CERTs.About.Annual Reports.Year 4.CERTs Progress.Informing.Providers.Patients

The CERTs program is dedicated to ensuring that its research results get into the hands of the public, health care providers, and policymakers. In this section, we discuss projects aimed at increasing physician awareness of drug risks and prescribing guidelines. In addition, we describe the latest research on promoting and preserving bone health in children and the elderly.

In order to minimize the risk of torsades de pointes, a type of irregular heartbeat that can be fatal, it is important for physicians to know how to measure the QT interval on an electrocardiogram, which drugs and other factors can prolong the QT interval, and how to prescribe medications appropriately in light of QT prolongation risks.

In a survey of health care providers, CERTs researchers found that a significant number of practitioners cannot correctly measure the QT interval or identify factors and medications that can prolong the QT interval. This is a particular problem for health care providers who frequently prescribe QT-prolonging medications. These results strongly suggest a need for physician education in this area.

To address this need, CERTs researchers developed an interactive online educational module to teach health care providers about the meaning and measurement of the QT interval, factors and medications that can prolong the QT interval, and how to assess the risks and benefits of medications known to affect the QT interval.

Understanding the QT Interval-A Duke CERTs Educational Program is an online training module for health care providers. It is available at qtmodule.mc.duke.edu

CERTs researchers conducted a study to evaluate adherence to NSAID prescribing guidelines at veterans' health care centers. The study included more than 700,000 veterans, of whom about 43 percent were considered at high risk for upper gastrointestinal (GI) side effects. Compliance with prescribing guidelines was generally low. Only 27 percent of patients with GI risk factors received medications in compliance with the current prescribing guidelines-either an NSAID combined with a drug designed to protect the GI system or a specific type of NSAID known to lessen the chance of GI side effects. These findings suggest the need for future studies to focus on what occurs when the guidelines are not followed and on defining ways to improve provider adherence.

In response to increases in the incidence of rickets caused by Vitamin D deficiency among infants and toddlers in the United States, CERTs researchers conducted a study between October 2002 and March 2003 of attitudes and practices of U.S. pediatricians and family physicians related to Vitamin D supplementation in infants.

The survey found no consensus about Vitamin D supplementation among about 2,000 primary care providers. Almost half did not recommend Vitamin D supplementation under any conditions. Of those who did recommend supplements, many began at a late age and/or did not continue the supplementation for an adequate length of time. The study also found that family physicians were much less likely to recommend Vitamin D supplementation than were pediatricians. Because Vitamin D supplementation can help prevent nutritional rickets, primary care providers need to instruct mothers to give Vitamin D supplements to their breastfed infants.

To encourage a healthy start in life for infants and young children, CERTs researchers collaborated with the Center for Children's Healthcare Improvement to find gaps in health care for newborns and to develop educational tools and resources to help close these gaps.

Currently, this partnership is focusing on ways to work with the American Academy of Pediatrics to prevent severe hyperbilirubinemia in newborns, to provide better support for breastfeeding mothers, and to ensure that communication between parents and health care providers continues when newborns go home from the hospital. This collaboration will also address safety concerns for infants, such as sleep position, maternal depression, the use of car seats, and the prevention of shaken baby syndrome.

As more effective treatments for human immunodeficiency virus (HIV) become available, many HIV patients find themselves living with a complex, chronic condition instead of facing a rapidly terminal illness. Recent advancements in therapeutics suggest new approaches to providing the best possible medical care.

Changing treatment regimens involves risk-patients can suffer negative side effects from a new medication, develop resistance to new drugs, or even miss doses as they adjust to an unfamiliar routine. However, current treatment guidelines recommend that doctors change treatment routines as soon as the level of HIV in the blood increases, even if the levels are very low.

A CERTs research team studied a group of HIV patients to determine what happened when very low levels of the virus were detected in the blood and to examine the risks of not changing therapy once low levels of the virus were found.

With enhanced detection of low virus levels, they found that low levels of the virus did not necessarily progress to high levels that would put the patient's immune system at greater risk. In fact, increases to high levels occurred in only about one-third of the 79 cases examined. Another one-third had less severe increases in viral activity, while the final one-third had undetectable levels of the virus at the end of the followup period.

