Temporal Trends in Percutaneous Coronary Intervention Appropriateness: Insights From the Clinical Outcomes Assessment Program.

BACKGROUND: It is unknown whether the appropriate use of percutaneous coronary intervention (PCI) has improved over time and whether trends in PCI appropriateness have been accompanied by changes in the use of PCI. METHODS AND RESULTS: We applied appropriate use criteria to determine the appropriateness of all 51 872 PCI performed in Washington State from 2010 through 2013. We evaluated the number of PCIs performed from 2006 through 2013 to provide a comparator period that preceded statewide appropriateness assessment beginning in 2010. Between 2010 and 2013, the overall number of PCI decreased by 6.8% (13 267 PCIs in 2010 to 12 193 in 2013) with a 43% decline in the number of PCIs for elective indications (3818 PCIs in 2010 to 2193 PCIs in 2013). The decline in the use of elective PCI was significantly larger after the onset of statewide PCI appropriateness assessment in 2010 (P=0.03). The proportion of elective PCIs classified as appropriate increased from 26% in 2010 to 38% in 2013, whereas the proportion of inappropriate PCIs decreased from 16% to 13% (P<0.001 for trends). Significant improvements in the proportion of inappropriate PCI were limited to the tertile of hospitals with the largest decline in PCIs classified as inappropriate (25% in 2010 to 12% in 2013; P=0.03). CONCLUSIONS: In Washington State, the use of PCI for elective indications has decreased over time with concurrent improvements in PCI appropriateness. However, improvements in PCI appropriateness were limited to a minority of hospitals. Understanding processes at these high-performing hospitals may inform efforts to improve PCI appropriateness.

Association between alcohol use and cardiovascular self-care behaviors among male hypertensive Veterans Affairs outpatients: a cross-sectional study.

BACKGROUND: Alcohol use is associated with health behaviors that impact cardiovascular outcomes in patients with hypertension, including avoiding salt, exercising, weight management, and not smoking. This study examined associations between varying levels of alcohol use and self-reported cardiovascular health behaviors among hypertensive Veterans Affairs (VA) outpatients. METHODS: Male outpatients with self-reported hypertension from 7 VA sites who returned mailed questionnaires (N = 11,927) were divided into 5 levels of alcohol use: nondrinking, low-level use, and mild, moderate, and severe alcohol misuse based on AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) scores (0, 1-3, 4-5, 6-7, and 8-12, respectively). For each category, adjusted logistic regression models estimated the prevalence of patients who self-reported avoiding salt, exercising, controlling weight, or not smoking, and the composite of all four. RESULTS: Increasing level of alcohol use was associated with decreasing prevalence of avoiding salt, controlling weight, not smoking, and the combination of all 4 behaviors (P values all <.001). A linear trend was not observed for exercise (P =.83), which was most common among patients with mild alcohol misuse (P =.01 relative to nondrinking). CONCLUSIONS: Alcohol consumption is inversely associated with adherence to cardiovascular self-care behaviors among hypertensive VA outpatients. Clinicians should be especially aware of alcohol use level among hypertensive patients.

Estimating the Impact of Oral Diabetes Medication Adherence on Medical Costs in VA.

BACKGROUND: . Despite evidence demonstrating clinical benefits of oral hypoglycemic agents (OHAs), adherence to OHAs is generally poor. The economic benefit of OHA adherence among patients in the Veterans Affairs Health System (VA) is unknown. OBJECTIVE: . This study assessed the impact of OHA adherence on medical costs and hospitalization probability in a VA population. METHODS: . This retrospective cohort study included 26 051 VA patients with diabetes who completed the 2006 Survey of Health Care Experiences of Patients. We calculated total costs in fiscal year (FY) 2007 from the VA perspective as the sum of costs for all inpatient and outpatient services provided by VA. We measured adherence using the medication possession ratio (MPR), which reflected the proportion of days covered in FY2007. Patients were classified as adherent if MPR ≥80%. Analyses using instrumental variables (IVs) addressed potential biases from unobserved confounding. RESULTS: . On average, adherent patients incurred lower total medical costs ($4051 vs $5133, P < 0.001) and were less likely to be hospitalized (4.6% vs 7.2%, P < 0.001) compared with nonadherent patients. After covariate adjustment, adherence was associated with a $170 reduction in total costs (P < 0.011) and a 1.5 percentage point decrease (P < 0.001) in hospitalization probability. IV estimates indicated that the impacts of OHA adherence were larger in magnitude. CONCLUSION: . On average, OHA adherence was associated with lower medical costs of at least $170 per patient over a 1-year period. Results from this study are important for informing policy decisions to broadly disseminate programs to promote diabetes medication adherence, particularly in a VA setting.

