mean (SD) age of 43.1 years (2.8) and 52.4% men followed for 3.1 (1.7) years before and 4.5 (1.4) years after the diagnosis. In this population, 65.9% received ≥1 opioid prescription, and 8.8% received chronic opioid therapy. Of those receiving chronic opioid therapy, only 26.4% received a guideline-recommended medication before chronic opioid status. For guideline-recommended medications, 35.7% received ≥1, 12.4% ≥2, and 3.8% ≥3 different medications. No patient-level factors were associated with both high opioid utilization (initiation and chronic use) and low guideline-recommended medication utilization. Pain specialists were associated with high opioid utilization and high guideline-recommended medication utilization. In conclusion, opioid initiation and transition to chronic opioid therapy are frequent in a peripheral neuropathy population despite few patients receiving more than one guideline-recommended medication. Efforts to decrease opioid utilization and increase guideline-recommended medication use are needed to improve current neuropathic pain treatment.

Socioeconomic variation in absolute cardiovascular disease risk and treatment in the Australian population

Cardiovascular disease (CVD), preventable through appropriate management of absolute CVD risk, disproportionately affects socioeconomically disadvantaged individuals. The aim of this study was to estimate absolute and relative socioeconomic inequalities in absolute CVD risk and treatment in the Australian population using cross-sectional representative data on 4751 people aged 45–74 from the 2011–12 Australian Health Survey. Poisson regression was used to calculate prevalence differences (PD) and ratios (PR) for prior CVD, high 5-year absolute risk of a primary CVD event and guideline-recommended medication use, in relation to socioeconomic position (SEP, measured by education). After adjusting for age and sex, the prevalence of high absolute risk of a primary CVD event among those of low, intermediate and high SEP was 12.6%, 10.9% and 7.7% (PD, low vs. high = 5.0 [95% CI: 2.3, 7.7], PR = 1.6 [1.2, 2.2]) and for prior CVD was 10.7%, 9.1% and 6.7% (PD = 4.0 [1.4, 6.6], PR = 1.6 [1.1, 2.2]). The proportions using preventive medication use among those with high primary risk were 21.3%, 19.5% and 29.4% for low, intermediate and high SEP and for prior CVD, were 37.8%, 35.7% and 17.7% (PD = 20.1 [9.7, 30.5], PR = 2.1 [1.3, 3.5]). Proportions at high primary risk and not using medications among those of low, intermediate and high SEP were 10.6%, 8.8% and 4.7% and with prior CVD and not using medications were 8.5%, 6.3% and 4.1%. Findings indicate substantial potential to prevent CVD and reduce inequalities through appropriate management of high absolute risk in the population.

Socioeconomics differences in absolute cardiovascular disease risk and treatment: Opportunities for reducing inequalities in cardiovascular events in the population

Introduction A large number of cardiovascular disease (CVD) events in the population can be prevented through appropriate management of absolute CVD risk. CVD disproportionately affects socioeconomically disadvantaged individuals, challenging efforts to reduce overall CVD morbidity and mortality in the population. While there are demonstrated links between socioeconomic position and CVD morbidity and mortality, population-level data on variations in absolute CVD risk and treatment are needed to inform interventions and policies to prevent CVD and address inequalities. We estimated absolute and relative socioeconomic inequalities in absolute CVD risk and the use of guideline-recommended medications in the Australian population to identify opportunities to reduce inequalities in CVD events. Methods We used cross-sectional representative population-based data on 4751 men and women aged 45–74 from the 2011–12 Australian National Health Survey, including interview, physical measurement and blood and urine sample data. We used Poisson regression with robust standard errors to calculate prevalence differences (PD) and ratios (PR) for prior CVD, high 5-year absolute risk of a primary CVD event and guideline-recommended medication use, in relation to socioeconomic position measured by highest level of education attained. The models were adjusted for age and sex and then additionally for region of residence and region of birth. Weights were applied to the prevalence estimates to account for the sampling strategy and non-response, and a series of sensitivity analyses were done to assess whether the results were robust to using alternative measures of socioeconomic position. Results Overall, 9.3% of participants had prior CVD and 11.0% had high absolute risk of a primary CVD event. Thirty-four percent of those with prior CVD and 22% of those at high absolute risk of a primary CVD event were using guideline-recommended medications. After adjusting for age and sex, the prevalence of prior CVD and high absolute risk of a primary CVD event increased linearly with decreasing socioeconomic position (test for trend, P = 0.005 and P = 0.001, respectively). People with the lowest (no post-school qualifications) compared to the highest (university degree) socioeconomic position had 1.6 (95% confidence intervals [CI]: 1.1, 2.2) times the prevalence of prior CVD (10.7% vs 6.7%, respectively) and 1.6 (95% CI: 1.2, 2.2) times the prevalence of high absolute risk of a primary CVD event (12.6% vs 7.7%, respectively). In absolute terms, the prevalence of prior CVD and of high absolute risk of a primary CVD event were 4 and 5 percentage points higher, respectively, among the most disadvantaged within the population. Among people with prior CVD those with low compared to high socioeconomic position were 2.1 (95% CI: 1.3, 3.5) times more likely to use lipid- and blood pressure-lowering and antithrombotic medications as recommended in clinical guidelines. Among those at high primary risk there was no clear relationship between socioeconomic position and use of preventive medications. Results were not materially different when additionally adjusted for region of residence and region of birth, or when socioeconomic position was ascertained using measures of income and area-level disadvantage. Conclusion In this nationally representative population-based Australian study, the prevalence of prior CVD and high absolute CVD risk increased with increasing levels of disadvantage. Socioeconomic differentials in high absolute risk of CVD, combined with low treatment levels among high risk individuals, indicates substantial potential to prevent CVD and reduce inequalities in CVD events through appropriate management of high absolute risk in the population.

