Computerized community cholesterol control (4C): meeting the challenge of secondary prevention.

BACKGROUND: Dyslipidemia remains underdiagnosed and undertreated in patients with coronary artery disease. The Computer-based Clinical Decision Support System provides an opportunity t close these gaps. OBJECTIVES: To study the impact of computerized intervention on secondary prevention of CAD. METHODS: The CDSS was programmed to automatically detect patients with CAD and to evaluate the availability of an updated lipoprotein profile and treatment with lipid-lowering drugs. The program produced automatic computer-generated monitoring and treatment recommendations. Adjusted primary clinics were randomly assigned to intervention (n=56) or standard care arms (n=56). Reminders were mailed to the primary medical teams in the intervention arm every 4 months updating them with current lipid levels and recommendations for further treatment. Compliance and lipid levels were monitored. The study group comprised all patients with CAD who were alive at least 3 months after hospitalization. RESULTS: Follow-up was available for 7448 patients (median 19.8 months, range 6-36 months). Overall, 51.7% of patients were adequately screened, and 55.7% of patients were compliant with treatment to lower lipid level. In patients with initial low density lipoprotein >120 mg/dl, a significant decrease in LDL levels was observed in both arms, but was more pronounced in the intervention arm: 121.9 +/- 34.2 vs. 124.3 +/- 34.6 mg/dl (P < 0.02). A significantly lower rate of cardiac rehospitalizations was documented in patients who were adequately treated with lipid-lowering drugs, 37% vs. 40.9% (P < 0.001). CONCLUSIONS: This initial assessment of our data represent a real-world snapshot where physicians and CAD patients often do not adhere to clinical guidelines, presenting a major obstacle to implementing effective secondary prevention. Our automatic computerized reminders system substantially facilitates adherence to guidelines and supports wide-range implementation.

Psoriasis and the metabolic syndrome.

Previous reports have shown a possible association between psoriasis and obesity, ischaemic heart disease, hypertension or diabetes mellitus. However, most of these studies were uncontrolled and were based on small sample sizes. We therefore investigated the association between psoriasis and the metabolic syndrome in a case control study. Case patients were defined as patients with a diagnosis of psoriasis vulgaris. Control patients were subjects who underwent hernioplasty or appendectomy. We used data mining techniques utilizing the database of the southern district of Clalit Health Services. The proportions of patients with diseases that belong to the metabolic syndrome were compared between case and control patients by univariate analyses. chi2 tests were used to compare categorical parameters between the groups. Logistic regression models were used to measure the association between psoriasis and the metabolic syndrome. A total of 340 patients with psoriasis and 6643 controls were included in the study. The mean age of case patients was 47.7 years (SD 10.7 years). There were 50.3% men and 49.7% women. Ischaemic heart disease was present in 23.5% of the patients with psoriasis, compared with 17.2% of the controls (p=0.003). Diabetes mellitus was present in 27.9% of the patients with psoriasis, compared with 19.5% of the controls (p <0.001). Hypertension was present in 44.4% of the patients with psoriasis, compared with 37.2% of the controls (p=0.007). Obesity was present in 29.4% of the patients with psoriasis, compared with 23.5% of the controls (p=0.012). Dyslipidaemia was present in 50.9% of the patients with psoriasis, compared with 44.2% of the controls (p=0.015). The association between psoriasis and the metabolic syndrome was pronounced after the age of 50 years and in men. Multivariate models adjusting for age and gender demonstrated that psoriasis was associated with an increased risk for ischaemic heart disease (odds ratio (OR) 1.4 95% confidence interval (CI) 1.0-1.8), diabetes mellitus (OR 1.5 95% CI 1.2-2.0), hypertension (OR 1.3 95% CI 1.0-1.7), obesity (OR 1.3 95% CI 1.0-1.7) and dyslipidaemia (OR 1.2 95% CI 1.0-1.6). Our findings demonstrate a possible association between psoriasis and the metabolic syndrome. Further studies are needed to establish this observation.

