Compliance after switching from branded to generic statins.

PURPOSE: The purpose of this study was to evaluate the impact of switching from branded to generic statins on medication compliance. METHODS: In this historic cohort study, we identified patients taking branded statins between January 2003 and December 2012 from Sutter Health's electronic health records in Northern California. Patients with ≥2 consecutive pharmacy claims for generic statins after initiating branded statins were classified as switchers. Switchers and non-switchers were matched 1:1 on the propensity for switching. Medication possession ratio (MPR) was calculated as the sum of days supply of therapy divided by treatment duration. We assessed between-group differences in compliance (MPR ≥ 0.80) by logistic regression. RESULTS: Among 16,364 patients meeting eligibility criteria, 8470 were retained in the matched cohort. No significant differences in compliance with statin therapy were observed for non-switchers versus switchers, overall, or versus patients switched from a branded to generic statin of the same agent (generic substitutions). Patients switched from a branded to generic statin of a different agent (therapeutic substitutions) more frequently received less potent statin dosing relative to those with generic substitutions (42.2% vs. <2%, respectively) and were significantly less compliant with statin therapy in the first 6 months after switching (73.9% vs. 77.6%; p = 0.011); however, compliance significantly improved among patients with therapeutic substitutions relative to generic substitutions more than 12 months after switching (66.2% vs. 61.3%; p = 0.021). CONCLUSIONS: Compliance with statin therapy was largely similar among patients who switch to generic statins and those remaining on branded statins. Dosing should be reviewed when changing therapy to optimize clinical outcomes.

Multivariate analysis of factors associated with persistent colesevelam treatment among patients with hypercholesterolemia.

BACKGROUND: Persistent treatment with lipid-lowering therapies is important for achieving optimal clinical outcomes. To date, no study has evaluated the real-world use of colesevelam and the factors associated with persistent colesevelam treatment. OBJECTIVE: The primary objective of this study was to examine patient demographic and characteristics associated with persistent colesevelam treatment in real-world clinical practice. METHODS: In this retrospective cohort study, adult patients with hypercholesterolemia, an initial order for colesevelam between January 2004 and December 2011, a low-density lipoprotein cholesterol (LDL-C) value ≤ 3 months from the initial order date (baseline), and ≥ 12 months of follow-up were identified through electronic health records. Persistent treatment was defined as no medication order gap >30 days during a 12-month period. Multivariate logistic regression was performed to assess factors associated with persistent treatment. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. A P value <.05 was considered statistically significant. RESULTS: A total of 971 patients met eligibility criteria. Forty-nine percent of patients had ≥ 12 months of persistent treatment. Multivariate analysis showed that female sex (OR = 0.69; 95% CI = 0.53, 0.90; P = .004) was associated with lesser odds of persistence, whereas baseline LDL-C at goal (1.39; 1.06, 1.82; P = .015) and concomitant use of the intestinal cholesterol absorption inhibitor ezetimibe (1.64; 1.18, 2.28; P = .003) were associated with greater odds of persistence. CONCLUSIONS: This study identified several patient demographic and characteristics associated with persistent colesevelam treatment that may help develop strategies to improve treatment persistence and optimize clinical outcomes.

Disparities in blood pressure control within a community-based provider network: an exploratory analysis.

BACKGROUND: Despite treatment for hypertension, blood pressure (BP) remains uncontrolled in many individuals. Identification of patterns in BP control may inform strategies to improve treatment and optimize health outcomes. OBJECTIVE: To examine patterns in BP control among individuals receiving antihypertensive treatment in a diverse, community-based provider network. METHODS: In this retrospective exploratory analysis, a total of 51,772 hypertensive subjects were identified in the electronic medical record between January 1, 2007, and June 30, 2010, who were aged 18 years or older, with 2 or more claims for antihypertensive medication, documented race/ethnicity, and 1 or more documented BP readings. RESULTS: On the basis of Joint National Committee VII guidelines, 76.4% of nondiabetic patients had their BP controlled with treatment (<140/90 mm Hg) and 52.3% of those with diabetes had their BP controlled with treatment (<130/80 mm Hg). The overall rate of BP control was 71.4%. Factors associated with controlled BP included younger age, lower disease burden, better medication adherence, fewer concurrent prescriptions, lower prescription copayments, and living in a region with a higher median household income. Furthermore, when adjusting for age, sex, and disease burden, black (OR 0.68; 95% CI 0.62 to 0.75; p < 0.001), Hispanic (OR 0.80; 95% CI 0.74 to 0.86; p < 0.001), and other race/ethnic group (OR 0.81; 95% CI 0.70 to 0.94; p = 0.005) individuals were less likely than white individuals to have their treated BP controlled. Among nondiabetic hypertensive subjects with controlled BP, the most frequently prescribed therapy was a ß-blocker or an angiotensin-converting enzyme (ACE) inhibitor across race/ethnicities; however, those who were black were most frequently prescribed a diuretic or calcium channel blocker. Among diabetic patients with controlled BP, the most frequently prescribed therapy was an ACE inhibitor, regardless of race/ethnicity. CONCLUSIONS: Potential disparities, particularly among diabetic individuals and those of minority race/ethnicity, were found with regard to BP control and the agents used to treat hypertension. Future studies should address these disparities by designing interventions to improve the treatment of hypertension in high-risk populations.

