A Metaanalysis of Interventions to Improve Adherence to Lipid-Lowering Medication.

BACKGROUND: Inadequate patient adherence to a medication regimen is a major factor in the lack of success in treating hyperlipidemia. Improved adherence rates may result in significantly improved cardiovascular outcomes in populations treated with lipid-lowering therapy. The purpose of this metaanalysis was to evaluate the effectiveness of interventions aimed at improving adherence to lipid-lowering drugs, focusing on measures of adherence and clinical outcomes. METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature databases through January 14, 2015, and also used the results from previous Cochrane reviews of this title. Randomized controlled trials of adherence-enhancing interventions for lipid-lowering medication in adults in an ambulatory setting with measurable outcomes were evaluated with criteria outlined by the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: Twenty-seven studies randomly assigning 899,068 participants to a variety of interventions were analyzed. One group of interventions categorized as intensified patient care showed significant improvement in adherence rates when compared to usual care (odds ratio 1.93; 95% confidence interval [CI] 1.29-2.88). Additionally, after <6 months of follow-up, total cholesterol decreased by a mean of 17.15 mg/dL (95% CI 1.17-33.14), while after >6 months total cholesterol decreased by a mean of 17.57 mg/dL (95% CI 14.95-20.19). CONCLUSION: Healthcare systems that can implement team-based intensified patient care interventions, such as electronic reminders, pharmacist-led interventions, and healthcare professional education of patients, may be successful in improving adherence rates to lipid-lowering medicines.

Initial Match Rates of an Innovative International Partnership: The Ochsner Clinical School Experience.

BACKGROUND: Ochsner Clinical School (OCS) is a unique partnership between Ochsner Health System in New Orleans, LA, and The University of Queensland (UQ) School of Medicine in Brisbane, Australia. OCS trains physicians in global medicine and promotes careers in primary care through its unique structure. The purpose of this study was to determine how OCS graduates perform in the National Resident Matching Program (NRMP)-The Match-compared to applicants from other types of medical schools. METHODS: The match outcomes for all OCS graduates since the first graduating class in November 2012 were compared to the match outcomes in the NRMP database for graduates from other types of medical schools in the years 2013-2015. We also examined the number of OCS students electing residencies in primary care compared to the number of US medical school graduates overall during the same time period of 2013-2015. RESULTS: The cumulative match rate from 2013-2015 for applicants from OCS was 91.8%. The OCS graduates' match rate was greater than the match rate for US citizen graduates of international medical schools during the same period (53.0% vs 91.8% [z=6.066, P<0.0002]), greater than the match rate for applicants from US osteopathic medical schools (77.3% vs 91.8% [z=25.233, P<0.0002]), and greater than the match rate for applicants from Canadian medical schools (62.7% vs 91.8% [z=3.815, P<0.0002]). The OCS match rate was not significantly different from that of US medical school graduates: 94.0% vs 91.8% (z=-0.728, P=0.4666). During the 2013-2015 time frame, 44.3% of OCS graduates chose residencies in primary care fields compared to 38.3% of US graduates (z=-0.9634, P=0.337). CONCLUSION: Graduates of OCS are obtaining residency positions through The Match at rates comparable to those of US medical school graduates and at rates significantly greater than other groups, and we are seeing a trend in the number of graduates choosing careers in primary care.

Long-term effects of a diabetes boot cAMP on measures of diabetic care.

BACKGROUND: Diabetic patients should receive self-management education to improve self-care and quality of life but are frequently unable to attend such programs because of the time commitment. We instituted an intensive 2-hour Diabetes Boot Camp to provide this education in a condensed time frame. The objective was to determine the long-term effect of the boot camp on mean hemoglobin A1c (HgA1c) levels in patients with diabetes compared to diabetic patients receiving the standard of care. METHODS: The Diabetes Boot Camp population was defined as all diabetic patients referred to the boot camp from the 10 highest utilizing physicians between August 2009 and August 2010. A control population was randomly selected from these same physicians' diabetic patients during the same period. Baseline and postintervention HgA1c measurements on the same patients in both groups were extracted from the electronic medical record. Subpopulations studied included those with HgA1c ≥9% and <9% at baseline. To evaluate long-term effects, we compared HgA1c levels 3 years later (between July 1, 2012 and December 31, 2012) for all groups. RESULTS: Using comparison-over-time analysis, the overall boot camp group (n=69) showed a mean decrease in HgA1c from 8.57% (SD ± 2.32%) to 7.76% (SD ± 1.85%) vs an increase from 7.92% (SD ± 1.58%) to 8.22% (SD ± 1.82%) in the control group (n=107, P<0.001). Mean length of follow-up was 3.2 (SD ± 0.54) years. CONCLUSION: An intensive 2-hour multidisciplinary diabetes clinic was associated with significant long-term improvements in glycemic control in diabetic participants of the clinic.

