Adherence to oral antidiabetic therapy in a managed care organization: a comparison of monotherapy, combination therapy, and fixed-dose combination therapy

BACKGROUND: Although medication adherence is one of the most important aspects of the management of diabetes mellitus, low rates of adherence have been documented. OBJECTIVE: This study sought to examine medication adherence among patients with diabetes mellitus in a managed care organization who were receiving antidiabetic monotherapy (metformin or glyburide), combination therapy (metformin and glyburide), or fixed-dose combination therapy (glyburide/metformin). METHODS: Medication adherence was evaluated through a retrospective database analysis of pharmacy claims. The adherence rate was defined as the sum of the days' supply of oral antidiabetic medication obtained by the patient during the follow-up period divided by the total number of days in the designated follow-up period (180 days). Health plan members were included in the analysis if they had an index pharmacy claim for an oral antidiabetic medication between August 1 and December 31, 2000, were continuously enrolled in the health plan, and were aged > or =18 years. A 6-month pre-index period was used to classify patients as newly treated or previously treated. Patients were grouped according to their medication-use patterns. RESULTS: After adjustment for potential confounding factors, including overall medication burden at index, there were no significant differences in adherence rates among 6502 newly treated patients receiving monotherapy, combination therapy, or fixed-dose combination therapy. Among the 1815 previously treated patients receiving glyburide or metformin monotherapy who required the addition of the alternative agent, resulting in combination therapy, adherence rates were significantly lower (54.0%; 95% CI, 0.52-0.55) than in the 105 patients receiving monotherapy who were switched to fixed-dose combination therapy (77.0%; 95% CI, 0.72-0.82). The 59 previously treated patients receiving combination therapy who were switched to fixed-dose combination therapy had a significant improvement in adherence after the switch (71.0% vs 87.0%; P < 0.001). CONCLUSIONS: In a managed care organization, previously treated patients receiving monotherapy with an oral antidiabetic medication who required additional therapy exhibited significantly greater adherence when they were switched to fixed-dose combination therapy compared with combination therapy. Patients receiving combination therapy who were switched to fixed-dose combination therapy exhibited significantly greater adherence after the switch.     

A retrospective cohort pilot study to evaluate a triage tool for use in a pandemic

Introduction  

The objective of this pilot study was to assess the usability of the draft Ontario triage protocol, to estimate its potential impact on patient outcomes, and ability to increase resource availability based on a retrospective cohort of critically ill patients cared for during a non-pandemic period.     

Intensive care patients receiving vasoactive medications: A retrospective cohort study

BackgroundVasoactive medications are high-risk drugs commonly used in intensive care units (ICUs), which have wide variations in clinical management.ObjectivesThe aim of this study was to describe the patient population, treatment, and clinical characteristics of patients who did and did not receive vasoactive medications while in the ICU and to develop a predictive tool to identify patients needing vasoactive medications.MethodsA retrospective cohort study of patients admitted to a level three tertiary referral ICU over a 12-month period from October 2018 to September 2019 was undertaken. Data from electronic medical records were analysed to describe patient characteristics in an adult ICU. Chi square and Mann–Whitney U tests were used to analyse data relating to patients who did and did not receive vasoactive medications. Univariate analysis and Pearson's r² were used to determine inclusion in multivariable logistic regression.ResultsOf 1276 patients in the cohort, 40% (512/1276) received a vasoactive medication for haemodynamic support, with 84% (428/512) receiving noradrenaline. Older patients (odds ratio [OR] = 1.02; 95% confidence interval [CI] = 1.01–1.02; p < 0.001) with higher Acute Physiology and Chronic Health Evaluation (APACHE) III scores (OR = 1.04; 95% CI = 1.03–1.04; p < 0.001) were more likely to receive vasoactive medications than those not treated with vasoactive medications during an intensive care admission. A model developed using multivariable analysis predicted that patients admitted with sepsis (OR = 2.43; 95% CI = 1.43–4.12; p = 0.001) or shock (OR = 4.05; 95% CI = 2.68–6.10; p < 0.001) and managed on mechanical ventilation (OR = 3.76; 95% CI = 2.81–5.02; p < 0.001) were more likely to receive vasoactive medications.ConclusionsMechanically ventilated patients admitted to intensive care for sepsis and shock with higher APACHE III scores were more likely to receive vasoactive medications. Predictors identified in the multivariable model can be used to direct resources to patients most at risk of receiving vasoactive medications.     

