Associations of Community and Individual Social Determinants of Health With Medication Adherence in Patients With Atrial Fibrillation: A Retrospective Cohort Study.

Background Despite guideline-recommended use of oral anticoagulation (OAC) for stroke prevention in atrial fibrillation (AF), OAC medication adherence among patients with AF in the United States ranges from 47% to 82%. To characterize potential causes of nonadherence, we analyzed associations between community and individual social risk factors and OAC adherence for stroke prevention in AF. Methods and Results A retrospective cohort analysis of patients with AF was conducted using the IQVIA PharMetrics Plus claims data from January 2016 to June 2020, and 3-digit ZIP code-level social risk scores were calculated using American Community Survey and commercial data. Logistic regression models evaluated associations between community social determinants of health, community social risk scores for 5 domains (economic climate, food landscape, housing environment, transportation network, and health literacy), patient characteristics and comorbidities, and 2 adherence outcomes: persistence on OAC for 180 days and proportion of days covered ≥0.80 at 360 days. Of 28 779 patients with AF included in the study, 70.8% of patients were male, 94.6% were commercially insured, and the average patient age was 59.2 years. Multivariable regression found that greater health literacy risk was negatively associated with 180-day persistence (odds ratio [OR]=0.80 [95% CI, 0.76-0.83]) and 360-day proportion of days covered (OR, 0.81 [95% CI, 0.76-0.87]). Patient age and higher AF stroke risk score and AF bleeding risk scores were positively associated with both 180-day persistence and 360-day proportion of days covered. Conclusions Social risk domains, such as health literacy, may affect OAC adherence among patients with AF. Future studies should explore associations between social risk factors and nonadherence with greater geographic granularity.

A systematic review of primary care-focused, self-reported medication adherence tools.

BACKGROUND: Clinician recognition of nonadherence is generally low. Tools that clinicians have used to assess medication adherence are self-reported adherence instruments that ask patients questions about their medication use experience. There is a need for more structured reviews that help clinicians comprehensively distinguish which tool might be most useful and valuable for their clinical setting and patient populations. OBJECTIVES: This systematic review aimed to (1) identify validated, self-reported medication adherence tools that are applicable to the primary care setting and (2) summarize selected features of the tools as an assessment of clinical feasibility and applicability. METHODS: The investigators systematically reviewed MEDLINE via Ovid, Embase via Ovid, International Pharmaceutical Abstracts, and CINAHL from inception to December 1, 2020. Investigators independently screened 3394 citations, identifying 43 articles describing validation parameters for 25 unique adherence tools. After screening each tool, 17 tools met the inclusion criteria and were qualitatively summarized. RESULTS: Findings highlight 25 various tool characteristics (i.e., descriptions, parameters and diseases, measures and validity comparators, and other information), which clinicians might consider when selecting a self-reported adherence tool with strong measurement validity that is practical to administer to patients. There was much variability about the nature and extent of adherence measurement. Considerable variation was noted in the objective measures used to correlate to the self-reported tools' measurements. There were wide ranges of correlation between self-reported and objective measures. Several included tools had relatively low to moderate criterion validities. Many manuscripts did not describe whether tools were associated with costs, had copyrights, and were available in other languages; how much time was required for patients to complete self-report tools; and whether patient input informed tool development. CONCLUSION: There is a critical need to ensure that adherence tool developers establish a key list of tool characteristics to report to help clinicians and researchers make practical comparisons among tools.

GEOlimma: differential expression analysis and feature selection using pre-existing microarray data.

