Acute coronary syndrome emergency treatment strategies: Improved treatment and reduced mortality in patients with acute coronary syndrome using guideline-based critical care pathways.

BACKGROUND: An acute coronary syndrome (ACS) emergency treatment strategies (ACSETS) critical care pathway (CCP), embedding guideline-based treatment, was evaluated in a 4-hospital system in Buffalo, NY, for its impact on ACS drug utilization, length of stay, and mortality. METHODS: The study used an observational design comparing pre- (n = 1,240) and post- (n = 1,709) ACSETS implementation cohorts followed over 1 year. Both myocardial infarction (MI) (59%) and unstable angina (UA) (41%) patients were studied. Multivariate regression analysis was used to analyze possible differences in major end points. RESULTS: Appropriate ACS medication use was significantly higher in the ACSETS group in the first 24 hours and at discharge. In a subgroup of managed care health insurance patients (n = 884 ), prescription refills for statins, beta-blockers, angiotensin-converting enzyme inhibitors, and clopidogrel were significantly greater in the ACSETS group up to and including 7 months after discharge, although at 7 months, actual refill rate was poor (30%-50%) for both groups. Length of stay was significantly reduced (HR 0.82 [0.72-0.90]). Inpatient mortality was not significantly reduced. One-year adjusted mortality was reduced significantly compared to non-ACSETS in the MI group (by 19%) (HR 0.81 [0.66-0.99]) but not in the UA group (HR 1.13 [0.71-1.79]). CONCLUSIONS: ACSETS contributes to the proof of concept of critical care pathway (CCP) improvement of ACS care, as revealed by increased acute and chronic evidence-based use of medication, decreased length of stay, and, in the case of MI patients, decreased adjusted 1-year mortality. One-year mortality benefit was observed in MI but not UA patients.

Assessing incidence and economic burden of genital warts with data from a US commercially insured population.

OBJECTIVE: This study examined the incidence of and healthcare costs attributable to genital warts within a large US commercially insured, geographically dispersed population. RESEARCH DESIGN AND METHODS: Using a retrospective cohort study design, this longitudinal analysis assessed administrative claims of integrated medical and pharmacy encounters from five Blue Cross Blue Shield health plans. Genital warts cases were identified using a methodology previously described by Insinga et al. MAIN OUTCOME MEASURES: Age- and gender-specific incidence of genital warts per 1000 person-years in 2004, and duration-of-episode attributable direct medical costs (2004 US dollars) and healthcare resource utilization of cases diagnosed in 2002. Overall outcome measures were age- and gender-adjusted to the 2004 US civilian population. RESULTS: Genital warts incidence in 2004 was 1.2/1000 females and 1.1/1000 males. Incidence was highest among females aged 20-24 (4.6/1000) and males aged 25-29 (2.7/1000). Projected overall incidence was over 340,000 cases in 2004. Mean duration-of-episode per incident case in 2002 was 95.4 days (males 116.3 days; females 69.7 days). Mean ambulatory visits per episode were 1.5 for females and 1.9 for males, with <1 drug prescription/episode. Mean costs were $647/episode ($745 males; $528 females). The 2004 estimated economic burden was $760 per 1000 individuals in the general population with the total exceeding $220 million. LIMITATIONS: Only those genital warts cases that sought evaluation or for which the treating provider was covered by the health plan were captured in the study. CONCLUSIONS: Genital warts represent a significant health and cost burden in the US. Adoption of novel healthcare technologies such as vaccines along with traditional interventions such as physician education of signs and symptoms, condom use and abstinence or limiting number of sexual partners may significantly help reduce the burden of genital warts.

Comparison of cardiovascular event rates in patients without cardiovascular disease in whom atorvastatin or simvastatin was newly initiated.

OBJECTIVE: To compare cardiovascular (CV) event rates and risk in patients without previous CV disease in whom atorvastatin or simvastatin was newly initiated in a managed care setting. PATIENTS AND METHODS: Patients aged 18 to 64 years in whom atorvastatin or simvastatin was newly initiated between January 1, 2003, and December 31, 2006, and who had no history of CV disease and at least 12 months of preindex and 3 months of postindex continuous eligibility in a managed care health plan, were identified using administrative claims from the HealthCore Integrated Research Database. Descriptive statistics were reported for sample characteristics. Unadjusted CV event rates were compared between treatment groups. A multivariate Cox proportional hazards model was developed to evaluate adjusted CV risk in all patients, as well as in a subset of patients with diabetes mellitus. RESULTS: A total of 168,096 patients in the atorvastatin group and 51,333 patients in the simvastatin group were analyzed. Mean+/-SD age was 50.2+/-9.0 years for patients using atorvastatin and 50.6+/-9.0 years for patients using simvastatin. Mean+/-SD follow-up time was 664.2+/-386.2 days for the atorvastatin group and 511.4+/-359.8 days for the simvastatin group. Mean+/-SD dose and mean+/-SD therapy duration for patients taking simvastatin were 29.1+/-15.1 mg and 188.6+/-236.3 days, respectively, compared with 16.8+/-11.1 mg and 241.8+/-292.0 days, respectively, for patients taking atorvastatin. Unadjusted CV event rates were lower with use of atorvastatin than with simvastatin (hazard ratio, 0.80; 95% confidence interval, 0.75-0.84; P<.001). Adjusting for demographic/clinical characteristics, patients taking atorvastatin experienced a 13% risk reduction in total CV events during the entire follow-up period compared with those who were taking simvastatin (hazard ratio, 0.87; 95% confidence interval, 0.82-0.92; P<.001). No significant differences in CV events were found between patients taking atorvastatin or simvastatin in the diabetes mellitus subset (n=36,969). CONCLUSION: In a managed care population with no history of CV disease, risk of CV events was lower among patients taking atorvastatin compared with patients taking simvastatin, after adjusting for known baseline differences.