Factors associated with a persistent delirium in the intensive care unit: A retrospective cohort study

PurposeTo explore differences between ICU patients with persistent delirium (PD), non-persistent delirium (NPD) and no delirium (ND), and to determine factors associated with PD.Materials and methodsRetrospective cohort study including all ICU adults admitted for ≥12 h (January 2015–February 2020), assessable for delirium and followed during their entire hospitalization. PD was defined as ≥14 days of delirium. Factors associated with PD were determined using multivariable logistic regression analysis.ResultsOut of 10,295 patients, 3138 (30.5%) had delirium, and 284 (2.8%) had PD. As compared to NPD (n = 2854, 27.7%) and ND (n = 7157, 69.5%), PD patients were older, sicker, more physically restrained, longer comatose and mechanically ventilated, had a longer ICU and hospital stay, more ICU readmissions and a higher mortality rate.Factors associated with PD were age (adjusted odds ratio [aOR] 1.03; 95% confidence interval [CI] 1.02–1.04); emergency surgical (aOR 1.84; 95%CI 1.26–2.68) and medical (aOR 1.57; 95%CI 1.12–2.21) referral, mean Sequential Organ Failure Assessment (SOFA) score before delirium onset (aOR 1.18; 95%CI 1.13–1.24) and use of physical restraints (aOR 5.02; 95%CI 3.09–8.15).ConclusionsPatients with persistent delirium differ in several characteristics and had worse short-term outcomes. Physical restraints were the most strongly associated with PD.     

Predicting a low cortisol response to adrenocorticotrophic hormone in the critically ill: a retrospective cohort study

Introduction  

Identification of risk factors for diminished cortisol response to adrenocorticotrophic hormone (ACTH) in the critically ill could facilitate recognition of relative adrenal insufficiency in these patients. Therefore, we studied predictors of a low cortisol response to ACTH.     

Health economics of a palliative care unit for terminal cancer patients: a retrospective cohort study

Purpose  

The objective of this study was to evaluate cost-reduction efficacy of a palliative care unit (PCU) by analyzing medical expenses of terminal cancer patients.     

Brief therapy for managed mental health companies: becoming a learning organization

Nearly all of the services offered through managed behavioral health care companies are brief or time effective in nature. It is often the view of these companies that many of their providers have insufficient backgrounds in doing such treatment and have been trained in longer, less efficient modes of service delivery. Although this is often the case, what is frequently not recognized is that most managed behavioral health care companies themselves lack knowledge and clarity about such therapies. We address the critical need for behavioral health care companies to become learning organizations focused on research and development and internal as well as external training in time-efficient therapies. Such activities will allow for creativity and enhancement of the substance abuse and mental health care areas.     

Safety of nicotine replacement therapy in critically ill smokers: a retrospective cohort study

Purpose

Nicotine replacement therapy (NRT) has been used to ameliorate nicotine withdrawal in the intensive care unit (ICU). Previous cohort studies have suggested an increased mortality with NRT use: methodological problems may call into question the validity of these findings. We undertook a retrospective cohort study to determine if NRT use was associated with adverse outcomes.

Methods

This retrospective cohort study was conducted in a 30-bed, university affiliated, teaching hospital ICU.

Results

We identified 423 smokers admitted over 2?years, of whom 73 received transdermal NRT. Cox proportional hazard regression models, with NRT modelled as a time-varying covariate, were used to test the hypothesis that NRT was associated with an altered ICU or hospital mortality. A second analysis utilized propensity scores. The unadjusted ICU and hospital mortalities were lower for the NRT group; although both differences were non-significant. The Cox models showed that, after adjustment for APACHE risk, age, sex and alcohol use, risk associated with NRT administration was not statistically different than non-administration for both ICU (hazard ratio 0.50, [95?% CI 0.20–1.24], p?=?0.14) and hospital (hazard ratio 0.95, [95?% CI 0.52–1.75], p?=?0.88) mortality. Similar findings occurred with the propensity matched analysis.

Conclusion

We were unable to demonstrate any harm associated with NRT, with the ICU model actually trending towards benefit. We conclude that a randomised, blinded, placebo controlled trial is required to assess adequately the safety and efficacy of NRT as a treatment in critically ill smokers.     

Testing strategies for building member loyalty in a managed care organization serving Medicare beneficiaries

Member retention has been a challenge for Medicare HMOs. This article describes how a hybrid Medicare HMO is testing methods of strengthening member loyalty and member retention. Methods include managing member expectations and involving sales representatives and Personal Care Planner in outreach to new members. An early problem detection project yielded information that was used to resolve member difficulties and preempt disenrollment.     