BACKGROUND: Differential expression and feature selection analyses are essential steps for the development of accurate diagnostic/prognostic classifiers of complicated human diseases using transcriptomics data. These steps are particularly challenging due to the curse of dimensionality and the presence of technical and biological noise. A promising strategy for overcoming these challenges is the incorporation of pre-existing transcriptomics data in the identification of differentially expressed (DE) genes. This approach has the potential to improve the quality of selected genes, increase classification performance, and enhance biological interpretability. While a number of methods have been developed that use pre-existing data for differential expression analysis, existing methods do not leverage the identities of experimental conditions to create a robust metric for identifying DE genes. RESULTS: In this study, we propose a novel differential expression and feature selection method-GEOlimma-which combines pre-existing microarray data from the Gene Expression Omnibus (GEO) with the widely-applied Limma method for differential expression analysis. We first quantify differential gene expression across 2481 pairwise comparisons from 602 curated GEO Datasets, and we convert differential expression frequencies to DE prior probabilities. Genes with high DE prior probabilities show enrichment in cell growth and death, signal transduction, and cancer-related biological pathways, while genes with low prior probabilities were enriched in sensory system pathways. We then applied GEOlimma to four differential expression comparisons within two human disease datasets and performed differential expression, feature selection, and supervised classification analyses. Our results suggest that use of GEOlimma provides greater experimental power to detect DE genes compared to Limma, due to its increased effective sample size. Furthermore, in a supervised classification analysis using GEOlimma as a feature selection method, we observed similar or better classification performance than Limma given small, noisy subsets of an asthma dataset. CONCLUSIONS: Our results demonstrate that GEOlimma is a more effective method for differential gene expression and feature selection analyses compared to the standard Limma method. Due to its focus on gene-level differential expression, GEOlimma also has the potential to be applied to other high-throughput biological datasets.

Medication adherence following coronary artery bypass graft surgery: assessment of beliefs and attitudes.

BACKGROUND: The medication management of patients following coronary artery bypass graft (CABG) surgery may include antiplatelet agents, beta-blockers, angiotensin-converting enzyme inhibitors, and statins. However, poor adherence is common, and patient attitudes and beliefs play a role in adherence. OBJECTIVE: To evaluate the association between self-reported adherence and the beliefs patients have about cardiovascular medicines used after CABG. METHODS: Adults were surveyed 6-24 months following CABG. The validated Beliefs about Medicines Questionnaire (BMQ) assessed attitudes concerning the Specific Necessity, Specific Concerns, General Harm, and General Overuse of medicines. The validated medication adherence scale assessed self-reported adherence. Analysis included univariate comparison (BMQ scales) and multivariate logistic regression (identification of adherence predictor variables). RESULTS: Of 387 patients surveyed, 132 (34%) completed the questionnaire. Nonparticipants were more likely to be female and have undergone 1- or 2-vessel CABG procedures compared with 3- or 4-vessel procedures. Subjects were primarily English-speaking, white, and male. Adherent behavior was reported in 73 of 132 patients (55%). The average period between CABG and the survey was 16 months. Nonadherent patients were in stronger agreement on the General Overuse (p = 0.01) and General Harm (p = 0.04) scales. The adjusted odds of adherent behavior were significantly lower, with an increasing General Overuse score (OR 0.83; 95% CI 0.72 to 0.95; p = 0.007); an annual income of $50,000 to $100,000 relative to less than $20,000 (OR 0.36; 95% CI 0.14 to 0.91; p = 0.031), and a living status of "alone" compared with "with adults and no children" (OR 0.20; 95% CI 0.06 to 0.65; p = 0.007). The odds ratio of self-reported adherence was higher with increasing age (OR 1.05; 95% CI 1.01 to 1.09; p = 0.023). CONCLUSIONS: In summary, patient beliefs and attitudes regarding medications, along with other social, economic, and demographic factors, help explain differences in self-reported adherence to standard drug therapy following CABG.

Prevalence of comorbidities and their influence on blood pressure goal attainment in geriatric patients.

Hypertension in elderly patients is common and is associated with unique challenges. This study examines the prevalence of comorbidities in elderly hypertensive patients and evaluates the association between comorbidities and other covariates with blood pressure goal attainment. Data were collected through retrospective review of medical records and included patient characteristics, comorbidities, treatment-related variables, and blood pressure goal attainment. At least 1 comorbidity was present in 88% of patients, and 61% had multiple comorbidities. The most common comorbidity was isolated systolic hypertension. The presence of diabetes or isolated systolic hypertension at initial visit and treatment with a thiazide diuretic at the final clinic visit were associated with significantly higher odds of patients not achieving blood pressure goal. A diagnosis of heart failure was associated with lower odds of not achieving blood pressure goal. These issues should be given special consideration during the evaluation, treatment selection, and long-term monitoring of this population.