The practice of transradial percutaneous coronary intervention in the Washington State Clinical Outcomes Assessment Program.

BACKGROUND: Transradial percutaneous coronary intervention (tPCI) as opposed to the femoral approach (fPCI) is associated with lower rates of bleeding. The purposes of this study were to describe the use of tPCI in the Washington State Clinical Outcomes Assessment Program, identify the predictors of bleeding, and determine whether tPCI was associated with less bleeding in women vs men, age <75 years vs ≥75 years, and baseline creatinine <2.0 mg/dL vs ≥2.0 mg/dL. METHODS: This study included 23,599 individuals who had a first tPCI or fPCI performed in 30 centers in Washington State in 2010 and 2011. Data were collected according to specifications from the American College of Cardiology National Cardiovascular Data Registry Cath-PCI version 4.3. The American College of Cardiology National Cardiovascular Data Registry bleeding model was used to calculate adjusted rates. RESULTS: Transradial percutaneous coronary intervention was used in only 5% of procedures, and in just 3 centers, tPCI was used in >10% of cases. Patient demographics and medical histories were similar in tPCI and fPCI, although the percent of acute cases was higher in fPCI (68% vs 45%, P < .0001). The overall bleeding rate was 2.2%, and the 3 most important predictors of bleeding were acute procedure, women, and age ≥75 years. For women, unadjusted rates of bleeding were 1.4% for tPCI and 4.0% for fPCI (P = .013). Among women, adjusted rates were almost 20% lower for tPCI (3.3% vs 4.1%). CONCLUSION: In Washington State, tPCI was used infrequently, although it was associated with lower bleeding rates in high-risk groups including women.

Wide clinic-level variation in adherence to oral diabetes medications in the VA.

BACKGROUND: While there has been extensive research into patient-specific predictors of medication adherence and patient-specific interventions to improve adherence, there has been little examination of variation in clinic-level medication adherence. OBJECTIVE: We examined the clinic-level variation of oral hypoglycemic agent (OHA) medication adherence among patients with diabetes treated in the Department of Veterans Affairs (VA) primary care clinics. We hypothesized that there would be systematic variation in clinic-level adherence measures, and that adherence within organizationally-affiliated clinics, such as those sharing local management and support, would be more highly correlated than adherence between unaffiliated clinics. DESIGN: Retrospective cohort study. SETTING: VA hospital and VA community-based primary care clinics in the contiguous 48 states. PATIENTS: 444,418 patients with diabetes treated with OHAs and seen in 158 hospital-based clinics and 401 affiliated community primary care clinics during fiscal years 2006 and 2007. MAIN MEASURES: Refill-based medication adherence to OHA. KEY RESULTS: Adjusting for patient characteristics, the proportion of patients adherent to OHAs ranged from 57 % to 81 % across clinics. Adherence between organizationally affiliated clinics was high (Pearson Correlation = 0.82), and adherence between unaffiliated clinics was low (Pearson Correlation = 0.04). CONCLUSION: The proportion of patients adherent to OHAs varied widely across VA primary care clinics. Clinic-level adherence was highly correlated to other clinics in the same organizational unit. Further research should identify which factors common to affiliated clinics influence medication adherence.

Measures of adherence to oral hypoglycemic agents at the primary care clinic level: the role of risk adjustment.

BACKGROUND: Prior research found that in the Veterans Affairs health care system (VA), the proportion of patients adherent to oral hypoglycemic agents varies from 50% to 80% across primary care clinics. This study examined whether variation in patient and facility characteristics determined those differences. METHODS: Retrospective cohort study of 444,418 VA primary care patients with diabetes treated in 559 clinics in fiscal year (FY) 2006-2007. Patients' adherence to each oral hypoglycemic agent was computed for the first 3 months of FY2007, and averaged across agents to produce an adherence score for the patient's overall regimen. Patients with an adherence score over 0.8 were defined as adherent. Risk adjustment used hierarchical logistic regression accounting for patient factors and facility effects by clustering patients within clinics and clinics within parent VA medical centers. We then assessed the influence of risk adjustment using observed-to-expected (O/E) ratios computed for each clinic. RESULTS: The mean unadjusted proportion of adherent patients in clinics was 0.715 (interdecile range 0.559-0.826). The percent variation in patient's likelihood of being adherent explained at the patient, clinic, and parent VA medical center levels was 2.94%, 0.27%, and 0.76%, respectively. The mean clinic-level observed-to-expected ratio was 1.001 (interdecile range 0.975-1.027). CONCLUSIONS: The variation in the proportion of patients adherent across clinics remained large after risk adjustment. As patient and facility effects explained only 4% of the variance in adherence, comparing clinics based on unadjusted scores is a reasonable starting point unless more predictive patient, provider, and facility factors are identified.

