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Susan E Andrade

Publications and source records attributed to Susan E Andrade.

35 records · Page 2Linked to original sources
PubMed2005

Potentially inappropriate medication use by elderly persons in U.S. Health Maintenance Organizations, 2000-2001.

OBJECTIVES: To determine rates of potentially inappropriate medication use in elderly persons in managed care plans in the United States in 2000-2001. DESIGN: Cross-sectional study using automated medication-dispensing data. SETTING: Ten geographically distributed health maintenance organizations (HMOs). PARTICIPANTS: One hundred fifty-seven thousand five hundred seventeen members aged 65 years and older enrolled in one of the HMOs. MEASUREMENTS: Prevalence of use of 33 potentially inappropriate medications from January 1, 2000 through June 30, 2001. RESULTS: In 2000-2001, 28.8% (95% confidence interval=28.6-29.1) of elderly individuals received at least one of 33 potentially inappropriate medications. This rate ranged from 23.0% to 36.5% across the 10 HMOs. Approximately 5% of elderly patients received at least one of the 11 medications classified by an expert panel as "always avoid," 13% received at least one of the eight medications that would rarely be considered appropriate, and 17% received at least one of the 14 medications that have some indications but are often misused. Overall, rates of use of these medications were greater in women (32.4%) than in men (24.2%). At least 1% of elderly members received belladonna alkaloids (2.3%), dicyclomine (1.1%), or hyoscyamine (1.2%), each of which multiple expert panels have classified as always inappropriate in patients aged 65 years and older. Seven percent of elderly members received propoxyphene, an analgesic medication considered rarely appropriate in the elderly and a drug that has a long history of limited efficacy and potential for toxicity. CONCLUSION: Recent rates of potentially inappropriate medication use by elderly HMO members were at least as great as in a 1996 national sample. This study highlights the need to understand more fully the rationale behind the continued use of these medications.

Age Distribution↗
PubMed2005

Incidence of Churg-Strauss syndrome in asthma drug users: a population-based perspective.

OBJECTIVE: To estimate the incidence of Churg-Strauss syndrome (CSS) among a large population of asthma drug users. METHODS: A retrospective study was conducted among patients who had been dispensed asthma drugs at 3 managed care organizations. Adults who received >or =3 dispensings of an asthma drug during any consecutive 12-month period between January 1, 1995 and June 30, 2000 were identified. Information on patient age, gender, enrollment status, asthma drugs dispensed, and inpatient and outpatient diagnoses and procedures was obtained from automated databases. Chart reviews were performed on persons identified by combinations of diagnostic and billing codes indicative of CSS. A rheumatologist reviewed abstracted information on all subjects; those who met >or =2 American College of Rheumatology criteria for CSS were reviewed by 2 clinical experts. Each clinical expert independently rated the cases; disagreements were resolved by consensus. Cases classified as having "probable/definite" CSS were included in these analyses. The incidence of CSS was estimated overall and according to patient gender, age, and calendar year. RESULTS: From a population of 184,667 asthma drug users contributing 606,184 person-years of exposure, 21 incident cases of CSS were identified (overall incidence of 34.6 per million person-years; 95% confidence interval 21.4 to 53.0). Incidence rates did not differ by gender and age group. The incidence rates for 1995, 1996, 1997, 1998, 1999, and the first 6 months of 2000 were 0, 22, 52, 75, 14, and 14 per million person-years respectively. CONCLUSIONS: Results from this population-based study suggest a somewhat lower incidence of CSS in asthma drug users than previously reported and provides important information as to the risk of developing CSS from a population-based perspective.

Adolescent↗
PubMed2004

Incidence of hospitalized rhabdomyolysis in patients treated with lipid-lowering drugs.

