Albuminuria: An Underappreciated Risk Factor for Cardiovascular Disease.

Albuminuria, an established biomarker of the progression of chronic kidney disease, is also recognized as a biomarker for the risk of cardiovascular disease. Elevated urinary albumin excretion indicates kidney damage and systemic vascular disease, including myocardial capillary disease and arterial stiffness. Albuminuria is associated with an increased risk of coronary artery disease, stroke, heart failure, arrhythmias, and microvascular disease. There are now several therapeutic agents that can lead to albuminuria lowering and a reduction in cardiovascular risk. However, screening for albuminuria is still low. Considering the importance of multidisciplinary management of patients with cardiovascular disease, it is crucial that health care professionals managing such patients are aware of the benefits of albuminuria surveillance and management.

Albuminuria Screening in People With Type 2 Diabetes in a Managed Care Organization.

Introduction: Albuminuria-an increased amount of urine albumin, in milligrams, adjusted for grams of urine creatinine-is an early marker of diabetic kidney disease. Several new classes of medications are now available that effectively lower albuminuria levels with the potential to delay or prevent the progression of diabetic kidney disease. However, screening for albuminuria in the U.S. is low in population-based studies (<10% to ∼50% at most). In this study, we examine whether screening for albuminuria was improved in an integrated model of healthcare delivery following the recommendations of the National Committee for Quality Assurance mandate (an umbrella group for the managed healthcare industry) to screen for albuminuria. Methods: We examined screening for albuminuria over a 2-year period among people with Type 2 diabetes in a U.S. HMO with an electronic medical record, onto which automated laboratory ordering for albuminuria could be added when a patient appeared at the laboratory (for any reason) if albuminuria testing had not been obtained within the previous 365 days. Participants under this plan received diabetes education at no cost and panel managers to guide their diabetes care. Logistic regression using data from 2020 and 2021, separately, evaluated the relationship between patient characteristics and the likelihood of albuminuria screening. Results: There were 20,688 and 22,487 participants with Type 2 diabetes mellitus in 2020 and 2021, respectively, who were analyzed. Approximately 80% were screened for albuminuria in both years. African American participants and those aged >64 years were more likely to have completed albuminuria screening. Screened individuals had lower HbA1c, blood pressure, and low-density lipoprotein cholesterol levels than those who were not screened. Conclusions: In an integrated healthcare model, it is possible to achieve consistently high rates of albuminuria screening in people with Type 2 diabetes, especially in groups at high risk for kidney disease.

Pharmacist Interventions for Medication Adherence: Community Guide Economic Reviews for Cardiovascular Disease.

INTRODUCTION: Adherence to medications for cardiovascular disease and its risk factors is less than optimal, although greater adherence to medication has been shown to reduce the risk factors for cardiovascular disease. This paper examines the economics of tailored pharmacy interventions to improve medication adherence for cardiovascular disease prevention and management. METHODS: Literature from inception of databases to May 2019 was searched, yielding 29 studies for cardiovascular disease prevention and 9 studies for cardiovascular disease management. Analyses were done from June 2019 through May 2020. All monetary values are in 2019 U.S. dollars. RESULTS: The median intervention cost per patient per year was $246 for cardiovascular disease prevention and $292 for cardiovascular disease management. The median change in healthcare cost per person per year due to the intervention was -$355 for cardiovascular disease prevention and -$2,430 for cardiovascular disease management. The median total cost per person per year was -$89 for cardiovascular disease prevention, with a median return on investment of 0.01. The median total cost per person per year for cardiovascular disease management was -$1,080, with a median return on investment of 7.52, and 6 of 7 estimates indicating reduced healthcare cost averted exceeded intervention cost. For cardiovascular disease prevention, the median cost per quality-adjusted life year gained was $11,298. There were no cost effectiveness studies for cardiovascular disease management. DISCUSSION: The evidence shows that tailored pharmacy-based interventions to improve medication adherence are cost effective for cardiovascular disease prevention. For cardiovascular disease management, healthcare cost averted exceeds the cost of implementation for a favorable return on investment from a healthcare systems perspective.

Evaluation of a Pharmacists' Patient Care Process Approach for Hypertension.