The influence of informal caregivers on adherence in COPD patients.

BACKGROUND: Contributions of informal caregivers to adherence among chronic obstructive pulmonary disease (COPD) patients remain understudied. PURPOSE: This study aims to evaluate the association between caregiver presence and adherence to medical recommendations among COPD patients. METHODS: Three hundred and seventy-four COPD patients were asked whether they had a caregiver. Medication adherence was assessed using pharmacy refill data. Smoking status was based on patient self-report. One-way ANOVAs and chi-square analyses were performed controlling for age and number of illnesses. RESULTS: Compared with the "no caregiver" group, antihypertensive medications adherence was higher in the "spousal caregiver" (0.68 vs. 0.81; 95% CI=0.04 and 0.22) and "non-spousal caregiver" (0.68 vs. 0.80; 95% CI=0.03 and 0.22) groups; long-acting beta agonist adherence was higher in the "spousal caregiver" group (0.60 vs.0.80; 95% CI=0.05 and 0.43). Patients in the "spousal caregiver" group had fewer current smokers compared with the "no caregiver" (χ(2)=16.08; p<0.001) and "non-spousal caregiver" (χ(2)=5.07; p<0.05) groups; those in the "non-spousal caregiver" group reported fewer smokers than the "no caregiver" group (χ(2)=4.54; p<0.05). CONCLUSIONS: Caregivers, especially spouses, may improve adherence in COPD. Future interventions may target patients without caregivers to optimize COPD management.

Use of outpatient care in VA and Medicare among disability-eligible and age-eligible veteran patients.

BACKGROUND: More than half of veterans who use Veterans Health Administration (VA) care are also eligible for Medicare via disability or age, but no prior studies have examined variation in use of outpatient services by Medicare-eligible veterans across health system, type of care or time. OBJECTIVES: To examine differences in use of VA and Medicare outpatient services by disability-eligible or age-eligible veterans among veterans who used VA primary care services and were also eligible for Medicare. METHODS: A retrospective cohort study of 4,704 disability- and 10,816 age-eligible veterans who used VA primary care services in fiscal year (FY) 2000. We tracked their outpatient utilization from FY2001 to FY2004 using VA administrative and Medicare claims data. We examined utilization differences for primary care, specialty care, and mental health outpatient visits using generalized estimating equations. RESULTS: Among Medicare-eligible veterans who used VA primary care, disability-eligible veterans had more VA primary care visits (p < 0.001) and more VA specialty care visits (p < 0.001) than age-eligible veterans. They were more likely to have mental health visits in VA (p < 0.01) and Medicare-reimbursed visits (p < 0.01). Disability-eligible veterans also had more total (VA+Medicare) visits for primary care (p < 0.01) and specialty care (p < 0.01), controlling for patient characteristics. CONCLUSIONS: Greater use of primary care and specialty care visits by disability-eligible veterans is most likely related to greater health needs not captured by the patient characteristics we employed and eligibility for VA care at no cost. Outpatient care patterns of disability-eligible veterans may foreshadow care patterns of veterans returning from Afghanistan and Iraq wars, who are entering the system in growing numbers. This study provides an important baseline for future research assessing utilizations among returning veterans who use both VA and Medicare systems. Establishing effective care coordination protocols between VA and Medicare providers can help ensure efficient use of taxpayer resources and high quality care for disabled veterans.

Does the presence of a pharmacist in primary care clinics improve diabetes medication adherence?

