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Enhancing our Patients Compliance with their Medical Regimen Phil Mendys, Pharm D, FAHA, CPP, Co-Director, UNC Lipid and Prevention Clinic.

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Presentation on theme: "Enhancing our Patients Compliance with their Medical Regimen Phil Mendys, Pharm D, FAHA, CPP, Co-Director, UNC Lipid and Prevention Clinic."— Presentation transcript:

1 Enhancing our Patients Compliance with their Medical Regimen Phil Mendys, Pharm D, FAHA, CPP, Co-Director, UNC Lipid and Prevention Clinic

2 Disclosures Dr. Mendys is an employee of Pfizer and works as a Senior Director in Medical Affairs. Dr. Mendys carries both academic and clinical appointments at the University of North Carolina in the School of Medicine- Division of Cardiology and the School of Pharmacy- Pharmacotherapy and Experimental Therapeutics. 1/15/20152

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4 Talk Objectives  Key Concepts in Medication Adherence  Making the case for supporting Adherence Programs – Case Study with Dyslipidemia  Cardiac Rehabilitation – A Perfect Match to Improve Patient Outcomes  Patient Provider Quiz- Facts and misperceptions 1/15/20154

5 Heart medicine advances help patients enjoy active life British Heart Foundation July 9, 2011 …In the 1960s, there was no treatment for a heart attack. If they survived, victims were confined to a hospital bed, given painkillers and told to take complete rest…If they died in their 50s or 60s…it was considered a fact of life… 1/15/20155

6 The Burden of Chronic Disease “ …poor adherence increases with the duration and complexity of treatment regimens…duration and complex treatment are inherent to chronic illnesses. Across diseases, adherence is the single most important modifiable factor that compromises treatment outcome.” - World Health Organization, 2003

7 The Five Dimensions of Adherence Health System/Health Care Team Factors Patient-related Factors Social/Economic Factors Condition-related Factors Therapy-related Factors World Health Organization. World Health Organization; Geneva, Switzerland HCT = health care team

8 Health Care System Factors That Affect Adherence Resources and set policies that support optimal practices Provision of preventive services Integration of other health care professionals as part of the treatment To augment role of primary providers To provide more intensive intervention when needed Mandatory provisions that allow: Educating providers about guidelines Training in treatment strategies (including patient counseling) Providing office support mechanisms Cost Koeck C. BMJ. 1998;317: ; Ockene IS, et al. J Am Coll Cardiol. 2002;40: Extent to which the health care system facilitates or impedes provider’s adherence-related activities Organizational structures and processes

9 Case Study: Cholesterol Management When to Start Cholesterol Lowering Therapy in Patients with Coronary Heart Disease A Statement for Healthcare Professionals From the AHA Task Force on Risk Reduction several studies suggest that plasma lipoprotein measurements can be made immediately upon admission to the hospital for acute coronary syndromes to establish a baseline cholesterol levels. If LDL cholesterol > 130 at time of discharge, a cholesterol- reducing drug can reasonably be started at time of discharge one important issue concerns responsibility for initiating cholesterol-lowering therapy in the setting of acute coronary events …divided responsibility often lead to no therapy at all. Circulation. 1997; 95:

10 Improved Treatment of Coronary Heart Disease by Implementation of Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) Fonarow G., et.al. Am J Cardiol; 2001; 87:819-22

11 Provider Factors Counseling skills Involvement of patients in decision- making/plan of care Time constraints Knowledge, awareness, adherence to clinical practice guidelines Individual vs team-provider approach

12 Recognizing Predictors of poor adherence N Engl J Med 2005;353:

13 World Health Organization. World Health Organization; Geneva, Switzerland, What Drives Health Care Team to Improve Adherence? Knowledge of the broad determinants of nonadherence Ability to assess, detect, and understand the potential for nonadherence Understand how patients might progress to adherence Develop specific strategies for addressing adherence Tailor interventions to the needs of individual patients

14 A Tool to Improve Adherence 1/15/

15 Patient Factors Knowledge, attitudes, skills Organic factors (memory, cognitive- information processing) Self-efficacy Decision-making processes – discounting Co-morbidities/complexity of therapeutic regimen Individual resources

16 Cheng JWM, et al. Pharmacotherapy. 2001;21: Patient Reasons for Nonadherence Don’t think it’s necessary all the time Hate taking drugs Don’t like being dependent Drugs give me side effects Don’t think drugs are working Too expensive Don’t like being told what to take Just forget Other Supply will last longer Prospective, open-label, interview-based study in metropolitan New York area pharmacies (N=821).

