Improved persistence and adherence to diuretic fixed-dose combination therapy compared to diuretic monotherapy

<p>Abstract</p> <p>Background</p> <p>Diuretics are recommended as initial treatment for hypertension. Several studies have suggested suboptimal persistence and adherence to thiazide diuretic monotherapy; this study compared patient persistence and adherence with hydrochlorothiazide (HCTZ) monotherapy to fixed-dose combinations containing HCTZ.</p> <p>Methods</p> <p>Patients with at least one prescription claim during 2001 to 2003 for either HCTZ or one of the following fixed-dose combinations: angiotensin-receptor blockers/HCTZ (ARB/HCTZ), angiotensin-converting enzyme inhibitor/HCTZ (ACEI/HCTZ), or beta blockers/HCTZ (BB/HCTZ) were identified. Patients were required to be continuously benefit-eligible six months pre- and one year post-index date, and to have no prescription claims for any antihypertensive therapy six months prior to the index date. Patients were followed for one year to assess persistence, medication possession ratio (MPR), adherence (MPR >80%), and proportion of days covered (PDC) with initial antihypertensive therapy. Logistic regression was used to calculate adjusted odds ratios for persistence, adherence and PDC, adjusted for age, gender, business segment, RxRisk disease categories, average co-pay and concurrent cardiovascular-related medication utilization.</p> <p>Results</p> <p>The study cohort consisted of 48,212 patients; 72.5% used HCTZ, 13.2% ACEI/HCTZ, 9.3% ARB/HCTZ, and 5.0% BB/HCTZ. Mean age was 53.7 years and 66.5% were female. A significantly lower proportion of patients using HCTZ (29.9%) remained persistent with therapy at 12 months compared with ARB/HCTZ (52.6%; OR = 0.37, CI = 0.36, 0.38), ACEI/HCTZ (51.4%; OR = 0.38, CI = 0.37, 0.39), and BB/HCTZ (51.9%; OR = 0.38, 0.37, 0.40). Similarly, PDC was lower for HCTZ patients (32.5%) as compared to ARB/HCTZ (53.7%; OR = 0.39, CI = 0.37, 0.40), ACEI/HCTZ (50.9%; OR = 0.42, CI = 0.40, 0.43), and BB/HCTZ (51.3%; OR = 0.44, CI 0.42, 0.45). MPR was also significantly lower for HCTZ patients as compared to those using fixed-dose combination therapies.</p> <p>Conclusion</p> <p>Initiating HCTZ fixed-dose combination therapy with an ACEI, ARB, or BB was associated with greater persistence and adherence as compared to HCTZ monotherapy. Further research is needed to determine the relationship between improved persistence and adherence with blood pressure control.</p

Best Practices for Progressive Return to Activity after Concussion: Lessons Learned from a Prospective Study of U.S. Military Service Members

Primary care providers can play a crucial role in the clinical management of concussion. However, many providers lack up-to-date information about best practices for rest and return to activity after these injuries. Most research on this topic has been conducted in athletes, and so less is known about how to assist patients with returning to activity in other settings and populations. This article provides a review of best practices for management of progressive return to activity after concussion, with an emphasis on "lessons learned" from the Defense and Veterans Brain Injury Center (DVBIC) Progressive Return to Activity (PRA) study, a multi-site longitudinal research project conducted to evaluate concussion management practices and the effectiveness of provider training on DVBIC clinical recommendations (CRs). Provider clinical practices and patient outcomes were examined at three U.S. military treatment facilities before and after providers completed a standardized training on DVBIC PRA CRs. In summary, research findings provide additional support that concussion recovery can be influenced by patients' activity levels after injury. Patients with concussion may experience poorer outcomes if they return to pre-injury levels of activity too rapidly, but they may also be at risk for prolonged symptoms if they fail to increase activity levels over time after an initial period of rest. Additionally, training primary care providers in return to activity guidelines can result in more effective patient education and better clinical outcomes. This knowledge can be used to inform best practices for progressive return to activity in both civilian and military settings

Walking mediates associations between neighborhood activity supportiveness and BMI in the Women's Health Initiative San Diego cohort

ObjectivesTo investigate whether walking mediates neighborhood built environment associations with weight status in middle- and older-aged women.MethodsParticipants (N=5085; mean age=64 ± 7.7; 75.4% White non-Hispanic) were from the Women's Health Initiative San Diego cohort baseline visits. Body mass index (BMI) and waist circumference were measured objectively. Walking was assessed via survey. The geographic information system (GIS)-based home neighborhood activity supportiveness index included residential density, street connectivity, land use mix, and number of parks.ResultsBMI was 0.22 units higher and the odds ratio for being obese (vs. normal or overweight) was 8% higher for every standard deviation decrease in neighborhood activity supportiveness. Walking partially mediated these associations (22-23% attenuation). Findings were less robust for waist circumference.ConclusionsFindings suggest women who lived in activity-supportive neighborhoods had a lower BMI than their counterparts, in part because they walked more. Improving neighborhood activity supportiveness has population-level implications for improving weight status and health

Associations of cardiovascular disease risk factors with abdominal aortic calcium volume and density: The Multi-Ethnic Study of Atherosclerosis (MESA)

