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Background— Intensive statins are superior to moderate statins in reducing morbidity and mortality after an acute myocardial infarction. Although studies have documented rates of statin prescription as a quality performance measure, variations in hospitals’ rates of initiating, intensifying, and maximizing statin therapy after acute myocardial infarction are unknown. Methods and Results— We assessed statin use at admission and discharge among 4340 acute myocardial infarction patients from 24 US hospitals (2005–2008). Hierarchical models estimated site variation in statin initiation in naïve patients, intensification in those undergoing submaximal therapy, and discharge on maximal therapy (defined as a statin with expected low-density lipoprotein cholesterol lowering ≥50%) after adjustment for patient factors, including low-density lipoprotein cholesterol level. Site variation was explored with a median rate ratio, which estimates the relative difference in risk ratios of 2 hypothetically identical patients at 2 different hospitals. Among statin-naïve patients, 87% without a contraindication were prescribed a statin, with no variability across sites (median rate ratio, 1.02). Among patients who arrived on submaximal statins, 26% had their statin therapy intensified, with modest site variability (median rate ratio, 1.47). Among all patients without a contraindication, 23% were discharged on maximal statin therapy, with substantial hospital variability (median rate ratio, 2.79). Conclusions— In a large, multicenter acute myocardial infarction cohort, statin therapy was begun in nearly 90% of patients during hospitalization, with no variability across sites; however, rates of statin intensification and maximization were low and varied substantially across hospitals. Given that more intense statin therapy is associated with better outcomes, changing the existing performance measures to include the intensity of statin therapy may improve care.

Objectives: While mortality following acute myocardial infarction (AMI) has decreased over time, subsequent hospitalizations due to unstable angina (UA) and coronary revascularization (CR) continue to be a great source of burden both from a patient’s and a societal perspective. It is unknown, however, how AMI patients who experience these additional readmissions value their health and what the associated costs are, beyond the hospitalization itself. Methods: From TRIUMPH, a 24-center observational AMI registry, we identified patients readmitted for unstable angina (UA) or unplanned CR ≥1 month following index AMI discharge. Propensity matching was used to compare (1) patients who were vs. were not readmitted for UA and (2) patients who were vs. were not readmitted for CR. We examined one-year quality-adjusted life-years (QALYs) using the EQ-5D measurements at 1, 6 and 12 months, as well as post-discharge costs (office visits, cardiac rehabilitation and cardiovascular readmissions, excluding costs for the UA/CR event). Confidence intervals were calculated via bootstrap analysis. Results: A total of 140 (4.26%) were readmitted for UA and 112 (3.41%) patients underwent CR after their AMI. Unadjusted mean 1-year QALYs for UA and non-UA patients were 0.743 and 0.821 [propensity-matched difference -0.076 (95% CI -0.100, -0.042)]. Unadjusted mean 1-year QALYs for CR and non-CR patients were 0.798 and 0.828 [propensity-matched difference -0.032 (95% CI -0.063, -0.003]. Mean differences in costs were $8009 (95% CI $3997, $14229) for UA vs. non-UA patients and $4498 (95% CI $4046, $4966) for CR vs. non-CR patients. Cardiovascular rehospitalizations contributed most to these costs (Table) . Conclusion: In this study, over the year following AMI, patients experiencing UA or unplanned coronary revascularization were challenged in maintaining their health status as compared with those not experiencing the respective event and had significantly higher health care costs.