Analysis of changes in pharmacotherapy of stable angina over the five-year period at specialized out-patient level of medical care (pharmacoepidemiological study)

Introduction: Ischemic heart disease (IHD) remains the leading cause of death both in Europe and in Russia. The most common form of IHD is stable angina. There is compelling evidence that strict adherence to clinical guidelines greatly contributes to mortality reduction. However, the gap between modern knowledge and use of guideline-recommended medications remains significant. As shown by Western practice, one of the possible solutions of this problem is regular conduction of pharmacoepidemiological studies.&#x0D; Objective: Investigate the dynamics of drug prescription rates in patients with stable angina over the five-year period on the example of routine clinical practice of outpatient cardiology institution of Moscow for the purpose of further eliminating the prescribing gap for guideline recommended pharmacological strategies.&#x0D; Materials and methods: Our research work was performed as a retrospective pharmacoepidemiological study including two stages with five-year interval using cross-section method.&#x0D; Results and discussion: We found a significant increase in use of antiplatelets (82.7 vs. 56.2%, p&lt;0.05) and statins (45.6 vs. 16.1%, p&lt;0.05). Despite the unchanged use of ACE inhibitors, the prescription rate of angiotensin receptor blockers II increased (14.7 vs. 9.7%, p&lt;0.05). Analysis of anti-ischemic pharmacotherapy revealed an increase in beta-adrenoblockers use (74.3 vs. 63.6%, р&lt;0.05) and a decrease in use of long-acting nitrates (26.3 vs. 31.1%, р&lt;0.05) and calcium channel blockers (35.7 vs. 39.6%, р&lt;0.05). Significant changes were found in prescription rates and dosage regimens of single medications in each pharmacological group. The study results demonstrated an increase in frequency of capturing data on lipid profile and diet recommendations in patient records.&#x0D; Conclusion: Such type of pharmacoepidemiological study carried out for the first time made it possible to investigate the dynamics of specialists’ adherence to guidelines of stable angina pharmacotherapy in routine outpatient clinical practice.

Body mass index in acute heart failure: association with clinical profile, therapeutic management and in-hospital outcome.

Increased body mass index (BMI) is a risk factor for heart failure, but evidence regarding BMI in acute heart failure (AHF) remains inconclusive. We sought to compare the clinical profile, treatment and in-hospital outcome across BMI categories in a large international AHF cohort. The Acute Heart Failure Global Survey of Standard Treatment (ALARM-HF) is a retrospective survey on 4953 patients admitted for AHF from nine countries in Europe, Latin America, and Australia. Patients with unavailable BMI data or BMI <18.5 kg/m(2) were excluded. Clinical data and in-hospital mortality were compared among the following BMI categories: 18.5-24.9 kg/m(2) (normal weight), 25-29.9 kg/m(2) (overweight) and ≥30 kg/m(2) (obese). Overweight/obese patients represented 75.7% of patients and had worse New York Heart Association class (P < 0.001) and higher admission systolic blood pressure (P < 0.001). The prevalence of comorbidities increased in parallel with BMI and included arterial hypertension, diabetes mellitus, dyslipidaemia (all P < 0.001), chronic obstructive pulmonary disease (P = 0.041) and chronic kidney disease (P = 0.056). Use of guideline-recommended medications also increased in parallel with BMI (angiotensin converting enzyme inhibitors/angiotensin II receptor blockers, P < 0.001; β-blockers P < 0.001; mineralocorticoid receptors antagonist, P = 0.002). In-hospital mortality had a U-shaped relationship with BMI, with overweight patients having significantly lower rate (log-rank P = 0.027); this relationship vanished after adjustment for confounders. Overweight/obese patients represented the vast majority of AHF cases, had a higher prevalence of non-cardiovascular comorbidities and were more likely to receive guideline-recommended medications. The U-shaped relationship between in-hospital mortality and BMI may be explained by differences in clinical profile and treatment and not by an effect of body composition per se.

