Trends of prescribing adherence of antiplatelet agents in Hong Kong patients with acute coronary syndrome: a 10-year retrospective observational cohort study.

OBJECTIVES: The objective of this study is to examine the temporal trend of antiplatelet prescribing pattern during index hospitalisation discharge in Hong Kong (HK) acute coronary syndrome (ACS) population. DESIGN: The study is a retrospective observational cohort study. SETTING: The study retrieved data from electronic health record from Hospital Authority (HA), HK. PARTICIPANTS: The study included patients aged 18 years old or above, who were admitted to seven institutions under HA with diagnosis of ACS during 2008-2017. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the frequency of antiplatelet therapy prescription at the point of index hospitalisation discharge each year during 2008-2017. Association between demographics, baseline comorbidities, procedures and antiplatelet prescription were examined as secondary outcome using multivariate logistic regression model, with commonly used antiplatelet groups selected for comparison. RESULTS: Among the included 14 716 patients, 5888 (40.0%) discharged with aspirin alone, 6888 (46.8%) discharged with dual antiplatelet therapy (DAPT) with clopidogrel, and 973 (6.6%) discharged with DAPT with prasugrel/ticagrelor. Prescribing rate of aspirin alone decreased substantially from 56.8% in 2008 to 27.5% in 2017. Utilisation of DAPT with clopidogrel increased from 33.7% in 2008 to 52.7% in 2017. Use of DAPT with prasugrel/ticagrelor increased from 0.3% in 2010 to 15.3% in 2017. Compared with those prescribed with DAPT with clopidogrel, male patients (adjusted OR (aOR) 1.34, 95% CI 1.09 to 1.65), patients with non-ST-elevation myocardial infarction (aOR 2.50, 1.98 to 3.16) or ST-elevation myocardial infarction (aOR 3.26, 2.59 to 4.09), use of glycoprotein IIb/IIIa (aOR 3.03, 2.48 to 3.68) or undergoing percutaneous coronary intervention (aOR 3.85, 3.24 to 4.58) or coronary artery bypass graft (aOR 6.52, 4.63 to 9.18) during index hospitalisation, concurrent use of histamine-2 receptor antagonists (aOR 1.35, 1.10 to 1.65) or proton pump inhibitors (aOR 3.57, 2.93 to 4.36) during index hospitalisation discharge were more likely to be prescribed with DAPT with prasugrel/ticagrelor. Patients with older age (aOR 0.97, 0.96 to 0.97), diabetes (aOR 0.68, 0.52 to 0.88), chronic kidney disease (aOR 0.43, 0.22 to 0.85) or concurrent use of oral anticoagulant (aOR 0.16, 0.07 to 0.42) were more likely to received DAPT with clopidogrel. CONCLUSIONS: Use of DAPT with prasugrel/ticagrelor was suboptimal yet improving during 2008-2017 in HK patients with ACS. Considering DAPT, predictors for clopidogrel prescription, compared with prasugrel/ticagrelor, were consistent with identified risk factors of bleeding.

Descriptive analysis of real-world medication use pattern of statins and antiplatelet agents among patients with acute coronary syndrome in Hong Kong and the USA.

OBJECTIVES: The objective was to explore the differences in medication use pattern of lipid-lowering drug (LLD) and antiplatelet agents among post-percutaneous coronary intervention patients with acute coronary syndrome aged <65 in Hong Kong (HK) and the USA. DESIGN: Retrospective study. SETTING: This study used deidentified claims data from Clinformatics Data Mart database (OptumInsight, Eden Prairie, Minnesota, USA) and electronic health records from HK Hospital Authority Clinical Data Analysis and Reporting System database. PARTICIPANTS: We used 1 year prescription records of LLDs and antiplatelet agents among 1013 USA patients and 270 HK Chinese patients in 2011-2013. PRIMARY AND SECONDARY OUTCOME MEASURES: Continuity was investigated on the assumption that one defined daily dose represented 1 day treatment. Medication possession ratio method was used to evaluate the adherence. Multivariate-adjusted logistic regressions were constructed to compare the good continuity and adherence levels in the merged database with the cutoffs set at 80%, and Cox proportional hazard models were built using the time to discontinuation as the dependent variable, to assess the persistence level. RESULTS: HK Chinese patients were less adherent (67.41% vs 84.60%, adjusted odds ratio (AOR) for Americans over Chinese=2.23 (95% CI=1.60 to 3.12), p<0.001) to antiplatelet agents compared with American patients but better adherent to statins (90.00% vs 78.18%, AOR=0.37 (0.23 to 0.58), p<0.001). The discontinuation with statins was more common in American patients (13.33% vs 34.25%, adjusted hazard ratio (AHR)=2.95 (2.05 to 4.24), p<0.001). Low-to-moderate potency statins and clopidogrel were favoured by our HK local physicians, while American patients received higher doses of statins and prasugrel. CONCLUSIONS: We seemed to find HK physicians tended to prescribe cheaper and lower doses of statins and antiplatelet agents when compared with the privately insured patients in the USA, though the adherence and persistence levels of HK patients with statins were relatively good.