Adherence to K/DOQI practice guidelines for bone metabolism and disease.

OBJECTIVE: To determine adherence to Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines for frequency of testing and control of parathyroid hormone (PTH), calcium, and phosphorus levels among patients with chronic kidney disease (CKD). STUDY DESIGN: Retrospective cohort. METHODS: The analysis was performed with administrative claims data from large US managed care plans. Patients with CKD were identified based on claims and laboratory data. Patients were excluded if they were <18 years or >or=65 years old, had fewer than 18 months of continuous eligibility, or had renal cancer. RESULTS: A total of 793 patients were identified with CKD stages 3, 4, or 5 (n = 424, n = 212, and n = 157, respectively). Serum calcium testing was conducted according to guidelines (once a year) in a high percentage of patients with stage 3 CKD (91%); however, the percentage dropped among patients with stage 4 CKD (64%), for whom the guidelines recommend testing 4 times a year. Plasma PTH and serum phosphorus levels were tested infrequently. Among those tested, a high percentage of both stage 3 and 4 CKD patients were in K/DOQI target ranges for calcium and phosphorus. However, fewer than half of the patients tested had PTH values within the target ranges. CONCLUSION: There remains substantial opportunity to improve the quality of care with respect to bone and mineral metabolism in patients with CKD.

Race and electronically measured adherence to immunosuppressive medications after deceased donor renal transplantation.

Nonadherence to immunosuppressive medications may partly explain the worse allograft outcomes among black recipients of renal transplants. In a prospective cohort study of recipients of deceased donor renal transplants, microelectronic cap monitors were placed on bottles of one immunosuppressive medication to (1) measure average daily percentage adherence during the first posttransplantation year and (2) determine the factors associated with adherence. A total of 278 transplant recipients who provided sufficient microelectronic adherence data were grouped into four categories of average daily percentage adherence: 95 to 100% adherence (41.0% of patients), 80 to 95% adherence (32.4%), 50 to 80% adherence (12.9%), and 0 to 50% adherence (13.7%). In the unadjusted ordinal logistic regression model, black race was associated with decreased adherence (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.26 to 0.72; P = 0.001). Cause of renal disease, Powerful Others health locus of control, transplant center, and dosing frequency were also associated with adherence. After adjustment for transplant center and dosing frequency, the association between black race and decreased adherence was substantially attenuated (OR, 0.65; 95% CI, 0.38 to 1.14, P = 0.13). Transplant center (P = 0.003) and increased dosing frequency (OR, 0.43; 95% CI, 0.22 to 0.86, for three or four times per day dosing; OR, 2.35; 95% CI, 1.01 to 5.45, for daily dosing; versus two times per day dosing; P = 0.003) remained independently associated with adherence. Other baseline demographic, socioeconomic, medical, surgical, and psychosocial characteristics were not associated with adherence. The transplant center and dosing frequencies of immunosuppressive medications are associated with adherence and explain a substantial proportion of the race-adherence relationship.

Duffy antigen receptor and genetic susceptibility of African Americans to acute rejection and delayed function.

BACKGROUND: The unique distribution of the alleles for the Duffy antigen receptor complex (DARC) that binds to chemokines may be associated with the rates of acute rejection and delayed allograft function (DGF) among African Americans. METHODS: A prospective, multicenter cohort study enrolled 222 African American recipients of cadaveric renal allografts from eight adult transplant centers. Subjects were typed by allele-specific polymerase chain reaction (ASPCR) for the polymorphism at position 535 that determines the level of transcription. Associations of DARC genotypes were examined in Cox hazards models with episodes of acute rejection and in logistic regression models with the development of DGF. RESULTS: FyB Null homozygosity was observed among 67% of the recipients. Fifteen percent of the study cohort experienced at least one episode of acute rejection, and the incidence of DGF was 42.5%. The number of FyB Null alleles and FyB Null homozygosity had no detectable association with the rate of acute rejection (P > 0.50) or with the development of DGF (P > 0.50). CONCLUSION: The susceptibility of African American recipients to acute rejection and to DGF was not confirmed to be associated with DARC alleles or genotype. Future studies should exclude a potential role of donor-related DARC in transplant outcomes.