BACKGROUND: Although oral hypoglycemic agents (OHAs) are an essential element of therapy for the management of type 2 diabetes, OHA adherence is often suboptimal. Pharmacists are increasingly being integrated into primary care as part of the move towards a patient-centered medical home and may have a positive influence on medication use. We examined whether the presence of pharmacists in primary care clinics was associated with higher OHA adherence. METHODS: This retrospective cohort study analyzed 280,603 diabetes patients in 196 primary care clinics within the Veterans Affairs healthcare system. Pharmacists presence, number of pharmacist full-time equivalents (FTEs), and the degree to which pharmacy services are perceived as a bottleneck in each clinic were obtained from the 2007 VA Clinical Practice Organizational Survey-Primary Care Director Module. Patient-level adherence to OHAs using medication possession ratios (MPRs) were constructed using refill data from administrative pharmacy databases after adjusting for patient characteristics. Clinic-level OHA adherence was measured as the proportion of patients with MPR >= 80%. We analyzed associations between pharmacy measures and clinic-level adherence using linear regression. RESULTS: We found no significant association between pharmacist presence and clinic-level OHA adherence. However, adherence was lower in clinics where pharmacy services were perceived as a bottleneck. CONCLUSIONS: Pharmacist presence, regardless of the amount of FTE, was not associated with OHA medication adherence in primary care clinics. The exact role of pharmacists in clinics needs closer examination in order to determine how to most effectively use these resources to improve patient-centered outcomes including medication adherence.

Association between alcohol screening results and hospitalizations for trauma in Veterans Affairs outpatients.

BACKGROUND: Alcohol consumption is a risk factor for traumatic injury, but it is unknown whether responses to alcohol screening questionnaires administered routinely in primary care are associated with subsequent hospitalization for traumatic injury. OBJECTIVE: We evaluated the association between alcohol screening scores and the risk for subsequent hospitalizations for trauma among Veterans Affairs (VA) general medicine patients. METHOD: This study included VA outpatients (n = 32,623) at seven sites who returned mailed surveys (1997-1999). Alcohol Use Disorders Identification Test Consumption (AUDIT-C) scores grouped patients into six drinking categories representing nondrinkers, screen-negative drinkers, and drinkers who screened positive for mild, moderate, severe, and very severe alcohol misuse (scores 0, 1-3, 4-5, 6-7, 8-9, 10-12, respectively). VA administrative and Medicare data identified primary discharge diagnoses for trauma. Cox proportional hazard models were used to estimate the risk of trauma-related hospitalization for each drinking group adjusted for demographics, smoking, and comorbidity. RESULTS: Compared with screen-negative drinkers, patients with severe and very severe alcohol misuse (AUDIT-C 8-9 and ≥10) were at significantly increased risk for trauma-related hospitalization over the follow-up period (adjusted hazard ratios AUDIT-C: 8-9 2.06, 95% confidence interval (CI) 1.31- 3.24 and AUDIT-C≥10 2.13, 95% CI 1.32-3.42). CONCLUSIONS: Patients with severe and very severe alcohol misuse had a twofold increased risk of hospital admission for trauma compared to drinkers without alcohol misuse. SCIENTIFIC SIGNIFICANCE: Alcohol screening scores could be used to provide feedback to patients regarding risk of trauma-related hospitalization. Findings could be used by providers during brief alcohol-related interventions with patients with alcohol misuse.

Adherence to long-acting inhaled therapies among patients with chronic obstructive pulmonary disease (COPD).

BACKGROUND: Long-acting inhaled medications are an important component of the treatment of patients with chronic obstructive pulmonary disease (COPD), yet few studies have examined the determinants of medication adherence among this patient population. OBJECTIVE: We sought to identify factors associated with adherence to long-acting beta-agonists (LABA) and inhaled corticosteroids (ICS) among patients with COPD. METHODS: We performed secondary analysis of baseline data collected in a randomized trial of 376 Veterans with spirometrically confirmed COPD. We used electronic pharmacy records to assess adherence, defined as a medication possession ratio of ≥0.80. We investigated the following exposures: patient characteristics, disease severity, medication regimen complexity, health behaviors, confidence in self-management, and perceptions of provider skill. We performed multivariable logistic regression, clustered by provider, to estimate associations. RESULTS: Of the 167 patients prescribed LABA, 54% (n = 90) were adherent to therapy while only 40% (n = 74) of 184 the patients prescribed ICS were adherent. Higher adherence to LABA and ICS was associated with patient perception of their provider as being an "expert" in diagnosing and managing lung disease [For LABA: OR = 21.70 (95% CI 6.79, 69.37); For ICS OR = 7.93 (95% CI 1.71, 36.67)]. Factors associated with adherence to LABA, but not ICS, included: age, education, race, COPD severity, smoking status, and confidence in self-management. CONCLUSIONS: Adherence to long-acting inhaled medications among patients with COPD is poor, and determinants of adherence likely differ by medication class. Patient perception of clinician expertise in lung disease was the factor most highly associated with adherence to long-acting therapies.

