Association Between Pharmacy Proximity With Cardiovascular Medication Use and Risk Factor Control in the United States.

BACKGROUND: Poor neighborhood-level access to health care, including community pharmacies, contributes to cardiovascular disparities in the United States. The authors quantified the association between pharmacy proximity, antihypertensive and statin use, and blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) among a large, diverse US cohort. METHODS AND RESULTS: A cross-sectional analysis of Black and White participants in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study during 2013 to 2016 was conducted. The authors designated pharmacy proximity by census tract using road network analysis with population-weighted centroids within a 10-minute drive time, with 5- and 20-minute sensitivity analyses. Pill bottle review measured medication use, and BP and LDL-C were assessed using standard methods. Poisson regression was used to quantify the association between pharmacy proximity with medication use and BP control, and linear regression for LDL-C. Among 16 150 REGARDS participants between 2013 and 2016, 8319 (51.5%) and 8569 (53.1%) had an indication for antihypertensive and statin medication, respectively, and pharmacy proximity data. The authors did not find a consistent association between living in a census tract with higher pharmacy proximity and antihypertensive medication use, BP control, or statin medication use and LDL-C levels, regardless of whether the area was rural, suburban, or urban. Results were similar among the 5- and 20-minute drive-time analyses. CONCLUSIONS: Living in a low pharmacy proximity census tract may be associated with antihypertensive and statin medication use, or with BP control and LDL-C levels. Although, in this US cohort, outcomes were similar for adults living in high or low pharmacy proximity census tracts.

Analysis of Therapeutic Inertia and Race and Ethnicity in the Systolic Blood Pressure Intervention Trial: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Therapeutic inertia may contribute to racial and ethnic differences in blood pressure (BP) control. Objective: To determine the association between race and ethnicity and therapeutic inertia in the Systolic Blood Pressure Intervention Trial (SPRINT). Design, Setting, and Participants: This cross-sectional study was a secondary analysis of data from SPRINT, a randomized clinical trial comparing intensive (<120 mm Hg) vs standard (<140 mm Hg) systolic BP treatment goals. Participants were enrolled between November 8, 2010, and March 15, 2013, with a median follow-up 3.26 years. Participants included adults aged 50 years or older at high risk for cardiovascular disease but without diabetes, previous stroke, or heart failure. The present analysis was restricted to participant visits with measured BP above the target goal. Analyses for the present study were performed in from October 2020 through March 2021. Exposures: Self-reported race and ethnicity, mutually exclusively categorized into groups of Hispanic, non-Hispanic Black, or non-Hispanic White participants. Main Outcomes and Measures: Therapeutic inertia, defined as no antihypertensive medication intensification at each study visit where the BP was above target goal. The association between self-reported race and ethnicity and therapeutic inertia was estimated using generalized estimating equations and stratified by treatment group. Antihypertensive medication use was assessed with pill bottle inventories at each visit. Blood pressure was measured using an automated device. Results: A total of 8556 participants, including 4141 in the standard group (22 844 participant-visits; median age, 67.0 years [IQR, 61.0-76.0 years]; 1467 women [35.4%]) and 4415 in the intensive group (35 453 participant-visits; median age, 67.0 years [IQR, 61.0-76.0 years]; 1584 women [35.9%]) with at least 1 eligible study visit were included in the present analysis. Among non-Hispanic White, non-Hispanic Black, and Hispanic participants, the overall prevalence of therapeutic inertia in the standard vs intensive groups was 59.8% (95% CI, 58.9%-60.7%) vs 56.0% (95% CI, 55.2%-56.7%), 56.8% (95% CI, 54.4%-59.2%) vs 54.5% (95% CI, 52.4%-56.6%), and 59.7% (95% CI, 56.5%-63.0%) vs 51.0% (95% CI, 47.4%-54.5%), respectively. The adjusted odds ratios in the standard and intensive groups for therapeutic inertia associated with non-Hispanic Black vs non-Hispanic White participants were 0.85 (95% CI, 0.79-0.92) and 0.94 (95% CI, 0.88-1.01), respectively. The adjusted odds ratios for therapeutic inertia comparing Hispanic vs non-Hispanic White participants were 1.00 (95% CI, 0.90-1.13) and 0.89 (95% CI, 0.79-1.00) in the standard and intensive groups, respectively. Conclusions and Relevance: Among SPRINT participants above BP target goal, this cross-sectional study found that therapeutic inertia prevalence was similar or lower for non-Hispanic Black and Hispanic participants compared with non-Hispanic White participants. These findings suggest that a standardized approach to BP management, as used in SPRINT, may help ensure equitable care and could reduce the contribution of therapeutic inertia to disparities in hypertension. Trial Registration: ClinicalTrials.gov identifier: NCT01206062.