CONTEXT: Lipid-lowering agents are widely prescribed in the United States. Reliable estimates of rhabdomyolysis risk with various lipid-lowering agents are not available. OBJECTIVE: To estimate the incidence of rhabdomyolysis in patients treated with different statins and fibrates, alone and in combination, in the ambulatory setting. DESIGN, SETTING, AND PATIENTS: Drug-specific inception cohorts of statin and fibrate users were established using claims data from 11 managed care health plans across the United States. Patients with at least 180 days of prior health plan enrollment were entered into the cohorts between January 1, 1998, and June 30, 2001. Person-time was classified as monotherapy or combined statin-fibrate therapy. MAIN OUTCOME MEASURE: Incidence rates of rhabdomyolysis per 10,000 person-years of treatment, number needed to treat, and relative risk of rhabdomyolysis. RESULTS: In 252,460 patients treated with lipid-lowering agents, 24 cases of hospitalized rhabdomyolysis occurred during treatment. Average incidence per 10,000 person-years for monotherapy with atorvastatin, pravastatin, or simvastatin was 0.44 (95% confidence interval [CI], 0.20-0.84); for cerivastatin, 5.34 (95% CI, 1.46-13.68); and for fibrate, 2.82 (95% CI, 0.58-8.24). By comparison, the incidence during unexposed person-time was 0 (95% CI, 0-0.48; P = .056). The incidence increased to 5.98 (95% CI, 0.72-216.0) for combined therapy of atorvastatin, pravastatin, or simvastatin with a fibrate, and to 1035 (95% CI, 389-2117) for combined cerivastatin-fibrate use. Per year of therapy, the number needed to treat to observe 1 case of rhabdomyolysis was 22,727 for statin monotherapy, 484 for older patients with diabetes mellitus who were treated with both a statin and fibrate, and ranged from 9.7 to 12.7 for patients who were treated with cerivastatin plus fibrate. CONCLUSIONS: Rhabdomyolysis risk was similar and low for monotherapy with atorvastatin, pravastatin, and simvastatin; combined statin-fibrate use increased risk, especially in older patients with diabetes mellitus. Cerivastatin combined with fibrate conferred a risk of approximately 1 in 10 treated patients per year.

Clofibric Acid↗
PubMed2004

Nonadherence as a predictor of antidiabetic drug therapy intensification (augmentation).

PURPOSE: To determine if nonadherence with antidiabetic drug therapy is predictive of subsequent antidiabetic drug therapy intensification. METHODS: We conducted a retrospective cohort study examining retail pharmacy dispensings of sulfonylureas or metformin to 1067 patients having diabetes. Patients that did not receive a sufficient quantity of medication to cover at least 80% of days during the evaluation period were classified as nonadherent. Outcomes identified were increase in the dose of antidiabetic medication utilized, the addition of a second antidiabetic agent to the regimen or either. RESULTS: Among users of sulfonylurea monotherapy, those classified as nonadherent were 45% more likely to intensify therapy in subsequent months as compared with those classified as adherent (age-adjusted odds ratio (OR) 1.45; 95% confidence interval (CI) 1.06-2.00). This finding was largely driven by observed increases in dosage, which were more likely among patients classified as nonadherent (age-adjusted OR 1.48, 95%CI 1.07-2.05). Nonadherence was not found to be predictive of the subsequent addition of a second antidiabetic agent (OR 1.02; 95%CI 0.64-1.63). Overall findings were similar for the smaller sample of patients receiving metformin monotherapy, though observed differences did not achieve statistical significance. CONCLUSIONS: Patients who were poorly adherent to oral antidiabetic drug therapy more frequently experienced an increase in the dose of medication prescribed, as compared to patients that were classified as adherent. This finding underscores the need for prescribers to consider nonadherence as a root cause when patients fail to achieve therapeutic goals.

Age Factors↗
PubMed2004

Identification of patients with Churg-Strauss syndrome (CSS) using automated data.

