Trends in high intensity statin use among secondary prevention patients 76 years and older.

BACKGROUND: High intensity statin therapy (HIST) is the gold standard therapy for decreasing the risk of recurrent atherosclerotic cardiovascular disease (ASCVD); however, little is known about the use of HIST in older adults with ASCVD. OBJECTIVES: The aim of this cross-sequential study was to determine trends in statin intensity in older adults over a 10-year timeframe. METHODS: The study was conducted in an integrated healthcare delivery system. Patients were 76 years or older with validated coronary ASCVD. Data were collected from administrative databases. Statin intensity level was assessed in eligible patients on January 1st and July 1st from January 1, 2007 to December 31, 2016. RESULTS: Overall, a total of 5,453 patients were included with 2,119 (38.9%) and 3,334 (61.1%) categorized as HIST and Non-HIST, respectively. Included patients had a mean age of 79.8 years and were primarily male and white and had a cardiac intervention. The rate of HIST use increased from 14.5% to 41.3% over the study period (p<0.001 for trend). Conversely, the rates of moderate and low intensity statin use decreased from 61.8% and 9.8% to 41.2% and 4.8%, respectively (both p<0.001 for trend). Similar trends were identified for females and males. CONCLUSIONS: The percentage of patients with ASCVD 76 years and older who received HIST substantially increased from 2007 to 2016. This trend was identified in both females and males. Future comparative effectiveness research should be conducted in this patient population to examine cardiac-related outcomes with HIST and Non-HIST use.

Trends in high intensity statin use among secondary prevention patients 76 years and older

Background: High intensity statin therapy (HIST) is the gold standard therapy for decreasing the risk of recurrent atherosclerotic cardiovascular disease (ASCVD); however, little is known about the use of HIST in older adults with ASCVD. Objectives: The aim of this cross-sequential study was to determine trends in statin intensity in older adults over a 10-year timeframe. Methods: The study was conducted in an integrated healthcare delivery system. Patients were 76 years or older with validated coronary ASCVD. Data were collected from administrative databases. Statin intensity level was assessed in eligible patients on January 1st and July 1st from January 1, 2007 to December 31, 2016. Results: Overall, a total of 5,453 patients were included with 2,119 (38.9%) and 3,334 (61.1%) categorized as HIST and Non-HIST, respectively. Included patients had a mean age of 79.8 years and were primarily male and white and had a cardiac intervention. The rate of HIST use increased from 14.5% to 41.3% over the study period (p<0.001 for trend). Conversely, the rates of moderate and low intensity statin use decreased from 61.8% and 9.8% to 41.2% and 4.8%, respectively (both p<0.001 for trend). Similar trends were identified for females and males. Conclusions: The percentage of patients with ASCVD 76 years and older who received HIST substantially increased from 2007 to 2016. This trend was identified in both females and males. Future comparative effectiveness research should be conducted in this patient population to examine cardiac-related outcomes with HIST and Non-HIST use

No disponible

Clinical Pharmacist Patient-Safety Initiative to Reduce Against-Label Prescribing of Statins With Cyclosporine.

BACKGROUND: Against-label prescribing of statins with interacting drugs, such as cyclosporine, represents an important patient safety concern. OBJECTIVE: To implement and evaluate the effectiveness of a clinical pharmacist patient-safety initiative to minimize against-label prescribing of statins with cyclosporine. METHODS: Kaiser Permanente Colorado clinical pharmacists identified patients receiving both cyclosporine and against-label statin through prescription claims data. Academic detailing on this interaction was provided to health care providers. Clinical pharmacists collaborated with physicians to facilitate conversion to on-label statin. Conversion rates along with changes in low-density lipoprotein cholesterol (LDL-C) were assessed. RESULTS: Of the 157 patients identified as taking cyclosporine, 48 were receiving concurrent statin therapy. Of these 48 patients, 33 (69%) were on an against-label statin regimen; 25 (76%) of these patients were converted to on-label statin. Overall, patients converted to on-label statin had a mean LDL-C prior to conversion of 82.9 (±26.4) mg/dL and mean LDL-C after conversion of 90.7 (±31.2) mg/dL ( P = 0.21). In all, 17 patients (68%) were switched to pravastatin 20 mg daily and 8 patients (32%) to rosuvastatin 5 mg daily. In patients converted to pravastatin 20 mg daily, the mean LDL-C was 13.5 mg/dL higher than prior to conversion ( P = 0.066). In patients converted to rosuvastatin 5 mg daily, the mean LDL-C was 3.8 mg/dL lower than prior to conversion ( P = 0.73). CONCLUSION: Utilizing a patient-safety-centered approach, clinical pharmacists were able to reduce the number of patients on against-label statin with cyclosporine while maintaining a comparable level of LDL-C control.