17 Health Literacy and Heart Disease Over the past 50 years, we have learn a lot about the relationships between “risk factors” and the cause of cardiovascular illness, but we have much work yet to do in the area of preventing heart disease. One’s ability to read, listen, and comprehend health information is a vital element of maintaining and improving health, including the prevention of chronic illness. Evidence has shown that improved knowledge of one’s condition may improve patient adherence to lifestyle changes and the use of preventive medication, however- Vascular Health and Risk Management 2006:2(4)

18 Literacy Skills and Calculated 10-Year Risk of Coronary Heart Disease Literacy skills: 1. reading comprehension, 2.numeracy 3. oral language (speaking) 4. aural language (listening) J Gen Intern Med DOI: /s , published online Aug 10, 2010

19 A meta-analysis of the association between adherence to drug therapy and mortality good adherence was associated with lower mortality association between good adherence to placebo and mortality supports the existence of the “healthy adherer” effect adherence to drug therapy may be a surrogate marker for overall healthy behavior. BMJ 2006;333;1-6

20 What Drives Patients to Improve Adherence? People learn best by active participation Individuals need to have adequate information Individuals need to believe in their ability to make changes (self-efficacy) and have positive expected outcomes Individuals need skills, support, resources Interventions need to be tailored to the individual or organization and its social context Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall; 1986.

21 Adherence: Social/Economic Factors Formal/informal support from members of the community Awareness level of policy makers and health managers »Application of adherence materials to different socioeconomic settings »Health system programs promoting adherence/self-management Socioeconomic status, literacy/education, employment, living conditions, distance from treatment center, transportation, medication cost, environment, culture/beliefs about illness/treatment, fear of health care system, and family dysfunction »Poverty and chronic disease interrelationships, compounding non- adherence World Health Organization. World Health Organization; Geneva, Switzerland

22 Societal Factors Examples: Obesity Food used to be expensive – now it’s cheap Physical activity used to be cheap – now it’s expensive Smoking Was associated with style and freedom of choice –now its considered unhealthy and socially incorrect

23 Adherence: Condition-related Factors Illness-related demands faced by the patient, affecting patients’ risk perception and the priority placed on adherence –Severity of symptoms and level of disability –Severity of the disease and rate of disease progression –Availability of effective treatments –Co-morbidities, such as depression –Drug and alcohol abuse World Health Organization. World Health Organization; Geneva, Switzerland

24 Better Knowledge Improves Adherence to Lifestyle Changes and Medication in Patients With CHD  Men and women, <71 years, who had a cardiac event (n=509)  392 interviewed, examined, and received a questionnaire  347 completed questionnaire about their general knowledge of CHD risk factors, compliance to lifestyle changes, and drug adherence  Statistically significant correlation between CHD risk factor knowledge and compliance to certain lifestyle changes (weight, physical activity, stress management, diet, attaining lipid level goals, likelihood of taking prescribed antihypertensives)  No correlation between this knowledge and blood glucose or blood pressure levels nor smoking habits or treatment patterns for prescribed lipid- and blood glucose-lowering drugs  Knowledge correlated to patient behavior with respect to some risk factors, which should be recognized in prevention programs Alm-Roijer C, et al. Eur J Cardiovasc Nurs. 2004;3:

25 Adherence: Therapy-related factors Complexity of the medical regimen, concomitant medications Frequency and duration of treatment Previous treatment failures Frequent changes in treatment Immediacy of beneficial effects and side effects, availability of medical support to deal with them World Health Organization. World Health Organization; Geneva, Switzerland