Reliance on Veterans Affairs outpatient care by Medicare-eligible veterans.

OBJECTIVE: To examine longitudinal changes in Medicare-eligible veterans' reliance on the Department of Veterans Affairs (VA) healthcare system for primary and specialty care over 4 years. METHODS: We merged VA administrative and Medicare claims data to examine outpatient use during fiscal years (FY) 2001 to 2004 by 15,520 Medicare-eligible veterans who used VA primary care in FY2000. Reliance on VA outpatient care was defined as the proportion of total (VA/Medicare) visits received in VA for primary or specialty care. RESULTS: Of 869,000 primary and specialty care visits in the study period, 39% occurred within VA and 77% were specialty care. Reliance on VA primary care was substantially higher than specialty care (66% vs. 50% in FY2001; P<0.001). Reliance on VA primary and specialty care decreased over time (57% vs. 31% in FY2004; P<0.001). Significant shifts occurred at both extremes of VA reliance. From FY2001 to FY2004, the proportion of patients in the top decile of reliance on VA primary care decreased from 39% to 31%, whereas the proportion in the bottom decile doubled from 8% to 18%. Similarly, the proportion of patients in the top decile of reliance on VA specialty care decreased from 24% to 13%, whereas the proportion in the bottom decile doubled from 22% to 47%. CONCLUSIONS: Reliance on VA primary and specialty care among VA primary care patients decreased substantially over time, particularly for specialty care. Increasing use of non-VA services may complicate VA's implementation of patient-centered medical home models and performance measurement.

Alcohol screening and risk of postoperative complications in male VA patients undergoing major non-cardiac surgery.

BACKGROUND: Patients who misuse alcohol are at increased risk for surgical complications. Four weeks of preoperative abstinence decreases the risk of complications, but practical approaches for early preoperative identification of alcohol misuse are needed. OBJECTIVE: To evaluate whether results of alcohol screening with the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire-up to a year before surgery-were associated with the risk of postoperative complications. DESIGN: This is a cohort study. SETTING AND PARTICIPANTS: Male Veterans Affairs (VA) patients were eligible if they had major noncardiac surgery assessed by the VA's Surgical Quality Improvement Program (VASQIP) in fiscal years 2004-2006, and completed the AUDIT-C alcohol screening questionnaire (0-12 points) on a mailed survey within 1 year before surgery. MAIN OUTCOME MEASURE: One or more postoperative complication(s) within 30 days of surgery based on VASQIP nurse medical record reviews. RESULTS: Among 9,176 eligible men, 16.3% screened positive for alcohol misuse with AUDIT-C scores ≥ 5, and 7.8% had postoperative complications. Patients with AUDIT-C scores ≥ 5 were at significantly increased risk for postoperative complications, compared to patients who drank less. In analyses adjusted for age, smoking, and days from screening to surgery, the estimated prevalence of postoperative complications increased from 5.6% (95% CI 4.8-6.6%) in patients with AUDIT-C scores 1-4, to 7.9% (6.3-9.7%) in patients with AUDIT-Cs 5-8, 9.7% (6.6-14.1%) in patients with AUDIT-Cs 9-10 and 14.0% (8.9-21.3%) in patients with AUDIT-Cs 11-12. In fully-adjusted analyses that included preoperative covariates potentially in the causal pathway between alcohol misuse and complications, the estimated prevalence of postoperative complications increased significantly from 4.8% (4.1-5.7%) in patients with AUDIT-C scores 1-4, to 6.9% (5.5-8.7%) in patients with AUDIT-Cs 5-8 and 7.5% (5.0-11.3%) among those with AUDIT-Cs 9-10. CONCLUSIONS: AUDIT-C scores of 5 or more up to a year before surgery were associated with increased postoperative complications.

Importance of health system context for evaluating utilization patterns across systems.