Positive predictive values of ICD-9 codes to identify patients with stroke or TIA.

OBJECTIVES: To determine the positive predictive values of inpatient and outpatient ICD-9 codes and status code V12.54 for identifying confirmed history of stroke or transient ischemic attack (cerebral event) among patients within a managed care organization. STUDY DESIGN: Retrospective, cohort study. METHODS: Inpatient hospital claims and outpatient visit records were used to identify patients with ICD-9 codes (430.XX to 438.XX) or status code V12.54 in the primary or secondary position recorded between January 1, 2001, and December 31, 2009. A standardized chart abstraction tool was used by trained chart abstractors blinded to the coding to confirm the cerebral event and classify stroke type. Positive predictive values (PPVs) were calculated for each code based on care setting. RESULTS: A total of 4689 patients with 10,376 unique stroke codes recorded in the administrative data were reviewed. Of these, 2785 (59.4%) patients had a confirmed cerebral event. The codes with PPV less than 90% were 434.XX, 433 .X1, and V12.54 where codes were recorded in both the inpatient and outpatient settings. Overall, inpatient-only codes produced higher PPVs; however, relatively fewer events were captured in this setting. CONCLUSIONS: Administrative ICD-9 codes 434.XX, 433.X1, and V12.54 had consistently high PPVs in identifying patients with a confirmed cerebral event. These codes could be used as part of a probabilistic approach to focus care activities on patients with the highest likelihood of a cerebral event.

Ambulatory treatment gaps in patients with ischemic stroke or transient ischemic attack.

BACKGROUND: This study evaluated goal attainment for patients with a history of non-cardioembolic ischemic stroke (NCIS) or transient ischemic attack (TIA). METHODS: A cross-sectional study was conducted in patients aged 18 to 85 years with a history of validated NCIS or TIA. Data collected were demographics, comorbidities, blood pressure (BP), low-density lipoprotein cholesterol (LDL-C) values, and medications within 365 days and most proximal to December 31, 2010. Goal LDL-C and BP were defined as < 100 mg/dL and < 140/90 mm Hg, respectively. Differences in sex and age (< 65 vs ≥ 65 years) were evaluated. RESULTS: There were 1731 patients evaluated (mean age: 73.6 years; 58% women). Stroke type was NCIS in 51.9% and TIA in 48.1%. The LDL-C and BP were measured in 75.4% and 50.3% of patients, respectively. No difference in LDL-C screening rates existed for sex or age. Men and patients younger than age 65 years were significantly more likely to have BP measured. Overall, LDL-C and BP goals were attained by 48.9% and 43.3% of patients, respectively. Men and patients age 65 years or older were likelier than women and patients younger than age 65 years to attain LDL-C goals (p < 0.01). Men were also likelier than women to attain BP < 140/90 mm Hg (p < 0.01), but more patients younger than age 65 years vs older than age 65 years attained this goal (p < 0.01). Statins and antihypertensives were received by 51.9% and 46.9% of the patients, respectively. CONCLUSION: Although attaining guideline-recommended goals for LDL-C and BP may present challenges, future research should focus on innovative methods to help patients attain optimal treatment goals.

Angiotensin-converting enzyme inhibitor therapy for coronary artery disease and diabetes mellitus.