26 Adapted from cohort study using linked population-based administration data from Ontario, Canada (N=85,020). Jackevicius et al. JAMA. 2002;288: Adherence continues to drop over time, particularly when treating the asymptomatic patient Nonadherence to Statin Treatment begins early

27 Adherence Measurements Patient self-reports or questionnaires Clinician perception Pill counts Electronic monitoring devices Biochemical measurement or pharmacologic tracers Electronic prescription refill records (refill rates) Sikka R, et al. Am J Manag Care. 2005;11: ; World Health Organization. World Health Organization; Geneva, Switzerland, Most adherence research is observational, rather than Conducted in a trial setting, to better reflect real-world patient behavior.

28 Meta-analysis of trials of interventions to improve medication adherence Medication non-adherence has a profound negative impact on every aspect of health care. For decades we have searched for that one perfect solution to the problem; however, there does not seem to be any one intervention that robustly enhances adherence, perhaps because so many variables affect a patient’s decision to take a drug. A combined approach intuitively may best address patients’ needs, but more data must be collected through standardized research methods. Studies focusing on the relationship between adherence and health outcome measures, specific interventions, and cost-effectiveness and between adherence and various combinations of interventions are needed Conclusion Meta-analysis of studies of interventions to improve medication adherence revealed an increase in adherence of 4–11%. No single strategy appeared to be best. Am J Health-Syst Pharm—Vol 60 Apr 1, 2003

29 Thus, a Multifaceted Approach to Patient Treatment is Required Patient Payers (employers/HP/PBM) Direct to Consumer Family/ Peers Nurse Pharmacy Physician Direct Mail AdhereRx Pharmacy bag newsletter HAL, CAVEAT Pilot My Heart Wise AdhereRx Pharmacy bag newsletter HAL, HEART DTC Print Physician direction to patient Starters Refill Reminder Letters Follow-up with patient Follow-up with patient DTC TV Website 800# IVR DTC Print Physician direction to patient Starters Refill Reminder Letters Follow -- up with patient Follow - -up with patient DTC TV Web 800# IVR AdhereRx CareMark Refill Reminder IVR Pharmacy First Outbound Direct Mail CVS Mailer Starters House Call Poster Starters House Call Radio

30 The challenge of non-adherence More than 50% of patients with diabetes, hypertension, tobacco addiction, hyperlipidemia, congestive heart failure, asthma, depression, and chronic atrial fibrillation are currently managed inadequately ,000 Americans die each year from heart attacks because they did not receive preventive medications, although they were eligible for them Low adherence to prescribed treatments is common; typical adherence rates for prescribed medications are ~50% with a range of 0 – 100+%. 12 1/3 or more of ambulatory patients take prescribed doses at intervals that frequently are longer than prescribed — hours, days, sometimes weeks. 13 Within 6 months, 60% of patients discontinue their CV prevention medications. 1. Institute of Medicine, 2003c; 2. Clark et al., 2000; 3. Joint National Committee on Prevention, 1997; 4. Legorreta et al., 2000; 5. McBride et al., 1998; 6. Ni et al., 1998; 7. Perez-Stable and Fuentes-Afflick, 1998; 8. Samsa et al., 2000; 9. Young et al., 2001; 10. Chassin, 1997; 11. Institute of Medicine, 2003a. 12. Sackett and Snow, 1979; 13. Houston, et al

31 Patients Nonadherent to Statin Therapy Are Twice as Likely to Experience Subsequent MI TotalPatients <65 Years Patients ≥65 Years P=.047P=.001 P=.73 Adherent Nonadherent Adherence defined as fill frequency ≥80% (n=661). Nonadherence defined as fill frequency ≤60% (n=395). Blackburn DF, et al. Pharmacotherapy. 2005;25:

