Relationship between Adherence Level to Statins, Clinical Issues and Health-Care Costs in Real-Life Clinical Setting

AbstractObjectiveStatins have been shown to reduce the risk of major cardiovascular disease. We recognize that there is a major gap between the use of statins in actual practice and treatment guidelines for dyslipidemia. Low adherence to statins may have a significant impact on clinical issues and health-care costs. The objective is to evaluate the impact of low adherence to statins on clinical issues and direct health-care costs.MethodsA cohort of 55,134 patients newly treated with statins was reconstructed from the Régie de l'Assurance Maladie du Québec and Med-Echo databases. Subjects included were aged between 45 and 85, initially free of cardiovascular disease, newly treated with statins between 1999 and 2002, and followed-up for a minimum of 3 years. Adherence to statins was measured in terms of the proportion of days' supply of medication dispensed over a defined period, and categorized as ≥80% or <80%. The adjusted odds ratio (OR) of cardiovascular events between the two adherence groups was estimated using a polytomous logistic analysis. The mean costs of direct health-care services were evaluated. A two-part model was applied for hospitalization costs.ResultsThe mean high adherence level to statins was around to 96% during follow-up; and this value was at 42% for the low adherence level. The patients with low adherence to statins were more likely to have coronary artery disease (OR 1.07; 95% confidence interval [CI], 1.01–1.13), cerebrovascular disease (OR 1.13; 95% CI 1.03–1.25), and chronic heart failure within 3-year period of follow-up (OR 1.13; 95% CI 1.01–1.26). Low adherence to statins was also associated with an increased risk of hospitalization by 4% (OR 1.04; 95% CI 1.01–1.09). Among patients who were hospitalized, low adherence to statins was significantly associated with increase of hospitalization costs by approximately $1060/patient for a 3-year period.ConclusionLow adherence to statins was correlated with a higher risk of cardiovascular disease, hospitalization rate, and hospitalization costs. An increased level of adherence to statins agents should provide a better health status for individuals and a net economic gain

Priority interventions to improve the management of chronic non-cancer pain in primary care: a participatory research of the ACCORD program

Purpose: There is evidence that the management of chronic non-cancer pain (CNCP) in primary care is far from being optimal. A 1-day workshop was held to explore the perceptions of key actors regarding the challenges and priority interventions to improve CNCP management in primary care. Methods: Using the Chronic Care Model as a conceptual framework, physicians (n=6), pharmacists (n=6), nurses (n=6), physiotherapists (n=6), psychologists (n=6), pain specialists (n=6), patients (n=3), family members (n=3), decision makers and managers (n=4), and pain researchers (n=7) took part in seven focus groups and five nominal groups. Results: Challenges identified in focus group discussions were related to five dimensions: knowledge gap, “work in silos”, lack of awareness that CNCP represents an important clinical problem, difficulties in access to health professionals and services, and patient empowerment needs. Based on the nominal group discussions, the following priority interventions were identified: interdisciplinary continuing education, interdisciplinary treatment approach, regional expert leadership, creation and definition of care paths, and patient education programs. Conclusion: Barriers to optimal management of CNCP in primary care are numerous. Improving its management cannot be envisioned without considering multifaceted interventions targeting several dimensions of the Chronic Care Model and focusing on both clinicians and patients

Faire connaître les recommandations d’un guide de pratiques : développement et évaluation d’une intervention de formation continue

Contexte : Une trousse de pratiques préventives des fractures de fragilisation a été développée et présentée lors d’un atelier de formation continue, offert aux médecins de famille dans leur milieu de travail. L’objectif de l’intervention est de diffuser les recommandations du guide de pratiques canadien sur l’ostéoporose. Buts : Évaluer les facteurs influençant l'utilisation de la trousse et mesurer les changements du niveau de connaissances des médecins lorsque la trousse est utilisée. Sujets : Quarante-quatre médecins de famille en clinique privée et en centre local de services communautaires de la région de Laval (banlieue de Montréal) ont participé à l’intervention et complété un questionnaire sur leurs connaissances au début et à la fin de l’atelier. Une entrevue semi-structurée a été réalisée avec 12 médecins, trois à six mois après l’atelier, pour documenter l’utilisation de la trousse. Résultats : Une amélioration des connaissances des facteurs de risque (pré-atelier : 80 % versus post-atelier 100 %), des tests diagnostics (40 % versus 100 %) et des ressources communautaires disponibles (0 % versus 50 %) a été observée. Tous les médecins interviewés s'accordent sur la qualité et l'utilité potentielle de la trousse. Huit médecins ont utilisé au moins une section de la trousse. Les raisons pour ne pas l’avoir utilisée sont: 1) avoir oublié ; 2) avoir l’impression d’en connaître le contenu ; 3) manquer de temps. Conclusion : Une trousse de pratiques préventives des fractures de fragilisation présentée lors d’un atelier de formation continue peut constituer une méthode efficace de dissémination des lignes directrices de traitement

Development of an interprofessional program for cardiovascular prevention in primary care: A participatory research approach

Background: The chronic care model provides a framework for improving the management of chronic diseases. Participatory research could be useful in developing a chronic care model–based program of interventions, but no one has as yet offered a description of precisely how to apply the approach. Objectives: An innovative, structured, multi-step participatory process was applied to select and develop (1) chronic care model–based interventions program to improve cardiovascular disease prevention that can be adapted to a particular regional context and (2) a set of indicators to monitor its implementation. Methods: Primary care clinicians (n = 16), administrative staff (n = 2), patients and family members (n = 4), decision makers (n = 5), researchers, and a research coordinator (n = 7) took part in the process. Additional primary care actors (n = 26) validated the program. Results: The program targets multimorbid patients at high or moderate risk of cardiovascular disease with uncontrolled hypertension, dyslipidemia or diabetes. It comprises interprofessional follow-up coordinated by case-management nurses, in which motivated patients are referred in a timely fashion to appropriate clinical and community resources. The program is supported by clinical tools and includes training in motivational interviewing. A set of 89 process and clinical indicators were defined. Conclusion: Through a participatory process, a contextualized interventions program to optimize cardiovascular disease prevention and a set of quality indicators to monitor its implementation were developed. Similar approach might be used to develop other health programs in primary care if program developers are open to building on community strengths and priorities