Early impact of the 2018 AHA/ACC/multisociety cholesterol guideline on lipid monitoring after statin initiation.

BACKGROUND: The 2018 AHA/ACC/multisociety cholesterol guideline emphasizes the need for lipid monitoring more strongly than the previous 2013 guideline to ensure patients reach recommended percent low-density lipoprotein cholesterol reductions. Real-world compliance to monitoring recommendations is currently unknown. OBJECTIVES: This study examined the proportion of patients with a lipid panel measured within 3 months of statin initiation. METHODS: This retrospective cohort study evaluated University of Colorado Health primary care patients aged 18 to 89 years with a new statin prescription identified via the Epic Clarity database. Patients initiated on a statin during January 1, 2018 to June 30, 2018 and January 1, 2019 to June 30, 2019 were included in the pre-2018 guideline cohort and the post-2018 guideline cohort, respectively. Patients with active liver disease, pregnancy, or missing demographic data were excluded. RESULTS: A total of 13,726 patients were included, 7476 in the preguideline cohort and 6250 in the postguideline cohort. A total of 13.9% of patients in the preguideline cohort had a lipid panel completed within 3 months of statin initiation compared with 16.2% in the postguideline cohort (adjusted P < .001). In the postguideline cohort, 56% (n = 857) of patients with lipid monitoring warranted a therapeutic intensification as recommended by the 2018 guideline; however, only 5% had their lipid-lowering regimen changed. CONCLUSION: In a large integrated health system, lipid monitoring increased among patients newly started on statin therapy soon after release of the 2018 guideline but remains low. Clinical interventions are needed to improve lipid monitoring to optimize low-density lipoprotein cholesterol-lowering therapy and ensure that guideline-recommended goals are achieved.

Trends in Antihypertensive Medication Monotherapy and Combination Use Among US Adults, National Health and Nutrition Examination Survey 2005-2016.

Blood pressure (BP) control rates among US adults taking antihypertensive medication have not increased over the past decade. Many adults require 2 or more classes of antihypertensive medication to achieve guideline-recommended BP goals, but the proportion of US adults taking antihypertensive medication monotherapy, versus combination therapy, has not been quantified using contemporary data. We analyzed data from 2005 to 2008, 2009 to 2012, and 2013 to 2016 National Health and Nutrition Examination Surveys to determine trends in monotherapy and combinations of antihypertensive medication classes among US adults age ≥20 years with hypertension taking antihypertensive medication (n=7837). The proportion of US adults taking antihypertensive medication with uncontrolled BP (ie, systolic BP ≥140 or diastolic BP ≥90 mm Hg) was 32.3%, 30.2%, and 31.0% in 2005 to 2008, 2009 to 2012, and 2013 to 2016, respectively (Ptrend=0.37). Between 2005 to 2008 and 2013 to 2016, there was no evidence of changes in the proportions of US adults taking antihypertensive monotherapy (39.5%-40.4%, Ptrend=0.67), dual-therapy (37.9%-38.3%, Ptrend=0.75), triple-therapy (17.6%-16.5%, Ptrend=0.36), or quadruple-therapy (4.4%-4.3%, Ptrend=0.93). Between 2005 to 2008 and 2013 to 2016, there was no evidence of changes in the proportions of US adults with uncontrolled BP taking antihypertensive monotherapy (39.3%-40.6%, Ptrend=0.78). A high proportion of US adults with hypertension, including those with uncontrolled BP, are taking one antihypertensive medication class. Increasing the use of dual- and triple-therapy antihypertensive medication regimens may restore the upward trend in BP control rates among US adults.

Blood pressure control rates measured in specialty vs primary care practices within a large integrated health system.