PURPOSE: Our aim was to identify individuals with Churg-Strauss syndrome (CSS) among asthma drug users, based on patterns of diagnostic and procedural codes (termed 'algorithms') contained in automated claims data. METHODS: A retrospective study was conducted among patients who had been dispensed asthma drugs at three HMOs. Individuals who received > or =3 dispensings of an asthma drug during any consecutive 12-month period beginning 1 January 1994 through 20 June 2000 were identified. Information on patient age, gender, enrollment status, asthma drugs dispensed, inpatient and outpatient diagnoses and procedures were obtained from the HMO automated databases. Twelve combinations of diagnostic and billing codes ('algorithms') were developed using the claims data to identify potential cases of CSS. Chart reviews blinded to drug exposure were performed using a standardized abstraction form. A rheumatologist reviewed abstracted information on all subjects, and those who met two or more American College of Rheumatology (ACR) criteria for CSS were further reviewed by two clinical experts. Cases were classified as unlikely, possible, or probable/definite CSS. Each clinical expert independently rated the cases; disagreements were resolved by consensus. RESULTS: A total of 185 604 patients who had been dispensed asthma drugs were identified. Three hundred fifty subjects were selected for chart review, and 15 were classified as having 'probable/definite' CSS. The algorithms that were most successful in identifying patients with CSS were as follows: (1) two or more codes for vasculitis (13 confirmed cases from 129 reviewed; positive predictive value 10%); (2) codes for both vasculitis and neurologic symptoms (6 confirmed cases from 15 reviewed; positive predictive value 40%) and (3) codes for both eosinophilia and vasculitis (4 confirmed cases from 5 reviewed; positive predictive value 80%). CONCLUSION: Automated claims data can be used to identify patients with CSS. This approach can facilitate better epidemiologic study of the risk factors for the condition.

Algorithms↗
PubMed2004

Prescription drug use in pregnancy.

OBJECTIVE: The purpose of this study was to provide information on the prevalence of the use of prescription drugs among pregnant women in the United States. STUDY DESIGN: A retrospective study was conducted with the use of the automated databases of 8 health maintenance organizations that are involved in the Health Maintenance Research Network Center for Education and Research on Therapeutics. Women who delivered of an infant in a hospital from January 1, 1996, through December 31, 2000, were identified. Prescription drug use according to therapeutic class and the United States Food and Drug Administration risk classification system was evaluated, with the assumption of a gestational duration of 270 days, with three 90-day trimesters of pregnancy, and with a 90-day period before pregnancy. Nonprescription drug use was not assessed. RESULTS: During the period 1996 through 2000, 152,531 deliveries were identified that met the criteria for study. For 98,182 deliveries (64%), a drug other than a vitamin or mineral supplement was prescribed in the 270 days before delivery: 3595 women (2.4%) received a drug from category A; 76,292 women (50.0%) received a drug from category B; 57,604 women (37.8%) received a drug from category C; 7333 women (4.8%) received a drug from category D, and 6976 women (4.6%) received a drug from category X of the United States Food and Drug Administration risk classification system. Overall, 5157 women (3.4%) received a category D drug, and 1653 women (1.1%) received a category X drug after the initial prenatal care visit. CONCLUSION: Our finding that almost one half of all pregnant women received prescription drugs from categories C, D, or X of the United States Food and Drug Administration risk classification system highlights the importance of the need to understand the effects of these medications on the developing fetus and on the pregnant woman.

Databases, Factual↗
PubMed2004

Increased use of second-generation macrolide antibiotics for children in nine health plans in the United States.

BACKGROUND: Widespread use of broad-spectrum antibiotics contributes to increasing rates of bacterial resistance to antibiotics. Second-generation macrolides have become popular for use among children because of their broad spectrum and favorable dosing and side-effect profiles, although experts do not generally recommend them for use as initial treatment of infections among younger children. OBJECTIVE: To assess trends in second-generation macrolide use from 1996 to 2000 among children treated as outpatients in 9 US health plans, including associated diagnoses and use as initial treatment. METHODS: We sampled claims data for 25000 children, 3 months to <18 years of age, who were enrolled between September 1, 1995, and August 31, 2000, in each of 9 US health plans. Medications dispensed were linked with ambulatory visit claims to assign diagnoses. Dispensings without another antibiotic dispensing recorded in the previous 42 days were analyzed as initial treatment of a new illness episode. We analyzed trends in prescribing overall, for initial therapy, and, within specific diagnoses, for differences among health plans. RESULTS: From 1995-1996 to 1999-2000, although overall antibiotic use decreased from 1.15 to 0.91 dispensings per person-year, second-generation macrolide use increased from 0.022 to 0.063 dispensings per person-year. Use as a proportion of all antibiotic dispensings increased from 1.9% to 6.9%, and use as initial therapy increased from 1.4% to 6%. For children <6 years of age, second-generation macrolide use as initial therapy increased from 0.9% to 5.0% for otitis media and from 5.2% to 24.0% for pneumonia. There was a wide range of prescribing rates among health plans during the last year of the study, from 0.006 to 0.135 dispensings per person-year. CONCLUSIONS: Despite recent trends toward decreased antibiotic use among children, the use of second-generation macrolides among children has increased dramatically, even among younger children, for whom use for initial treatment of illness is not recommended. Large differences in prescribing rates exist among health plans. Continued efforts to promote the use of narrower-spectrum agents when appropriate are needed.

