Physicians' knowledge, attitudes, and practice of pharmacologic treatment of hypertension.

OBJECTIVE: To explore how well physicians who treat hypertension know the indications and contraindications for particular antihypertensive therapies, and how closely their opinions and practice of hypertension treatment agree with national guidelines. METHODS: We surveyed by mail a stratified random sample of 10,000 US cardiologists, internists, and general/family practitioners. This survey explored their knowledge, attitudes, and practices with respect to the treatment of hypertension. Responses were compared with national guidelines and product labeling at the time of the survey. Results were stratified by physician specialty. RESULTS: A total of 1,023 physicians, or 10.2% of the sample, responded to the survey. Only 37.3% answered all four knowledge questions correctly, including 25.7% of general/family practitioners, 38.3% of internists, and 49.5% of cardiologists (p < 0.001). In their attitudes with respect to evaluating high blood pressure and establishing treatment goals, most respondents agreed with established guidelines. However, when asked how they would treat uncomplicated, mild hypertension, only 23% limited their selection to diuretics and beta-blockers in accordance with the guidelines. Cardiologists in particular were more likely than internists or general/family practitioners to choose other drug classes, such as angiotensin-converting enzyme Inhibitors or calcium-channel blockers. CONCLUSIONS: The results of our survey suggest that national efforts to educate physicians about the increasingly complex armamentarium for hypertension, and to persuade them to base their prescribing on the results of randomized, controlled trials of primary prevention, must be continued.

Cost effectiveness of HMG-CoA reductase inhibition in Canada.

OBJECTIVE: To assess the cost effectiveness of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor therapy, particularly atorvastatin, in primary and secondary prevention of coronary artery disease (CAD) in Canada. METHODS: A Markov model was developed in which costs and effectiveness of atorvastatin were compared with those of other statins and with no drug therapy in primary and secondary prevention of CAD. PATIENTS: Cost effectiveness was assessed for cohorts of patients with risk profiles defined by CAD status, age, sex, pretreatment low density lipoprotein cholesterol level and presence of sentinel coronary risk factors. Coronary risk was estimated by using initial and subsequent event coronary risk equations from the Framingham Heart Study, and risk factors were estimated by using Canadian population survey data. Recent estimates of the costs of CAD-related medical care in Canada were used to assign costs to health states and acute coronary events. INTERVENTIONS: Interventions included atorvastatin 10 mg, simvastatin 10 mg, pravastatin 20 mg, fluvastatin 20 mg, lovastatin 20 mg and no pharmacological therapy. RESULTS: Incremental cost effectiveness ratios (CDN$/year of life gained) relative to no therapy were lowest for atorvastatin and highest for pravastatin across all risk profiles. Atorvastatin was less costly and more effective than lovastatin, pravastatin and simvastatin in primary and secondary prevention, and conferred additional health benefits at a reduced cost per year of life gained compared with fluvastatin. CONCLUSIONS: Atorvastatin was found to be the most cost effective statin in primary and secondary prevention of CAD.

Primary and subsequent coronary risk appraisal: new results from the Framingham study.

BACKGROUND: Coronary heart disease continues to be one of the most common chronic illnesses in the United States and most of the developed world. Clinicians and health authorities have interest in identifying individuals at increased risk of CHD. The Framingham Heart Study has over the years produced mathematical "health risk appraisal models" that relate risk factors to the probability of developing CHD. METHODS AND RESULTS: New sex-specific models from The Framingham Heart Study for primary and secondary (subsequent) CHD have been produced. The primary CHD models are appropriate for assessing CHD risk in persons free of cardiovascular disease and contain risk factors such as triglyceride levels, alcohol use, and menopausal status, risk factors not included in previously published models. The subsequent CHD models are applicable for persons with a history of CHD or ischemic stroke who have survived the acute period after the event. Age, blood lipid levels (total cholesterol and HDL cholesterol), and diabetes status are significant for men and women. In addition, systolic blood pressure and cigarette smoking are significant predictors of subsequent CHD in women. CONCLUSIONS: These new models are useful tools for better understanding the relation between risk factors and the occurrences of CHD events in individuals who are free of cardiovascular disease as well as persons who have had a prior CHD event or stroke. With the development of these latter models, the importance of blood lipid levels, diabetes, and, in women, systolic blood pressure and cigarette smoking as independent predictors of risk is once again underscored.

Anti-inflammatory therapy reduces total costs of asthma care compared with bronchodilation: the Asthma Outcomes Registry.