Background: The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the treatment of hypercholesterolemia marked a departure from previously established guidelines in regards to pharmacologic therapy. This study identified patients with atherosclerotic cardiovascular disease (ASCVD) using the new guidelines, and examined their patterns of lipid lowering medication (LLM) use in a real-world environment. Methods: This retrospective cohort study utilized claims data from the HealthCore Integrated Research Database (HIRD SM ). Newly diagnosed ASCVD patients aged ≥18 years were identified between 1/1/2007 and 11/30/2012 (index date=first ASCVD diagnosis date). Patients had both ≥ 12 months pre- and post- index health plan enrollment and no LLM use at baseline. Index LLM was identified based on earliest fill of LLM within 6 months after the index date. Index LLM dose titration, discontinuation, switch, and augmentation were examined among monotherapy initiators only. Descriptive statistics were used to examine patterns of LLM use at 12 and 36 months follow-up among all patients and those with ≥36 months post-index health plan enrollment respectively. Results: The study identified 128,017 ASCVD patients with a mean age of 59 years, 43.1% (55,136 of 128,017) female, and 48.8% (62,493 of 128,017) with ≥36 months follow-up. Within 6 months after the index date, 7.8% (9,929 of 128,017) initiated high-intensity statin monotherapy; 27.8% (35,634 of 128,017) moderate/low-intensity statin monotherapy; 1.6% (2,024 of 128,017) non-statin monotherapy; 1.4% (1,770 of 128,017) combination therapy; and 61.4% (78,660 of 128,017) had no fills for any LLM. Among monotherapy initiators over 12 and 36 months follow-up, 8.8% (4,180 of 47,587) and 12.4% (2,635 of 21,198) had up-titration of index LLM, 54.5% (25,938 of 47,587) and 77.8% (16,488 of 21,198) discontinued index LLM, 9.6% (4,579 of 47,587) and 13.9% (2,935 of 21,198) switched their index LLM, and 3.0% (1,403 of 47,587) and 2.8% (586 of 21,198) augmented index LLM. Among all patients over 12 and 36 months follow-up, 41.4% (53,049 of 128,017) and 49.7% (31,057 of 62,493) had statins, 10.6% (13,522 of 128,017) and 13.0% (8,134 of 62,493) had high-intensity statins, 5.8% (7,361of 128,017) and 12.8% (7,989 of 62,493) had ≥2 types of statins, 4.9% (6,253 of 128,017) and 9.3% (5,798 of 62,493) had both statins and non-statin LLMs, and 56.9% (72,897 of 128,017) and 47.9% (29,923 of 62,493) had no LLM. Conclusions: Few patients initiated a high-intensity statin within 6 months of ASCVD diagnosis and at 12 months and 36 months follow-up. Our findings suggest that treatment for ASCVD patients was not optimal in relation to the recent ACC/AHA guideline recommendations and significant modifications in prescribing patterns should be made towards use of high-intensity statins to improve treatment outcomes.

Rationale: Parkinsonism can be secondary to many internal diseases, in some certain conditions, it seems that the clinical manifestations of parkinsonism presenting reversible. We report a case of patient with parkinsonism secondary to pseudohypoparathyroidism, who improved markedly after the supplement of serum calcium. Patient concerns and diagnoses: A 52-year-old woman with acute parkinsonism was diagnosed as pseudohypoparathyroidism after the conducting of brain computed tomography, laboratory examinations, and gene detection. The son of the patient was also examined and was diagnosed as pseudohypoparathyroidism, who had ever complained of the history of epilepsy. The clinical manifestations of parkinsonism of the patient was reevaluated after the supplement of serum calcium according to the diagnosis. Interventions and outcomes: The brain computed tomography revealed the basal ganglia calcification of the patient, accompanying by serum hypocalcemia and hyperphosphatemia. Loss of function mutation also confirmed the diagnosis. Five days after the therapy targeting at correction of serum hypocalcemia, the patient improved greatly in dyskinesia. Lessons: This study reported a patient presenting as acute reversible parkinsonism, who was finally diagnosed as pseudohypoparathyroidism. It indicated us that secondary parkinsonism should be carefully differentiated for its dramatic treatment effect. And the family history of seizures might be an indicator for the consideration of pseudohypoparathyroidism.