Is lipid goal one-size-fits-all: A review of evidence for recommended low-density lipoprotein treatment targets in Asian patients.

The international guideline recommendations for low-density lipoprotein cholesterol (LDL-C) lowering were made based on the results of randomized controlled trials (RCTs), meta-analyses, and observational studies mostly in the White population. It was not clear whether these LDL-C targets could be applicable to other ethnic groups, for example, Asian patients. This review aimed to address major aspects related to the lipid goal and statin therapy in Asia, including the epidemiology of cardiovascular disease, the LDL-C profiles, the lipid goals from localized guidelines, genetics and lifestyles, and the efficacy and safety of statins. Owing to the geographic, ethnic, genetic, and cultural diversity in this region, we observed a geographic pattern of diversity in cardiovascular epidemiology and statin response in Central Asia, East Asia (particularly for Asia-Pacific region), and South Asia. The rapidly growing literature from Asian countries questioning "lower is better" hypothesis was noticed. However, owing to the nature of these dominantly observational data, the conclusion was hardly confirmative. Despite the rapid expansion of the current literature in this region, efforts should be made to ensure an adequate sample size to assess the significance of a given lipid parameter on overall cardiovascular outcomes in this Asian population.

The impact of flare on disease costs of patients with systemic lupus erythematosus.

OBJECTIVE: To evaluate both direct and indirect costs of systemic lupus erythematosus (SLE) patients with and without flares from a societal perspective, and to investigate the impact of the severity and clinical manifestations of flares on direct/indirect costs. METHODS: A retrospective cost-of-illness study was performed on 306 SLE patients. Participants completed questionnaires on sociodemographics, employment status, and out-of-pocket expenses. Health resources consumption was recorded by chart review and patient self-reported questionnaire. The total number of flares and involved organs during the preceding 12 months were recorded. Multiple linear regression was performed to determine the cost predictors. RESULTS: Patients with flares were younger, had shorter disease duration, and had higher disease activity at the time of the assessment. The overall incidence of lupus flares was 0.24 episodes per patient-year. Patients with flares used more health care resources and incurred significantly higher annual direct and indirect costs. The mean total costs per patient-year were 2-fold higher for patients with flares ($22,580 versus $10,870 [2006 US dollars]; P < 0.0005). Multiple regression analysis showed that the number of flares was an independent explanatory variable associated with increased direct costs. Patients with multiorgan flares or renal/neuropsychiatric flares incurred higher direct costs compared with those with single-organ flares or with other organ flares. CONCLUSION: Patients with flares incur higher direct and indirect costs compared with those without flares. Major organ flares incur higher disease costs than other organ flares. Treatments that effectively control disease activity and prevent flares, especially major organ flares, may reduce the high costs associated with flare in SLE.

Clinical outcome of hypertension management.

OBJECTIVE: This study aimed to investigate the association between inadequately controlled hypertension, medication use pattern and the incidence of cardiovascular events (CVEs) over 5 years. The cost of hospitalisation associated with inadequately controlled hypertension was estimated. METHODS: This was a retrospective observational study of patients who were diagnosed with hypertension with at least one blood pressure reading recorded at baseline (year 2000), reviewed from 2001-2005. Primary endpoints were the extent, duration and prevalence of blood pressure deviation from treatment goals. Secondary endpoints were incidence of CVEs and the number of days of hospitalisation associated with inadequately controlled hypertension. RESULTS: In total, the medical records of 210 patients were reviewed. Statistically significant positive associations were found between inadequately controlled systolic blood pressure with the incidence of CVEs (p=0.018) and increased cardiovascular drugs (p<0.001), non-cardiovascular drugs (p=0.019) and total drug usage (p<0.001). Similar observations were observed between inadequately controlled diastolic blood pressure and increased cardiovascular (p<0.05) and total (p=0.007) drug usage. Patients with uncontrolled blood pressure at all times during the study period were associated with a higher incidence of CVEs (p=0.026). The mean cost of hospitalisation due to CVEs was estimated to be HK$42,584.0 +/- 36,670.0 (US$1 = HK$7.8) and it accounted for 3.3% of the total healthcare expenditure during 2005. CONCLUSION: Inadequately controlled blood pressure is positively associated with an increased incidence of CVEs and polypharmacy in Hong Kong Chinese hypertensive patients.