BACKGROUND: Current consensus guidelines recommend reliance on anti-inflammatory drugs to treat asthma, reserving theophylline and other long-acting bronchodilators as adjuncts for patients whose symptoms are not well controlled with anti-inflammatory therapy. The effect of such recommendations on total costs of asthma care has not yet been examined, however. OBJECTIVE: To explore the relation between choice of maintenance therapy with anti-inflammatory agents vs long-acting bronchodilators and annual costs of asthma care using data from the Asthma Outcomes Registry. METHODS: Patients 16 years and older were selected from the Asthma Outcomes Registry cohort if they had received either anti-inflammatories (inhaled corticosteroids or cromones) or long-acting bronchodilators (theophylline, salmeterol, oral beta-agonists, or ipratropium bromide), but not both, for at least 1 year before study entry. Oral corticosteroid-dependent patients, those with other chronic lung disease, and those with incomplete cost data during the 365 days before and after their enrollment in the Asthma Outcomes Registry (baseline and follow-up years) were excluded. The effect of anti-inflammatory vs bronchodilator therapy was assessed by comparing the change (follow-up minus baseline) in total costs of asthma care. RESULTS: A total of 314 patients met criteria for study inclusion (237 treated with anti-inflammatories and 77 treated with bronchodilators). Median costs during the baseline year were similar in the anti-inflammatory and bronchodilator groups ($341 and $335, respectively). In the follow-up year, the median change in cost in the anti-inflammatory group was a decline of $93 compared with an increase of $76 in the bronchodilator group (P < .0001). This treatment effect was consistent across subgroups defined by age and amount of medication consumed. CONCLUSIONS: These findings add support to current guidelines recommending reliance on anti-inflammatory therapy to control asthma. The emergence of new therapeutic agents to control inflammation may continue to reduce the costs of treating this important disease.

Selective use of calcium channel blockers to treat high-risk hypertensive patients.

PURPOSE: While hypertension treatment is aimed at reducing cardiovascular disease (CVD) risk, there are reports of association between calcium channel blockers (CCB) use and increased risk. However, these studies may be misleading if CCBs are used selectively in high-risk patients. METHODS: We conducted a knowledge, attitudes, and practice (KAP) survey by mail of a stratified random sample of 10,000 US cardiologists, internists, and family/general practitioners. Completed surveys were received from 1023 physicians, and population means and frequencies (+/-standard errors) were estimated RESULTS: While only 36.3 (+/-0.6)% of physicians use long-acting CCBs for mild hypertension without additional risk factors, use increases with moderate or severe hypertension and other risk factors, including history of myocardial infarction (48.4 (+/-0.6)%), family history of CVD (54.6 (+/-0.6)%), diabetes (57.3 (+/-0.6)%), and angina (63.8 (+/-0.5)%). Physicians use CCBs as initial therapy for 24.8 (+/-0.3)% of mildly and 33.1 (+/-0.3)% of moderately hypertensive patients, and add CCBs to the regimens of 39.0 (+/-0.3)% of moderately hypertensive patients not controlled on other antihypertensive therapy. In multiple regression analysis, the proportion of hypertensive patients treated with CCBs was significantly elevated among geriatricians and physicians who believe severity of hypertension is an indication for their use. CONCLUSION: These findings suggest that CCBs are used selectively for high-risk hypertensive patients. Copyright (c) 2000 John Wiley & Sons, Ltd.

Cost-effectiveness of statins.

Currently, 6 hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) are marketed in the United States (US). Given the wide variation in the prices and efficacy of statins, formal cost-effectiveness analysis may improve drug selection decisions. To assess the cost-effectiveness of statin therapy in primary and secondary prevention of coronary heart disease, we developed a model of the costs and consequences of lipid-regulating therapy and estimated the incremental cost-effectiveness of 5 statins (atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin) at usual starting doses versus no therapy. Drug effects on serum lipids were assessed using data approved by the US Food and Drug Administration for product labeling. Annual risks of coronary event occurrence were estimated using Framingham Heart Study coronary risk equations developed for use in this model. Current estimates of direct medical costs of coronary heart disease were used to assign costs to health states and acute coronary events. Main outcome measurements were net cost (statin therapy minus savings in coronary heart disease treatment), gain in life expectancy, and cost per life-year saved. The maximum gain in life expectancy was achieved with atorvastatin, which also had a lower net cost than lovastatin, pravastatin, and simvastatin. Compared with fluvastatin, atorvastatin's greater effectiveness is attained at a lower cost per life-year saved. The cost-effectiveness of HMG-CoA reductase inhibition in primary and secondary prevention of coronary heart disease has been improved with the introduction of atorvastatin.