Adolescent↗
PubMed2004

Hypertension management: the care gap between clinical guidelines and clinical practice.

OBJECTIVE: To evaluate how well hypertension is managed in HMO patients and to assess opportunities for improvement. STUDY DESIGN: Retrospective cohort study. PATIENTS AND METHODS: The study population included HMO members (age 45-84 years) who had at least 1 ambulatory encounter with an ICD-9-CM diagnosis code of essential hypertension during the first 6 months of 1999. Medical records were reviewed to obtain information on blood pressure measurements, sex, age, coexisting medical conditions, smoking status, and changes made to the antihypertensive drug regimen. RESULTS: We identified 681 members with 3347 encounters related to hypertension management during 1999. Overall, 74 (11%) patients were at target blood pressure for all visits and 260 (38%) were at target blood pressure for at least 50% of the visits; 222 (33%) patients were not at target blood pressure for any visit. A history of coronary artery disease or cerebrovascular disease was associated with better blood pressure control (defined as being at goal levels during at least 50% of visits), while being older (age > or = 75) or having diabetes mellitus was associated with poorer control. Medication regimen intensifications occurred in 10% of visits with systolic blood pressure levels of 140-149 mm Hg, compared with 45% of visits with levels of > or = 180 mm Hg. Medication regimen intensifications occurred in 21% of visits with diastolic blood pressure levels of 90-99 mm Hg and 43% of visits with levels of > or = 100 mm Hg. CONCLUSION: Efforts are required to reduce "therapeutic inertia," particularly in patients with modestly elevated systolic blood pressure levels.

Aged↗
PubMed2003

Low frequency of treatment of osteoporosis among postmenopausal women following a fracture.

BACKGROUND: Osteoporosis is a major cause of morbidity. Treatment of osteoporosis reduces the risk of fracture, particularly for postmenopausal women with a history of fracture. METHODS: A retrospective study was conducted using the automated databases of 7 health maintenance organizations to evaluate the use of drugs recommended for secondary prevention of osteoporotic fracture. Women 60 years and older with an inpatient or outpatient diagnostic code for a fracture of the hip, vertebra, or wrist between October 1, 1994, and September 30, 1996, and at least 1 year of continuous enrollment with a drug benefit plan following the date of fracture, were identified. The frequency of use of medications for the treatment of osteoporosis (estrogen replacement therapy, bisphosphonates, and calcitonin) during the 1-year period following the date of the initial fracture was estimated overall and according to patient age, fracture site, and year of fracture. RESULTS: During the study period, 3492 women 60 years and older were diagnosed with a fracture of the hip, vertebra, or wrist, and met the inclusion criteria. Of these patients, 822 (24%) received a drug for osteoporosis treatment during the year following the fracture. The proportion of women receiving treatment for osteoporosis was approximately 2-fold higher among those with a fracture of the vertebra (44%) than among those with a fracture of the hip (21%) or wrist (23%) (P<.001). Of the 2605 women who had not been treated for osteoporosis in the 90 days before a fracture, 14% received treatment for osteoporosis in the year following a fracture. Increasing age was associated with a reduced likelihood of receiving osteoporosis treatment (P<.001). CONCLUSIONS: Most of the older women who had experienced a fracture of the hip, vertebra, or wrist did not receive drug treatment for osteoporosis within 1 year following the fracture. Interventions to improve the detection and treatment of osteoporosis in high-risk patients need to be developed.