The Need Associated with Diabetes Primary Care and the Impact of Referral to a Specialist-Centered Multidisciplinary Diabetes Program (the NADIR Study)

The impact of specialist care on glycemia and cardiovascular risk factors in patients with diabetes is uncertain. This observational cohort study investigated metabolic risk factors in patients referred to LMC Diabetes & Endocrinology for diabetes management. The cohort included 306 consecutive patients with diabetes referred to LMC in Ontario between January and June 2010. Sources of prereferral data included consultation notes, records from primary care physicians and the Ontario Lab Information System. Postreferral data were obtained from LMC's patients' records. The mean duration of diabetes before referral was 11 years, and the mean baseline glycated hemoglobin (A1C) level was 8.8%. Among patients with uncontrolled A1C levels at baseline, 73% had had no A1C values ≤7% for up to 6 years before referral. Following referral, mean A1C levels decreased to 7.8% at 6 and 12 months (both p<0.001 vs. baseline). Attendance at diabetes education programs improved from 28% to 67% postreferral, and attendees achieved significantly greater A1C reductions than nonattendees (mean 1.1% vs. 0.7%, respectively). Mean low-density lipoprotein levels declined from 2.3 mmol/L at referral to 1.8 mmol/L at 12 months (p<0.05). Mean blood pressure was similar, at 128/75 before and 129/75 mm Hg after referral; however, following referral, blood pressure improved from 143/89 to 134/80 (p<0.001) in patients with previously uncontrolled blood pressure. Use of guideline-recommended medications increased significantly following referral. Referral to specialist care should be considered early in the course of diabetes in order to optimize management of glycemia and cardiovascular risk factors.

Evidence-to-practice gaps in the management of community-dwelling Australian patients with ischaemic heart disease.

Ischaemic heart disease (IHD) is a major cause of death in developed countries. Patients with IHD are at greater risk of subsequent myocardial infarction (MI). International studies suggest that guideline recommended therapies proven to reduce this risk are underutilised. The objectives of this study were to review the use of guideline-recommended medications for the secondary prevention of IHD in Australians and identify patient characteristics influencing use of these medications. The medication regimens of community dwelling Australians with documented IHD who received a Home Medicines Review (HMR) between January 2010 and September 2012 were extracted from a pharmacist decision support software database and retrospectively reviewed. Each patient's use of antithrombotics; angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs); statins; and β-blockers (BBs) or non-dihydropyridine calcium channel blockers (CCBs) was evaluated in conjunction with documented contraindications. Guideline concordance in all four categories was classified as 'Optimal Medical Therapy' (OMT). Univariate and multivariate analyses identified patient characteristics influencing OMT use. Of the 5396 patient medication regimens reviewed, 24·3% demonstrated OMT. Guideline concordance was observed in 91·6%, 75·6%, 74·8%, and 42·4% of patients for antithrombotics, statins, ACEI/ARBs, and BB/CCBs, respectively. The independent predictors of not receiving OMT were age 75 years or over (adjusted odds ratio [AOR] 0·76; 95% confidence interval [CI] 0·67-0·87), asthma (AOR 0·69; 95% CI 0·57-0·84), and depression or anxiety (AOR 0·84; 95% CI 0·71-0·99). Diabetes (AOR 1·20; 95% CI 1·04-1·38), hypertension (AOR 1·56; 95% CI 1·36-1·79) and a high Charlson Comorbidity Index score (AOR 1·37; 95% CI 1·15-1·64) independently predicted receipt of OMT. Only one quarter of community dwelling Australian patients with IHD receive antithrombotics, ACEI/ARBs, BB/CCBs and statins. The potential consequences of these evidence-to-practice gaps are exacerbated by Australia's increasing prevalence of IHD. Healthcare professionals must work to ensure that recommended therapies are prescribed and adhered to long-term, especially in the elderly and patients with asthma and mental health problems, to reduce IHD-related mortality and morbidity and the consequent healthcare and financial impact.