OBJECTIVES: To use a population management strategy to increase the proportion of patients with coronary artery disease (CAD) and diabetes receiving target-dose angiotensin-converting enzyme (ACE) inhibitor therapy and to assess the safety and tolerability of this initiative. STUDY DESIGN: Prospective cohort. METHODS: Patients were eligible for enrollment if they were not receiving target-dose ACE inhibitor therapy. Clinical pharmacy specialists were responsible for initiation, titration, and appropriate follow-up of ACE inhibitor therapy. RESULTS: A total of 453 subjects were enrolled. Their mean age was 67.9 years and 77% were male. At baseline, 30.9% (n = 140) of eligible patients were on no ACE inhibitor therapy and no patients were at the target dose. The mean systolic blood pressure, serum creatinine, and serum potassium values were 128.0 mm Hg, 1.0 mg/dL, and 4.4 mEq/dL, respectively. At follow-up, 8.2% (n = 37; P < .001) were on no ACE inhibitor therapy and 68.7% (n = 311; P < .001) of patients had achieved the target dose. From baseline to follow-up, mean systolic blood pressure decreased 4.4 mm Hg (P < .001). Changes in serum potassium or creatinine were not clinically significant. Of the 142 subjects unable to achieve the target dose, 31 experienced hypotension, 29 did not have the dose increased because of the potential for hypotension, and 23 experienced cough. CONCLUSION: A population management approach to increasing the proportion of patients with CAD and diabetes who receive target-dose ACE inhibitor therapy was effective and safe.

Assessment of patient satisfaction with telephone and mail interventions provided by a clinical pharmacy cardiac risk reduction service.

OBJECTIVE: Kaiser Permanente of Colorado developed a population-based program, the Clinical Pharmacy Cardiac Risk Service (CPCRS), to help close the treatment gap for patients with coronary artery disease. CPCRS provides much of its care via telephone. The purpose of this study was to determine the level of satisfaction among patients in this unique service. METHODS: This was a cross-sectional survey of patients enrolled in CPCRS for at least 6 months. A sample of patients who met the inclusion criteria were chosen at random to receive the satisfaction survey via mail. Questions pertained to overall satisfaction and satisfaction with individual components of CPCRS. A Likert-type, 5-point scale was used for the majority of the questions. Analyses of the results were primarily descriptive. RESULTS: Of 1,000 surveys mailed, 491 (49.1%) were returned. The majority of respondents were male (68.5%). The average age of respondents was 71.7 (SD) 9 years. Of those surveyed, 94.6% (95% confidence interval [CI], 92.6%- 96.6%) reported being satisfied (agree or strongly agree) with the care they received for cholesterol management from their CPCRS clinical pharmacy specialist. Respondents reported that their CPCRS clinical pharmacy specialist was easy to contact (83.7%, 95% CI, 80.3%-87.1%), provided timely service (94.8%; 95% CI, 92.8%-96.8%), and addressed all questions or concerns in a way that was easy to understand (85.8%; 95% CI, 82.6%-89.0%). The majority of respondents reported that they were content receiving care over the telephone (86.7%; 95% CI, 83.5%-89.9%) and by mail (90.0%; 95% CI, 87.1%-92.9%). CONCLUSION: Overall, survey respondents indicated a high level of satisfaction with the services provided by CPCRS. Based upon patient satisfaction, the results of this survey suggest that the use of telephone and mail systems to provide patient care can allow clinical pharmacy specialists to manage a large number of patients successfully. Health care systems may wish to explore similar methods to address the needs of patients with coronary artery disease.

The state of clinical pharmacy practice in family practice residency programs.

BACKGROUND: Clinical pharmacists have been involved with family practice residencies for more than 20 years. This survey was designed to evaluate the current state of clinical pharmacy services in the family practice residency program (FPRP) in the United States. METHODS: All FPRPs were contacted to identify clinical pharmacists involved with their programs. These pharmacists were directed to a password-protected Web address where the survey was posted. Completed surveys were submitted on-line, and data were retrieved for analysis. RESULTS: Of the 579 residencies, 155 (26.7%) acknowledged 174 clinical pharmacists working within their program. Responses were received by 130 of the pharmacists (74.7% response rate). These pharmacists held academic appointments in both their institution's school of pharmacy (80%) and the school of medicine (53.2%). The mean age of the respondents was 36.5 +/- 8.2 years, and the mean salary was $66,000 (range $46,000-$125,000). A majority of the pharmacists received their funding from a single source, and 32.2% received full salary support from the FPRP. The respondents spent more than half of their time with the residency program. Overall, their time was divided into teaching responsibilities (42.7%), patient care activities (37.1%), research (12.1%), administrative functions (11.8%), and drug distribution (< 5%). CONCLUSIONS: Pharmacists are actively involved in 26.7% of FPRPs. This survey demonstrates increased salary support from the FPRP in comparison to past surveys. Additionally, more pharmacists hold academic appointments within schools of medicine.