Measuring health services provided to patients can be difficult when patients see providers across multiple health systems and all visits are rarely captured in a single data source covering all systems where patients receive care. Studies that account for only one system will omit the out-of-system health-care use at the patient level. Combining data across systems and comparing utilization patterns across health systems creates complications for both aggregation and accuracy because data-generating processes (DGPs) tend to vary across systems. We develop a hybrid methodology for aggregation across systems, drawing on the strengths of the DGP in each system, and demonstrate its validity for answering research questions requiring cross-system assessments of health-care utilization. Positive and negative predictive probabilities can be useful to assess the impact of the hybrid methodology. We illustrate these issues comparing public sector (administrative records from the US Department of Veterans Affairs system) and private sector (billing records from the US Medicare system) patient level data to identify primary-care utilization. Understanding the context of a particular health system and its effect on the DGP is important in conducting effective valid evaluations.

Recent hospitalization for non-coronary events and use of preventive medications for coronary artery disease: an observational cohort study.

BACKGROUND: High-quality systems have adopted a comprehensive approach to preventive care instead of diagnosis or procedure driven care. The current emphasis on prescribing medications to prevent complications of coronary artery disease (CAD) at discharge following an acute coronary syndrome (ACS) may exclude high-risk patients who are hospitalized with conditions other than ACS. METHODS: Among a sample of patients with CAD treated at Veterans Affairs medical centers between January, 2005 and November, 2006, we investigated whether recent non-ACS hospitalization was associated with prescriptions of preventive medications as compared with patients recently hospitalized with ACS. RESULTS: Of 13,211 patients with CAD, 58% received aspirin, 70% ß-blocker, 60% angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB), and 65% lipid-lowering therapy. Twenty-five percent of eligible patients were receiving all four medications. Having been hospitalized for a non-ACS event in the prior 6 months did not substantially affect the adjusted proportion on preventive medications. In contrast, among patients hospitalized for ACS in the prior 6 months, the adjusted proportion prescribed aspirin was 21% higher (p < 0.001), ß-blocker was 14% higher (p < 0.001), ACE-I or ARB was 9% higher (p < 0.001), lipid therapy was 12% higher (p < 0.001), and prescribed all four medications was 18% higher (p < 0.001) than among patients hospitalized for ACS more than 2 years earlier. CONCLUSIONS: Being hospitalized for a non-ACS condition did not appear to influence preventive medication use among patients with CAD and represents a missed opportunity to improve patient care. The same protocols employed to improve use of preventive medications in patients discharged for ACS might be extended to CAD patients discharged for other conditions as well.

Obesity and COPD: associated symptoms, health-related quality of life, and medication use.

BACKGROUND: There is little data about the combined effects of COPD and obesity. We compared dyspnea, health-related quality of life (HRQoL), exacerbations, and inhaled medication use among patients who are overweight and obese to those of normal weight with COPD. METHODS: We performed secondary data analysis on 364 Veterans with COPD. We categorized subjects by body mass index (BMI). We assessed dyspnea using the Medical Research Council (MRC) dyspnea scale and HRQoL using the St. George's Respiratory Questionnaire. We identified treatment for an exacerbation and inhaled medication use in the past year. We used multiple logistic and linear regression models as appropriate, with adjustment for age, COPD severity, smoking status, and co-morbidities. RESULTS: The majority of our population was male (n = 355, 98%) and either overweight (n = 115, 32%) or obese (n = 138, 38%). Obese and overweight subjects had better lung function (obese: mean FEV(1) 55.4% ±19.9% predicted, overweight: mean FEV(1) 50.0% ±20.4% predicted) than normal weight subjects (mean FEV(1) 44.2% ±19.4% predicted), yet obese subjects reported increased dyspnea [adjusted OR of MRC score ≥2 = 4.91 (95% CI 1.80, 13.39], poorer HRQoL, and were prescribed more inhaled medications than normal weight subjects. There was no difference in any outcome between overweight and normal weight patients. CONCLUSIONS: Despite having less severe lung disease, obese patients reported increased dyspnea and poorer HRQoL than normal weight patients. The greater number of inhaled medications prescribed for obese patients may represent overuse. Obese patients with COPD likely need alternative strategies for symptom control in addition to those currently recommended.

Medication adherence: its importance in cardiovascular outcomes.