Trends in the use of guideline-recommended medications and in-hospital mortality of patients with acute myocardial infarction in a Chinese population.

ObjectiveCurrent practice guidelines recommend the routine use of several cardiac medications early in the course of acute myocardial infarction (AMI). Our objective was to analyze temporal trends in medication use and in-hospital mortality of AMI patients in a Chinese population.MethodsThis is a retrospective observational study using electronic medical records from the hospital information system (HIS) of 14 Chinese hospitals. We identified 5599 patients with AMI between 2005 and 2011. Factors associated with medication use and in-hospital mortality were explored by using hierarchical logistic regression.ResultsThe use of several guideline-recommended medications all increased during the study period: statins (57.7%–90.1%), clopidogrel (61.8%–92.3%), β-Blockers (45.4%–65.1%), ACEI/ARB (46.7%–58.7%), aspirin (81.9%–92.9%), and the combinations thereof increased from 24.9% to 42.8% (P<0.001 for all). Multivariate analyses showed statistically significant increases in all these medications. The in-hospital mortality decreased from 15.9% to 5.7% from 2005 to 2011 (P<0.001). After multivariate adjustment, admission year was still a significant factor (OR = 0.87, 95% CI 0.79–0.96, P = 0.007), the use of aspirin (OR = 0.64, 95% CI 0.46–0.87), clopidogrel (OR = 0.44, 95% CI 0.31–0.61), ACEI/ARB (OR = 0.73, 95% CI 0.56–0.94) and statins (OR = 0.54, 95% CI 0.40–0.73) were associated with a decrease in in-hospital mortality. Patients with older age, cancer and renal insufficiency had higher in-hospital mortality, while they were generally less likely to receive all these medications.ConclusionUse of guideline-recommended medications early in the course of AMI increased between 2005 and 2011 in a Chinese population. During this same time, there was a decrease in in-hospital mortality.

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

Abstract 183: Optimal Medical Therapy for Cardiovascular Disease in the Obese Undergoing Elective Percutaneous Coronary Intervention: Insights from the VA CART Program

Background: Stigma against obese patients is well described in primary care settings and may contribute to bias in therapeutic decision-making. It is unknown if similar stigma exists in obese patients referred for elective PCI. Accordingly, we evaluated the association between body mass index (BMI) and pre-procedural guideline-recommended medication use in patients undergoing elective PCI. The presence of lower medication use in overweight and obese patients may suggest the presence of a treatment bias. Methods: Using data from the VA Clinical Assessment, Reporting, and Tracking System (CART) Program, we identified patients undergoing elective PCI from 2007-2012. We classified patients by BMI into normal (19-25), overweight (25-30), obese (&gt;30). Rates of guideline-indicated medication use by BMI were assessed among eligible patients: beta-blockers (BB) for HF or prior MI, statins for CAD or equivalent (DM, CVD, PAD), anticoagulation for AFib and CHADS2&gt; 1, and ACEI/ARB for HF. We also assessed composite rates of BB and statin in eligible MI patients and BB and ACEI/ARB use in eligible HF patients, respectively. Multivariable logistic regression analyses assessed the association between BMI class and use of indicated medications. Results: Among 9,630 patients undergoing elective PCI from 2007-2012, 13.9% of patients had normal BMI, 35.6% overweight, and 50.6% obese. Overweight and obese patients were more likely to have sleep apnea, HTN and DM, while normal BMI patients were more likely to smoke, have lung disease, and CVD. Rates of medication use ranged from 45% to 69% depending on the class of medication assessed. After adjustment for CV risk factors, overweight and obese patients were more likely to receive statins and ACE/ARBs and equally likely to receive the other classes of medications compared to normal BMI patients (Table). Conclusions: Over 85% of patients undergoing elective PCI in the VA are overweight or obese. Rates of indicated medication use remained low across BMI categories (&lt;70%). There was an association between overweight and obese patients with greater use of some guideline-indicated medications, suggesting that a treatment bias against obesity prior to elective PCI does not exist. Future studies should assess for any impact of BMI on treatment of patients during and following elective PCI.