Primary care visits and ambulatory care sensitive diabetes hospitalizations among adult Alabama Medicaid beneficiaries.

PURPOSE: To describe patterns of care use for Alabama Medicaid adult beneficiaries with diabetes and the association between primary care utilization and ambulatory care sensitive (ACS) diabetes hospitalizations. METHODS: This retrospective cohort study analyzes Alabama Medicaid claims data from January 2010 to April 2018 for 52,549 covered adults ages 19-64 with diabetes. Individuals were characterized by demographics, comorbidities, and health care use including primary, specialty, mental health and hospital care. Characteristics of those with and without any ACS diabetes hospitalization are reported. A set of 118,758 observations was created, pairing information on primary care use in one year with ACS hospitalizations in the following year. Logistic regression analysis was used to assess the impact of primary care use on the occurrence of an ACS hospitalization. RESULTS: One third of the cohort had at least one ACS diabetes hospitalization over their observed periods; hospital users tended to have multiple ACS hospitalizations. Hospital users had more comorbidities and pharmaceutical and other types of care use than those with no ACS hospitalizations. Controlling for other types of care use, comorbidities and demographics, having a primary care visit in one year was significantly associated with a reduced likelihood of ACS hospitalization in the following year (odds ratio comparing 1-2 visits versus none 0.79, 95% confidence interval 0.73-0.85). CONCLUSIONS: Program and population health interventions that increase access to primary care can have a beneficial effect of reducing excess inpatient hospital use for Medicaid covered adults with diabetes.

Quality of Life in Patients With Heart Failure With Recovered Ejection Fraction.

Importance: Heart failure with recovered ejection fraction (HFrecEF) is a recently recognized phenotype of patients with a history of reduced left ventricular ejection fraction (LVEF) that has subsequently normalized. It is unknown whether such LVEF improvement is associated with improvements in health status. Objective: To examine changes in health-related quality of life in patients with heart failure with reduced ejection fraction (HFrEF) whose LVEF normalized, compared with those whose LVEF remains reduced and those with HF with preserved EF (HFpEF). Design, Setting, and Participants: This prospective cohort study was conducted at a tertiary care hospital from November 2016 to December 2018. Consecutive patients seen in a heart failure clinic who completed patient-reported outcome assessments were included. Clinical data were abstracted from the electronic health record. Data analysis was completed from February to December 2020. Main Outcomes and Measures: Changes in Kansas City Cardiomyopathy Questionnaire overall summary score, Visual Analog Scale score, and Patient-Reported Outcomes Measurement Information System domain scores on physical function, fatigue, depression, and satisfaction with social roles over 1-year follow-up. Results: The study group included 319 patients (mean [SD] age, 60.4 [15.5] years; 120 women [37.6%]). At baseline, 212 patients (66.5%) had HFrEF and 107 (33.5%) had HFpEF. At a median follow-up of 366 (interquartile range, 310-421) days, LVEF had increased to 50% or more in 35 patients with HFrEF (16.5%). Recovery of systolic function was associated with heart failure-associated quality-of-life improvement, such that for each 10% increase in LVEF, the Kansas City Cardiomyopathy Questionnaire score improved by an mean (SD) of 4.8 (1.6) points (P = .003). Recovery of LVEF was also associated with improvement of physical function, satisfaction with social roles, and a reduction in fatigue. Conclusions and Relevance: Among patients with HFrEF in this study, normalization of left ventricular systolic function was associated with a significant improvement in health-related quality of life.

