How treatment priorities influence triptan preferences in clinical practice: perspectives of migraine sufferers,neurologists, and primary care physicians

ABSTRACT

Background: In treating migraine sufferers, physicians can choose from among seven triptans with different attributes.

Objective: To develop a system for selecting an oral triptan based on treatment priorities of migraine sufferers, neurologists, and primary care physicians (PCPs) in the United States, and evidence-based performance of triptans in clinical trials.

Methods: The TRIPSTAR project combines data on the treatment preferences of migraineurs and physicians with results from a meta-analysis of individual triptans, which evaluated their effectiveness on various clinical endpoints. Telephone interviews with migraine sufferers, neurologists, and PCPs were conducted to elicit individual views on the relative importance of a prespecified set of acute treatment outcomes. Four hundred and fifteen migraine sufferers, both triptan-experienced and triptan-naive, were interviewed. Also, 200 board-certified neurologists and 200 PCPs provided information on migraine patients from their clinical practice. A multi-attribute decision model for selecting an oral triptan was constructed using attribute importance weights collected at telephone interview and the meta-analysis data, which were drawn from 53 clinical trials of 6 oral triptans.

Results: Efficacy attributes were rated significantly more important than tolerability or consistency in selecting an oral triptan, according to migraine sufferers and physicians. Freedom from cardiovascular adverse events was the most important tolerability attribute, according to migraine sufferers and physicians alike. Pain free at 1?h was the most important lower-level efficacy attribute for migraine sufferers, while sustained pain free was most important for physicians. When weighted treatment attributes were combined with meta-analysis data in a multi-attribute decision model, almotriptan 12.5?mg, eletriptan 80?mg, and rizatriptan 10?mg were significantly closer to the hypothetical ideal triptan than was sumatriptan 100?mg. Triptans selected by the model were generally closer to the patient-specific ideal triptan than were the triptans prescribed by physicians.

Conclusions: Almotriptan, eletriptan, and rizatriptan were the three triptans closest to the ideal, from the perspectives of migraine sufferers, PCPs, and neurologists alike. The TRIPSTAR model may be a potentially useful decision-support tool to help physicians select the triptan most likely to produce a successful outcome in migraine sufferers.     

Assessment of asthma control in primary care

Abstract

Objective:

To determine the prevalence of uncontrolled asthma in patients who are visiting their primary care provider for any reason.     

Methodological considerations in using claims databases to evaluate persistence with bisphosphonates for osteoporosis

ABSTRACT

Objective: To demonstrate that retrospective analyses of medication persistence require careful methodological approaches to assure accuracy and consistency across various types of databases. Bisphosphonates (BPs) are used as an example because of the availability of diverse dosing options that can create a unique set of challenges for persistence analyses.

Methods: Reports of BP persistence were compared for methodological approaches, including data source, duration of follow-up, allowed gap for persistence, and presentation of results.

Main outcome measures: Medication persistence.

Results: Comparisons among reports of BP persistence for weekly and monthly formulations revealed inconsistent definitions and a variety of methods. Persistence analyses varied greatly, particularly in allowed gaps and adjustment for demographic and clinical characteristics that affected results. Persistence with weekly dosing was 179–249 days, with 24–78% remaining on treatment at 1 year. Analyses of persistence with monthly treatment was complicated by the variety of gap lengths (30–90 days). The studies reviewed had many limitations, including lack of an established threshold for efficacy, inadequacy of information in databases, and potential biases in case selection (treatment-naïve or experienced).

Conclusions: The limitations of published studies reveal the need for a more consistent approach to medication persistence analyses using claims databases to allow for comparison across reports. The analysis plan should present definitions of all terms, details of all methods and types of adjustments needed for demographic and clinical characteristics, as well as specify allowed gaps between refills. These approaches would improve clinical utility of data describing BP persistence and its impact on fracture risk.     

Long dosing intervals in the treatment of postmenopausal osteoporosis

ABSTRACT

Background: Osteoporosis is a common disease associ­ated with diminished bone strength and increased risk of fracture. With the aging of the population, the number of people with osteoporosis, particularly postmenopausal women, is expected to increase. There are excellent tools for diagnosing osteoporosis and widely available treat­ments that are safe and effective. Nevertheless, osteo­porosis is underdiagnosed and undertreated. Even among those who are diagnosed and treated, widespread non­adherence with treatment regimens undermines the efficacy of osteoporosis therapy.

Purpose: To examine the pharmacological options for the treatment of postmenopausal osteoporosis and the influence of extended dosing intervals upon outcomes, medication adherence, and patient preference.

Methods: A Medline and Cochrane Review database search was conducted for appropriate clinical trials, meta-analyses, and systematic reviews published between 1987 and 2007.