Treatment and control of blood pressure in patients with diabetes mellitus.

PURPOSE: A study was conducted to characterize the prevalence of hypertension in patients with diabetes mellitus and the percentage of patients with diabetes and hypertension who achieved a targeted blood pressure goal (<135/80 mm Hg). METHODS: A retrospective, cross-sectional study was conducted in an ambulatory care clinic. Eligible patients were those individuals being managed for type 2 diabetes mellitus at least once each year for two consecutive years. Blood pressure measurements that were recorded in the medical chart or written diagnoses of hypertension were used to determine the presence of comorbid hypertension. Data were collected from the chart and electronic record using a standardized form. Clinic visits over the previous 12 months were reviewed to evaluate hypertension criteria. A blood pressure of > or = 135/80 mm Hg was used to define hypertension. RESULTS: A final sample of 362 patients with type 2 diabetes mellitus was included in the study. Of these, 79% had concomitant diabetes and hypertension. Blood pressure was controlled in 175 of 270 (65%) patients. Patients who met the blood pressure goal tended to be older and weigh less than those who did not. The adjusted odds of achieving the blood pressure goal were 1.9 times higher in those patients who also achieved their low-density-lipoprotein cholesterol goal. Most patients were on at least one antihypertensive agent; approximately 39% of the 89 patients treated with monotherapy were above the blood pressure goal. Combination therapy was used in 164 patients; approximately 32% of patients treated with combination therapy were above the blood pressure goal. CONCLUSION: Among ambulatory care patients with diabetes, 79% also had hypertension. Hypertension was controlled in 65% of patients with that disorder.

Statin initiation following coronary artery bypass grafting: outcome of a hospital discharge protocol.

STUDY OBJECTIVES: To evaluate the outcome of a hospital discharge statin drug therapy initiation protocol following coronary artery bypass graft (CABG) surgery. Our goal was to measure the percentage of patients receiving statin drugs at hospital discharge and at a post-hospital discharge assessment following the implementation of the statin drug therapy initiation protocol. We also evaluated low-density lipoprotein cholesterol (LDL-C) goal attainment (ie, < 100 mg/dL), safety monitoring, and tolerability of the statin drug. DESIGN: Single-center, observational study with a historical control group. SETTING: University-affiliated health system with a comprehensive heart care program that included a 14-bed cardiac surgery ICU. Approximately 400 CABG procedures are performed annually. PATIENTS: Patients who underwent CABG surgery were eligible for inclusion in the study. The exclusion criteria were as follows: contraindications to statin therapy; refusal to take a statin drug; refusal to give informed consent; and age < 18 years. INTERVENTION: A protocol was implemented to recommend treatment with a statin drug at hospital discharge in all post-CABG surgery patients if the presurgical LDL-C level was > 100 mg/dL or the patient was receiving a statin prior to hospital admission. The protocol also included a presurgical assessment of lipoprotein levels and hepatic function. All cardiac surgery staff were educated regarding the specifics of the protocol. RESULTS: A total of 403 patients were included in the study. The historical control group (202 subjects) and the intervention group (201 subjects) were similar with respect to gender, age, and baseline lipoprotein levels. The follow-up assessment interval was approximately 6 months in both groups. Overall, patients were more likely to receive a statin at hospital discharge in the intervention group compared to the control group (relative risk [RR], 1.6; 95% confidence interval [CI], 1.3 to 2.0). Attainment of the goal for LDL-C level was similar between the intervention and control groups in the overall sample. Patients who were not at their LDL-C goal at baseline were more likely to have a follow-up LDL-C level of < 100 mg/dL in the intervention group (RR, 1.9; 95% CI, 1.0 to 3.5). The rate of liver function assessment was similar in the control and intervention groups. No patients in either group experienced elevations of alanine aminotransferase levels that were more than three times the upper limit of normal, and no cases of muscle toxicity were noted. CONCLUSION: The initiation of therapy with a statin drug at hospital discharge following CABG surgery was associated with increased utilization rates. The LDL-C goal attainment improved in patients who were not at their goal prior to surgery. However, the persistence of medication use declined within 6 months. Statin therapy initiation was well-tolerated in this cohort of patients.