Background: Subsequent hospitalizations after acute myocardial infarction (AMI) for unstable angina (UA) and coronary revascularization represent common and important clinical events. While numerous studies sought to predict survival, AMI, and all-cause rehospitalization after AMI, there are limited data about how to best risk-stratify patients for UA and subsequent revascularization. Understanding these factors can support the development of more efficient AMI care. Methods: In the multi-center TRIUMPH registry, we used 3,283 patients with detailed baseline and 1-year follow-up information, including adjudicated hospitalizations, following initial AMI admission. An initial prediction model was derived after examining > 60 demographic, socio-economic, comorbidity, AMI severity, treatment, psychosocial and health status characteristics using hierarchical Cox Proportional Hazards for UA or revascularization. Staged PCIs and elective CABGs performed ≤1 month were excluded. Results: A total of 140 (4.3%) patients were readmitted ≤1 year for UA and 158 (4.8%) for revascularization. Independent predictors of UA were female sex (HR=1.88; 95%CI: 1.33, 2.65), prior PCI (HR=1.64; 95%CI: 1.12, 2.39), prior CABG (HR=2.06; 95%CI: 1.28, 3.32), and GRACE risk score (HR per 1 point increase=0.99; 95%CI: 0.98, 0.99). Independent predictors of revascularization were diseased vessels >1 (HR=2.50; 95%CI: 1.74, 3.60), and GRACE risk score (HR=0.99; 95%CI: 0.99, 1.00). While high-risk patients (those with diabetes, peripheral artery and cerebrovascular disease) were at increased risk of being readmitted for UA (HR=1.48; 95%CI 1.04, 2.10) or revascularization (HR=1.35; 95%CI: 0.97, 1.88), there was no interaction between these associations and risk status, suggesting equal prognostic significance in those with and without high-risk characteristics. Conclusion: Unique characteristics are associated with admissions for UA and revascularization. Creating multivariable models, risk scores and prospective risk stratification can support tailoring treatment to those at highest risk, although prospective studies are needed to establish the best management for high-risk patients.

BACKGROUND: Despite progress in treatment, high-risk vascular diseases (HRVD), including cerebrovascular disease (CVD), coronary artery disease with diabetes (CADD), acute coronary syndrome (ACS), and peripheral artery disease (PAD), account for approximately half of the rates of morbidity and mortality in the US. Limited research has been done to systematically study statin use patterns, adherence, and persistence for HRVD patients using real-world large claims databases. The objective was to examine statin use patterns, adherence, and persistence in patients with HRVD. METHODS: A retrospective cohort study was conducted using a large US administrative claims database for over 10 million beneficiaries annually from more than 100 self-insured Fortune 500 companies. HRVD patients (defined as patients with CVD, PAD, CADD, or a history of ACS [≥30 days through 365 days after discharge for ACS between 10/01/2008 and 09/30/2009]) aged 18 to 64 years, with minimum 12-month pre-index and 24-month post-index health plan eligibility, were identified for this study. Statin use, statin median/mean dose, percent of patients using maximal statin dose (defined as atorvastatin ≥80 mg and rosuvastatin ≥40 mg), and statin adherence (calculated using the medication possession ratio [MPR]) were measured at 6-month, 12-month, and 24-month follow-up periods. Persistence was assessed with survival analysis techniques using a ≥30-day gap to define a discontinuation. RESULTS: Among 516,863 identified HRVD patients, 38.7% used statins during the baseline period (PAD: 31.5%; CVD: 29.2%; CADD: 54.6%; ACS: 65.5%). The number increased to 40.6%, 43.3%, and 45.6% during the 6-month, 12-month, and 24-month follow-up periods, respectively, with greater increase of statin use in PAD and CVD patients (38.3%, 37.9%, respectively, during the 24-month follow-up period). Simvastatin (39.0%, 39.0%, 39.2%), atorvastatin (31.0%, 29.1%, 27.5%), and rosuvastatin (18.0%, 18.6%, 19.2%) were the most commonly used statins with 8.1%, 7.4%, and 7.3% of patients using maximum statin doses at 6-month, 12-month, and 24-month follow-up periods, respectively. There appeared to be little changes in statin doses during the 24-month follow-up period (mean/median dose: simvastatin 44.1/40 mg, 44.3/40 mg, 44.7/40 mg; atorvastatin 36.7/30 mg, 37.2/30 mg, 37.6/40 mg; rosuvastatin 17.2/10 mg, 17.4/10 mg, 17.9/10 mg). The mean/median MPR was 0.64/0.66, 0.60/0.66, and 0.49/0.49 among HRVD patients who used a statin with only 13.8%, 14.0%, and 10.9% of patients adherent (MPR≥80%) to their statin therapy during the 6-month, 12-month, and 24-month follow-up periods, respectively. The mean time to statin discontinuation was 357 days during the 24-month follow-up period. CONCLUSIONS: Nonadherence to statins is common for patients with HRVD, and the patterns of statin adherence persist over time with little titration in doses.

