Journal of General Internal Medicine

, Volume 25, Issue 4, pp 298–304 | Cite as

High-risk Diabetic Patients in Medicare Part D Programs: Are They Getting the Recommended ACEI/ARB Therapy?

  • Yi Yang
  • Vennela Thumula
  • Patrick F. Pace
  • Benjamin F. BanahanIII
  • Noel E. Wilkin
  • William B. Lobb
Original Article

Abstract

BACKGROUND

Diabetes patients with hypertension and/or renal disease are at an increased risk of cardiovascular morbidity and mortality. Clinical evidence suggests that the use of ACEI/ARB for these patients improves patient outcomes.

OBJECTIVE

To describe ACEI/ARB utilization among high-risk patients with diabetes and to identify patient characteristics that predict suboptimal utilization of ACEI/ARB.

DESIGN

A retrospective cohort study.

PATIENTS

Diabetic patients with coexisting hypertension and/or renal disease with continuous Medicare coverage from October 1, 2005 through June 30, 2006 in six states (Alabama, California, Florida, Mississippi, New York, and Ohio).

INTERVENTIONS AND MEASUREMENTS

Any ACEI/ARB use during the first 6 months of 2006.

RESULTS

A total of 1,250,466 Medicare Part D enrollees met our inclusion criteria. ACEI/ARB utilization rates were 63%, 58.3%, and 43.1% among diabetic patients with hypertension and renal disease, hypertension without renal disease, and renal involvement without hypertension, respectively. After adjusting for all other characteristics studied, patients in the hypertension only (OR 0.83; 95% CI: 0.82–0.84) and renal disease only (OR: 0.48; 95% CI: 0.46–0.50) risk groups were less likely to use ACEI/ARB compared to diabetes patients with both hypertension and renal disease. Several demographics, including male gender, age older than 65, and white race, were all predictors of suboptimal ACEI/ARB use. Results from state-specific analyses are consistent with those for all six states.

CONCLUSION

In this cohort, less than 60% of high-risk patients with diabetes were receiving the recommended ACEI/ARB therapy. Several patient demographic and clinical characteristics are strongly associated with suboptimal ACEI/ARB use.

KEY WORDS

diabetes ACEI/ARB hypertension renal disease Medicare Part D 

Notes

Acknowledgements

A version of this paper was presented at the 14th Annual Meeting of the International Society for Pharmacoeconomics and Outcomes Research on May 19th, 2009. This work was supported through a sub-contract with Information and Quality Healthcare, Inc. (IQH), as part of the Centers for Medicare and Medicaid Services (CMS) quality improvement and intervention activities.

Conflict of interest

The authors declare no conflict of interest regarding this manuscript.