The Interaction Between Statins and Exercise: Mechanisms and Strategies to Counter the Musculoskeletal Side Effects of This Combination Therapy.

BACKGROUND: Broad indications for the use of statin medications are resulting in more patients using these therapies. Simultaneously, healthcare professionals are strongly advocating recommendations to increase exercise training (ET) as a means of decreasing cardiovascular disease (CVD) risk and improving other parameters of fitness. METHODS: We review the literature to explore mechanisms that may increase the risk of statin/ET interactions, examine the benefits and risks of combining ET and statin use, and offer strategies to minimize the hazards of this combination therapy. RESULTS: The combined use of statins and ET can result in health gains and decreased CVD risk; however, multiple factors may increase the risk of adverse events. Some of the events that have been reported with the combination of statins and ET include decreased athletic performance, muscle injury, myalgia, joint problems, decreased muscle strength, and fatigue. The type of statin, the dose, drug interactions, genetic variants, coenzyme Q10 deficiency, vitamin D deficiency, and underlying muscle diseases are among the factors that may predispose patients to intolerance of this combined therapy. CONCLUSION: Effective strategies exist to help patients who may be intolerant of combined statin therapy and ET so they may benefit from this proven therapy. Careful attention to identifying high-risk groups and strategies to prevent or treat side effects that may occur should be employed.

Patient Preferences for Doctor Attire: The White Coat's Place in the Medical Profession.

BACKGROUND: The white coat's place in the medical profession is a heavily debated topic. Five years after the bare-below-the-elbow policy took effect in England, we reexamined the evidence about coats' potential to transmit infection, reviewed previous studies, and explored our patients' opinions on doctor attire. METHODS: We administered a survey at 3 locations in the Ochsner Health System (hospital clinic, satellite clinic, and inpatient ward) in 2013. The survey assessed patient preference for doctors to wear white coats and included 4 images of the same doctor in different attire: traditional white coat, bare-below-the-elbow attire, a white coat with scrubs, and scrubs alone. Respondents rated images head-to-head for their preferences and individually for their confidence in the physician's skills and for their comfort level with the physician based upon the displayed attire. Participants' attitudes were then reassessed after they were given information about potential disease transmission. RESULTS: Overall, 69.9% of the 153 patients surveyed preferred doctors to wear white coats. When locations were compared, a statistically higher proportion of outpatients preferred coats (P=0.001), a trend most pronounced between hospital clinic (84%) and ward inpatients (51.9%). Patients disliked bare-below-the-elbow attire, scoring it lowest on the comfort and confidence scales (0.05 and 0.09, respectively). Information regarding risks of coat-carried infections did not influence respondents' opinions; 86.9% would still feel comfortable with a doctor who wore one. CONCLUSIONS: These findings suggest patients prefer white coats, and they contribute to greater comfort and confidence in their physicians, despite knowledge of theoretic concerns of disease transmission.

Effects of a diabetes boot cAMP on hemoglobin a1c levels.

BACKGROUND: Diabetic education can have significant effects in improving glycemic markers in patients with diabetes. This study sought to determine if the Diabetes Boot Camp, a novel 2-hour, intensive educational program by a multidisciplinary team, was effective in lowering mean hemoglobin A1c (HgA1c) levels in diabetic patients when compared to the standard of care. METHODS: The research design was that of a retrospective cohort study. The Diabetes Boot Camp population was defined as all diabetic patients referred to the boot camp clinic from the 10 physicians referring the most patients to the clinic from August 2009-August 2010. Three control populations were randomly selected from the same physicians' diabetic patients identified in the Ochsner primary care diabetes database during the same period. Pre- and postintervention HgA1c measurements on the same patients in all groups were analyzed. Control populations studied included an overall group, patients with HgA1c >9%, and patients with HgA1c ≤9%. RESULTS: Overall, the Diabetes Boot Camp cohort showed a significant decrease in mean HgA1c of 1.25% versus 0.11% compared to the control cohort (P<0.001). In the other analyses, Diabetes Boot Camp patients with HgA1c >9% and those with HgA1c ≤9% had statistically significant reductions in HgA1c compared to the control groups (P<0.001). CONCLUSION: An intensive 2-hour multidisciplinary diabetes clinic demonstrated significant improvements in glycemic control as measured by HgA1c compared to standard care.