Home Healthcare Nursing Visits for Nonhomebound Patients With Heart Failure After Hospital Discharge: A Quality-Improvement Pilot Project.

Frequent rehospitalizations among patients with heart failure (HF) result in patient burden and high cost. Homebound patients with HF qualify for home healthcare after hospital discharge. It is not known if nonhomebound patients with HF could also benefit from home healthcare nursing (HHN) visits to improve the transition from hospital to home. The purpose of this quality-improvement pilot study was to assess the impact of HHN visits provided to nonhomebound HF patients after hospital discharge on 30-day rehospitalization rates. We included patients with HF who were ineligible for home healthcare services due to their nonhomebound status. Home healthcare nurses followed a modified version of the discharge checklist from the American Heart Association's Rise Above Heart Failure materials, and provided education as appropriate based on patients' responses. We enrolled 68 patients in the study. The mean age was 60.2 years; 61.8% were male and 77.9% were White. Based on patient responses to the checklist, key areas addressed during HHN visits were medication management and HF self-care. In the HHN visit group, 15% of the patients experienced rehospitalization within 30 days, compared with 23% in the non-HHN visit group among 540 patients discharged in the same time frame who met the inclusion criteria but were not enrolled in the study (p = .12). Our pilot data show that HHN visits for nonhomebound patients are feasible and result in a numerically lower 30-day rehospitalization rate after discharge. Further study is needed to confirm the clinical efficacy of this approach.

Social support and diabetes distress among adults with type 2 diabetes covered by Alabama Medicaid.

AIMS: Diabetes distress affects approximately 36% of adults with diabetes and is associated with worse diabetes self-management and poor glycaemic control. We characterized participants' diabetes distress and studied the relationship between social support and diabetes distress. METHODS: In this cross-sectional study, we surveyed a population-based sample of adults with type 2 diabetes covered by Alabama Medicaid. We used the Diabetes Distress Scale assessing emotional burden, physician-related, regimen-related and interpersonal distress. We assessed participants' level of diabetes-specific social support and satisfaction with this support, categorized as low or moderate-high. We performed multivariable logistic regression of diabetes distress by level of and satisfaction with social support, adjusting for demographics, disease severity, self-efficacy and depressive symptoms. RESULTS: In all, 1147 individuals participated; 73% were women, 41% White, 58% Black and 3% Hispanic. Low level of or satisfaction with social support was reported by 11% of participants; 7% of participants had severe diabetes distress. Participants with low satisfaction with social support were statistically significantly more likely to have severe diabetes distress than those with moderate-high satisfaction, adjusted odds ratio 2.43 (95% CI 1.30, 4.54). CONCLUSIONS: Interventions addressing diabetes distress in adults with type 2 diabetes may benefit from a focus on improving diabetes-specific social support.

Patient Perspectives on Factors Influencing Medication Adherence Among People with Coronary Heart Disease (CHD) and CHD Risk Factors.