Opioid prescribing for chronic pain in a community-based healthcare system.

OBJECTIVES: We sought to evaluate opioid prescribing in an ambulatory setting among patients with noncancer chronic pain (CP). STUDY DESIGN: Cross-sectional analysis. METHODS: We identified patients with at least 2 CP encounters at least 30 days apart in 2012 in the electronic health records of a community-based healthcare delivery system in northern California. We used logistic regression models to assess associations of receiving an opioid prescription with respect to number and type of CP conditions and patient demographics and characteristics. Odds ratios (ORs) with 95% confidence intervals (CIs) and the adjusted prevalence of receiving an opioid prescription were generated after controlling for important covariates. RESULTS: A total of 120,481 patients with CP met eligibility criteria, with 58% receiving an opioid in 2012. The adjusted prevalence of receiving an opioid was highest for back/cervical pain (71%). The odds of receiving an opioid increased linearly with the number of CP conditions per patient (OR, 1.29; 95% CI, 1.25-1.33; P <.001). Men were generally more likely to receive an opioid than women, as were patients with noncommercial insurance, especially Medicaid (OR, 2.77; 95% CI, 2.56-3.01; P <.001) versus commercial. CONCLUSIONS: In an ambulatory healthcare setting, opioid prescribing to patients with CP varied by type and number of pain conditions. Opioid prescriptions to men, those with back/cervical pain, and Medicaid beneficiaries were particularly prevalent. The identification of populations more likely to receive an opioid in the treatment of CP should be of interest to healthcare systems to ensure these drugs are being used appropriately and safely.

Patient characteristics and healthcare utilization of a chronic pain population within an integrated healthcare system.

OBJECTIVES: We sought to characterize the chronic pain (CP) population and healthcare utilization across types of CP within a community-based healthcare system. STUDY DESIGN: Cross-sectional study of electronic health records data from 2012. METHODS: Patients 18 years or older with at least 2 encounter diagnoses for CP conditions in 2012 were included in the study. Patients were categorized into non-mutually exclusive CP types: arthritis/joint pain, back/cervical pain, neuropathies/neuralgias, headaches/migraines, and unclassified pain. RESULTS: Of 1,784,114 patients, 120,481 (6.8%) met the criteria for the CP study cohort. Within the cohort, the most common types of CP were arthritis/joint pain (57%), back/cervical pain (49%), and neuropathy/neuralgias (40%). Patients with neuropathies/neuralgias were older than patients with other pain types and had more comorbidities (for neuropathies/neuralgias: mean age, 59 years; Charlson Comorbidity Index score >3, in 28% of patients). Patients with unclassified pain were most likely to be female (82%). Rates of office and emergency department (ED) visits were highest in patients with unclassified pain (5136 events and 209 events per 1000 patients, respectively). Rates of hospitalizations and 30-day hospital readmissions were highest in patients with neuropathies/neuralgias (70 events and 287 events per 1000 patients, respectively). An increased number of CP types was linearly associated with higher rates of office, ED, and hospital visits. CONCLUSIONS: Based on prevalence, comorbidities, and healthcare utilization, several types of CP, including neuropathies/neuralgias, arthritis/joint pain, and unclassified pain, appear to be most impactful. Health systems can use these findings to target efforts to improve the management of patients with CP, particularly those with multiple pain-related conditions.

Pharmacist-led medication management program within a patient-centered medical home.

PURPOSE: The impact of a clinical pharmacist-led medication management program (MMP) within a patient-centered medical home (PCMH) was evaluated. METHODS: This retrospective analysis included patients in Sutter Health's electronic health records who (1) were seen by the MMP clinical pharmacist within the PCMH (MMP cohort), (2) were within the PCMH but were not referred to the MMP pharmacist (PCMH cohort), or (3) received usual care at two non-PCMH primary care clinics (usual care cohort). Patients were matched on their propensity for receiving medication management. The primary outcome measure was healthcare resource use (i.e., ambulatory care visits, emergency department [ED] visits, and hospitalizations). RESULTS: MMP patients had a higher percentage of ambulatory care visits relative to PCMH patients (p = 0.004) but a lower rate of hospitalizations (p = 0.003). The MMP group had a lower frequency of hospitalizations (p < 0.001) and ED visits (p = 0.014) relative to patients in the usual care group. No differences in healthcare resource use were observed between the PCMH and usual care cohorts. Glycosylated hemoglobin, blood pressure, or low-density-lipoprotein cholesterol at goal did not significantly differ among the three cohorts. CONCLUSION: Patients in a pharmacist-led MMP had a significantly higher estimated rate of ambulatory care visits but a lower rate of hospitalizations than did patients who attended the same clinic but were not in the MMP. MMP patients had a similar rate of ambulatory care visits but significantly lower rates of hospitalizations and ED visits than patients receiving usual care.