Drug exposure and psoriasis vulgaris: case-control and case-crossover studies.

Intake of drugs is considered a risk factor for psoriasis. The aim of this study was to investigate the association between drugs and psoriasis. A case-control study including 110 patients who were hospitalized for extensive psoriasis was performed. A control group (n = 515) was defined as patients who had undergone elective surgery. A case-crossover study included 98 patients with psoriasis. Exposure to drugs was assessed during a hazard period (3 months before hospitalization) and compared to a control period in the patient's past. Data on drug sales were extracted by data mining techniques. Multivariate analyses were performed by logistic regression and conditional logistic regression. In the case-control study, psoriasis was associated with benzodiazepines (OR 6.9), organic nitrates (OR 5.0), angiotensin-converting enzyme (ACE) inhibitors (OR 4.0) and non-steroidal anti-inflammatory drugs (NSAIDs) (OR 3.7). In the case-crossover study, psoriasis was associated with ACE inhibitors (OR 9.9), beta-blockers (OR 9.9), dipyrone (OR 4.9) and NSAIDs (OR 2.1). Extensive psoriasis may be associated with intake of ACE inhibitors, NSAIDs or beta-blockers.

Efficacy of substituting innovator propafenone for its generic formulation in patients with atrial fibrillation.

The clinical outcomes of 114 patients with atrial fibrillation who had been treated with the innovator propafenone, and in whom the drug was then replaced with generic propafenone because of cost containment, were compared. The generic formulation was found to be at least as safe and effective as the innovator drug, with regard to atrial fibrillation recurrence, emergency room and hospital admissions, and necessity for concomitant therapy.

Impact of subsidizing effective anti-osteoporosis drugs on compliance with management guidelines in patients following low-impact fractures.

Early in 2000, proven-effective antiresorptive drugs (alendronate and raloxifene) were included in the national "health basket" in Israel. We carried out the present study to evaluate the effect of subsidizing antiosteoporosis drugs on the use of antiosteoporosis drugs in patients following low-impact fractures. The rates of dispensation of antiosteoporosis drugs, in the hospital and in the community, before and after an incident of a newly diagnosed low-impact fracture, respectively, were evaluated during January and February 1998 and 1999 ("pre-basket") and the corresponding months of 2000 and 2001 ("post-basket"). The study was carried out in a 950-bed teaching hospital, the only one serving the area, and the largest health maintenance organization in the area. Hospital charts of women and men age 50 years and older with new fractures following low- or moderate-impact trauma treated in the emergency room, or admitted to the orthopedic surgery and rehabilitation departments, were reviewed. A centralized pharmacy computerized database was used to follow antiosteoporosis drug dispensation in the community. A significant, approximately two-fold, increase in the baseline (before fracture) rate of osteoporosis drug dispensation was observed between the pre- and post-basket periods. The rate of patients treated after a fracture incident also increased significantly, 1.6 fold, in the post-basket period; however, even in the post-basket period, two-thirds of the patients remained untreated following a fracture incident, and most of those treated received only calcium and vitamin D; only 17% received potent antiosteoporosis drugs. In a multivariate analysis, female gender, hospitalization, having the incident of fracture in the post-basket period, and above all being treated for osteoporosis before the fracture incident, had the greatest effect on the likelihood of being treated following a low-impact fracture incident. The increase in the pooled use of antiosteoporosis drugs and/or calcium/vitamin D supplements was continuous, and subsidizing created no step-up effect, besides a transient increase in the use of potent antiosteoporosis drugs in the first year following the health-basket amendment. We conclude that while subsidizing may have a significant, positive effect on antiosteoporosis drug utilization, other factors may be even more important. There is an ongoing need to find ways to encourage the use of effective pharmacological interventions for primary and secondary prevention of osteoporotic fractures.