Evaluation of adherence to guideline-directed therapy and risk factors for exacerbation in mild asthma: a retrospective chart review.

BACKGROUND: A significant update was made to both the Global Initiative for Asthma (GINA) in 2019 and the National Heart Lung and Blood Institute (NHLBI) asthma guidelines in 2020 for mild asthma. These groups no longer recommend short-acting beta-agonists (SABA) as monotherapy for mild (GINA) or mild-persistent (NHLBI) asthma. With the lag that can occur between guideline or evidence updates and changes in practice, this study sought to evaluate whether guideline adoption had occurred. METHODS: In this retrospective chart review, patient electronic medical records from a large healthcare system were evaluated from July 1 of 2021 to July 1 of 2022 to determine how many patients with mild asthma were prescribed as needed or daily inhaled corticosteroids (ICS) in addition to as needed SABA. The secondary outcome was to evaluate the incidence of exacerbations in patients with mild asthma, comparing those on guideline-directed therapy or not. In addition, we evaluated other patient factors increasing exacerbation risk in mild asthma. RESULTS: For the primary outcome, of the 1,107 patients meeting inclusion criteria, 284 patients (26%) did not have documentation of guideline-directed therapy for mild asthma during the study period, while 823 (74%) were on guideline-directed therapy (Diff:48.7%; 95% CI:45.1 to 52.3%, p < 0.001). For the secondary objective, 161 patients had an exacerbation (12% on guideline-directed therapy, 15.4% not on guideline-directed therapy). This difference in incidence of exacerbation between the two treatment groups was not statistically significant (Diff: -3.4%; 95% CI: -8 to 1.1%; p = 0.133). In addition, being female, having GERD, and being obese were all statistically significant factors associated with having asthma exacerbations among our patient population. CONCLUSIONS: Nearly one-fourth of patients with mild persistent asthma were not on guideline-directed therapy, despite updates in asthma guidelines (GINA 2019, NHLBI 2020). Factors such as being female, having GERD, and being obese were all statistically significant factors associated with having asthma exacerbations among patients with mild persistent asthma.

Understanding medication use behaviors and perspectives in an older cardiovascular patient population: Opportunities for patient-centered deprescribing.

Study objective: Describe self-reported medication use behaviors and perspectives to identify opportunities for collaborative deprescribing among older cardiovascular patients. Design: Patient survey using convenience sampling. Setting: Private cardiology practice in Maricopa County, Arizona, USA. Participants: Established patients aged ≥65 years with an active medication list indicating prescription polypharmacy (≥5 medications) and/or use of ≥1 high risk medication (anticoagulant, antiarrhythmic, anti-hypotensive, insulin). Intervention: Anonymous online survey. Main outcome measures: Current medication use (prescription and over-the-counter), self-reported medication use behaviors measured by the Adherence to Refills and Medications Scale (ARMS-12), and perspectives on deprescribing. Results: Overall, 138 participants were recruited, with a mean age of 76.7 years. All but two self-identified as Caucasian. Prescription polypharmacy was reported by 80 (58.0 %), with use of 5-9 medications by 66 (47.8 %) and use of ≥10 medications (excessive polypharmacy) by 14 (10.1 %). Approximately one-third (n = 45, 32.6 %) had ARMS = 12, indicating adherence to taking and refilling medications. More than 1 in 10 patients (11.6 %) used >1 high-risk medication. About 4 in 10 (40.6 %) used ≥5 OTC medications. Most highly prioritized reasons for continuing medications were to prolong life (40 %), feel better (17 %), and reduce stroke risk (15 %). Despite 66.7 % of patients indicating taking "just the right amount of medications," willingness to stop ≥1 medication was very high at 80.4 %. Conclusion: Among older cardiovascular patients, prescription polypharmacy is prevalent as are medication use behaviors associated with some degree of nonadherence. Patients are supportive of deprescribing. Prioritizing what matters most to patients and focusing efforts to deprescribe potentially inappropriate medications is recommended.

Timing of Anticoagulation after Stroke in Patients with Non-Valvular Atrial Fibrillation Assessment of Provider Practices.

BACKGROUND: Optimal timing of oral anticoagulation (TOAC) in acute ischemic stroke (AIS) in patients with atrial fibrillation (AF) is unknown. The risk of recurrent ischemic events when treatment is delayed is often weighed against that of hemorrhagic transformation (HT) when anticoagulation is started in the subacute phase, especially in moderate to large infarctions. Despite substantial evidence for the benefit of oral anticoagulation (OAC) in reducing stroke recurrence, current nationally recognized practice guidelines do not provide clear recommendations on the TOAC after AF-related AIS. MATERIALS AND METHODS: We surveyed neurologists on therapeutic approaches to timing of anticoagulation after stroke in patients with AF (without moderate or severe mitral stenosis or a mechanical heart valve) using an online questionnaire. Several ischemic and hemorrhagic stroke scenarios with various stroke sizes, locations, and high-risk thrombotic complications were presented, and survey respondents were asked to provide post-stroke timeframe for TOAC. Practice background, specialty and years of experience of respondents were recorded. RESULTS: Majority of participants favored early initiation of OAC in small infarcts. In moderate to larger infarct burden, or when ischemia was complicated by HT, there was an overall trend to delay any initiation of OAC, irrespective of specialty or years of experience. The overt presence of an additional cardiac embolic source such as cardiac thrombus led decisions for early anticoagulation. CONCLUSION: Although general practice trends were captured, optimal TOAC following AIS in AF remains unknown. Further research is warranted to determine optimal timing and anticoagulant selection.

The need for a systematic approach to statin switching: an analysis of real-world experience.

BACKGROUND: In the advent of generic statins becoming increasingly available and with the recent addition of atorvastatin to the generic market, healthcare providers are often encouraged by payers to switch from a branded statin to an alternate, less costly agent. OBJECTIVE: The aim of this study was to determine the impact of a therapeutic switch on cholesterol goal attainment among patients with existing cardiovascular disease (CVD) or risk factors for CVD. STUDY DESIGN: A cross-sectional, multisite retrospective review of patient records evaluating low-density lipoprotein cholesterol (LDL-C) control before and after switching statins was conducted. METHODS: Participants were 18 to 89 years olds who were stable on statin therapy and had 1 or more risk factors for CVD. Patients meeting switch criteria (n = 833) were evaluated for changes in their statin therapy and LDL-C goal attainment. Drug/dose information, cholesterol values, and goal attainment in accordance with National Cholesterol Education Panel Third Adult Treatment Panel guidelines were determined before and after the switch. Dose potency was based on mean LDL-C reductions. RESULTS: Data were collected from 22 US sites. Risk factors for CVD were common, with 88.5% of patients identified as high risk. Overall, patients' mean LDL-C levels improved from 87.1 to 81.5 mg/dL, and goal attainment increased from 75.5% to 82.5% (P < .05). Switches to a comparable or higher statin/dose improved mean LDL-C and goal attainment (P < .05). However, in patients transitioned to a lower statin/dose equivalency (36.4%), mean LDL-C level increased from 79.8 to 85.6 mg/dL and goal attainment fell from 84.2% to 78.6% (P < .05). Logistic regression confirmed that LDL-C goal attainment was reduced by 53% in patients switched to a lower statin/dose (odds ratio, 0.47; 95% confidence interval, 0.30-0.76; P = .002) compared with patients switched to an equipotent dose. The use of adjunctive lipid-lowering therapies increased in patients switched to a lower statin/dose (P < .05). CONCLUSIONS: Cholesterol values and goal attainment can be negatively impacted when a systematic approach is not used and patients are switched to lower potency therapies.