32 As Adherence Goes Down, Health Care Costs and Hospitalizations Go Up Sokol MC, et al. Med Care. 2005;43: Diabetes Hypertension Hypercholesterolemia CHF $ All-Cause Health Care Costs Diabetes Hypertension Hypercholesterolemia CHF % All-Cause Hospitalization Risk 1%-19% Adherence Level80%-100% Adherence Level

33 The great statin debate - Do they have magical properties? Dr. Topol: Do you believe that statins have pleiotropic effects or “magical properties”? Dr. Califf: Absolutely Dr. Topol: Do you think its related to inflammatory markers, effect on endothelial function, or some unique effect on the vascular wall? Dr. Califf: Nope Dr. Topol: Is it about early treatment, early benefit or intensity? Dr. Califf: Nah Dr. Topol: What then do you attribute the magic of statins? Dr. Califf: When patients actually take them….

34 UNC LIPID AND PREVENTION CLINIC

35 Patient Knowledge of Coronary Risk Profile Improves the Effectiveness of Dyslipidemia Therapy Communicating risk is consistent with many of the recommendations to improve adherence, including enhancing self-monitoring and using the support of family and friends. Informing patients of their coronary risk may also increase the effectiveness of primary prevention by identifying individuals most likely to benefit from treatment while reassuring those at low risk. Grover SA, et al. Arch Intern Med. 2007;167: As a result of these changes, your cardiovascular age has dropped from 60.8 y to 53.8 y. Your 8-y cardiovascular risk has dropped from 24.5% to 7.5% 0 Sep 2002 Dec 2002 Mar 2003 Jun 2003 Sep 2003 Dec 2003 Month y Cardiovascular Risk, % Low Risk Moderate Risk High Risk

36 Misperception among physicians and patients regarding the risks and benefits of statin treatment: the potential role of direct-to-consumer advertising Rachel H. Kon, MD, Mark W. Russo, MD, Bridget Ory, MD, Phil Mendys, PharmD, Ross J. Simpson, Jr., MD, PhD* 1/15/

37 Physician Follow-up/Provider Continuity Associated With Long-term Adherence Statin use is dynamic; many patients have long periods of nonadherence An estimated 48% restarted treatment within 1 year; 60% restarted within 2 years Continuity of care combined with increased follow-up and cholesterol testing could promote long-term adherence by shortening or eliminating long gaps in statin use Brookhart MA, et al. Arch Intern Med. 2007;167: Statin Therapy Start Date No Statin Use in Past Year Statin Rx 1 Statin Rx 2 Statin Rx 3 Control Period Hazard Period Statin Rx n +1 Statin Therapy Restart Date Statin Therapy Stop Date 90-d Gap in Statin Coverage 14 d

38 Point-of-Care Lipid Testing Address gap in testing to treatment Improves option to titrate, adjust Rx Gets additional patient engagement Improves goal attainment

39 Statin Titration and Goal Attainment:Start with the end in mind! AJC, Vol 92 July 1, high risk patients At Goal on Starting Dose Not At Goal Titrated NOT Titrated Not At Goal At Goal 48% 52% (N=1464) (N=203) (N=813) (N=448) 14% of patients not at goal on initial dose reached Goal by 6 months

40 The relationship of vitamin D deficiency to statin myopathy Both statins and vitamin D affect skeletal muscle metabolism and function. There is preliminary data to suggest that vitamin D deficiency is associated with increased statin-associated skeletal muscle complaints, but no definitive evidence that vitamin D contributes to statin myalgia or is effective in its treatment. Vitamin D supplementation reduced myalgic symptoms in some statin treated patients although a placebo effect cannot be excluded. Consequently, it is reasonable to determine vitamin D levels in statin-myalgic patients and to provide vitamin D supplementation in doses of 400–2000 IU to those with low vitamin D levels (<32 ng/mL) until definitive placebo controlled trials of this therapy are available. 1/15/ Atherosclerosis 215 (2011) 23–29

41 Cardiac rehabilitation The perfect “fit” to improve adherence Collaborative Team Approach Emphasis on Continuity of Care Multi-dimensional Systematic Process of Care delivery 1/15/201541