Aged↗
PubMed2003

Liver function testing in patients on HMG-CoA reductase inhibitors.

PURPOSE: The Food and Drug Administration currently requires the labeling of HMG-CoA reductase inhibitors to recommend liver function tests (LFTs) before the start of therapy and at various intervals during therapy, depending on the specific agent. We sought to determine the frequency and patterns of LFT screening in patients receiving HMG-CoA reductase inhibitors. METHODS: A retrospective study was conducted at a staff-model health maintenance organization among 4178 new users of HMG-CoA reductase inhibitors during the period 1 January 1991 through 31 December 1996. The number and proportions of HMG-CoA reductase inhibitor therapy courses with baseline LFTs (within 180 days prior to dispensing), follow-up LFTs and LFT abnormalities were calculated. RESULTS: For the initial HMG-CoA reductase inhibitor dispensed, 1947 patients (47%) had at least one screening LFT at baseline and 3063 (73%) had at least one follow-up LFT. Twenty-seven (0.9%) patients with at least one follow-up LFT performed had a level greater than 3 times the upper limit of normal. In a random sample of 100 discontinued patients, none discontinued due to elevated LFTs or liver disease. CONCLUSIONS: A large proportion of patients dispensed HMG-CoA reductase inhibitors in this managed care setting did not have baseline and follow-up LFTs performed. Modest LFT abnormalities were common among users of HMG-CoA reductase inhibitors; however, in this population, serious abnormalities were rare.

Aged↗
PubMed2002

Gastric and duodenal safety of daily alendronate.

BACKGROUND: Isolated case reports of gastric ulcers after alendronate sodium use raised concern about the gastroduodenal safety of daily alendronate. This study was conducted to estimate the excess risk of hospitalizations for gastric or duodenal perforations, ulcers, and bleeding associated with alendronate use. PARTICIPANTS AND METHODS: Study subjects were 6432 men and women, 35 years or older. The subjects were members of 8 health maintenance organizations who were dispensed alendronate from October 1995 through September 1997. There was also a group of 33 176 age-, sex-, and health maintenance organization-matched unexposed persons. Because of concerns that osteoporosis might confound the association between alendronate use and perforation, ulcer, or bleeding, a second comparison group of 9776 women, 60 years or older, who had osteoporotic fractures was assembled. Hospitalizations for gastroduodenal events were identified by discharge diagnosis codes in automated claims records, and confirmed by manual record review. RESULTS: Based on the 14 confirmed events in the alendronate group and 35 in the unexposed group, the crude incidence rate ratio of gastroduodenal perforation, ulcer, or bleeding for the alendronate cohort was 3.0. The incidence rate ratio was 1.8 (95% confidence interval, 0.8-3.9) after control for prior hospitalizations, comorbidity, and recent exposure to prescription nonsteroidal anti-inflammatory drugs and oral corticosteroids. The crude incidence ratio rate for the age, sex, and health maintenance organizations-restricted cohort of alendronate users relative to the fracture cohort was 1.1 and the adjusted incidence rate ratio was 1.1 (95% confidence interval, 0.6-2.2). CONCLUSIONS: Osteoporosis and related factors appear to play an important role in the relationship between alendronate use and confirmed gastroduodenal perforation, ulcer, or bleeding; a substantial fraction of the increased risk we observed for alendronate users in the unadjusted analysis was the result of confounding.

Adult↗
PubMed2002

Validation of diagnoses of peptic ulcers and bleeding from administrative databases: a multi-health maintenance organization study.