Direct medical costs of coronary artery disease in the United States.

To generate current incidence-based estimates of the direct medical costs of coronary artery disease (CAD) in the United States, a Markov model of the economic costs of CAD-related medical care was developed. Risks of initial and subsequent CAD events (sudden CAD death, fatal/nonfatal acute myocardial infarction [AMI], unstable angina, and stable angina) were estimated using new Framingham Heart Study risk equations and population risk profiles derived from national survey data. Costs were assumed to be those related to treatment of initial and subsequent CAD events ("event-related") and follow-up care ("nonevent-related"), respectively. Cost estimates were derived primarily from national public-use databases. First-year direct medical costs of treating CAD events are estimated to be $17,532 for fatal AMI, $15,540 for nonfatal AMI, $2,569 for stable angina, $12,058 for unstable angina, and $713 for sudden CAD death. Nonevent-related direct costs of CAD treatment are estimated to be $1,051 annually. The annual incidence of CAD in the United States is estimated at 616,900 cases, with first-year costs of treatment totaling $5.54 billion. Five- and 10-year cumulative costs in 1995 dollars for patients who are initially free of CAD are estimated at $9.2 billion and $16.5 billion, respectively; for all patients with CAD, these costs are estimated to be $71.5 billion and $126.6 billion, respectively. The direct medical costs of CAD create a large economic burden for the United States health-care system.

Descriptors of alcohol consumption among noninstitutionalized nonalcoholic elderly.

This paper describes relationships between reported alcohol consumption and selected sociodemographic and health variables. Two hundred and four men and 367 women aged 60-95 years were examined as part of a nutritional status survey of elderly. Fifty-three percent of men and 44% of women reported drinking at least 2 g of alcohol per week. Men were more likely to drink than women, and the level of alcohol consumption decreased with age. Drinking was positively associated with education (p less than 0.01) and negatively associated with recent medical care (p less than 0.01), history of MI (p less than 0.05), and denture use (p less than 0.05). Among drinkers, reported alcohol intake was higher for subjects less than age 70 (p less than 0.01), males (p less than 0.01), the college educated (p less than 0.01), and smokers (p less than 0.05). Level of alcohol intake was lower for those who had received medical care in the year preceding study participation (p less than 0.05). Identical results were observed for alcohol intake expressed as percent of total calories. Intake ranged from 3.8% of total calories among subjects 80+ years old to 6.2% of total calories among 60-69-year-olds.

Moderate alcohol intake and nutritional status in nonalcoholic elderly subjects.

Three hundred and seventy-three female and 213 male nonalcoholic subjects, aged 60-100 y, who had participated in a nutritional status survey of elderly people in the Boston area were grouped according to usual alcohol intake: 0-4, 5-14, or 15+ g/d. The age- and sex-adjusted mean intake of calories, fat, protein, carbohydrate, and 10 micronutrients and the mean levels of 14 nutrient and 22 nonnutrient biochemical indices were compared for the three categories of alcohol intake. The mean micronutrient intakes were also adjusted for total caloric intake and the mean nutrient biochemical concentrations were also adjusted for the corresponding nutrient intakes. The results suggest that caloric intake and blood concentrations of retinol, iron, ferritin, HDL cholesterol, AST, and ALT increased with increasing alcohol intake whereas folate and phosphorus intakes and blood measures of riboflavin, copper, zinc, urea nitrogen, and creatinine decreased with increasing alcohol intake.

Relationship of vitamin A and vitamin E intake to fasting plasma retinol, retinol-binding protein, retinyl esters, carotene, alpha-tocopherol, and cholesterol among elderly people and young adults: increased plasma retinyl esters among vitamin A-supplement users.

We studied the relationships of supplemental and total vitamin A and supplemental vitamin E intake with fasting plasma biochemical indicators of vitamin A and vitamin E nutritional status among 562 healthy elderly people (aged 60-98 y) and 194 healthy young adult (aged 19-59 y) volunteers. All subjects were nonsmokers. For the young adults, plasma retinol was significantly greater in males than in females (p less than 0.01); retinol was not related to supplemental vitamin A intake for either group. Fasting plasma retinyl esters demonstrated a significant increase with vitamin A supplement use. For supplemental vitamin A intakes of 5001-10,000 IU/d, a 2.5-fold increase over nonusers in fasting plasma retinyl esters was observed for elderly people (p less than 0.05) and a 1.5-fold increase for young adults (p greater than 0.20). For elderly people, greater fasting plasma retinyl esters were associated with long-term vitamin A supplement use (greater than 5 y) and biochemical evidence of liver damage. Elderly people who take vitamin A supplements may be at increased risk for vitamin A overload.