INTRODUCTION: An estimated 116 million American adults (47.3%) have hypertension. Most adults with hypertension do not have it controlled-3 in 4 (92.1 million) U.S. adults with hypertension have a blood pressure ≥130/80 mmHg. The Pharmacists' Patient Care Process is a standardized patient-centered approach to the provision of pharmacist care that is done in collaboration with other healthcare providers. Through the Michigan Medicine Hypertension Pharmacists' Program, pharmacists use the Pharmacists' Patient Care Process to provide hypertension management services in collaboration with physicians in primary care and community pharmacy settings. In 2019, the impact of Michigan Medicine Hypertension Pharmacists' Program patient participation on blood pressure control was evaluated. METHODS: Propensity scoring was used to match patients in the intervention group with patients in the comparison group and regression analyses were then conducted to compare the 2 groups on key patient outcomes. Negative binomial regression was used to examine the number of days with blood pressure under control. The findings presented in this brief are part of a larger multimethod evaluation. RESULTS: More patients in the intervention group than in the comparison group achieved blood pressure control at 3 months (66.3% vs 42.4%) and 6 months (69.1% vs 56.5%). The intervention group experienced more days with blood pressure under control within a 3-month (18.6 vs 9.5 days) and 6-month period (57.0 vs 37.4 days) than the comparison group did. CONCLUSIONS: Findings support the effectiveness of the Michigan Medicine Hypertension Pharmacists' Program approach to implementing the Pharmacists' Patient Care Process to improve blood pressure control.

The uses and expenses of antihypertensive medications among hypertensive adults.

BACKGROUND: The literature lacks information about the use and cost of prescribed antihypertensive medications, especially by the type and class of medication prescribed. OBJECTIVE: This study investigated the uses and expenses of antihypertensive medications among hypertensive adults in the United States. METHODS: Using the 2014-2015 Medical Expenditure Panel Survey data, adult men and nonpregnant women aged 18 or older who had a diagnosis code of hypertension and used any prescribed antihypertensive medication were included in the study (n = 10,971). Adults with hypertension who were using a single antihypertensive medication were defined as single medication users, and those using two or more medications were defined as multiple medication users. Medications were classified into angiotensin-converting-enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), thiazide-type diuretics (TDs), ß-blockers (BBs), and others. The average annual total antihypertensive medication expenses and the expenditures of each medication class were estimated by using generalized linear models with a log link and gamma distribution and were adjusted to 2015 US dollars. RESULTS: Among 10,971 hypertensive adults, 4759 (44.1%) were single medication users, and 6212 (55.9%) were multiple medication users. The average annual total cost for antihypertensive medications was $336 per person (95% confidence interval [CI] = $319-$353); $199 (95% CI = $177-$221) for single medication users and $436 (95% CI = $413-$459) for multiple medication users. The average annual costs for each medication class were estimated at $438 (95% CI = $384-$492) for ARBs and $49 for TDs (95% CI = $44-$55). CONCLUSIONS: Users of multiple medications incurred more than twice the expense than single medication users. When comparing classes of medications, the cost for ARBs was the highest, whereas the cost for TDs was the lowest. This information can be used in evaluating the cost-effectiveness of antihypertension therapies.

National Rates of Nonadherence to Antihypertensive Medications Among Insured Adults With Hypertension, 2015.

Despite the importance of antihypertensive medication therapy for blood pressure control, no single data system provides estimates of medication nonadherence rates across age groups and health insurance plans types. Using multiple administrative datasets and national survey data, we determined health insurance plan-specific and overall weighted national rates of nonadherence to antihypertensive medications among insured hypertensive US adults in 2015. We used 2015 prescription claims data from Medicare Part D and 3 IBM MarketScan databases (Commercial, Medicaid, Medicare Supplemental) to calculate medication nonadherence rates among hypertensive adults aged ≥18 years with public or private health insurance using the proportion of days covered algorithm. These findings, in combination with National Health Interview Survey findings, were used to project national weighted estimates of nonadherence. We included 23.8 million hypertensive adults who filled 265.8 million prescriptions for antihypertensive medications. Nonadherence differed by health insurance plan type (highest for Medicaid members, 55.4%; lowest for Medicare Part D members, 25.2%). The overall weighted national nonadherence rate was 31.0%, with greater nonadherence among women versus men, younger versus older adults (aged 18-34 years, 58.1%; aged 65-74 years, 24.4%), fixed-dose combination medication nonusers (31.2%) versus users (29.4%), and by pharmacy outlet type (retail only, 30.7%; any mail order, 19.8%). In 2015, almost one-third (≈16.3 million) of insured US adults with diagnosed hypertension were considered nonadherent to their antihypertensive medication regimen, and considerable disparities were evident. Public health and healthcare professionals can use available evidence-based interventions to address nonadherence and improve blood pressure control.