The nature of the U.S. health care system leaves insufficient time for quality patient education during medical visits. To supplement health information given by providers, patients are increasingly using the Internet to seek information about diseases and treatments. CERTs researchers systematically evaluated Internet Web sites and developed a "Webliography," or list of Web sites that provide reliable medication information for health care consumers. The list and a downloadable brochure will soon be available on the University of Arizona CERTs Center Web site.

Protease inhibitors are a class of medications that have greatly improved the treatment of HIV infection. Unfortunately, they can raise levels of cholesterol in the blood, putting patients at risk of heart disease. In many cases, patients taking protease inhibitors are given prescriptions for lipid-lowering medications such as statins. However, some statin drugs interact with protease inhibitors so as to increase the risk of dangerous side effects.

CERTs researchers examined the use of protease inhibitors and statins in a large group of HIV patients to determine how often physicians prescribed combinations of drugs that are not recommended. Specifically, researchers wanted to see if prescribing patterns had changed after the publication of preliminary guidelines for combining these drugs. They found that the number of combinations of drugs that are not recommended decreased significantly after the release of the preliminary guidelines but remained relatively high. CERTs researchers believe that further continued education will be required for physicians to further reduce the use of combinations of protease inhibitors and statins.

Improvements made in HIV treatment are quickly offset if patients do not take their prescribed medications. Two CERTs studies used pharmacy records to determine whether patients who reported that they took their medicines in a timely fashion actually did so, and whether the method of dispensing the medicines would help patients follow their treatment routine.

One study compared 110 patients' own accounts of whether they took their medicines each day with records of how often they had their prescriptions refilled, and correlated each of these measures with the amount of HIV in the blood. According to the pharmacy records, only 27 percent of the patients had complied 100 percent with their prescribed treatment, although 67 percent of the patients reported 100 percent compliance for themselves. The study also found that pharmacy-reported compliance correlated more strongly with changes in HIV level than did patient-reported compliance. Patients who regularly refilled their prescriptions were more likely to have a drop in HIV blood levels.

The same investigators searched for links between the method of refilling prescriptions and how well HIV patients followed their treatment routines. This study compared patients who (1) refilled prescriptions by visiting the pharmacy, (2) had their medications delivered by mail, and (3) obtained their refills from a pharmacist but had them packaged in daily pill organizers. Compliance was significantly lower in the group who picked up their prescriptions compared with the mail-order and pill-organizer groups, but the latter two groups did not differ substantially from each other. The rate of good compliance (=85 percent) was highest for those who received the pill organizers, followed by the mail-order group. These findings suggest that some methods of prescription refills and packaging may improve adherence to treatment.

CERTs researchers looked at racial disparities in health care for osteoporosis. They conducted a telephone survey among 1,424 older women. Of the 251 women who suffered a bone fracture after age 45, African Americans were 60-percent less likely than Caucasians to have received a bone-density scan and 80-percent less likely to have been prescribed medication for osteoporosis.

These findings are of particular interest, given that fractures result in more disability, longer hospital stays, and higher overall mortality among African American women than among Caucasian women, even though the incidence of osteoporosis is lower among African American women. Researchers concluded that reducing disparities in osteoporosis care could substantially reduce the burden of osteoporosis and fractures among high-risk African American women.

Glucocorticoids, steroid hormones that have antiinflammatory properties, are often prescribed for diseases such as rheumatoid arthritis and lupus. In addition to their benefits, they can have negative side effects such as osteoporosis. A CERTs research team used databases from a national managed-care organization to evaluate how well physicians take steps to prevent osteoporosis in patients taking glucocorticoid drugs.

Despite increases in screening for and treating glucocorticoid- induced osteoporosis, prevention measures remained low, especially among men and African American patients of both sexes. This study also found significant differences in prevention efforts between various types of physicians. Rheumatologists, for example, were almost twice as likely as family and general practitioners to measure bone mass in patients for whom they prescribed glucocorticoid medications. Patients of gastroenterologists were significantly less likely to receive osteoporosis-specific prescription drugs than were patients of internal medicine physicians. Similar variations among physician specialties were found in other preventive measures, such as recommending the use of over-the-counter calcium and Vitamin D supplements.

About CERTs

Annual Report Year 5

CERTs Progress

Informing Providers and Patients