Adherence and persistence associated with the pharmacologic treatment of osteoporosis in a managed care setting

BACKGROUND: The effectiveness of chronic therapies can be compromised by poor adherence and persistence. MATERIALS AND METHODS: Investigators identified a continuously benefit-eligible cohort of women from a large, geographically diverse, national managed care plan who were newly diagnosed and treated for osteoporosis with alendronate, risedronate, or raloxifene. Drug utilization parameters were evaluated over a 12-month follow-up period for the study population. Adherence was assessed using a medication possession ratio calculated as total days of therapy for medication dispensed/365 days of study follow-up. Persistence was defined as continuous therapy on the same drug for each month over the entire study period. Adherence and persistence were also evaluated for all three study agents in women > or = 65 years of age. RESULTS: In the study cohort (N = 10,566), 12-month adherence/ persistence rates were alendronate 61%/21%, risedronate 58%/19%, and raloxifene 54%/16%. Rates in women > or = 65 years were similar to those in the entire study cohort. Weekly bisphosphonate users had slightly higher 12-month adherence (63% versus 54%, P < 0.05) and persistence (22% versus 19%, P = NS) rates than did daily users, independent of agent. CONCLUSION: Chronic oral-dosed osteoporosis therapies are associated with poor adherence and persistence, regardless of age or dosing regimen. Drug therapies and patient management approaches associated with improved adherence and persistence could improve the likelihood of achieving the therapeutic benefits observed in rigorously controlled clinical trials.     

Weighted-incidence syndromic combination antibiograms to guide empiric treatment of critical care infections: a retrospective cohort study

Introduction

Empiric antimicrobial selection for critical care infections must balance the need for timely adequate coverage with the resistance pressure exerted by broadspectrum agents. We estimated the potential of weighted incidence syndromic combination antibiograms (WISCAs) to improve time to adequate coverage for critical care infections. In contrast to traditional antibiograms, WISCAs display the likelihood of coverage for a specific infectious syndrome (rather than individual pathogens), and also take into account the potential for poly-microbial infections and the use of multi-drug regimens.

Methods

Cases of ventilator-associated pneumonia (VAP) and catheter-related bloodstream infection (CRBSI) were identified over three years using stringent surveillance criteria. Based on the susceptibility profile of the culprit pathogens, we calculated the WISCA percentages of infections that would have been adequately covered by common antimicrobial(s). We then computed the excess percentage coverage offered by WISCA regimens compared to the actual antimicrobials administered to patients by 12 h, 24 h, and 48 h from culture collection.

Results

Among 163 patients with critical care infection, standard practice only resulted in adequate coverage of 35% of patients by 12 h, 52% by 24 h, and 75% by 48 h. No WISCA mono-therapy regimen offered greater than 85% adequate overall coverage for VAP and CRBSI. A wide range of dual therapy regimens would have conferred greater than 90% adequate coverage, with excess coverage estimated to be as high as +56%, +42% and +18% at 12 h, 24 h and 48 h, respectively. We did not detect a decrease in mortality associated with early adequate treatment, and so could not estimate potential downstream benefits.

Conclusions

WISCA-derived empiric antimicrobial regimens can be calculated for patients with intensive care unit (ICU)-acquired infections, and have the potential to reduce time to adequate treatment. Prospective research must confirm whether implementation of WISCA prescribing aids facilitate timely adequate treatment and improved ICU outcomes.     

The influence of volume and intensive care unit organization on hospital mortality in patients admitted with severe sepsis: a retrospective multicentre cohort study

Introduction  

The aim of the study was to assess the influence of annual volume and factors related to intensive care unit (ICU) organization on in-hospital mortality among patients admitted to the ICU with severe sepsis.     

Phosphate abnormalities and outcomes among admissions to the intensive care unit: A retrospective multicentre cohort study

PurposeWe investigated the effect of serum phosphate abnormalities at intensive care unit (ICU) admission on risk of death and length of stay in critically ill patients.Materials and methodsA retrospective cohort of patients admitted to three adult ICUs in Queensland, Australia from April 2014 to 2019 was studied. Hypophosphataemia, normophosphataemia and hyperphosphataemia were defined as serum phosphate level of <0.8, 0.8–1.5 and >1.5 mmol/L respectively. Univariable and logistic regression analyses were performed to investigate the association between the phosphate groups and the risk of death.Measurements and main resultsWe included 13,155 patients in the analysis, of which 1424 (10.8%) patients had hypophosphataemia and 2544 (19.3%) hyperphosphataemia. The mean admission phosphate level was 1.25 (SD, ±0.43) mmol/L. Both hypophosphatemia (OR 1.29; 95% CI, 1.02–1.64; p = 0.034) and hyperphosphataemia (OR 1.39; 95% CI, 1.15–1.68; p = 0.001) at admission were independently associated with increased risk of death after adjusting for covariables using logistic regression analysis.ConclusionHypophosphatemia and hyperphosphatemia were both independently associated with an increased case fatality rate and ICU length of stay in a large multicentre ICU cohort.     