BACKGROUND: Few qualitative studies have explored factors influencing medication adherence among people with coronary heart disease (CHD) or CHD risk factors. We explored how factors related to the patient (e.g. self-efficacy), social/economic conditions (e.g. social support and cost of medications), therapy (e.g. side effects), health condition (e.g. comorbidities), and the healthcare system/healthcare team (e.g. support from healthcare providers and pharmacy access) influence medication adherence, based on the World Health Organization Multidimensional Adherence Model (WHO-MAM). METHODS: We conducted 18 in-depth qualitative interviews from April to July 2018 with ambulatory care patients aged ≥45 years (8 black men, 5 black women, 2 white men, and 3 white women) who were using medications for diabetes, hypertension, dyslipidemia and/or CHD. We used thematic analysis to analyze the data, and sub-themes emerged within each WHO-MAM dimension. FINDINGS: Patient-related factors included beliefs about medications as important for self and faith; the desire to follow the advice of family, friends, and influential others; and self-efficacy. Social/economic factors included observations of social network members and information received from them; social support for medication adherence and pharmacy utilization; and economic influences. Therapy-related barriers included side effects and medicine schedules. Only a few participants mentioned condition-related factors. Healthcare system/healthcare team-related factors included support from doctors and pharmacists; and ease of pharmacy access and utilization. CONCLUSION: These results underscore the need for multidimensional interventions aimed at improving medication adherence and overall health of patients with CHD and CHD risk factors.

Medicaid Expansion and Hospitalization for Ambulatory Care-Sensitive Conditions Among Nonelderly Adults With Diabetes.

Among nonelderly adults with diabetes, we compared hospitalizations for ambulatory care-sensitive conditions from 2013 (pre-Medicaid expansion) and 2014 (post-Medicaid expansion) for 13 expansion and 4 nonexpansion states using State Inpatient Databases. Medicaid expansion was associated with decreases in proportions of hospitalizations for chronic conditions (difference between 2014 and 2013 -0.17 percentage points in expansion and 0.37 in nonexpansion states, P = .04), specifically diabetes short-term complications (difference between 2014 and 2013 -0.05 percentage points in expansion and 0.21 in nonexpansion states, P = .04). Increased access to care through Medicaid expansion may improve disease management in nonelderly adults with diabetes.

Association of functional and structural social support with medication adherence among individuals treated for coronary heart disease risk factors: Findings from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study.

BACKGROUND: Functional social support has a stronger association with medical treatment adherence than structural social support in several populations and disease conditions. Using a contemporary U.S. population of adults treated with medications for coronary heart disease (CHD) risk factors, the association between social support and medication adherence was examined. METHODS: We included 17,113 black and white men and women with CHD or CHD risk factors aged ≥45 years recruited 2003-2007 from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Participants reported their perceived social support (structural social support: being partnered, number of close friends, number of close relatives, and number of other adults in household; functional social support: having a caregiver in case of sickness or disability; combination of structural and functional social support: number of close friends or relatives seen at least monthly). Medication adherence was assessed using a 4-item scale. Multi-variable adjusted Poisson regression models were used to calculate prevalence ratios (PR) for the association between social support and medication adherence. RESULTS: Prevalence of medication adherence was 68.9%. Participants who saw >10 close friends or relatives at least monthly had higher prevalence of medication adherence (PR = 1.06; 95% CI: 1.00, 1.11) than those who saw ≤3 per month. Having a caregiver in case of sickness or disability, being partnered, number of close friends, number of close relatives, and number of other adults in household were not associated with medication adherence after adjusting for covariates. CONCLUSIONS: Seeing multiple friends and relatives was associated with better medication adherence among individuals with CHD risk factors. Increasing social support with combined structural and functional components may help support medication adherence.

Diabetes, diabetes severity, and coronary heart disease risk equivalence: REasons for Geographic and Racial Differences in Stroke (REGARDS).