BACKGROUND: High-risk vascular diseases (HRVD), including cerebrovascular disease (CVD), coronary artery disease with diabetes (CADD), acute coronary syndrome (ACS), and peripheral artery disease (PAD), are still the leading cause of death in the US, despite progress in treatment. Little research has been done to systematically study statin use patterns, adherence, and persistence for HRVD patients using real-world large claims databases. The objective was to examine statin use patterns, adherence, and persistence in elderly patients with HRVD. METHODS: A large US administrative claims database for over 10 million beneficiaries annually from more than 100 self-insured Fortune 500 companies was used to conduct a retrospective cohort study. Patients with HRVD, defined as CVD, PAD, CADD, or a history of ACS (≥30days through 365 days after discharge for ACS) between 10/01/2008 and 09/30/2009, were ≥65 years of age and identified with minimum 12-month pre-index and 24-month post-index health plan eligibility. Statin use, statin median/mean dose, percent of patients using maximal statin dose (defined as atorvastatin ≥80 mg and rosuvastatin ≥40 mg), and statin adherence (calculated using the medication possession ratio [MPR]) were measured at 6 months, 12 months, and 24 months. Persistence was assessed with survival analysis techniques using a ≥30-day gap to define a discontinuation. RESULTS: A total of 525,893 patients with HRVD were identified; 50.3% used statins during the baseline period (PAD: 44.9%; CVD: 45.2%; CADD: 63.9%; ACS: 61.7%). This number changed slightly to 49.2%, 51.8%, and 54.3% during the 6-month, 12-month, and 24-month follow-up periods, respectively, with PAD and CVD patients having greater increase of statin use (49.7%, 50%, respectively) during the 24-month follow-up period. Simvastatin (41.6%, 42.2%, 42.8%), atorvastatin (31.9%, 30.5%, 28.8%), and rosuvastatin (11.5%, 12.0%, 12.4%) were the most commonly used statins with 4.8%, 4.6%, and 4.3% of patients using maximum statin doses at 6-month, 12-month, and 24-month follow-up periods. There appeared to be few changes in statin doses during the 24-month follow-up period (mean/median dose: simvastatin 34.6/40 mg, 34.8/40 mg, 34.8/40 mg; atorvastatin 29.6/20 mg, 29.8/20 mg, 30.2/20 mg; rosuvastatin 14.1/10 mg, 14.2/10 mg, 14.4/10 mg). The mean/median MPR was 0.66/0.68, 0.67/0.74, and 0.60/0.65 among HRVD patients who used a statin with only 17.4%, 20.9 %, and 20.7% of patients adherent (MPR≥80%) to their statin therapy during the 6-month, 12-month, and 24-month follow-up periods, respectively. The median time to statin discontinuation was 406 days during the 24-month follow-up period. CONCLUSIONS: Statin adherence is suboptimal for elderly patients with HRVD and the patterns of statin adherence persist over time with little titration in doses.

BACKGROUND: High risk vascular disease (HRVD defined as cerebrovascular disease [CVD], coronary artery disease with diabetes [CADD], history of acute coronary syndrome [ACS], or peripheral artery disease [PAD]) is among the biggest health problems affecting Japanese, with CVD and coronary artery disease (CAD) being the 2nd and 3rd most common causes of death. Despite proven efficacy of statins in reducing CV mortality, limited research is available to systematically study statin adherence and persistence for HRVD patients in Japan. OBJECTIVE: Examine statin adherence and persistence in HRVD patients. METHOD: A retrospective cohort study was conducted using the Japan Medical Data Center (JMDC) database, a large Japanese administrative claims database with 10 insurance societies (payers), and integrated inpatient, outpatient, and pharmacy claims of approximately 0.8 million covered lives from 2006-2011. Patients > 18 years with HRVD (CVD, PAD, CADD or history of ACS [≥30days through 365 days after discharge for ACS]) between 01/01/2008 to 12/31/2009, were identified for this study with minimum 12-month pre- and 24-month post-index insurance eligibility. Statin use was measured during the 12-month baseline period and the 24-month follow-up period. The date of the first HRVD claim(s) satisfying the above inclusion criteria was defined as the index date. Statin use was examined for the overall HRVD group as well as subgroups of patients with CVD only, PAD only, CADD only, history of ACS only, and patients with multiple HRVDs. Statin adherence, calculated using the medication possession ratio [MPR], and statin persistence, assessed with survival analysis techniques using a ≥30-day gap to define discontinuation, were measured in the 24-month follow-up period for the overall HRVD patient group. RESULTS: There were 10,400 HRVD patients identified in the JMDC database. Mean age was 52.8 and 57.1% were male. Statin use during the baseline period showed 12.1% of HRVD patients taking statins (CVD only: 10.2%; PAD only: 9.6%; CADD only: 14.6%; history of ACS only: 46.7%; CADD and a history of ACS: 48.3%; 2 affected artery beds: 17.8%; 3 affected artery beds: 19.5%). Statin use increased to 32.9% during the 24-month follow-up period (CVD only: 27.6%; PAD only: 26.6%; CADD only: 45.1%; history of ACS only: 54.4%; CADD and a history of ACS: 58.3%; 2 affected artery beds: 49.3%; 3 affected artery beds: 45.5%). For Japanese HRVD patients who used a statin, mean/median MPR was 0.89/0.94 and 82.1% of statin users were adherent (MPR ≥80%) to their statin therapy during the 24-month follow up period. The median time to statin discontinuation was 679 days during the 24-month follow up period. CONCLUSION: Statin use after HRVD diagnosis was modest and highest in ACS patients and patients with multiple affected vascular beds. Statin adherence was high among patients with HRVD in Japan.