Health literacy and preventive health care use among Medicare enrollees in a managed care organization

BACKGROUND: Many older adults in Medicare managed care programs have low health literacy, and this may affect use of preventive services. OBJECTIVES: To determine whether older adults with inadequate health literacy were less likely to report receiving influenza and pneumococcal vaccinations, mammograms, and Papanicolaou smears than individuals with adequate health literacy after adjusting for other covariates. RESEARCH DESIGN: Cross-sectional survey; home interviews with community dwelling enrollees. SUBJECTS: Medicare managed care enrollees 65 to 79 years old in four US cities (n = 2722). MEASURES: Short Test of Functional Health Literacy in Adults and self-reported preventive service use. RESULTS: In bivariate analyses, self-reported lack of preventive services was higher among individuals with inadequate health literacy than those with adequate health literacy: never had an influenza vaccination: 29% versus 19% (P = 0.000); never had a pneumococcal vaccination: 65% versus 54% (P = 0.000); no mammogram in the last 2 years: 24% versus 17% (P = 0.017); never had a Papanicolaou smear: 10% versus 5% (P = 0.002). After adjusting for demographics, years of school completed, income, number of physician visits, and health status, people with inadequate health literacy were more likely to report they had never received the influenza (OR, 1.4; 95% CI, 1.1-1.9) or pneumococcal vaccination (OR, 1.3; 95% CI, 1.1-1.7), and women were less likely to have received a mammogram (OR, 1.5; 95% CI, 1.0-2.2) or Papanicolaou smear (OR, 1.7; 95% CI, 1.0-3.1). CONCLUSIONS: Among Medicare managed care enrollees, inadequate health literacy is independently associated with lower use of preventive health services.     

The impact of the addition of nurse practitioners to surgical intensive care units: A retrospective cohort study

BackgroundDemand for surgical critical care is increasing, but work-hour restrictions on residents have affected many hospitals. Recently, the use of nurse practitioners (NPs) as providers in the intensive care unit (ICU) has expanded rapidly, although the impacts on quality of care have not been evaluated.ObjectivesTo compare the outcomes of critically ill surgical patients before and after the addition of NPs to the ICU team.MethodsWe conducted a retrospective cohort study in a Taiwanese surgical ICU. We compared the outcomes of patients admitted to ICU during the 2-year period before and after the addition of NPs to the ICU team. Patients admitted in the 1-year transition phase were excluded from comparisons. The primary endpoint was ICU mortality. Secondary endpoints included ICU length of stay and incidence of unplanned extubation.ResultsA total of 8747 patients were included in the study. For all eligible admissions, primary and secondary outcomes did not differ significantly between the two groups. For scheduled ICU admissions, ICU mortality was significantly lower after the addition of NPs (2.2% before vs. 1.1% after addition of NPs, p = 0.014). For unscheduled ICU admissions, ICU mortality did not differ significantly between the two groups. In the multivariate analysis, admission after the addition of NPs was associated with significantly reduced ICU mortality (odds ratio = 0.481; 95% confidence interval = 0.263–0.865; p = 0.015) among scheduled admissions.ConclusionIncorporating NPs in the ICU team was associated with improved outcomes in scheduled admissions to surgical ICU when compared with a traditional, resident-based team.     

Fast-track rehabilitation program and conventional care after esophagectomy: a retrospective controlled cohort study

Purpose

The purpose of this article is to evaluate fast-track rehabilitation program and conventional care after esophagectomy using a retrospective controlled cohort study in esophageal cancer patients.

Methods

Fifty-five patients underwent fast-track rehabilitation program and 57 patients underwent conventional care after esophagectomy. Fast-track rehabilitation program was performed to patients who have early movement, epidural analgesia control, fluid infusion volume control and enteral nutrition for early discharge. The other 57 patients underwent conventional care after esophagectomy. The average of hospital stay and complications were calculated in the patients between the two groups.

Results

The median length of hospital stay in the patients was significantly shorter after fast-track rehabilitation program than after conventional care (7.7 vs 14.8 day, P?<?0.01). The percentage of patients who developed complications was significantly lower 30 day after fast-track rehabilitation program than after conventional care (29.1 vs 47.4 %, P?<?0.05). 87.3 % in patients of the fast-track rehabilitation program group and 54.4 % in those of the conventional care group reported excellent to very good satisfaction with their pain control (P?=?0.000).

Conclusions

The fast-track rehabilitation program results in fewer complications, less postoperative pain, a reduction in the hospital length of stay, and quicker return to work and normal activities after esophagectomy.