Use of strategies to improve antihypertensive medication adherence within United States outpatient health care practices, DocStyles 2015-2016.

Patients' adherence to antihypertensive medications is key to controlling high blood pressure. Evidence-based strategies to improve adherence exist, but their use, individually and in combination, has not been described. 2015-2016 DocStyles data were analyzed to describe health care professionals' and their practices' use of 10 strategies to improve antihypertensive medication adherence across 3 categories: prescribing, education, and tracking/encouragement. Among 1590 respondents, a mean of using 5 strategies was reported, with individual strategy use ranging from 17.2% (providing patients adherence-related rewards) to 69.4% (prescribing once-daily regimens). Those with higher odds of using ≥7 strategies and strategies across all 3 categories included: (1) nurse practitioners compared to family practitioners/internists and (2) health care professionals in practices with standardized hypertension treatment protocols who routinely recommend home blood pressure monitor use compared to respondents without those characteristics. Despite using an array of evidence-based adherence-promoting strategies, additional opportunities exist for health care professionals to provide adherence support among hypertensive patients.

Effect of lifestyle interventions on cardiovascular risk factors among adults without impaired glucose tolerance or diabetes: A systematic review and meta-analysis.

Structured lifestyle interventions can reduce diabetes incidence and cardiovascular disease (CVD) risk among persons with impaired glucose tolerance (IGT), but it is unclear whether they should be implemented among persons without IGT. We conducted a systematic review and meta-analyses to assess the effectiveness of lifestyle interventions on CVD risk among adults without IGT or diabetes. We systematically searched MEDLINE, EMBASE, CINAHL, Web of Science, the Cochrane Library, and PsychInfo databases, from inception to May 4, 2016. We selected randomized controlled trials of lifestyle interventions, involving physical activity (PA), dietary (D), or combined strategies (PA+D) with follow-up duration ≥12 months. We excluded all studies that included individuals with IGT, confirmed by 2-hours oral glucose tolerance test (75g), but included all other studies recruiting populations with different glycemic levels. We stratified studies by baseline glycemic levels: (1) low-range group with mean fasting plasma glucose (FPG) <5.5mmol/L or glycated hemoglobin (A1C) <5.5%, and (2) high-range group with FPG ≥5.5mmol/L or A1C ≥5.5%, and synthesized data using random-effects models. Primary outcomes in this review included systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), and triglycerides (TG). Totally 79 studies met inclusion criteria. Compared to usual care (UC), lifestyle interventions achieved significant improvements in SBP (-2.16mmHg[95%CI, -2.93, -1.39]), DBP (-1.83mmHg[-2.34, -1.31]), TC (-0.10mmol/L[-0.15, -0.05]), LDL-C (-0.09mmol/L[-0.13, -0.04]), HDL-C (0.03mmol/L[0.01, 0.04]), and TG (-0.08mmol/L[-0.14, -0.03]). Similar effects were observed among both low-and high-range study groups except for TC and TG. Similar effects also appeared in SBP and DBP categories regardless of follow-up duration. PA+D interventions had larger improvement effects on CVD risk factors than PA alone interventions. In adults without IGT or diabetes, lifestyle interventions resulted in significant improvements in SBP, DBP, TC, LDL-C, HDL-C, and TG, and might further reduce CVD risk.

Vital Signs: Disparities in Antihypertensive Medication Nonadherence Among Medicare Part D Beneficiaries - United States, 2014.