Findings: The causes of nonadherence include poor understanding of the consequences of a silent disease, concern regarding potential side-effects of medications, the inconvenience associated with administration of some osteoporosis medications, and medication costs. The recent development of effective oral and injectable osteo­porosis medications that can be given with long dosing intervals may improve patient adherence. Less frequent dosing lessens the inconvenience of administration, and dosing by injection assures that the medication is 100% bioavailable. Osteoporosis patients have shown a preference for monthly bisphosphonate dosing compared with weekly dosing.

Conclusion: Enhanced adherence with new dosing regimens can be expected to improve treatment efficacy, reduce fracture risk, and lessen the burden of osteo­porosis on patients and society. Further study is required to fully elucidate the relationship between extended dosing, adherence, and positive outcomes.     

Cost-effectiveness of alternative treatments for women with osteoporosis in Canada

ABSTRACT

Background: During the years following menopause, estrogen levels decline leading to accelerated bone loss and an increased risk of osteoporosis and osteoporosis-related fractures.

Methods: Using a Markov model and decision analytic techniques, the long-term costs and outcomes of five treatment and secondary prevention strategies for osteoporosis were compared: ‘no intervention’, alendronate, etidronate, risedronate, and raloxifene. The base case analysis examined postmenopausal (65 year old) osteoporotic women without prior fracture. Probabilistic sensitivity analysis (PSA) was used to incorporate the impact of parameter uncertainty, and deterministic sensitivity analysis (DSA) was used to compare alternative patient populations and modeling assumptions. Life years and Quality Adjusted Life Years (QALYs) were used as measures of effectiveness.

Results: In the base case analysis, risedronate was dominated by etidronate and alendronate. Alendronate and etidronate were projected to have similar costs and QALYs, and the efficiency frontier was represented by ‘no intervention’, etidronate, alendronate, and raloxifene (Can$32?571, Can$38?623 and Can$114?070 per QALY respectively). Alternative assumptions of raloxifene's impact on CHD and breast cancer, alternative discount rates and alternative patient risk factors (e.g., starting age of therapy, CHD risk, and prior fracture risk) had significant impacts on the overall cost-effectiveness results for both the bisphosphonates and raloxifene.

Discussion: Using conventionally quoted benchmarks and compared to no therapy, alendronate, etidronate, and raloxifene would all be considered cost-effective alternatives for treating women with osteoporosis. Potential limitations of this study include the usual caveats and cautions associated with long-term projection models and the fact that not all inputs into the model are Canadian data sources.     

A pharmacist's unique opportunity within a multidisciplinary team to reduce drug-related problems for older adults in an intermediate care setting

BackgroundThere is a paucity of research describing the pharmacist's role in the multidisciplinary care of older adults in the intermediate care setting.ObjectiveTo determine the types of drug-related problems (DRPs) in older patients in this setting, to evaluate the implementation rate of pharmacist recommendations and the factors affecting implementation, and to assess the clinical significance of these recommendations.MethodsData were collected over a 12-week period on one pharmacist's recommendations to reduce clinically relevant DRPs identified during medication reconciliation and review for all patients ≥65 years admitted to an intermediate care unit. The clinical significance of the recommendations was judged by four independent assessors using a validated tool. Statistical significance was predetermined as p < 0.05.ResultsOf 494 clinically relevant DRPs identified in 91 patients (mean age: 82 years), 406 recommendations were communicated to the medical team, and 89.2% were implemented. Overall, 48.5% were communicated verbally, but no difference was found between the implementation rates of verbal and written recommendations (87.8% versus 90.4%; p = 0.4). Medication reconciliation recommendations were implemented more commonly than those regarding medication review (96.5% versus 79.5%; p < 0.0001). Recommendations judged to be of ‘moderate significance’ (66.8% of total) were implemented more often than those of ‘minor significance’ (93.2% versus 81.6%; p < 0.001). The consultant was provided with a significantly higher proportion of recommendations of ‘moderate significance’ when compared to the junior doctor (79.6% versus 63.3%; p = 0.02), but implemented significantly fewer recommendations (69.4% versus 91.9%; p < 0.0001).ConclusionThe high implementation rate in this study shows the importance of pharmacist involvement to reduce DRPs in the multidisciplinary care of older adults in an intermediate care unit. Future research should focus on investigating the impact of pharmacist interventions on older patient outcomes and the associated cost-effectiveness in this setting.     