Effect of dementia on the use of drugs for secondary prevention of ischemic heart disease.

Background. Dementia and cardiovascular disease (CVD) are frequently comorbid. The presence of dementia may have an effect on how CVD is treated. Objective. To examine the effect of dementia on the use of four medications recommended for secondary prevention of ischemic heart disease (IHD): angiotensin-converting enzyme inhibitors, beta-blockers, lipid-lowering medications, and antiplatelet medications. Design. Retrospective analysis of data from the Cardiovascular Health Study: Cognition Study. Setting and Subjects. 1,087 older adults in four US states who had or developed IHD between 1989 and 1998. Methods. Generalized estimating equations to explore the association between dementia and the use of guideline-recommended medications for the secondary prevention of IHD. Results. The length of follow-up for the cohort was 8.7 years and 265 (24%) had or developed dementia during the study. Use of medications for the secondary prevention of IHD for patients with and without dementia increased during the study period. In models, subjects with dementia were not less likely to use any one particular class of medication but were less likely to use two or more classes of medications as a group (OR, 0.60; 95% CI, 0.36–0.99). Conclusions. Subjects with dementia used fewer guideline-recommended medications for the secondary prevention of IHD than those without dementia.

Practice-Level Variation in Use of Recommended Medications Among Outpatients With Heart Failure

Background— The objective of this study is to examine practice-level variation in rates of guideline-recommended treatment for outpatients with heart failure and reduced ejection fraction, and to examine the association between treatment variation and practice site, independent of patient factors. Methods and Results— Cardiology practices participating in the National Cardiovascular Disease Registry Practice Innovation and Clinical Excellence registry from July 2008 to December 2010 were evaluated. Practice rates of treatment with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and β-blockers and an optimal combined treatment measure were determined for patients with heart failure and reduced ejection fraction and no documented contraindications. Multivariable hierarchical regression models were adjusted for demographics, insurance status, and comorbidities. A median rate ratio was calculated for each therapy, which describes the likelihood that the treatment of a patient with given comorbidities would differ at 2 randomly selected practices. We identified 12 556 patients from 45 practices. The unadjusted practice-level prescription rates ranged from 44% to 100% for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (median, 85%; interquartile range, 75%–89%), from 49% to 100% for β-blockers (median, 92%; interquartile range, 83%–95%), and from 37% to 100% for optimal combined treatment (median, 79%; interquartile range, 66%–85%). The adjusted median rate ratio was 1.11 (95% confidence interval, 1.08–1.18) for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers therapy, 1.08 (95% confidence interval, 1.05–1.15) for β-blockers therapy, and 1.17 (1.13–1.26) for optimal combined treatment. Conclusions— Variation in the use of guideline-recommended medications for patients with heart failure and reduced ejection fraction exists in the outpatient setting. Addressing practice-level differences may be an important component of improving quality of care for patients with heart failure and reduced ejection fraction.

Effects of Individual Physician-Level and Practice-Level Financial Incentives on Hypertension Care

Pay for performance is intended to align incentives to promote high-quality care, but results have been contradictory. To test the effect of explicit financial incentives to reward guideline-recommended hypertension care. Cluster randomized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel (eg, nurses, pharmacists). Physician-level (individual) incentives, practice-level incentives, both, or none. Intervention participants received up to 5 payments every 4 months; all participants could access feedback reports. Among a random sample, number of patients achieving guideline-recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure, number of patients prescribed guideline-recommended medications, and number who developed hypotension. Mean (SD) total payments over the study were $4270 ($459), $2672 ($153), and $1648 ($248) for the combined, individual, and practice-level interventions, respectively. The unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75% to 84% and 8.84% (95% CI, 4.20% to 11.80%) for the individual group, 80% to 85% and 3.70% (95% CI, 0.24% to 7.68%) for the practice-level group, 79% to 88% and 5.54% (95% CI, 1.92% to 9.52%) for the combined group, and 86% to 86% and 0.47% (95% CI, -3.12% to 4.04%) for the control group. The adjusted absolute estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36% (95% CI, 2.40% to 13.00%; P=.005). The other incentive groups did not show a significant change compared with controls for this outcome. For medications, the unadjusted baseline and final percentages and the adjusted absolute change were 61% to 73% and 9.07% (95% CI, 4.52% to 13.44%), 56% to 65% and 4.98% (95% CI, 0.64% to 10.08%), 65% to 80% and 7.26% (95% CI, 2.92% to 12.48%), and 63% to 72% and 4.35% (95% CI, -0.28% to 9.28%), respectively. These changes in the use of guideline-recommended medications were not significant in any of the incentive groups compared with controls, nor was the incidence of hypotension. The effect of the incentive was not sustained after a washout. Individual financial incentives, but not practice-level or combined incentives, resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the incentives resulted in greater use of guideline-recommended medications or increased incidence of hypotension compared with controls. Further research is needed on the factors that contributed to these findings. clinicaltrials.gov Identifier: NCT00302718.