Background and aimsAbdominal aortic calcium (AAC) predicts future cardiovascular disease (CVD) events and all-cause mortality independent of CVD risk factors. The standard AAC score, the Agatston, up-weights for greater calcium density, and thus models higher calcium density as associated with increased CVD risk. We determined associations of CVD risk factors with AAC volume and density (separately).MethodsIn a multi-ethnic cohort of community living adults, we used abdominal computed tomography scans to measure AAC volume and density. Multivariable linear regression was used to determine the period cross-sectional independent associations of CVD risk factors with AAC volume and AAC density in participants with prevalent AAC.ResultsAmong 1413 participants with non-zero AAC scores, the mean age was 65&nbsp;±&nbsp;9 years, 52% were men, 44% were European-, 24% were Hispanic-, 18% were African-, and 14% were Chinese Americans (EA, HA, AA, and CA respectively). Median (interquartile range, IQR) for AAC volume was 628&nbsp;mm3 (157-1939&nbsp;mm3), and mean AAC density was 3.0&nbsp;±&nbsp;0.6. Compared to EA, each of HA, AA, and CA had lower natural log (ln) AAC volume, but higher AAC density. After adjustments for AAC density, older age, ever smoking history, higher systolic blood pressure, elevated total cholesterol, reduced HDL cholesterol, statin and anti-hypertensive medication use, family history of myocardial infarction, and alcohol consumption were significantly associated with higher ln(AAC volume). In contrast, after adjustments for ln(AAC volume), older age, ever smoking history, higher BMI, and lower HDL cholesterol were significantly associated with lower AAC density.ConclusionsSeveral CVD risk factors were associated with higher AAC volume, but lower AAC density. Future studies should investigate the impact of calcium density of aortic plaques in CVD

Race/ethnic and sex disparities in the non-alcoholic fatty liver disease-abdominal aortic calcification association: The Multi-Ethnic Study of Atherosclerosis

Background and aimsThis study investigated the associations of non-alcoholic fatty liver disease (NAFLD) and abdominal aortic calcification (AAC) volume and density, and whether these relationships vary by race/ethnicity and/or sex, information that are limited in current literature.MethodsWe studied 1004 adults from the Multi-Ethnic Study of Atherosclerosis to assess the relationship between NAFLD (liver-to-spleen ratio &lt;1) and the following measures of AAC: presence (volume score &gt;0, using Poisson regression); change in volume score (increasing vs. no change, using Poisson regression); and morphology (volume and density score, where volume score &gt;0, using linear regression); and interaction by race/ethnicity and sex.ResultsAmong Blacks, those with NAFLD had greater prevalence for AAC compared to Whites regardless of sex (Prevalence Ratio [PR]&nbsp;=&nbsp;1.41, CI&nbsp;=&nbsp;1.15-1.74, p-interaction&nbsp;=&nbsp;0.02). Concurrent interaction by race/ethnicity and sex was found comparing Chinese and Blacks to Whites (p-interaction&nbsp;=&nbsp;0.017 and 0.042, respectively) in the association between NAFLD and the prevalence of increasing AAC. Among women, this relationship was inverse among Chinese (PR&nbsp;=&nbsp;0.59, CI&nbsp;=&nbsp;0.28-1.27), and positive among Whites (PR&nbsp;=&nbsp;1.34, CI&nbsp;=&nbsp;1.02-1.76). This finding was reversed evaluating the men counterpart. Black men also had a positive association (PR&nbsp;=&nbsp;1.86, CI&nbsp;=&nbsp;1.29-2.70), which differed from the inverse relationship among White men, and was greater compared to Black women (PR&nbsp;=&nbsp;1.45, CI&nbsp;=&nbsp;1.09-1.94). NAFLD was unrelated to AAC morphology.ConclusionsNAFLD was related to the presence of AAC, however, limited to Blacks. Significant concurrent interaction by race/ethnicity (Chinese and Blacks vs. Whites) and sex was found in the relationship between NAFLD and increasing AAC. These findings suggest disparities in the pathophysiologic pathways in which atherosclerosis develops

Presenting symptoms as prognostic measures of mental health recovery among service members with concussion

BackgroundComorbid mental illness may negatively impact recovery from concussion. This study evaluated whether the level of symptom clusters at clinic intake contribute to poor mental health recovery in concussed patients during treatment, which may in turn serve as a target intervention.ObjectiveThe objective of this study is to examine the association between the level of initial symptoms and mental health symptoms among service members with concussion.MethodsData were obtained from 483 active duty service members treated in interdisciplinary treatment programs for traumatic brain injury, all of which were concussions. Pre-treatment symptom clusters included self-reported hyperarousal, dissociation/depression, cognitive dysfunction/headache and neurological symptoms. The outcomes, clinically-relevant decreases in depressive symptoms (assessed by the 8-item Patient Health Questionnaire, PHQ-8) and PTSD symptoms (assessed by the PTSD Checklist for DSM-5, PCL-5), were defined as a decrease in PHQ-8 &gt; 5 and PCL-5 &gt; 7, respectively. Poisson regression with robust error variance was used to evaluate the relationship between the level of each symptom cluster and clinically-relevant decrease in outcomes.ResultsParticipants with higher (vs. lower) levels of pre-treatment hyperarousal and dissociation/depression symptom cluster were less likely to improve in depressive and PTSD symptoms during treatment. The level of cognitive/headache and neurological symptom clusters were not significantly associated with any symptom changes.ConclusionThese findings support the need for individualized treatment for symptoms identified and treated after determining concussion history, with particular attention to high levels of hyperarousal and dissociation/depression prior to treatment