The automated health plan data and data from medical chart abstractions from eight large health maintenance organizations were used to evaluate the positive predictive values (PPVs) of the International Classification of Diseases, 9th revision (ICD-9) codes for cases of peptic ulcers and upper gastrointestinal bleeding. Overall, 207 of 884 cases of peptic ulcers and upper gastrointestinal bleeding (23%) were confirmed by surgery, endoscopy, X-ray, or autopsy. The PPVs were 66% for hospitalizations with codes for duodenal ulcer (ICD-9-CM 532), 61% for gastric/gastrojejunal ulcer (ICD-9-CM 531, 534), 1% for peptic ulcer (ICD-9-CM 533), and 9% for gastrointestinal hemorrhage (ICD-9-CM578). The overall and diagnostic category-specific PPVs were generally similar for the various HMOs. This study, using data from a large number of health plans located in different geographical regions, underscores the importance of evaluating the accuracy of the diagnoses from automated health plan databases.

Adult↗
PubMed2002

Drug benefit plans under managed care: to what extent do older subscribers selecting less drug coverage put themselves at increased financial risk?

Many health maintenance organizations (HMOs) have implemented programs that limit drug benefit coverage for Medicare beneficiaries. A retrospective study was conducted among Medicare beneficiaries enrolled in the Fallon Community Health Plan to evaluate the implications of the implementation of an HMO program that allowed Medicare beneficiaries to choose between three drug benefit plans: full drug coverage, a drug benefit plan with a maximum of $1,000 in coverage, or no drug benefit. The mean costs of prescription drugs and other healthcare services were calculated and compared for 14,762 patients enrolled in the three pharmacy benefit plans during the 6-month period before and the 12-month period after January 1, 1994, the date of benefit selection. Prescription drug utilization and associated costs were greatest among those members selecting full drug coverage, followed by those with a $1,000 maximum coverage benefit, followed by those selecting no drug coverage (P <.001). The proportion of patients that reached or exceeded $2,000 in prescription drug costs during the 12-month period was determined to evaluate the frequency of patients incurring potentially catastrophic drug expenditures if they were not enrolled in a full drug-coverage plan. Only 21 members (0.5%) with the $1,000 maximum drug benefit reached or exceeded this $2,000 threshold; only one member in the no drug coverage group exceeded this level. A relatively small percentage of patients had drug expenditures that exceeded what was allowed under the drug benefit plan selected. The vast majority of older people choosing less-comprehensive drug benefit plans appeared to make appropriate choices of plans based upon past utilization of prescription and other medical services.

Aged↗
PubMed2002

Chronic disease score as a predictor of hospitalization.

BACKGROUND: The Chronic Disease Score is a risk-adjustment metric based on age, gender, and history of dispensed drugs. We compared four versions of the score for their ability to predict hospitalization among members of eight health maintenance organizations nationwide. METHODS: The study included 29,247 women age 45 years and older. Logistic regression models were constructed using rank quintile and rank decile indicators for each of four scores as predictors of hospitalization during the year after 1 October 1995. Discrimination and model fit were compared using several model properties including the C statistic and the odds ratio comparing highest with lowest quantiles. RESULTS: All Chronic Disease Score versions performed similarly, with the version that predicts total healthcare cost, proposed by Clark et al. (Med Care 1995;33:783-795), performing somewhat better than the other three. The overall risk of hospitalization was 12%. Individuals with higher quantile ranks had a higher risk of hospitalization. Among the Chronic Disease Score versions, the risk of hospitalization ranged from 4% for the lowest decile to 27-29% for the highest decile. Odds ratios comparing the highest with the lowest deciles ranged from 8.9 to 10.2. CONCLUSIONS: The Chronic Disease Score predicts hospitalization and therefore may be a useful indicator of baseline comorbidity for control of confounding.

Age Factors↗
PubMed2002

Challenges of estimating health service utilization for osteoarthritis patients on a population level.