Blood pressure measurement is a diagnostic test and a key component of assessing and managing hypertension, a major contributor to cardiovascular risk. Based on real-world clinical observations within a large, university-based, accountable care organization, we sought to assess whether blood pressure control results varied by the assessment setting, primary care versus specialty. We studied the most recent outpatient measurement for patients with hypertension during the 2016 calendar year and categorized each as being performed in a primary care or specialty setting, and as being controlled (<140/90 mm Hg) or uncontrolled. Among the 86 512 patients identified, the 43 364 whose most recent blood pressure measurement was in a specialty setting were significantly less likely to be controlled compared to the 43 148 whose most recent measurement was in primary care (63% vs 68%, respectively, OR = 0.83 [0.80-0.85]). For the 27 955 patients who had measurements performed in both settings during the year, the control rates based upon their most recent specialty and primary care measurements were 63% and 71%, respectively (OR = 0.62, 0.60-0.65). For the subsets of patients whose measurements in each setting were within 30 or within seven days of each other, the odds of control in the specialty versus primary care setting were 0.63 (0.58-0.75) and 0.65 (0.57-0.75), respectively. Health systems should weigh the value of performing blood pressure measurement in specialty settings that do not manage this condition, taking into consideration the resources required to perform it and the potential negative consequences of inaccurate measurements.

Clinical and economic consequences of statin intolerance in the United States: Results from an integrated health system.

BACKGROUND: Although statins are considered safe and effective, they have been associated with statin intolerance (SI) in clinical and observational studies. OBJECTIVE: The objective of this study was to describe the clinical and economic consequences of SI through comparison of an SI cohort of patients with matched controls. METHODS: This study used data extracted from an integrated health system's electronic health records from 2008 to 2014. Adults with SI were matched to controls using a propensity score. Patients were hierarchically classified into 6 mutually exclusive cardiovascular (CV)-risk categories: recent acute coronary syndrome (ACS; ≤12 months preindex), coronary heart disease, ischemic stroke, peripheral artery disease, diabetes, or primary prevention. The study endpoints, low-density lipoprotein cholesterol (LDL-C) goal attainment, medical costs, and time to first CV event were compared using conditional logistic regression, generalized linear, and Cox proportional hazards models, respectively. RESULTS: Patients with SI (n = 5190) were matched with controls (n = 15,570). Patients with SI incurred higher medical costs and were less likely to reach LDL-C goals than controls. Patients with SI were at higher risk for revascularization procedures in all CV risk categories except ACS, and those in the diabetes risk category were at higher risk for any CV event. There was a lower risk of all-cause death among patients with SI. CONCLUSIONS: Patients with SI were less likely to reach LDL-C goals, incurred higher health care costs, and experienced a higher risk for nonfatal CV events than patients without SI. Alternative management strategies are needed to better treat high CV risk patients.

An off-site clinical pharmacy service in family medicine: development and 1-year outcomes.

BACKGROUND AND OBJECTIVES: Clinical pharmacists are a part of integrated health care teams and provide clinical medication recommendations for family physicians. On-site clinical pharmacy services are common in family medicine. This model may not be the most effective or efficient way to provide clinical pharmacy services in a small practice or in a remote location. The objectives of this study were to describe the development of an off-site clinical pharmacy service and to describe the 1-year clinical impact of this service. METHODS: The University of Colorado Park Meadows Family Medicine Clinic is located approximately 15 miles from the Anschutz Medical Campus. In July 2011, a clinical pharmacist implemented clinical pharmacy services with the goal of providing medication expertise primarily using an off-site model. The clinical pharmacist prospectively screened patients with appointments and provided medication recommendations in the electronic medical record for providers to consider at the patient appointment. RESULTS: For the first 12 months, the clinical pharmacist spent 118 hours providing the clinical pharmacy service. A total of 315 medication recommendations were made for 123 patients; 69.8% were implemented. Forty-nine vaccinations were administered, and 24 potentially dangerous major drug-drug interactions were identified and resolved. Thirty-one unnecessary high-cost drugs were discontinued, resulting in estimated annual savings of $52,215.36. CONCLUSIONS: Our data indicate that clinical pharmacy services can be implemented for smaller remote family clinics using an offsite model. Within this model, clinical pharmacy interventions optimized medication use, managed serious drug interactions, and resulted in cost avoidance.

Evaluation of fracture risk and potential drug holidays for postmenopausal women on long-term bisphosphonate therapy.

