Survey nonresponders to a medication-beliefs survey have worse adherence and persistence to chronic medications compared with survey responders.

OBJECTIVE: The primary objective of this study was to investigate whether nonresponders to a medication-beliefs survey exhibited different adherence and persistence patterns than survey responders. METHODS: A medication-beliefs survey was mailed to 7795 adults aged from 40 to 88 years, who filled a qualifying index prescription (cardiovascular, dyslipidemia, oral-antihyperglycemic, oral-bisphosphonate, and asthma-controller medications) in June 2008 at 1 national and 2 regional retail pharmacies. Adherence and persistence to the index drug class was measured using pharmacy-claims data over 12 months. A multivariate generalized linear model with a negative binomial distribution and log-link function was used to determine whether response status was a significant predictor of adherence. Kaplan-Meier estimates of survival curves were used to assess the time to discontinuation (persistence). Differences between nonresponders and responders were assessed using the log-rank test. RESULTS: The survey response rate was 24.25%. The final analytic sample size after exclusions was 6740 patients (5044 nonresponders and 1696 responders). On the basis of multivariate generalized linear model analysis, survey nonresponders had 11% lower medication adherence compared with responders (P < 0.01; goodness-of-fit=1.09 as defined by deviance/df statistics). The proportion of nonresponders deemed nonpersistent at day 305 was 66.3% compared with 58.1% of responders (P < 0.001). The Kaplan-Meier persistence curves were significantly different for nonresponders and responders as assessed by the log-rank test (χ statistic=49.38; P < 0.001). CONCLUSIONS: Our study found that the responders and nonresponders to a medication-beliefs survey differed significantly in their subsequent adherence and persistence, suggesting that biased survey results are likely to accompany low response rates in surveys of medication use. The use of modest monetary incentives had a small effect on survey response; multiple survey levers are recommended to reduce nonresponse and the potential for biased results.

Factors correlated with NPPV use in ALS.

In spite of emerging evidence of therapeutic benefit from non-invasive positive pressure ventilation (NPPV), only a minority of ALS patients use this therapy. We examined factors which correlate with use of NPPV in ALS patients. Data were analyzed from the ALS CARE Database on the use of NPPV in patients with FVC less than 50% of predicted and probable or definite ALS based on modified El Escorial criteria. Of the 403 eligible patients, 146 (36%) used NPPV. NPPV compliance was strongly correlated with symptoms of dyspnea and orthopnea as well as with the use of other therapies including PEG tubes, augmentative speech devices, and riluzole. Male gender and household income >$80,000 were also associated with higher NPPV use. There was no correlation between age, race, type of insurance, forced vital capacity, duration of symptoms, ALSFRS-R, caregiver burden or quality of life with the use of NPPV. These data suggest that the factors which are most closely associated with NPPV utilization are symptomatic orthopnea and dyspnea. The findings may be useful in designing prospective studies to examine the factors which might explain the underutilization of NPPV and the optimal use of this treatment.

Non-ST-segment elevation acute coronary syndrome in patients with renal dysfunction: benefit of low-molecular-weight heparin alone or with glycoprotein IIb/IIIa inhibitors on outcomes. The Global Registry of Acute Coronary Events.

AIMS: To determine whether low-molecular-weight heparin (LMWH)+glycoprotein (GP) IIb/IIIa inhibitors provide greater benefit than unfractionated heparin (UFH)+GP IIb/IIIa inhibitors, irrespective of renal status. METHODS AND RESULTS: Patients in the Global Registry of Acute Coronary Events (GRACE) were divided into three groups according to creatinine clearance (CrCl): normal renal function (CrCl >60 mL/min), moderate renal dysfunction (30

Implications of diabetes in patients with acute coronary syndromes. The Global Registry of Acute Coronary Events.

BACKGROUND: There are limited data describing the presenting characteristics, management, and outcomes of diabetic and nondiabetic patients with an acute coronary syndrome (ACS). OBJECTIVE: To examine differences in these factors, patients with ST-segment elevation acute myocardial infarction, non-ST-segment elevation acute myocardial infarction, and unstable angina were enrolled in a large multinational coronary disease registry. METHODS: The Global Registry of Acute Coronary Events is a prospective observational study of patients hospitalized with an ACS at 94 hospitals in 14 countries. The study sample consisted of 5403 patients with ST-segment elevation acute myocardial infarction, 4725 with non-ST-segment elevation acute myocardial infarction, and 5988 with unstable angina. RESULTS: Approximately 1 in 4 patients presented to participating hospitals with a history of diabetes. Patients with diabetes were older, more often women, with a greater prevalence of comorbidities, and they were less likely to be treated with effective cardiac therapies than nondiabetic patients. Patients with diabetes who developed an ACS were at increased risk for each hospital outcome examined including heart failure, renal failure, cardiogenic shock, and death. These differences remained after adjustment for potentially confounding prognostic factors. CONCLUSIONS: A considerable proportion of patients with an ACS has diabetes and is at increased risk for adverse outcomes compared with patients without diabetes. There are certain proven therapeutic strategies that remain underused in the diabetic population. A more widespread awareness of this increased risk and a more diligent use of proven cardiac treatment approaches are indicated for patients with diabetes who develop an ACS.

Use of noninvasive ventilation in patients with amyotrophic lateral sclerosis.

INTRODUCTION: Noninvasive positive pressure ventilation (NIPPV) is associated with improved survival in amyotrophic lateral sclerosis (ALS) and has been widely recommended. The extent of NIPPV use in ALS patients and the factors associated with its use have not been studied. METHODS: A cross-sectional study using the ALS Patient Care Database. Analyses were performed to assess the association of patient and care characteristics with use of ventilatory support. RESULTS: 1458 patients were studied. 15.6% used NIPPV and 2.1% used invasive mechanical ventilation. Patients who used NIPPV were significantly more likely to be male and have higher income than those who did not. They were also more likely to have a gastrostomy tube, lower vital capacity, more severe disease, bulbar involvement and poorer general health status as measured by the SF-12 and Sickness Impact Profile. Multivariate analysis revealed that lower FVC, higher income and use of gastrostomy tube were independently associated with use of NIPPV. CONCLUSIONS: NIPPV is used more than seven times as frequently as invasive ventilation in ALS patients. Patients who use NIPPV have more severe disease than those who do not use any respiratory intervention. Patients with lower income are less likely to use NIPPV, which raises concerns about disparities in the care of patients with ALS.