Vitamin C status and nutrient interactions in a healthy elderly population.

Vitamin C status and interactions with other nutrients were studied in 677 healthy, noninstitutionalized elderly people aged 60-98 y. Although 6% of the males and 3% of the females showed marginal vitamin C status (plasma ascorbic acid 11 to less than 23 mumol/L), only one person had a plasma ascorbic acid (AA) level less than 11 mumol/L. At all levels of total vitamin C intake, mean plasma AA levels were higher in females than males. Vitamin C supplement use was associated with generally higher blood levels of vitamins B-6, B-12, and E and folate in both sexes and with higher levels of retinol in females. However, after both age and the total dietary intake of the specific nutrient being examined were controlled for, plasma AA levels were significantly correlated only with plasma levels of vitamin E and folate in females.

Nutritional status in persons with and without senile cataract: blood vitamin and mineral levels.

As part of an exploratory study of nutrition and senile cataract relationships between biochemical markers of nutritional status and senile cataract were examined in 112 subjects aged 40-70 y. Seventy-seven subjects had a cataract in at least one lens. Blood levels were determined for total carotenoids, vitamin A, vitamin D, vitamin E, vitamin C, riboflavin, thiamin, vitamin B-6, zinc, copper, selenium, and magnesium. Subjects were grouped into quintiles for each nutrient. Logistic regression was used to estimate the odds ratios (ORs) for cataract among subjects in the highest quintile and the middle three quintiles relative to subjects in the lowest quintile. ORs were adjusted for age, sex, race, and presence of diabetes. Results suggest that risk of cortical cataract was reduced for subjects in the highest quintile of vitamin D and total carotenoids and that persons with cataract may have lower levels of vitamin C and higher levels of vitamin B-6 and Se.

Nutrient supplement use by healthy elderly.

As part of a nutritional status survey of 691 non-institutionalized men and women aged 60 years and older, supplement use was reported by 45% of the males and 55% of the females. Supplement use was more prevalent in females than males at each age decade. Vitamins C and E were the most commonly used supplements. Mean dietary nutrient intakes were calculated from a 3-day food diary. The percentage of dietary intakes falling below 2/3 1980 Recommended Dietary Allowance (RDA) was comparable for users and non-users of supplements. Use of supplements markedly decreased the proportion of subjects with inadequate nutrient intake (using a 2/3 RDA criterion), particularly for vitamins B6, B12, and D, folic acid, and calcium. However, for both males and females, potentially excessive intake levels (10 times the RDA) of thiamin, vitamin A, and vitamin E supplementation were observed.

Antioxidant status in persons with and without senile cataract.

The relationship between biochemical markers of antioxidant status and senile cataract was examined in 112 subjects aged 40 to 70 years. Seventy-seven of these subjects had a cataract in at least one lens. Antioxidant status was measured using erythrocyte superoxide dismutase, glutathione peroxidase, and glucose-6-phosphate dehydrogenase activity, and indexes that included these enzymes plus plasma levels of vitamin E, vitamin C, and carotenoids. Subjects were grouped by level (low, moderate, or high) of the enzymes and antioxidant indexes. Results suggest that subjects with high levels of at least two of the three vitamins (vitamin E, vitamin C, or carotenoids) are at reduced risk of cataract relative to subjects with low levels of one or more of these vitamins (odds ratio, 0.2). The erythrocyte enzymes, either individually or in combination, did not appear to differ between subjects with and without cataract.

Dietary intakes and biochemical indicators of nutritional status in an elderly, institutionalized population.

A dietary and biochemical assessment of the nutritional status of 260 elderly men and women, 60-101 y (average 80.5 y), was conducted in 15 long-term-care facilities in the Boston area. Subjects were free of clinically apparent terminal or wasting illness. Nutrient intakes were comparable to those in a simultaneously studied free-living population as were most biochemical markers of nutrient status. Although no specific nutrient deficiencies were identified, blood levels of vitamin A and retinol-binding protein in males and of zinc in both sexes were lower in this institutionalized group than in the free-living subjects. Hematologic indices, albumin, prealbumin, and transferrin levels were also lower than in noninstitutionalized elderly populations. These differences may reflect the greater prevalence of chronic diseases and medication use in a long-term-care population. However, there is no evidence that institutionalization in itself leads to impairment of nutritional status.