Risk assessment of NSAID-induced gastrointestinal toxicity in ambulatory care patients.

PURPOSE: The risk of gastrointestinal (GI) toxicity associated with the use of a traditional nonsteroidal antiinflammatory drug (NSAID) versus a cyclooxygenase-2 (COX-2) inhibitor was compared among patients in a managed care organization. METHODS: Patients over 18 years old who received a prescription for ibuprofen, naproxen, celecoxib, or rofecoxib between March 2001 and June 2001 were included in this study. All subjects were followed for 12 months for GI complications, medication use, and changes in physical conditions from baseline. A simplified risk-scoring scale was used to measure patients' risk of GI complications. RESULTS: A total of 172 patients were randomly selected: 86 receiving traditional NSAIDs and 86 receiving COX-2 inhibitors. Patients receiving COX-2 inhibitors were older and more likely to be receiving treatment for osteoarthritis (OA) or rheumatoid arthritis (RA), while patients taking traditional NSAIDs were more likely to be receiving treatment for acute pain. The average risk scores for patients receiving traditional NSAIDs and COX-2 inhibitors were 0.23% and 0.36%, respectively (p = 0.11). When stratified by indication, there was a significant difference in the risk score for acute pain (p = 0.02) but not for OA, RA, or chronic pain. No GI adverse effects occurred in either group. CONCLUSION: Among patients in a managed care organization who were taking NSAIDs, most were at low risk for an NSAID-related GI adverse effect. The risk of GI adverse effects did not differ significantly between patients treated with a traditional NSAID and those treated with a COX-2 inhibitor.

Antihypertensive medication compliance in a Veterans Affairs Healthcare System.

OBJECTIVE: To compare compliance rates associated with categories of antihypertensive medications in a Veteran's Affairs (VA) Healthcare System by use of readily available data and standard software. METHODS: Prescriptions from the Veteran's Health Information System Technology Architecture (VISTA) database for angiotension-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), beta-blockers, calcium-channel blockers (CCBs), diuretics, and a miscellaneous group of antihypertensives filled or refilled during a 12-month period were included in the analysis. Claims data for each prescription were exported from the VISTA database to Microsoft Excel, and compliance rates were calculated by use of a methodology reported elsewhere. Mean compliance rates for each antihypertensive category were compared. RESULTS: A total of 26 201 prescription records accounting for 51 927 separate prescription fills or refills were included. The majority of prescriptions (77%) were associated with calculated compliance rates >80%. The CCB category was associated with a significantly higher compliance rate (p < 0.001) than the beta-blockers (95% CI 1.3% to 3.7%), diuretics (95% CI 1.4% to 3.8%), and miscellaneous agents (95% CI 1.7% to 7.5%). The ACE inhibitor category was associated with a significantly higher rate (p < 0.001) than the beta-blockers (95% CI 0.7% to 3.0%), diuretics (95% CI 0.7% to 3.0%), and miscellaneous agents (95% CI 1.1% to 6.8%). The ARB category had a higher compliance rate (p < 0.001) than the miscellaneous category (95% CI 1.2% to 11.9%). There were no significant differences in compliance rates among ACE inhibitors, CCBs, or ARBs. CONCLUSIONS: VA outpatients are relatively compliant when taking their antihypertensive medications as measured by prescription refill rates. Compliance rates for CCBs and ACE inhibitors are higher than those for beta-blockers, diuretics, and agents such as clonidine, methyldopa, hydralazine, and reserpine. Compliance for ARBs compared favorably with those of CCBs and ACE inhibitors. The methods used in this evaluation can be easily implemented at other institutions as part of ongoing medication compliance improvement efforts.