Background: Research on the use of newer antiplatelet agents and their outcomes from a real-world setting is scarce. Hospital length of stay (LOS) has been used as a measure for resource use and as a proxy for patient outcomes. We analyzed a large geographically diverse database from the US and compared LOS between patients on clopidogrel or prasugrel. Patients were hospitalized for acute coronary syndrome (ACS) and had undergone percutaneous coronary intervention (PCI). Methods: Using a large database maintained by PREMIER, Inc., we analyzed patient characteristics and LOS during the index (first) hospitalization among ACS-PCI patients treated with clopidogrel or prasugrel between July 2009 and June 2011. Observed LOS was analyzed with t-tests. A multivariate regression model with a negative binomial distribution was used to evaluate differences in LOS, adjusting for the following covariates: age, ACS type (non-ST-elevation myocardial infarction [NSTEMI], STEMI, Unstable Angina [UA]), gender, race, renal insufficiency, diabetes, anemia, heart failure, number of vessels, bleeding events, and comorbidities based on the Charlson-Deyo weighting of disease states. Results: Data were available for 75,315 patients who received clopidogrel and 9,483 patients with prasugrel. For clopidogrel and prasugrel, respectively, the observed mean LOS (SD) was 3.5 (4.4) days and 2.9 (2.4) days (P Conclusion: In this study, prasugrel- treated patients had a shorter average LOS compared to clopidogrel-treated patients. After adjusting for patient demographics and clinical characteristics, the results still held. The unobserved confounder bias, however, may exist in this real-world observational database research.

Background: Newer, more potent antiplatelet therapy is commonly perceived as being associated with a higher incidence of bleeding complications. There are limited real-world data on bleeding among patients with acute coronary syndrome (ACS) who have undergone percutaneous coronary intervention (PCI) with new antiplatelet therapy. The objective of this study was to compare “real-world” incidence of bleeding among patients on clopidogrel vs. prasugrel therapy in a large database from diverse US hospitals. Methods: We analyzed patient characteristics and the incidence of bleeding complications during the index (first) hospitalization among ACS-PCI patients treated with clopidogrel or prasugrel between July 2009 and June 2011. Bleeding was defined as the presence of bleeding ICD-9 codes and transfusion. Cohort differences in outcomes were assessed with unadjusted chi-square tests and adjusted for demographics and baseline clinical differences using logistic regression. Results: 105,490 patients received clopidogrel and 10,544 received prasugrel. Among clopidogrel and prasugrel patients, respectively, 66% and 75% were men, 37% and 46% presented with STEMI, with median age of 64 and 57. During the index hospitalization, the unadjusted incidence of bleeding events was 7% in clopidogrel-treated patients and 4% in prasugrel-treated patients (P Conclusion: It appears that observed bleeding complications among patients treated with prasugrel is not higher than those treated with clopidogrel, even after multivariate adjustments. However, the potential for unobserved confounders remains a limitation for such observational research. It is conceivable that appropriate patient selection helps to control bleeding complications, as shown here in this large, “real-world” database.