STUDY OBJECTIVE: To describe characteristics of postmenopausal women on long-term bisphosphonate therapy who fall into one of four fracture risk categories (low, mild, moderate, high), and to determine the prevalence of women eligible for a drug holiday. DESIGN: Retrospective electronic health record review. SETTING: Eight primary care clinics within a university-based health care system. PATIENTS: A total of 201 postmenopausal women of ages 55-89 years, with osteopenia or osteoporosis, prescribed bisphosphonate therapy for >4 years, between October 10, 2002 and September 9, 2012. MAIN RESULTS: The patients' mean age was 71.4 (±8.2) years; their mean body mass index was 25.3 (±5.6) kg/m(2); and 73.1% were white. Seventy-four out of 201 patients (36.8%) were low-risk; 10/201 (5.0%) were mild-risk; 72/201 (35.8%) were moderate-risk; and 45/201 (22.4%) were high-risk. Eighty-one women (40.3%) were eligible for a drug holiday or discontinuation. The estimated drug cost avoided per eligible patient was $574.80. Calcium and/or vitamin D supplementation was documented in 52.7% of women. CONCLUSION: More than one-third of postmenopausal women taking long-term bisphosphonate therapy had low fracture risk, and over 40% of our patients were eligible for a drug holiday or discontinuation. These data emphasize the need to accurately assess risk and benefit in patients treated with bisphosphonate therapy.

Description of antihypertensive use in patients with resistant hypertension prescribed four or more agents.

Data describing the use of recommended antihypertensive agents in the resistant hypertension population are limited. Treatment recommendations for resistant hypertension include maximizing diuretic therapy by using chlorthalidone and/or adding an aldosterone antagonist. Additional recommendations include combining antihypertensive agents from different drug classes. This retrospective cohort study describes antihypertensive use in patients with resistant hypertension defined as the concurrent use of ≥4 antihypertensive agents. Claims data from the Medstat MarketScan Commercial Claims and Encounter database were used to identify patients with resistant hypertension based on International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes and National Drug Codes between May 1, 2008 and June 30, 2009. Of the 5 442 410 patients with hypertension in the database, 140 126 met study criteria. The most frequently prescribed antihypertensive classes were angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers (96.2%), diuretics (93.2%), calcium channel blockers (83.6%), and ß-blockers (80.0%). Only 3.0% and 5.9% of patients were on chlorthalidone or an aldosterone antagonist, respectively. A total of 15.6% of patients were treated with angiotensin-converting enzyme inhibitor plus angiotensin receptor blocker. Our findings demonstrate that frequently prescribed antihypertensive agents for the treatment of resistant hypertension included guideline-recommended first-line agents. However, evidence-based and recommended agents, such as chlorthalidone and aldosterone antagonists, were underused. Moreover, minimally efficacious combinations, such as an angiotensin-converting enzyme inhibitor with an angiotensin receptor blocker, were prescribed at higher rates than evidence-based and recommended agents.

Academic pharmacy and patient-centered health care: a model to prepare the next generation of pharmacists.

OBJECTIVE: To provide evidence regarding existing partnerships between academic pharmacy and primary care that focus on training practitioners in patient-centered health care (PCHC). DATA SOURCES: The report of the 2009-10 American Association of Colleges of Pharmacy Professional Affairs Committee identified 25 current U.S.-based examples of PCHC that incorporate the training and preparation of both student pharmacists and pharmacy residents. SUMMARY: The most frequently reported health care delivery model was an ambulatory care clinic followed by a Department of Veterans Affairs or military hospital clinic. Pharmacists worked alongside a variety of other health care providers in these settings. Collaboration occurred most commonly with family and internal medicine physicians but also with specialists such as psychiatrists, obstetricians/gynecologists, hematologists/oncologists, and other health care providers (e.g., nurses, physician assistants, dieticians, social workers). CONCLUSION: In light of the increasing demand for primary care services, pharmacists' documented ability to address these needs and the resulting benefits to patients, providers, and systems in these models, developing strategies for promoting pharmacist integration into PCHC is essential. Academic pharmacy provides a valuable platform for this integration through its expert faculty clinician involvement in care and practice-based research and student pharmacist and pharmacy residency training.