42 Patients' perspectives on cardiac rehabilitation, lifestyle change and taking medicines: implications for service development Patients tended to talk about the exercise component of cardiac rehabilitation and only talk about the information provision component when prompted, which suggested they viewed the program as being primarily about exercise. There was little subsequent contact with health services, except routine six-monthly check-ups for their coronary heart disease. Unmet information needs were common, especially about medicines Ensuring that individual patients' information needs about medicines and lifestyle are adequately met remains a key focus for cardiac rehabilitation development. 1/15/ jhsrp v1 15/suppl_2/47

43 The challenge of improving evidence-based therapy adherence in the secondary prevention of coronary artery disease: the next frontier of cardiac rehabilitation Non-adherence to prescribed drug regimens is an increasing medical problem affecting physicians and patients and contribute to negative outcomes, such as the increased risk of subsequent cardiovascular events. Analysis of various patient populations shows that the choice of drug, its tolerability and the duration of treatment influence the non-adherence. Intervention is required toward patients and health-care providers to improve medication adherence. This review deals about the prevalence of non- adherence to therapy after medical and surgical cardiac event, the risk factors affecting non-adherence and the strategies to implement it. Interventions that may successfully improve adherence should include improved physician compliance with guidelines, patient education and patient reminders, frequent visits or telephone calls from staff, simplification of the patient's drug regimen by reducing the number of pills and daily doses. Since single interventions do not appear efficacious, it is necessary to establish multiple interventions simultaneously addressing a number of barriers to adherence. 1/15/ Monaldi Arch Chest Dis. 2009, reference in Italian

44 Predictors of Smoking Cessation After a Myocardial Infarction 1/15/ While individual smoking cessation counseling was not associated with smoking cessation post-MI, hospital-based smoking cessation programs, as well as referral to cardiac rehabilitation, were strongly associated with increased smoking cessation rates. Arch Intern Med. 2008;168(18):

45 Long-term Medication Adherence after Myocardial Infarction: Experience of a Community CLINICAL SIGNIFICANCE ● More than 50% of the patients discontinue each of the cardio-protective medications after a myocardial infarction over a 3-year period. ● Clinical characteristics of the myocardial infarction were not associated with long-term medication adherence. ● Enrollment and use of cardiac rehab is associated with better long-term medication adherence. 1/15/ The American Journal of Medicine (2009) 122, 961.e7-961.e12

46 ACCF/AHA/AMA–PCPI 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension Medication Adherence …objection to the use of patient adherence as a measure of physician quality is that, although prescribing physicians have some influence on patient choices, adherence is largely not in the individual physician’s locus of control. …reliable information on patient adherence is often difficult and expensive to obtain. …it believed that measures of adherence, such as those included in HEDIS (Healthcare Effectiveness Data and Information Set), could be used at the health plan, employer, or health system levels as effective quality improvement tools. 1/15/ JACC Vol. 58, No. 3, 2011

47 Adherence as a Health Care Priority 1/15/

48 Quiz 1/15/201548

49 The Framingham risk score estimates 10-year absolute risk for cardiovascular disease events and age contributes enormously to the end result, given that indeed age is the greatest contributor to absolute cardiovascular risk. However, the Framingham Risk Score is less robust in the elderly (age > 70) as this group because: A) the likelihood of CV events decreases after age 70 B) have already had their “age-based” exposure C) cholesterol management in this group appears to provide no benefit D) the risk benefit ratio of treating these patients limits treatment considerations E) none of the above QUESTIONS FOR LIPID MANAGEMENT IN THE ELDERLY Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Full Report; Final Report; nih.gov

50 The Framingham risk score estimates 10-year absolute risk for cardiovascular disease events and age contributes enormously to the end result, given that indeed age is the greatest contributor to absolute cardiovascular risk. However, the Framingham Risk Score is less robust in the elderly (age > 70) as this group because: A) the likelihood of CV events decreases after age 70 B) have already had their “age-based” exposure C) cholesterol management in this group appears to provide no benefit D) the risk benefit ratio of treating these patients limits treatment considerations E) none of the above QUESTIONS FOR LIPID MANAGEMENT IN THE ELDERLY Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Full Report; Final Report; nih.gov

