Computerized community cholesterol control (4C): meeting the challenge of secondary prevention.

BACKGROUND: Dyslipidemia remains underdiagnosed and undertreated in patients with coronary artery disease. The Computer-based Clinical Decision Support System provides an opportunity t close these gaps. OBJECTIVES: To study the impact of computerized intervention on secondary prevention of CAD. METHODS: The CDSS was programmed to automatically detect patients with CAD and to evaluate the availability of an updated lipoprotein profile and treatment with lipid-lowering drugs. The program produced automatic computer-generated monitoring and treatment recommendations. Adjusted primary clinics were randomly assigned to intervention (n=56) or standard care arms (n=56). Reminders were mailed to the primary medical teams in the intervention arm every 4 months updating them with current lipid levels and recommendations for further treatment. Compliance and lipid levels were monitored. The study group comprised all patients with CAD who were alive at least 3 months after hospitalization. RESULTS: Follow-up was available for 7448 patients (median 19.8 months, range 6-36 months). Overall, 51.7% of patients were adequately screened, and 55.7% of patients were compliant with treatment to lower lipid level. In patients with initial low density lipoprotein >120 mg/dl, a significant decrease in LDL levels was observed in both arms, but was more pronounced in the intervention arm: 121.9 +/- 34.2 vs. 124.3 +/- 34.6 mg/dl (P < 0.02). A significantly lower rate of cardiac rehospitalizations was documented in patients who were adequately treated with lipid-lowering drugs, 37% vs. 40.9% (P < 0.001). CONCLUSIONS: This initial assessment of our data represent a real-world snapshot where physicians and CAD patients often do not adhere to clinical guidelines, presenting a major obstacle to implementing effective secondary prevention. Our automatic computerized reminders system substantially facilitates adherence to guidelines and supports wide-range implementation.

Incidence and causes for failure of treatment of women with proven osteoporosis.

The purpose of this study was to examine factors influencing women's compliance with medical therapy for osteoporosis in Israel. The study population consisted of women diagnosed with osteoporosis using a DEXA examination in the year 2000. Medication purchases for a period of 13 months after the exam were analyzed. Data were gathered from the computerized data base of Clalit Health Care Services and phone interviews. Treatment was divided into specific drugs and food additives (preparation of calcium plus vitamin D). Full, intermediate, low and no compliance were defined as >80, 50-80, 25-50 and <25% of treatment days, respectively. In the study, 857 women with a mean age of 73.6 years were enrolled; 581 (67.8%) were interviewed by telephone. Most of women were undereducated and unemployed. Twenty percent did not purchase any specific drug; 4.5% did not purchase any drug or food additive for osteoporosis; 60% were fully or intermittently compliant (by purchasing) with drug therapy. The most frequent single specific drugs purchased were bisphosphanates and SERM: 62.3 and 76.3% purchased bisphosphanates and/or food additives, respectively. Multi-variant analysis showed that predictors of compliance were healthy women, compliant with calcium plus vitamin D preparations, and/or spending more on drugs. Reasons for low or non-compliance were inconsistent recommendations by various physicians and the side effects of specific drugs. The relatively high compliance rate of osteoporosis treatment may be attributed to the increase in awareness of its benefits. The effect of physicians on compliance needs further investigation.