Medication adherence usually refers to whether patients take their medications as prescribed (eg, twice daily), as well as whether they continue to take a prescribed medication. Medication nonadherence is a growing concern to clinicians, healthcare systems, and other stakeholders (eg, payers) because of mounting evidence that it is prevalent and associated with adverse outcomes and higher costs of care. To date, measurement of patient medication adherence and use of interventions to improve adherence are rare in routine clinical practice. The goals of the present report are to address (1) different methods of measuring adherence, (2) the prevalence of medication nonadherence, (3) the association between nonadherence and outcomes, (4) the reasons for nonadherence, and finally, (5) interventions to improve medication adherence.

Medication acquisition and self-reported adherence in veterans with hypertension.

OBJECTIVES: To examine factors associated with oversupply and undersupply of antihypertensive medication, and examine evidence for medication acquisition as distinct from self-reported adherence. RESEARCH DESIGN: Analysis of pharmacy refill records, medical charts, and in-person interviews. SUBJECTS: Five hundred sixty-two male veterans with hypertension enrolled in a randomized controlled trial to improve BP control. MEASURES: Patients were classified as having undersupply (<0.80), appropriate supply (> or = 0.80 and < or = 1.20), or oversupply (>1.20) of antihypertensive medication in the 90 days before trial enrollment based on the ReComp algorithm. Determination of BP control was based on clinic measurements at enrollment. Demographic, clinical, psychosocial, and behavioral factors relevant to medication-taking behavior and BP were assessed at enrollment. RESULTS: Twenty-three percent of the patients had undersupply, 47% had appropriate supply, and 30% had oversupply of antihypertensive medication. Multinomial logistic regression revealed that using fewer classes of antihypertensive medications and greater perceived adherence barriers were independently associated with greater likelihood of undersupply. Current employment was associated with decreased likelihood of oversupply, and greater comorbidity and being married were associated with increased likelihood of oversupply. Agreement between ReComp and self-reported adherence was poor (kappa = 0.19, P < 0.001). Undersupply, oversupply, and self-reported nonadherence were all independently associated with decreased likelihood of BP control after adjusting for each other and patient factors. CONCLUSIONS: Antihypertensive oversupply was common and may arise from different circumstances than undersupply. Measures of medication acquisition and self-reported adherence appear to provide distinct, complementary information about patients' medication-taking behavior.

Alcohol screening scores and medication nonadherence.

BACKGROUND: Medication nonadherence is common and is associated with adverse outcomes. Alcohol misuse may be a risk factor for nonadherence; however, evidence is limited. OBJECTIVE: To identify whether alcohol misuse, as identified by a simple screening tool, is associated in a dose-response manner with increased risk for medication nonadherence in veterans attending primary care clinics. DESIGN: Secondary analysis of cohort data collected prospectively from 1997 to 2000 as part of a randomized, controlled trial. SETTING: 7 Veterans Affairs primary care clinics. PARTICIPANTS: 5473 patients taking a statin, 3468 patients taking oral hypoglycemic agents, and 13 729 patients taking antihypertensive medications. MEASUREMENTS: Patients completed the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) questionnaire, a validated 3-question alcohol misuse screening test. Their scores were categorized into nondrinkers; low-level alcohol use; and mild, moderate, and severe alcohol misuse. Medication adherence, defined as having medications available for at least 80% of the observation days, was measured from pharmacy records for either 90 days or 1 year after the alcohol screening date. Logistic regression was used to estimate the predicted proportions of adherent patients in each AUDIT-C group and adjusted for demographic and clinical covariates. RESULTS: The proportion of patients treated for hypertension and hyperlipidemia who were nonadherent increased with higher AUDIT-C scores. For 1-year adherence to statins, the percentage of adherent patients was lower in the 2 highest alcohol misuse groups (adjusted percentage of adherent patients, 58% [95% CI, 52% to 65%] and 55% [CI, 47% to 63%]) than in the nondrinker group (66% [CI, 64% to 68%]). For 1-year adherence to antihypertensive regimens, the percentage of adherent patients was lower in the 3 highest alcohol misuse groups (adjusted percentage of adherent patients, 61% [CI, 58% to 64%]; 60% [CI, 56% to 63%]; and 56% [CI, 52% to 60%]) than in the nondrinker group (64% [CI, 63% to 65%]). No statistically significant differences were observed for oral hypoglycemics in adjusted analyses. LIMITATION: This observational study cannot address whether changes in drinking lead to changes in adherence and may not be generalizable to other populations. CONCLUSION: Alcohol misuse, as measured by a brief screening questionnaire, was associated with increased risk for medication nonadherence.