51 QUESTIONS FOR LIPID MANAGEMENT IN THE ELDERLY The National Cholesterol Education Panel ATP III reaffirms their position that older persons who are at coronary disease higher risk and are in otherwise good health, are candidates for cholesterol-lowering therapy. As reported in the Cardiovascular Health Study in 2002, the use of statin therapy in study participants at baseline who were 65 years or older and free of cardiovascular disease, resulted in a A) Greater than 50 lower risk of CV events and more than 40 % lower all cause mortality. B) Greater than 50% risk reduction for CV events, but only 20% reduction in all cause death. C) Equal reduction of risk in CV events and all cause mortality D) Reduction in risk of CV events, but an increase of risk associated with adverse events of statin therapy E) None of the above Therapy with hydroxylmethylglutaryl Coenzyme A Reductase Inhibitors (Statins) and Associated Risk of Incident Cardiovascular Events in Older Adults – evidence from he Cardiovascular Health Study; Rozen LeMaitre, PhD, MHS et.al.; Arch IM 2002; 162:

52 QUESTIONS FOR LIPID MANAGEMENT IN THE ELDERLY The National Cholesterol Education Panel ATP III reaffirms their position that older persons who are at coronary disease higher risk and are in otherwise good health, are candidates for cholesterol-lowering therapy. As reported in the Cardiovascular Health Study in 2002, the use of statin therapy in study participants at baseline who were 65 years or older and free of cardiovascular disease, resulted in a A) Greater than 50 lower risk of CV events and more than 40 % lower all cause mortality. B) Greater than 50% risk reduction for CV events, but only 20% reduction in all cause death. C) Equal reduction of risk in CV events and all cause mortality D) Reduction in risk of CV events, but an increase of risk associated with adverse events of statin therapy E) None of the above Therapy with hydroxylmethylglutaryl Coenzyme A Reductase Inhibitors (Statins) and Associated Risk of Incident Cardiovascular Events in Older Adults – evidence from he Cardiovascular Health Study; Rozen LeMaitre, PhD, MHS et.al.; Arch IM 2002; 162:

53 QUESTIONS FOR LIPID MANAGEMENT IN THE ELDERLY Persons greater than the age of 65 account for approximately two out of three first major coronary events, and CHD deaths account for about ½ of all CHD events. If we accept the premise that statin therapy reduces risk for all CHD event categories, then the likely mortality benefit of statins is reasonably stated at: A) 40% B) 33% C) 70% D) 50% E) None of the above Ref: Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult TreatmentPanel III) Full Report; Final Report; nih.gov

54 QUESTIONS FOR LIPID MANAGEMENT IN THE ELDERLY Persons greater than the age of 65 account for approximately two out of three first major coronary events, and CHD deaths account for about ½ of all CHD events. If we accept the premise that statin therapy reduces risk for all CHD event categories, then the likely mortality benefit of statins is reasonably stated at: A) 40% B) 33% C) 70% D) 50% E) None of the above Ref: Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult TreatmentPanel III) Full Report; Final Report; nih.gov

55 QUESTIONS FOR LIPID MANAGEMENT IN THE ELDERLY Choose the one best answer which addresses the issues of Therapeutic Lifestyle in older patients. a) Weight reduction goals and increased physical activity are less critical for patients over the age of 65. b) Patients should be encouraged to reduce intake of saturated fats (7% of total calories) and cholesterol (200 mg /day). This Step I diet is then followed by a more restrictive Step II diet to achieve more reasonable treatment goals c) the clinician may consider drug therapy at a period of 4 to 6 weeks in older patients who are not approaching their respective treatment goal. d) Plant stanols and soluble fiber should be restricted in older patients due to the risk of sever GI intolerance. e) none of the above. Lipid Management and the Elderly; Mi Michael H. Davidson, MD, Sara B. Kurlandsky, PhD, Ruth M. Kleinpell, PhD, RN, Kevin C. Maki, PhD Prev Cardiol 6(3): , 2003