BACKGROUND: Evidence is mixed regarding whether diabetes confers equivalent risk of coronary heart disease (CHD) as prevalent CHD. We investigated whether diabetes and severe diabetes are CHD risk equivalents. METHODS: At baseline, participants in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study (black and white US adults ≥45 years old recruited in 2003-2007) were categorized as having prevalent CHD only (self-reported or electrocardiogram evidence; n = 3,043), diabetes only (self-reported or elevated glucose; n = 4,012), diabetes and prevalent CHD (n = 1,529), and neither diabetes nor prevalent CHD (n = 17,155). Participants with diabetes using insulin and/or with albuminuria (urinary albumin-to-creatinine ratio ≥30 mg/g) were categorized as having severe diabetes. Participants were followed up through 2011 for CHD events (myocardial infarction or fatal CHD). RESULTS: During a mean follow-up of 5 years, 1,385 CHD events occurred. The hazard ratios of CHD events comparing participants with diabetes only, diabetes, and prevalent CHD and neither diabetes nor prevalent CHD with those with prevalent CHD were 0.65 (95% CI 0.54-0.77), 1.54 (95% CI 1.30-1.83), and 0.41 (95% CI 0.35-0.47), respectively, after adjustment for demographics and risk factors. Compared with participants with prevalent CHD, the hazard ratio of CHD events for participants with severe diabetes was 0.88 (95% CI 0.72-1.09). CONCLUSIONS: Participants with diabetes had lower risk of CHD events than did those with prevalent CHD. However, participants with severe diabetes had similar risk to those with prevalent CHD. Diabetes severity may need consideration when deciding whether diabetes is a CHD risk equivalent.

Gender, Illness-Related Diabetes Social Support, and Glycemic Control Among Middle-Aged and Older Adults.

OBJECTIVES: This study examined whether the association between illness-related diabetes social support (IRDSS) and glycemic control among middle-aged and older adults is different for men and women. METHOD: This cross-sectional analysis included 914 adults with diabetes who completed the Health and Retirement Study's 2003 Mail Survey on Diabetes. IRDSS is a composite score of 8 diabetes self-care measures. Hemoglobin A1c levels were obtained to measure good glycemic control (<8.0%). Gender-stratified multivariate log-binomial regression models were used to estimate prevalence ratios and examine the association between IRDSS and glycemic control after controlling for sociodemographic, lifestyle, and clinical characteristics. RESULTS: The prevalence of good glycemic control was 48.9% among women and 51.1% among men. Mean composite IRDSS scores did not differ by gender. Among women, composite IRDSS was associated with adequate glycemic control (prevalence ratio: 1.06; 95% confidence interval: 1.02, 1.08), and all individual components of IRDSS, with the exception of keeping appointments, were positively associated with adequate glycemic control. No significant associations were observed in men for composite or individual components of IRDSS. DISCUSSION: Determining the gender-specific impact derived from IRDSS is a worthwhile approach to highlighting factors that differentially predict optimal glycemic control among middle-aged and older adults.

Diabetes risk, diagnosis, and control: do psychosocial factors predict hemoglobin A1c defined outcomes or accuracy of self-reports?

OBJECTIVE: To evaluate the accuracy of self-reported diabetes among multi-ethnic older adults by psychosocial factors and assess predictors of diabetes risk, diagnosis, and control. DESIGN AND METHODS: The 2006 Health and Retirement Study (N=5,594) was used to determine agreement between self-reported diabetes and measured diabetes (HbA1c> or = 6.5%) by age, sex, race/ethnicity, nativity, education, health insurance coverage, body mass index, depressive symptoms, and prior report of racial discrimination. We also examined associations between these factors and pre-diabetes (HbA1c > or = 6.0-<6.5%) among individuals without diabetes, and those with undiagnosed and poorly controlled (HbA1c > or = 8.0%) diabetes. RESULTS: Accuracy of self-reported diabetes was good (ie, sensitivity > or = 80% and specificity > or = 95%) among all demographic subgroups and across most social strata. Among those who reported racial discrimination, sensitivity of self-reported diabetes was lower among Blacks who reported racial discrimination in comparison to Blacks who did not report racial discrimination (82.7% vs 89.0%) an association that was marginally statistically significant (P=.05). Blacks and Hispanics had higher odds of pre-diabetes, undiagnosed diabetes, and poor glycemic control. CONCLUSIONS: Self-reported diabetes corresponded well with HbAlc assessed disease for all social strata examined in this sample of multi-ethnic older adults. Blacks with a history of racial discrimination may be less likely to know diabetes status.