INTRODUCTION: Nonadherence to taking prescribed antihypertensive medication (antihypertensive) regimens has been identified as a leading cause of poor blood pressure control among persons with hypertension and an important risk factor for adverse cardiovascular disease outcomes. CDC and the Centers for Medicare and Medicaid Services analyzed geographic, racial-ethnic, and other disparities in nonadherence to antihypertensives among Medicare Part D beneficiaries in 2014. METHODS: Antihypertensive nonadherence, defined as a proportion of days a beneficiary was covered with antihypertensives of <80%, was assessed using prescription drug claims data among Medicare Advantage or Medicare fee-for-service beneficiaries aged ≥65 years with Medicare Part D coverage during 2014 (N = 18.5 million). Analyses were stratified by antihypertensive class, beneficiaries' state and county of residence, type of prescription drug plan, and treatment and demographic characteristics. RESULTS: Overall, 26.3% (4.9 million) of Medicare Part D beneficiaries using antihypertensives were nonadherent to their regimen. Nonadherence differed by multiple factors, including medication class (range: 16.9% for angiotensin II receptor blockers to 28.9% for diuretics); race-ethnicity (24.3% for non-Hispanic whites, 26.3% for Asian/Pacific Islanders, 33.8% for Hispanics, 35.7% for blacks, and 38.8% for American Indians/Alaska Natives); and state of residence (range 18.7% for North Dakota to 33.7% for the District of Columbia). Considerable county-level variation in nonadherence was found; the highest nonadherence tended to occur in the southern United States (U.S. Census region nonadherence = 28.9% [South], 26.7% [West], 24.1% [Northeast], and 22.8% [Midwest]) CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: More than one in four Medicare Part D beneficiaries using antihypertensives were nonadherent to their regimen, and certain racial/ethnic groups, states, and geographic areas were at increased risk for nonadherence. These findings can help inform focused interventions among these groups, which might improve blood pressure control and cardiovascular disease outcomes.

Managing severe sepsis: a national survey of current practices.

PURPOSE: Current practices for managing severe sepsis in U.S. hospitals were studied. METHODS: A questionnaire was distributed to nurse managers who were members of the Association of Critical Care Nurses to assess current practices associated with the management of severe sepsis, including assessment of sepsis management priority, patient identification and screening process for sepsis, current treatment practices, process measures and outcomes measurements, and hospital demographics. Differences among small (<200 beds), medium (200-399 beds), and large (>/=400 beds) hospitals were identified using chi-square analysis and Student's t test. RESULTS: A total of 414 surveys were completed, received, and analyzed. As hospital bed size increased, so did the percentage of hospitals with an active severe sepsis program (p = 0.002). Hospitals rated the effect of severe sepsis on mortality as the paramount issue influencing severe sepsis prioritization. Screening for severe sepsis most commonly occurred upon deterioration of laboratory test values, regardless of hospital size. Of 17 Surviving Sepsis Campaign (SSC) treatment guidelines, hospitals most frequently reported adherence to ordering cultures within 6 hours of onset of acute organ dysfunction (71.3%). The least followed guideline was initiation of drotrecogin alfa (activated) within 24 hours of acute organ dysfunction (37.9%). CONCLUSION: A survey of critical care nurses revealed that of the 17 SSC treatment guidelines, hospitals most frequently reported adherence to those concerning prompt ordering of cultures, prompt administration of broad-spectrum antibiotics, and prompt initiation of deep venous thrombosis prophylaxis. Deterioration of laboratory test values was the most common identifier of severe sepsis, regardless of hospital size. Among all hospitals, the least followed guideline was prompt initiation of drotrecogin alfa (activated) therapy.

Hospital inpatient prospective payment system: incorporating new technology.

New technologies in the impatient prospective payment system are discussed. On December 21, 2000, Congress passed Public Law 106-554 that includes a requirement to establish a mechanism to more expeditiously incorporate the costs and establish qualifying criteria for payment of new services and technologies into the hospital inpatient prospective payment system. The final ruling of this law states that a new service or technology must demonstrate substantial improvement, be inadequately paid under the DRG system, and be "new." The intent of these criteria is to identify new technologies that offer substantial improvement over existing technologies and to provide supplemental payment that encourages physicians and hospitals to utilize the new technology. In November 2001, drotrecogin alfa (activated) received fast-track FDA approval because of the robust findings from the PROWESS trial. Drotrecogin alfa (activated) is the first agent proven to reduce mortality in patients suffering from severe sepsis associated with acute organ dysfunction who are at a high risk of death (i.e., APACHE II score > 24). In August 2002, drotrecogin alfa (activated) was one of four such new technologies and the first agent approved for new technology payment under the prospective payment system (PPS). This decision offers confidence that the PPS is effectively striving to incorporate new medical services and technologies at a pace similar to that of innovation. Providers may receive up to $3400 in additional reimbursement when drotrecogin alfa (activated) is administered in the Medicare population. Pharmacy and patient accounting personnel should develop a collaborative process to identify, document, and capture this new source of payment.