Background: Intensive statin therapy after an acute myocardial infarction (AMI) has been shown, in multiple trials, to be superior to less intensive treatment. Several studies have documented rates of statin prescription at discharge, in any dose, as a quality performance measure. However, variations in hospitals’ rates of initiating, intensifying and maximizing statin therapy after AMI are unknown. Methods: We assessed statin therapy at admission and discharge among 4340 AMI patients from 24 US hospitals (4/05-12/08). Initiation was defined as statin prescription at discharge in patients not admitted on them. Intensification reflected an increase in dose or change to a higher potency statin at discharge. The use of atorvastatin 80 mg or rosuvastatin 40 mg at discharge were considered maximal statin therapy. Hierarchical modified Poisson models estimated the association of site with initiation in naïve patients, intensification in those who arrived on submaximal therapy, and discharge on maximal therapy among all patients, after adjustment for patient factors including LDL level. Site variation was explored with a median rate ratio (MRR), which estimates the average relative difference in risk ratios of 2 hypothetically identical patients treated at 2 different sites. Results: On admission, 34.8% (1510/4340) of patients were taking a statin and 2.6% (112/4340) were on maximal therapy. 86.9% (2411/2776) of statin naïve patients without a contraindication were prescribed a statin at discharge, with no variability across sites after adjustment for patient factors (MRR 1.02). Among patients who arrived on submaximal statin therapy, 26.3% (323/1230) had their statin therapy intensified at discharge with modest site variability (MRR 1.47). Among all patients without a contraindication, 21.0% (899/4271) were discharged on maximal therapy with substantial site variability (MRR 2.79). Conclusions: In a large, multicenter AMI cohort, nearly all patients were started on statins during hospitalization, with no variability across sites. However, rates of statin intensification and maximization were lower and varied substantially across hospitals. Given that more intense statin therapy is important in optimizing outcomes, evolving the existing performance measures to include the intensity of statin therapy may be beneficial in improving care.

Objective: Evaluate index hospital resource use and costs for non-ACS elective PCI and ACS PCI patients. Methods: A national managed care database (affiliated with i3 Innovus) was linked to a large nationally representative hospital database (Premier Perspective) to identify patients, ≥18 years, treated by PCI in the absence or presence of an ACS diagnosis during their index hospitalization between 01/04-12/06. Patients with an ACS diagnosis and PCI 12 months prior to their index hospitalization were excluded. Results: Of 2,906 patients, elective PCI patients (35.9%, 1043 of 2906), compared to ACS PCI patients (64.1%, 1863 of 2906), were significantly older (aged 59.6±9.0 vs. 56.5±9.7, P P P P P P P P P P P P P Conclusions: Patients undergoing elective PCI, compared to ACS PCI patients, have lower index hospitalization resource use and costs reflected by shorter LOS, less time in the ICU and less use of concomitant medications.

Background: Statins are considered to play an important role in reducing coronary heart disease (CHD) risk. There are currently 6 statins available in the U.S. market and more than 193 million statin prescriptions were written in 2008. We sought to examine the prescription patterns of statins among privately insured commercial and Medicare patients in the U.S. Methods: A retrospective analysis was performed using MarketScan Commercial and Medicare data from Jan. 2008 to Dec. 2008. Two cohorts were created: 1) the commercial cohort (CC) and 2) the Medicare cohort (MC). Statin scripts of minimum 30 day supply were extracted from the pharmacy claims data and individual demographic and clinical information were linked from their medical and administrative records. Prescription patterns of 6 statins were examined and additional analyses by age and gender were performed. Results: There were 18 million and 9.8 million statin prescriptions filled by the CC and MC, respectively. In both cohorts, simvastatin accounted for the largest share of statin prescriptions (MC: 44%; CC: 44%), followed by atorvastatin (MC: 32%; CCl: 31%), rosuvastatin (MC: 7.8%; CC: 11.2%), pravastatin (MC: 8.1%; CC: 6.5%), lovastatin (MC: 7.4%; CC: 6.6%) and fluvastatin (MC: 0.9%; CC: 0.6%). The majority of statin prescriptions were for generics (MC: 60%; CC: 57%). For patients with at least one fill, the average number of statin prescription per year was 9.3 for the MC and 7.6 for the CC. In the CC, 58% of prescriptions were filled by male, while 50% of prescriptions were filled by male in the MC. Commercial patients aged 55-65 filled 56% of statin prescriptions, followed by 33% filled by patients aged 45-54, and 11% filled by patients aged < 45. In the MC, patients aged 65-75 filled 54% of statin prescriptions and the rest 46% of the prescriptions were filled by patients aged>75. Diabetic patients accounted for 35.2% of prescriptions in the MC, and 26.8% in the CC. Conclusions: This claims data analysis suggests different statin use patterns by age, gender, and insurance. Further research is warranted to understand appropriateness of statin use in the population.