References

  1. 1.
    Centers for Disease Control and Prevention. State-specific incidence of diabetes among adults–participating states, 1995–1997 and 2005–2007. MMWR Morb Mortal Wkly Rep. 2008;57(43):1169–73.Google Scholar
  2. 2.
    Centers for Disease Control and Prevention. National diabetes fact sheet. Available at: http://www.cdc.gov/diabetes/pubs/factsheet07.htm. Accessed October 28, 2009.
  3. 3.
    Adler AI, Stratton IM, Neil HA, Yudkin JS, Matthews DR, Cull CA, et al. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ. 2000;321(7258):412–9.CrossRefPubMedGoogle Scholar
  4. 4.
    Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for 1 million adults in 61 prospective studies. Lancet. 2002;360(9349):1903–13.CrossRefPubMedGoogle Scholar
  5. 5.
    Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care. 1993;16(2):434–44.CrossRefPubMedGoogle Scholar
  6. 6.
    Holman RR, Paul SK, Bethel MA, Neil HA, Matthews DR. Long-term follow-up after tight control of blood pressure in type 2 diabetes. N Engl J Med. 2008;359(15):1565–76.CrossRefPubMedGoogle Scholar
  7. 7.
    American diabetes association. Standards of medical care in diabetes—2009. Diabetes Care. 2009;32(Suppl 1):S13–S61.CrossRefGoogle Scholar
  8. 8.
    National Kidney Foundation. K/DOQI clinical guidelines for chronic kidney disease: evaluation, classification, and stratification. Available at: http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm. Accessed October 28, 2009.
  9. 9.
    Rodbard HW, Blonde L, Braithwaite SS, Brett EM, Cobin RH, Handelsman Y, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus. Endocr Pract. 2007;13(Suppl 1):1–68.PubMedGoogle Scholar
  10. 10.
    Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Heart Outcomes Prevention Evaluation Study Investigators. Lancet. 2000;355(9200):253–9.Google Scholar
  11. 11.
    Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001;345(12):861–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. The Collaborative Study Group. N Engl J Med. 1993;329(20):1456–62.CrossRefPubMedGoogle Scholar
  13. 13.
    Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345(12):851–60.CrossRefPubMedGoogle Scholar
  14. 14.
    Parving HH, Lehnert H, Brochner-Mortensen J, Gomis R, Andersen S, Arner P. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med. 2001;345(12):870–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Remuzzi G, Macia M, Ruggenenti P. Prevention and treatment of diabetic renal disease in type 2 diabetes: the BENEDICT study. J Am Soc Nephrol. 2006;17(4 Suppl 2):S90–S97.CrossRefPubMedGoogle Scholar
  16. 16.
    Cooke CE, Fatodu H. Physician conformity and patient adherence to ACE inhibitors and ARBs in patients with diabetes, with and without renal disease and hypertension, in a medicaid managed care organization. J Manag Care Pharm. 2006;12(8):649–55.PubMedGoogle Scholar
  17. 17.
    Rosen AB, Karter AJ, Liu JY, Selby JV, Schneider EC. Use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in high-risk clinical and ethnic groups with diabetes. J Gen Intern Med. 2004;19(6):669–75.CrossRefPubMedGoogle Scholar
  18. 18.
    Rosen AB. Indications for and utilization of ACE inhibitors in older individuals with diabetes. Findings from the National Health and Nutrition Examination Survey 1999 to 2002. J Gen Intern Med. 2006;21(4):315–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Arauz-Pacheco C, Parrott MA, Raskin P. Hypertension management in adults with diabetes. Diabetes Care. 2004;27(Suppl 1):S65–S67.PubMedGoogle Scholar
  20. 20.
    Molitch ME, DeFronzo RA, Franz MJ, Keane WF, Mogensen CE, Parving HH, et al. Nephropathy in diabetes. Diabetes Care. 2004;27(Suppl 1):S79–S83.PubMedGoogle Scholar
  21. 21.
    Ahluwalia IB, Mack KA, Murphy W, Mokdad AH, Bales VS. State-specific prevalence of selected chronic disease-related characteristics–Behavioral Risk Factor Surveillance System, 2001. MMWR Surveill Summ. 2003;52(8):1–80.PubMedGoogle Scholar
  22. 22.
    Ho PM, Rumsfeld JS, Masoudi FA, McClure DL, Plomondon ME, Steiner JF, et al. Effect of medication nonadherence on hospitalization and mortality among patients with diabetes mellitus. Arch Intern Med. 2006;166(17):1836–41.CrossRefPubMedGoogle Scholar
  23. 23.
    Winkelmayer WC, Fischer MA, Schneeweiss S, Wang PS, Levin R, Avorn J. Underuse of ACE inhibitors and angiotensin II receptor blockers in elderly patients with diabetes. Am J Kidney Dis. 2005;46(6):1080–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Boyer S, Kapur V. Obstructive sleep apnea: its relevance in the care of diabetic patients. Clin Diabetes. 2002;20(3):126–32.CrossRefGoogle Scholar
  25. 25.
    Hertz RP, Unger AN, Lustik MB. Adherence with pharmacotherapy for type 2 diabetes: a retrospective cohort study of adults with employer-sponsored health insurance. Clin Ther. 2005;27(7):1064–73.CrossRefPubMedGoogle Scholar
  26. 26.
    Struijs JN, Baan CA, Schellevis FG, Westert GP, van den Bos GA. Comorbidity in patients with diabetes mellitus: impact on medical health care utilization. BMC Health Serv Res. 2006;6:84.CrossRefPubMedGoogle Scholar
  27. 27.
    Steiner JF, Prochazka AV. The assessment of refill compliance using pharmacy records: methods, validity, and applications. J Clin Epidemiol. 1997;50(1):105–16.CrossRefPubMedGoogle Scholar
  28. 28.
    Arday DR, Fleming BB, Keller DK, Pendergrass PW, Vaughn RJ, Turpin JM, et al. Variation in diabetes care among states: do patient characteristics matter? Diabetes Care. 2002;25(12):2230–7.CrossRefPubMedGoogle Scholar
  29. 29.
    Massing MW, Henley N, Biggs D, Schenck A, Simpson RJ Jr. Prevalence and care of diabetes mellitus in the Medicare population of North Carolina. Baseline findings from the Medicare Healthcare Quality Improvement Program. N C Med J. 2003;64(2):51–7.PubMedGoogle Scholar
  30. 30.
    Riehle JF, Lackland DT, Okonofua EC, Hendrix KH, Egan BM. Ethnic differences in the treatment and control of hypertension in patients with diabetes. J Clin Hypertens (Greenwich). 2005;7(8):445–54.CrossRefGoogle Scholar
  31. 31.
    Deedwania PC. Diabetes and hypertension, the deadly duet: importance, therapeutic strategy, and selection of drug therapy. Cardiol Clin. 2005;23(2):139–52.CrossRefPubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2010

Authors and Affiliations

  • Yi Yang
    • 1
  • Vennela Thumula
    • 1
  • Patrick F. Pace
    • 1
  • Benjamin F. BanahanIII
    • 1
  • Noel E. Wilkin
    • 1
  • William B. Lobb
    • 1
  1. 1.School of PharmacyThe University of MississippiUniversityUSA

Personalised recommendations