Outcomes from primary care management of alcohol dependence in France

A prospective study assessed the outcome in a sample of 122 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition alcohol-dependent patients in primary care. Standardized questionnaires collected clinical, social, and management data during 875 visits over an 18-month follow-up. A time–event analysis identified outcome predictors. Forty-three percent of patients attempted at least one detoxification during follow-up, one out of three in a hospital. Despite a very high relapse rate (83%), only 14% of the patients attempted a repeated abstinence. Longest and cumulative durations of abstinence appeared to be very close, corresponding to 29% of the follow-up time. The frequency of visits (risk ratio [RR] = 1.08) and visits addressing alcohol consumption (RR = 1.73) significantly lead to detoxification. In this French sample, management by the general practitioners appears to be a positive predictor of outcome in alcohol dependence. Future research could (a) enlighten the relationship between detoxification and frequency or circumstances of the visits and (b) tell whether formal planned follow-up by general practice physicians could improve outcome in alcohol dependence.     

医师对临床药学服务需求的国外测量方法介绍及经验借鉴

目的：为我国开发科学合理的医师对临床药学服务测量工具提供参考。方法：通过文献检索归纳和分析国外现有医师对临床药学服务测量工具。结果：国外常用的医师对临床药学服务测量工具主要为加利福尼亚州的Current Expectations-Current Experience-Future Expectations问卷（简称为"California问卷"）和科威特的Perceptions-Expectations-Experience问卷（简称为"Kuwait问卷"）。与California问卷相比，Kuwait问卷的理论基础更加切合我国实际情况，维度内涵与我国部分医师对临床药学服务测量工具相近；Kuwait问卷的题项是以California问卷为基础进行科学合理调整编制；Kuwait问卷的实践应用范围更为广泛，并已在我国部分地区完成相关研究。结论：California问卷和Kuwait问卷对我国测量工具分析框架的明确、开发过程的完善、实证检验的加强具有较强的指导意义。     

Prevention of vertebral fractures in osteoporosis: mixed treatment comparison of bisphosphonate therapies

ABSTRACT

Objective: The objective was to compare the efficacy of bisphosphonates regarding the prevention of vertebral fractures in postmenopausal women with osteoporosis.

Methods: Seven randomized placebo controlled trials investigating the effects of zoledronic acid (one study), alendronate (three studies), ibandronate (one study), and risedronate (two studies) in terms of fractures with a follow-up of 3 years were identified with a systematic literature search. The endpoint of interest was vertebral fractures. Results of all trials were analyzed simultaneously with a Bayesian mixed treatment comparison (MTC). With MTC the relative treatment effect of one intervention to another can be obtained in the absence of head-to-head evidence. MTC can be considered a valid method when included studies are comparable regarding effect modifying baseline patient and study characteristics.

Results: There is a 98% probability that zoledronic acid shows the greatest reduction in vertebral fractures of all four bisphophonates compared. Zoledronic acid showed an OR of 0.28 (95% Credible Interval 0.22; 0.35) relative to placebo, an OR of 0.57 (0.36; 0.92) relative to ibandronate, an OR of 0.54 (0.39; 0.75) relative to alendronate, and an OR of 0.49 (0.34; 0.69) relative to risedronate. Alendronate, ibandronate, and risedronate showed comparable vertebral fracture reductions. Indirect comparisons using a conservative random effects model supported these findings.

Conclusion: An indirect comparison of findings from placebo controlled randomized studies indicates that zoledronic acid provides a greater vertebral fracture risk reduction in postmenopausal women with osteoporosis than ibandronate, alendronate, or risedronate.     

Awareness,perceptions and attitudes toward medication-related osteonecrosis of the jaw among physicians who treat osteoporosis

Osteoporosis is the most common indication for antiresorptive drugs (ARDs). Medication-related osteonecrosis of the jaw (MRONJ) is a severe complication of ARDs. Multiple risk factors can increase the risk of MRONJ, one of which is the duration of ARD intake, which is usually prolonged for osteoporosis cases. Prevention of MRONJ relies on collaborative care between treating physicians and dental practitioners. Therefore, knowledge about MRONJ and its prevention strategies is crucial for both teams.AimThis study aimed to assess the knowledge and attitudes of physicians toward MRONJ in osteoporosis patients. Another aim was to develop recommendations for the prevention of MRONJ.Materials and methodsThrough an online survey, basic information such as the practice location, training, knowledge, perceptions, and attitudes of physicians regarding ARDs and MRONJ in osteoporosis patients was collected. Statistical analysis was performed for all variables, and their correlations were explored.ResultsA total of 221 physicians participated in the survey: 34.8% were rheumatologists, 25.3% were endocrinologists, 8.6% were family medicine physicians, 5.9% were orthopedists, and 5.9% were internal medicine physicians. Of them, 58.0% reported more than 6 years of experience. Only 78.7% were aware of MRONJ and recognized that bisphosphonates (BPs) can contribute to MRONJ. In contrast, 56.0% recognized denosumab as a causative factor for MRONJ. Duration of ARD therapy and pre- and post-ARD dental care were known to influence the risk of MRONJ by 62% and 65.6% of the participants, respectively. Only 41.6% and 31.2% of participants informed patients about MRONJ prior to BP and denosumab therapy, respectively. Only 25.3% and 20.8% referred patients to dentists before BP and denosumab therapy, respectively. Overall, 65.6% of the participants had a negative attitude toward MRONJ, and 34.4% had a positive attitude. A positive attitude was mostly observed among rheumatologists (55.8%) compared to other specialists (p <0.001). More years of experience were associated with a higher level of knowledge and positive attitude.ConclusionThe findings of this study identified a notable gap in the awareness, knowledge and attitudes of physicians regarding MRONJ in osteoporosis patients. Continuing education programs about ARDs and MRONJ risk are highly recommended.     