Effects of lipid-lowering therapy on reduction of cardiovascular events in patients with end-stage renal disease requiring hemodialysis.

In the general population, dyslipidemia is an established independent risk factor for cardiovascular disease. In patients with end-stage renal disease (ESRD), comorbid cardiovascular disease is present at alarming rates, and those who require hemodialysis and have cardiovascular disease continue to have a high mortality rate. Lipid abnormalities associated with chronic kidney disease (CKD) vary depending on the stage of disease (stages 1-5), but low-density lipoprotein cholesterol (LDL) has been established as the primary lipid treatment target. Guidelines support an LDL level of less than 100 mg/dl in patients with all stages of CKD, except when the triglyceride level is above 500 mg/dl. As patients progress to stage 5 CKD (ESRD with hemodialysis), the high triglyceride, low high-density lipoprotein cholesterol, and increased lipoprotein(a) levels of the early stages become more pronounced, with increases in small dense LDL particles; however, total cholesterol and LDL values remain normal or decrease. In patients undergoing hemodialysis, lipid abnormalities are driven by an increase in hepatic secretion and delayed catabolism of very low-density lipoproteins, as well as a reduction in lipoprotein lipase and hepatic lipase. Epidemiologic data support the role of cholesterol lowering as a means to lower cardiovascular events in the hemodialysis population. We conducted a literature search of various databases (1966-September 2009) to identify relevant clinical trials that evaluated the efficacy and safety of multiple lipid-lowering agents for the treatment of dyslipidemia in patients with ESRD requiring hemodialysis. Only those trials that used clinical primary end points of coronary heart disease (e.g., cardiovascular death, myocardial infarction, stroke) were included in this review. Evidence demonstrates that 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin) therapy (i.e., atorvastatin and rosuvastatin) significantly reduces surrogate cardiovascular markers, particularly LDL, in patients with ESRD requiring hemodialysis; however, no statin has proved to reduce cardiovascular morbidity or mortality in this population. Trials evaluating omega-3 fatty acids did not show significant reductions in LDL or cardiovascular events in this population. Clinicians should appreciate these limitations when deciding whether to continue lipid-lowering pharmacotherapy in these patients, depending on their overall cardiovascular risk assessment.

Switching statin therapy using a pharmacist-managed therapeutic conversion program versus usual care conversion among indigent patients.

UNLABELLED: STUDY OBJECTIVE. To evaluate the effectiveness of switching statin therapy using a therapeutic conversion program versus usual care conversion among patients enrolled in the Colorado Indigent Care Program when atorvastatin was removed from the formulary. DESIGN: Prospective cohort study. SETTING: Family medicine center and other ambulatory care clinics of a university-based health care system. PATIENTS: One hundred seventeen ambulatory care patients with dyslipidemia who were treated with atorvastatin. INTERVENTION: Clinical pharmacists in the family medicine center implemented a therapeutic conversion program (30 patients), switching atorvastatin to a new formulary regimen of simvastatin, rosuvastatin, or ezetimibe-simvastatin, using an algorithm designed to achieve patient-specific goals for low-density lipoprotein cholesterol (LDL). Usual care occurred in the other ambulatory care clinics without clinical pharmacists (87 patients), where medical providers switched atorvastatin to a formulary regimen based on a suggested (but optional) equipotency conversion algorithm. MEASUREMENTS AND MAIN RESULTS: Primary end points were LDL concentration and LDL goal attainment before and after conversion. Before and after conversion, respectively, mean LDL concentrations were 86.7 and 82.3 mg/dl in the therapeutic conversion group (p=0.44) versus 78.3 and 85.2 mg/dl in the usual care group (p=0.01). Percentages of patients attaining LDL goal were 80% before and 97% after conversion in the therapeutic conversion group (p=0.04) compared with 90% before and 75% after conversion in the usual care group (p=0.01). CONCLUSION: Use of a prospective, therapeutic statin conversion program was associated with increased control of dyslipidemia, whereas usual care statin conversion was associated with decreased control. These data suggest that proactive involvement of clinical pharmacists in converting lipid-lowering drugs results in superior patient care outcomes compared with a less aggressive approach.