Methods: Patients, aged ≥18, with ACS diagnosis managed medically (MM), or by PCI or by coronary artery bypass graft (CABG), or no ACS with elective PCI (E-PCI), were identified from a linked managed care and hospital database from 01/2004 - 12/2006. Results: Of 4674 patients, 3329 (71.2%) were male, aged 57.6±10.4 with a Charlson Comorbidity Index (CCI) of 1.1±1.6. Of 4535 patients followed ≥30 days, compared to the PCI cohort (n=1811), MM patients (n=1342) had lower rates of cardiac related (64 [4.8%] vs. 140 [7.7%]; P P P P P P Table 1 ) showed compared to PCI; MM, CABG and E-PCI cohorts had a lower risk of cardiac related rehospitalization ( P P Conclusion: Compared to ACS PCI patients, the adjusted risk for cardiac rehospitalization was lower for MM, CABG and E-PCI cohorts with a lower rate for MM patients while both the risk and rate for coronary intervention rehospitalization were lower for MM and CABG with no differences in the E-PCI cohort. Table 1: Significant Predictors of Rehospitalization Risk (Cox Regression) Risk Of Cardiac Related Rehospitalization Risk of MI Rehospitalization Risk of Coronary Intervention (PCI or CABG) Rehospitalization Variables Hazard Ratio 95% CI Hazard Ratio 95% CI Hazard Ratio 95% CI Medically Managed (Reference: PCI cohort) 0.639 ‡ [0.539,0.756] 0.694 [0.420,1.148] 0.422 ‡ [0.328,0.542] CABG (Reference: PCI cohort) 0.782 * [0.619,0.989] 0.683 [0.343,1.360] 0.420 ‡ [0.284,0.622] Elective PCI (Reference: PCI cohort) 0.811 * [0.687,0.956] 0.870 [0.525,1.441] 0.898 [0.725,1.113] Male Gender 0.922 [0.808,1.052] 1.324 [0.872,2.012] 1.005 [0.834,1.212] 1 1.270 † [1.072,1.503] 1.369 [0.820,2.284] 1.179 [0.930,1.495] CCI>=3 ; Reference: CCI 1.630 ‡ [1.324,2.007] 2.683 ‡ [1.529,4.708] 1.499 † [1.113,2.019] STEMI 1.255 † [1.078,1.460] 2.225 ‡ [1.482,3.340] 1.197 [0.973,1.473] Prior Diabetes 1.222 * [1.005,1.486] 1.151 [0.658,2.014] 1.173 [0.894,1.539] Prior Hypertension 1.093 [0.947,1.262] 1.706 * [1.106,2.633] 1.127 [0.924,1.375] Baseline Beta-Blocker Use 1.270 ‡ [1.108,1.456] 1.420 [0.953,2.115] 1.187 [0.982,1.435] Baseline Statin Use 0.846 * [0.742,0.964] 0.663 * [0.451,0.973] 0.826 * [0.690,0.990] Baseline Proton Pump Inhibitor Use 0.967 [0.820,1.140] 1.558 * [1.007,2.412] 1.161 [0.931,1.449] Baseline Clopidogrel Use 1.271 † [1.066,1.516] 1.443 [0.861,2.419] 1.146 [0.901,1.459] Baseline Diuretics Use 1.167 * [1.010,1.348] 0.666 [0.430,1.034] 0.975 [0.795,1.195] Baseline Insulin Use 1.325 * [1.066,1.647] 0.949 [0.489,1.844] 1.432 * [1.064,1.927] Baseline Nitroglycerin Use 1.131 [0.956,1.337] 0.770 [0.436,1.360] 1.348 † [1.077,1.686] Baseline Warfarin Use 1.469 † [1.139,1.895] 1.858 [0.926,3.730] 1.023 [0.676,1.547] * P < 0.05, † P < 0.01, ‡ P < 0.001.