OBJECTIVE: To examine how estimates of osteoarthritis (OA) related health service utilization and medical care charges vary based on how the population of patients is defined, we compared a large cohort of patients identified through an administrative OA diagnosis relative to a subgroup of patients in whom this diagnosis had been validated through medical record review. METHODS: We identified all members (> or = 18 years of age) of a Massachusetts group model health maintenance organization (HMO) with documentation of at least one health care encounter associated with an OA diagnosis during the period 1994-96 (n = 10,740). From this population we randomly selected 700 subjects. Trained nurse reviewers abstracted relevant clinical, laboratory, and radiologic data from their medical records. Physician reviewers evaluated the abstracted information and rated the evidence for the presence of OA according to 3 levels (definite, possible, and unlikely). All persons rated by the physician reviewers as having definite OA were included in the validated subgroup (n = 442). Health service utilization and medical care charges were assessed in all persons with an administrative OA diagnosis who were not randomly sampled (n = 10,040) and the validated subgroup (n = 442) across the following domains: (1) ambulatory encounters associated with an OA diagnosis, (2) relevant radiographic studies, (3) relevant surgical procedures, and (4) relevant medication use. RESULTS: Those in the validated subgroup had higher rates of ambulatory OA associated health care encounters, radiographic studies, surgical procedures, and analgesic and/or antiinflammatory medication dispensings. Patients in the validated subgroup were significantly more likely to be in the highest quartile for total one year charges for the care of OA. CONCLUSION: Estimates of health service utilization are substantially higher for populations of patients in whom a diagnosis of OA has been validated through medical record review, as compared with unvalidated populations identified solely through diagnoses contained in administrative records. Thus using health service utilization estimates based on an unvalidated sample may lead to an inaccurate estimate when extrapolated to the overall population of patients with OA.

Adult↗
PubMedDate not supplied

Persistence with lipid-lowering therapy: influence of the type of lipid-lowering agent and drug benefit plan option in elderly patients.

OBJECTIVE: To determine the effects of lipid-lowering agent (LLA) class and drug plan design option on persistence with LLAs among elderly patients enrolled in a managed care plan. METHODS: A retrospective cohort study was conducted among 310 older adult members enrolled in a health maintenance organization operating in New England who were dispensed an LLA between July 1, 1994, and June 30, 1996. Survival analysis was used to examine differences in discontinuation of LLAs between different classes of LLAs and drug benefit plans as well as patient sex, age, prior hospitalization for coronary heart disease (CHD), hypertension, diabetes mellitus, and the number of other medications. RESULTS: The overall LLA discontinuation rate increased with time from 18% (95% confidence interval [CI], 13.8%-22.4%) at 6 months to 46% (95% CI, 39.7%- 52.5%) at 12 months and 66% (95% CI, 59.2%-73.0%) at 18 months. The likelihood of discontinuation increased from 54% (95% CI, 44.8%-63.6%) at 12 months to 77% (95% CI, 67.5%-85.5%) at 18 months in nonstatin users and from 39% (95% CI, 30.4%-47.6%) at 12 months to 57 % (95% CI, 47.3%-66.9%) at 18 months in statin users (P = 0.001). Among patients prescribed a statin at initial prescription (n = 182), the 12-month discontinuation rates were 33% (95% CI, 23.0%-43.6%) for those with full drug benefit coverage and 50% (95% CI, 34.8%-65.1%) for those with 1,000 dollars per year maximum coverage, while the 21-month discontinuation rates were 60% (95% CI, 46.3%-72.9%) for those with full coverage and 86% (95% CI, 73.7%-98.7%) for those with 1,000 dollars per year maximum coverage (P = 0.023). Adjusting for plan design and hypertension, statin users were less likely to discontinue compared with users of other LLAs (rate ratio [RR] = 0.58; 95% CI, 0.40-0.82; P = 0.002). Among patients dispensed a statin, full-coverage members were less likely to discontinue compared with members having an annual 1,000 dollars maximum drug coverage, adjusting for diabetes and hypertension (RR = 0.58; 95% CI, 0.34-0.98; P = 0.041). This finding was among a small sample after subanalyses, and further research is warranted. Plan design was not determined to be significantly associated with discontinuation of other LLAs. CONCLUSIONS: Our findings suggest that persistence with LLAs is low among older patients regardless of scope of drug benefit coverage or the drug class. Addressing the challenges of maintaining adherence to prescribed therapeutic regimens in the elderly will require a multifaceted approach; deficiencies will not be eliminated simply through the provision of prescription drug benefit coverage.

Aged↗