Colesevelam in the treatment of hypercholesterolemia and hyperglycemia: a retrospective analysis from an ambulatory care medical network.

OBJECTIVE: To examine outcomes associated with colesevelam treatment among patients with hypercholesterolemia in real-world clinical practice. METHODS: This analysis was conducted as a retrospective, observational cohort study in an ambulatory-care medical network in Northern California. Patients with orders for colesevelam were identified in the electronic health record between January 2004 and December 2011. The date of the first order during the study period was designated the index date. Patients were evaluated for the following eligibility criteria: a diagnosis of hypercholesterolemia, ≥18 years of age at index date, baseline laboratory values ≤3 months before the index date, ≥12 months of treatment and follow-up, and no prior orders for colesevelam ≤12 months before the index date. Patients who were pregnant during the study period were excluded. Changes in LDL-C and percentage of patients at LDL-C goal were examined. Among patients with diabetes mellitus (DM), changes in glycated hemoglobin (HBA1C) and percentage of patients at HBA1C goal were also examined. RESULTS: Overall, 468 and 181 patients with hypercholesterolemia met the predefined inclusion criteria with treatment and follow-up through 12 and 24 months, respectively. LDL-C decreased significantly from baseline by a mean of 11.4 mg/dL and 15.7 mg/dL (P < 0.0001, for each) at 12 and 24 months, respectively, and the percentages of patients at LDL-C goal increased by 13.9% and 21.0%. Among patients with DM and a baseline HBA1C ≥8%, 113 and 39 had treatment and follow-up through 12 and 24 months, respectively. HBA1C decreased significantly by a mean of 0.72% (P = 0.0001) and 0.75% (P = 0.010) and 11.5% and 12.8% were at HBA1C goal at 12 and 24 months, respectively. This study is limited by its retrospective and observational study design. CONCLUSIONS: Colesevelam treatment in a real-world setting was associated with improvements in LDL-C and HBA1C through 24 months of follow-up.

Disparities in adherence to and persistence with antihypertensive regimens: an exploratory analysis from a community-based provider network.

Despite the availability of effective antihypertensive therapies, adherence to and persistence with treatment is suboptimal. As such, there is a need to better understand factors associated with adherence and persistence, such as race/ethnicity. In a retrospective, exploratory analysis of 51,772 hypertensive adult subjects identified in the electronic medical record, we examined medication possession ratio and proportion of days covered as proxies for adherence and persistence, respectively. Logistic regression analyses were performed to assess the role of race/ethnicity in adherence to and persistence with antihypertensive treatments. Relative to white subjects, Asian American/Pacific Islander, black, Hispanic, and "other" subjects were significantly less likely to be adherent to and persistent with their antihypertensive regimens. Black and Hispanic subjects had the lowest odds of adherence (0.46, 95% CI: 0.43-0.49 and 0.58, 95% CI: 0.54-0.62, respectively) and persistence (0.70, 95% CI: 0.65-0.75 and 0.70, 95% CI: 0.66-0.74, respectively) relative to white subjects. Other factors significantly associated with both lower adherence and persistence included younger age and lower chronic disease score. Disparities were found with regard to adherence to and persistence with antihypertensive regimens. Future studies should address these disparities by designing interventions to improve medication-taking behavior in high-risk populations.

Improving adherence to best-practice guidelines for venous thromboembolism risk assessment and prevention.

PURPOSE: The effectiveness of a program to improve adherence to best-practice guidelines for venous thromboembolism (VTE) risk assessment and prevention in a community hospital setting was evaluated. SUMMARY: Variation in the use of best-practice guidelines for VTE risk assessment and prevention with regard to the frequency of VTE risk assessment and the risk score assigned, as well as the communication of the risk of VTE and the need for prophylaxis to treating physicians, was found. To improve adherence to established guidelines, the responsibilities of a nurse case manager were expanded to serve as a single point of contact who was accountable for identifying high-risk patients and advocating for appropriate pharmacologic prophylaxis in the absence of contraindications. To facilitate the role of the nurse case manager, an automated VTE-risk-assessment tool was developed to reliably identify high-risk patients in real time. This intervention was evaluated from January 1 to June 30, 2010. Before the intervention, contraindications to anticoagulation were reported for 19.1% of high-risk patients not receiving prophylaxis and pharmacologic prophylaxis was ordered for 47.9% of high-risk patients without contraindications. During the course of the intervention, contraindications to anticoagulation were reported for 36.2% of high-risk patients not receiving prophylaxis and pharmacologic prophylaxis was ordered for 64.9% of high-risk patients without contraindications. CONCLUSION: The appointment of a nurse case manager trained in anticoagulation and the development of an automated VTE-risk-assessment tool to identify patients at high risk of VTE were associated with improved adherence to best-practice guidelines for VTE risk assessment and prevention.