56 QUESTIONS FOR LIPID MANAGEMENT IN THE ELDERLY Choose the one best answer which addresses the issues of Therapeutic Lifestyle in older patients. a) Weight reduction goals and increased physical activity are less critical for patients over the age of 65. b) Patients should be encouraged to reduce intake of saturated fats (7% of total calories) and cholesterol (200 mg /day). This Step I diet is then followed by a more restrictive Step II diet to achieve more reasonable treatment goals c) the clinician may consider drug therapy at a period of 4 to 6 weeks in older patients who are not approaching their respective treatment goal. d) Plant stanols and soluble fiber should be restricted in older patients due to the risk of sever GI intolerance. e) none of the above. Lipid Management and the Elderly; Mi Michael H. Davidson, MD, Sara B. Kurlandsky, PhD, Ruth M. Kleinpell, PhD, RN, Kevin C. Maki, PhD Prev Cardiol 6(3): , 2003

57 BACK UP SLIDES 1/15/201557

58 Poor health literacy: a ‘hidden’ risk factor Low health literacy has been associated with non- adherence to treatment plans and medical regimens, poor patient self-care, high healthcare costs, and increased risk of hospitalization and mortality. realizing that health literacy affects prognosis affords the opportunity to better understand the causes of poor outcome and develop interventions to address this issue. Many cardiovascular diseases have complex mechanisms and etiologies and can be difficult for patients to understand. low health literacy, therefore, presents a particular challenge in treating the cardiac patient. nature reviews | cardiology volume 7 | Sept 2010 |

59 Niacin in Patients with Low HDL Cholesterol Levels Receiving Intensive Statin Therapy- AIM HIGH 1/15/ /nejmoa nejm.org/NEJM Nov 15, 2011

60 1/15/ Primary Outcome by Treatment Group and Baseline Subgroup - ACCORD Subgroup Fenofibrate % Events (Number in Grp) Place Events (Number in Grp) Feno to Placebo Hazard Ratio Interaction P-Value Overall10.5% (2,765)11.3% (2,753) LDL-c Tertile <=84 mg/dl9.4% (938)12.2% (891) –111 mg/dl9.9% (934)11.2% (922) >=112 mg/dl12.4% (877)10.6% (927) HDL-c Tertile <=34 mg/dl12.2% (964)15.6% (906) –40 mg/dl10.1% (860)9.5% (866) >=41 mg/dl9.1% (925)9.0% (968) Triglyceride Tertile <=128 mg/dl9.9% (891)11.3% (939) –203 mg/dl10.5% (924)9.9% (913) >=204 mg/dl11.1% (934)12.8% (888) Trig / HDL Combination TG204+ / HDL<=3412.4% (485)17.3% (456) All Others10.1% (2,264)10.1% (2,284) A1c Median A1c<=8.08.7% (1,324)10.6% (1,335) A1c % (1,435)11.9% (1,415) The ACCORD Study Group. NEJM ;17,

61 Vitamin D deficiency, myositis–myalgia, and reversible statin intolerance 1/15/ Current Medical Research & Opinion Vol. 27, No. 9, 2011, 1683–1690

62 Practical support predicts medication adherence and attendance at cardiac rehabilitation following acute coronary syndrome 1/15/ Journal of Psychosomatic Research 65 (2008) 581–586

63 Erectile Dysfunction & Risk Factors

64 The problem is… "Men with ED going to a general practitioner or a urologist need to be referred for a cardiology workup to determine existing cardiovascular disease and proper treatment,“… "ED is an early predictor of cardiovascular disease." Many men with ED see a general practitioner or a urologist to get medication for ED, he said. "The medication works and the patient doesn't show up anymore," …"These men are being treated for the ED, but not the underlying cardiovascular disease. A whole segment of men is being placed at risk.“ Erectile Dysfunction Strong Predictor of Death, Cardiovascular Outcomes ScienceDaily (Mar. 16, 2010)


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