Abstract 255: Temporal Trends and Factors Associated with Referral for Cardiac Rehabilitation Post Acute Coronary Syndrome: Insights from the Canadian Global Registry of Acute Coronary Events (GRACE)

Introduction: The beneficial effects of cardiac rehabilitation (CR) on morbidity and mortality after an acute coronary syndrome (ACS) are well established. Despite guidelines, CR referral rates have been low. Determining factors associated with CR referral would assist in closing this care gap and improve outcomes. Using the Canadian Global Registry of Acute Coronary Events (GRACE) database, we examined 1) the temporal trends of CR referral rates in Canada and its associated factors in a contemporary setting; 2) use of evidence-based medical therapies after ACS and its relationship with CR referral during index hospitalization. Hypothesis: CR referral rates have increased over time but remain below current guideline recommendations. Methods: From the Canadian GRACE registry, we retrospectively analyzed data from 11 Canadian centers during 2000 - 2007. CR referral rates were established and analyzed over time. We compared the CR Referral group to the Non-CR Referral group using univariate logistic regression in regards to patient characteristics, in-hospital diagnosis, clinical events and investigations. Categorical and continuous variables were compared using the chi-square and the Wilcoxon rank sum tests, respectively, with statistical significance at p&lt;0.05. Data of guideline-recommended medication use at discharge and 6 months post-discharge were also analyzed. Results: In the 8-year period, 3338 patients (median age 64 years, 32% women) were assessed. Initial CR referral rate in 2000 was 2.7% (6/219) and increased to 51.2% (220/430) in 2007 (p&lt;0.0001). Univariate factors for CR referral include younger age, larger infarct size, and a diagnosis of STE-ACS. Univariate factors for non-CR referral include CHF, higher GRACE score, and previous CAD. Hospitals with on-site supervised CR facilities had higher CR referral rates. CR Referral group had higher usage of evidence-based medications at time of discharge as well as 6 months post-discharge (all p&lt; 0.0001). Conclusions: There has been a steady increase in CR referrals; however, contemporary numbers are still below the current recommendation of an 85% referral rate. Higher usage of recommended medications in the CR Referral group were noted, likely reflecting the association of CR referral with overall quality of care. Factors associated with CR referral include younger age, larger infarct size, and STE-ACS. Lack of referral was associated with CHF, previous CAD and high GRACE score. Targeting non-referred populations may improve quality of care and close care gaps in secondary prevention.

Evaluating the association between type of prescription drug plan and asthma patients' use of controller medications

Abstract Objectives To explore the association between the type of prescription drug plan (PDP) and taking preventive daily asthma medication (controller medication) in patients with poor asthma control of their asthma (defined as taking more than three canisters of short-acting β-agonists each month). Methods A retrospective, cross-sectional study using the 2008 Medical Expenditure Panel Survey, a nationally representative sample of the non-institutionalized, civilian US population. Asthma patients were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code 493. Only those patients that reported use of more than three canisters of rescue inhalers in a 3-month period were included. Based on patients' self-reported use of preventive medications, they were classified as controller drug users and non-users. Descriptive statistics were used to describe the population. A multiple logistic regression model was used to determine odds of controller usage based on type of PDP using demographic characteristics (age, gender, race, ethnicity, income, perceived health status) as confounders. All analysis was done using SAS version 9.1. Key findings Asthma controller drug use was found to be 67% among the study population. The logistic regression analysis showed that patients having Medicare as their PDP were more likely to use controller medications compared with patients with no PDP (odds ratio (OR) 4.58, 95% confidence interval (CI) 1.33–15.77). Higher odds were seen for Medicaid (OR 2.09, CI 0.96–4.54) and Veterans Affairs (OR 1.66, CI 0.16–17.05) prescription beneficiaries too, but the effect was not significant. Conclusions Type of PDP was found to have an effect of utilization of controller drugs among asthma patients. Future research should explore viable plan options that encourage guideline-recommended medication use in asthma patients.