Objectives: A retrospective study examined post-discharge proton pump inhibitor (PPI) use with clopidogrel for Medicare patients hospitalized for ACS and treated with percutaneous coronary intervention (PCI). Methods: Claims from a large national US health plan were analyzed. Subjects were enrolled in Medicare Advantage with Part D prescription drug coverage (MAPD), >65 years old, had at least one inpatient hospitalization with a primary ACS diagnosis code between 1/1/2007 and 12/31/2008, and were treated with percutaneous coronary intervention (PCI). Excluded were patients with baseline stroke or TIA. Patients were followed up until death or 365 days post-discharge, whichever came first. Results: Of 1350 patients that met the inclusion criteria, 53.5% (722 of 1350) were ≥75 years old, 36.6% (494 of 1350) had diabetes comorbidity, and 6.9% (93 of 1350) had a prior myocardial infarction (MI). Of patients ≥ 75 years old, 37.8% (273 of 722) had either diabetes comorbidity or a prior MI. In the post-discharge period, 88.3% (1192 of 1350) had at least one clopidogrel fill and 33.1% (447 of 1350) had at least one PPI fill. Mean number of PPI claims was 6.1 (±4.3); mean number of clopidogrel fills was 8.3 (±4.1). Of patients with any PPI use, 87.9 % (393 of 447) were also on clopidogrel for an overlapping period of time. Average overlapping period was 161.1 (±114.7) days. The most common PPI fill was 47.7% (213 of 447) for omeprazol, followed by 31.1% (139 of 447) for pantoprazole, 21.0% (94 of 447) for esomeprazole, and 10.7% (48 of 447) for all others. Conclusion: Concomitant use of clopidogrel and PPI following hospital discharge for ACS-PCI was frequently observed in this managed Medicare population.

Objective: Diabetes is an independent prognostic factor for increased risk for ischemic heart disease. This study evaluates differences in resource utilization and health care costs for acute coronary syndrome (ACS) patients with and without diabetes mellitus (DM). Methods: A retrospective cohort study was conducted using a large US administrative claims database. Patients, ≥65, hospitalized with a primary diagnosis of ACS between 01/01/2007 and 12/31/2007 were identified and categorized into 2 groups: 1) with DM (ACS patients had ≥ 2 outpatient office visits or 1 hospitalization with the DM diagnosis during the 1 year before/within the index hospitalization) and 2) without DM. Patients with complete insurance coverage 1-year pre- and post- index hospitalization were included. Annual health care costs and resource utilization were compared usingChi-square tests for categorical variables and Wilcoxon rank-sum tests for continuous variables (all p Results: Of 5,840 identified patients, 1,609 (28%) were diabetic and 4,231 (72%) were non-diabetic. A higher percentage of diabetic patients had at least one all-cause rehospitalization event (44.4% vs. 35.7%) or CV-related rehospitalization event (27.0% vs. 19.5%). Mean length of stay (LOS) was longer for DM patients during the index hospitalization (6.3 days vs. 5.5 days), as well as during the CV-related rehospitalization (5.7 days vs. 4.8 days). In addition, patients with DM had more physician's office visits (18.3 vs. 15.0), ER visits (0.6 vs. 0.5), and outpatient hospital visits (7.4 vs. 6.1) during the 12-month follow-up period. Both cohorts had similar index ACS hospitalization costs ($18,532 vs. $17,609) but DM patients incurred higher rehospitalization costs (all-cause: $21,064 vs. $13,821; CV-related: $11,086 vs. $7,260), outpatient costs (all-cause: $28,167 vs. $19,815; CV-related: $7,193 vs. $5,686), and pharmacy costs (all-cause: $5,537 vs. $3,815; CV-related: $3,522 vs. $3,143). One-year follow-up health care costs were significantly higher for patients with DM compared with those without DM ($54,768 vs. $37,451). Conclusion: The presence of DM is significantly associated with greater resource utilization and health care costs for ACS patients.