Pharmacists in primary care Determinants of the care-providing function of Dutch community pharmacists in primary care

OBJECTIVE: To identify determinants of the care-providing function of the community pharmacists (CPs) to explain variations in professional practice. SETTING: The Netherlands 2001. PARTICIPANTS: 328 CPs. METHOD: A cross-sectional questionnaire survey was performed. Questionnaires were used to collect data about the care provided in pharmacies. As dependent variables three partial constructs: 'individual patient care', 'registration of the care', and 'cooperation with GPs', and one total construct: 'care function' were formed. Independent variables were: gender, work experience, attitude to the care-providing function, tenure, relationship with GPs, pharmacist trainer, frequency of postgraduate training, workload, part-time working, frequency of contact with pharmaceutical representatives, presence of technicians with a specialised caring duty, size of the pharmacy, urbanisation, competition, franchise pharmacy, presence of sufficient personnel. A multiple-regression analysis was performed. RESULTS: Respondents 71%; of the respondents 29% never enquired about the patient's experience when supplying a medication for the second time. The supply of self-care remedies was never registered by 11% of respondents. Ninety percent of pharmacists participate more than four times per year in Pharmacotherapy Audit Meetings. The attitude of the pharmacist, relationship with the GP, presence of specialised technicians, frequency of postgraduate training and the type of tenure are significantly positively correlated with a care-providing function. Being a pharmacist trainer is significantly positively related with 'individual patient care', the frequency of postgraduate training is significantly positively correlated with 'registration of the care' and the number of years in service is significantly negatively correlated with 'cooperation with GPs'. There is a negative correlation between the cooperation with GPs and the number of years a pharmacist has been in service. CONCLUSION: Based on this survey, the development of programmes focused on optimal attitude, and cooperation between pharmacists and GPs is recommended.     

Communication between hospitals,Family Medicine Groups and community pharmacists during transitions of care interventions

BackgroundPharmacist-led transitions of care (TOC) interventions have been associated with improved health outcomes. Community pharmacists’ (CP) TOC communications have been described whereas limited evidence is available for hospital pharmacists (HP) and none for non-dispensing pharmacists, integrated into Family Medicine Groups (FMG).ObjectiveTo assess information needs and perceptions about TOC communications of HP, FMG pharmacists (FMG-P) and CP and to identify optimal TOC practices and their barriers.MethodsIn a cross-sectional design, a survey was distributed via email to the 70 pharmacists who participated in a multicenter, single group, longitudinal TOC intervention study for older adults at risk of medication-related harm. All pharmacists were surveyed on their TOC practices before the TOC study, as part of usual care. Pharmacists who followed TOC study patients were also surveyed on their TOC practices during the TOC study.ResultsSurvey responses were received from 35 pharmacists (50%), including 8 HP, 6 FMG-P and 21 CP. The frequency of communication between pharmacists of different settings increased significantly during the TOC study, with more than 80% of pharmacists reporting satisfaction with the quality of the information provided. At hospital discharge, in optimal TOC, the FMG-P and CP reported that the most important information to transfer was the reasons of hospitalization, patient weight and height, and the therapeutic intent of the medications. The main barriers to TOC implementation were the lack of clinical information about patients for FMG-P and CP and understaffing for HP. FMG-P and CP reported a similar high degree of interest in assuming responsibility for the new extended scope of practice activities of medication adjustments according to therapeutic targets or laboratory results and the implementation of a plan for gradual dose increases or drug tapering.ConclusionsThe surveyed pharmacists reported an increased frequency of communication and satisfaction with the information exchanged between the pharmacists of different settings during the TOC study compared to usual care, before the study. The pharmacists extended scope of practice offers new opportunities to optimize TOC interventions.