Collateral benefits of improving glycemic control on lipids in a diabetic population.

BACKGROUND: Diabetes is an illness with multiple quality indicators. This retrospective cohort study sought to determine if interventions directed at physicians to target improvements in hemoglobin A1c (HgA1c) quality indicators had collateral benefits on similarly measured low-density lipoprotein (LDL) indicators. METHODS: We initially analyzed the primary care diabetic patient electronic databases from 2008 (N â€Š=  16,503) and 2010 (N â€Š=  23,040). We then identified and selected for the study the cohort of patients who appeared in both databases (N â€Š=  11,288) and analyzed various measures of process and outcomes. RESULTS: Mean HgA1c decreased from 7.34% to 7.21% (P < .0001). Mean LDL level also improved from 100.2 mg/dL to 95.6 mg/dL (P < .0001). The proportion of patients with poor glycemic control and poor lipid control decreased from 10.3% to 8.42% (P < .0001) and from 38.2% to 32.1% (P < .0001), respectively. CONCLUSIONS: Sustained interventions directed at the glycemic control of a large population of diabetic patients were associated with significant improvement in their glycemic control and had collateral benefits for indicators of their lipid control. Targeted interventions to improve HgA1c levels may have further benefits in improving other quality measures of diabetic care.

Impact of coenzyme Q-10 on parameters of cardiorespiratory fitness and muscle performance in older athletes taking statins.

Many older athletes take statins, which are known to have potential for muscle toxicity. The adverse effects of statins on muscles and the influence thereof on athletic performance remain uncertain. Coenzyme Q-10 (CoQ10) may improve performance and reduce muscle toxicity in older athletes taking statins. This trial was designed to evaluate the benefits of CoQ10 administration for mitochondrial function in this population. Twenty athletes aged ≥ 50 years who were taking stable doses of statins were randomized to receive either CoQ10 (200 mg daily) or placebo for 6 weeks in a double-blind, placebo-controlled, crossover study to evaluate the impact of CoQ10 on the anaerobic threshold (AT). Several secondary endpoints, including muscle function, cardiopulmonary exercise function, and subjective feelings of fitness, were also assessed. The mean (SD) change in AT from baseline was -0.59 (1.2) mL/kg/min during placebo treatment and 2.34 (0.8) mL/kg/min during CoQ10 treatment (P = 0.116). The mean change in time to AT from baseline was significantly greater during CoQ10 treatment than during placebo treatment (40.26 s vs 0.58 s, P = 0.038). Furthermore, muscle strength as measured by leg extension repetitions (reps) increased significantly during CoQ10 treatment, with a mean (SD) increase from baseline of 1.73 (2.9) reps during placebo treatment versus 3.78 (5.0) reps during CoQ10 treatment (P = 0.031). Many other parameters also tended to improve in response to CoQ10 treatment. Treatment with CoQ10 improved AT in comparison with baseline values in 11 of 19 (58%) subjects and in comparison with placebo treatment values in 10 of 19 (53%) subjects. Treatment with CoQ10 (200 mg daily) did not significantly improve AT in older athletes taking statins. However, it did improve muscle performance as measured by time to AT and leg strength (quadriceps muscle reps). Many other measures of mitochondrial function also tended to improve during CoQ10 treatment.

Sera from patients with diabetes do not alter the effect of mammalian target of rapamycin inhibition on smooth muscle cell proliferation.

Clinical studies of drug-eluting stents delivering the mammalian target of rapamycin (mTOR) inhibitor, rapamycin (Sirolimus), have demonstrated a reduced efficacy for these devices in patients with diabetes, which suggests that the mTOR pathway may cease to be dominant in mediating the vascular response to injury under diabetic conditions. We hypothesized that changes in serum composition accompanying diabetes may reduce the role of mTOR in mediating the vascular response to injury. We measured the ability of a median dose of rapamycin (10 nM) to inhibit the proliferation of human coronary artery smooth muscle cells (huCASMCs) stimulated with serum obtained from donors with diabetes (n = 14) and without diabetes (n = 16). In an additional analysis, we compared the effects of rapamycin on huCASMCs stimulated with the serum of donors with metabolic syndrome (n = 15) versus those without (n = 7). There was no difference in the effect of rapamycin on huCASMC proliferation after stimulation with serum from either donors with diabetes or donors with metabolic syndrome compared with the respective controls. We conclude that the changes in the serum composition common to diabetes and metabolic syndrome are insufficient to diminish the role of mTOR in the progression of cardiovascular disease.