Group-Based Trajectory Models to Evaluate the Association of Lipid Testing and Statin Adherence

Abstract Background and Objective Performing lipid testing after statin initiation is recommended to monitor response. Inadequate response may indicate non-adherence, which is associated with an increased risk of cardiovascular events and increased costs. Group-based trajectory modeling is an approach to establish probabilistic developmental trajectories of adherence, differentiating individuals by their distinct longitudinal medication-taking behaviors. We examined whether lipid testing is associated with distinct trajectories of statin adherence among individuals enrolled in a Medicare fee-for-service plan in the USA. Methods A retrospective cohort study was conducted using the Centers for Medicare & Medicaid Chronic Condition Warehouse 5% sample of Medicare fee-for-service data between 2006 and 2015. Statin use and lipid testing were identified using claims data. The proportion of days covered was calculated for each 30 days after the index date, which was used to estimate the probability of belonging to each potential adherence trajectory. Results In a cohort of 138,101 statin initiators, four statin adherence trajectory groups were identified. The four groups were differentiated as “rapid decline” (21.53%), “gradual decline” (10.25%), “decline first then improve later” (26.47%), and “high adherence” (41.75%). Compared with “high adherence,” initiators who had lipid tests within 360 days after statin initiation were less likely to fall into “rapid decline” (adjusted odds ratio: 0.661; 95% confidence interval 0.641–0.683), “gradual decline” (adjusted odds ratio: 0.834; 95% confidence interval 0.801–0.868), and “decline first then improve later” groups (adjusted odds ratio: 0.936; 95% confidence interval 0.910–0.962). Conclusions Lipid testing is positively associated with greater use of statin medication across different adherence trajectories in the present study

Analgosedation: A Paradigm Shift in Intensive Care Unit Sedation Practice

Objective: To critically evaluate the use of analgosedation in the management of agitation in critically ill mechanically ventilated patients. Data Sources: Literature was accessed through MEDLINE (1948-November 2011) and Cochrane Library (2011, issue 1) using the terms analgosedation, analgosedation, or analgesia-based sedation alone or in combination with intensive care unit or critically ill. Reference lists of related publications were also reviewed. Study Selection and Data Extraction: All articles published in English were evaluated. Randomized controlled trials examining critically ill mechanically ventilated patients older than 18 years were included. Data Synthesis: Limitations of current sedation practices include serious adverse drug events, prolonged mechanical ventilation time, and intensive care unit (ICU) length of stay. Studies have demonstrated that analgosedation, a strategy that manages patient pain and discomfort first, before providing sedative therapy, results in improved patient outcomes compared to standard sedative-hypnotic regimens. Nine randomized controlled trials comparing remifentanil-based analgosedation to other commonly used agents (fentanyl, midazolam, morphine, and propofol) for ICU sedation and 1 trial comparing morphine to daily sedation interruption with propofol or midazolam were reviewed. Remifentanil is an ideal agent for analgosedation due to its easy titratability and organ-in dependent metabolism. When compared to sedative-hypnotic regimens, remifentanil-based regimens were associated with shorter duration of mechanical ventilation, more rapid weaning from the ventilator, and shorter ICU length of stay. Compared to fentanyl-based regimens, remifentanil had similar efficacy with the exception of increased pain requirements upon remifentanil discontinuation. Analgosedation was well tolerated, with no significant differences in hemodynamic stability compared to sedative-hypnotic regimens. Conclusions: Analgosedation is an efficacious and well-tolerated approach to management of ICU sedation with improved patient outcomes compared to sedative-hypnotic approaches. Additional well-designed trials are warranted to clarify the role of analgosedation in the management of ICU sedation, including trials with nonopioid analgesics. </jats:sec