Heart failure is a chronic condition that increases the risk for death and disability. Beta blockers and ACE inhibitors have become standard treatments in heart failure because clinical trials have demonstrated their beneficial effect on mortality and morbidity in these patients. As not much is known about adherence to these medications, the main objectives of this project were to determine long term adherence to ACE inhibitors and beta blockers and determine how various degrees of adherence to a beta blocker can affect major health outcomes in patients with heart failure.<p> Data was obtained from Saskatchewan health from January 1, 1994 to December 31, 2003 for all heart failure patients from their first hospitalization for heart failure. Adherence was calculated using the fill frequency measure of adherence, and all survival analyses were completed using the Cox proportional hazards model.<p>Although 14, 000 patients were admitted to hospital for a first admission for heart failure, only 1143 subjects started a beta blocker and 5084 subjects started an ACE inhibitor within 3 months of the index hospitalization. Within the first year, adherence was excellent for both beta blockers (80.8 percent) and ACE inhibitors (82.5 percent). The proportion of patients remaining adherent slowly decreased to reach approximately 60 percent, for both medication classes, after 4 years. There was no significant difference in all-cause mortality between patients with high adherence and low adherence, but there appeared to be a trend towards decreased survival time in those remaining adherent throughout the study period [HR = 1.18 (95% CI: 0.98 to 1.43; p=0.07)].<p>Since the overall rate of adherence to beta blockers was excellent in most patients during the first year, it is possible that non-adherence is not responsible for a significant burden of mortality in Saskatchewan heart failure patients, and perhaps and the focus of quality improvement should be optimal prescribing of evidence-based therapies, and continued adherence over time.

Heart failure is a chronic condition that increases the risk for death and disability. Beta blockers and ACE inhibitors have become standard treatments in heart failure because clinical trials have demonstrated their beneficial effect on mortality and morbidity in these patients. As not much is known about adherence to these medications, the main objectives of this project were to determine long term adherence to ACE inhibitors and beta blockers and determine how various degrees of adherence to a beta blocker can affect major health outcomes in patients with heart failure.<p> Data was obtained from Saskatchewan health from January 1, 1994 to December 31, 2003 for all heart failure patients from their first hospitalization for heart failure. Adherence was calculated using the fill frequency measure of adherence, and all survival analyses were completed using the Cox proportional hazards model.<p>Although 14, 000 patients were admitted to hospital for a first admission for heart failure, only 1143 subjects started a beta blocker and 5084 subjects started an ACE inhibitor within 3 months of the index hospitalization. Within the first year, adherence was excellent for both beta blockers (80.8 percent) and ACE inhibitors (82.5 percent). The proportion of patients remaining adherent slowly decreased to reach approximately 60 percent, for both medication classes, after 4 years. There was no significant difference in all-cause mortality between patients with high adherence and low adherence, but there appeared to be a trend towards decreased survival time in those remaining adherent throughout the study period [HR = 1.18 (95% CI: 0.98 to 1.43; p=0.07)].<p>Since the overall rate of adherence to beta blockers was excellent in most patients during the first year, it is possible that non-adherence is not responsible for a significant burden of mortality in Saskatchewan heart failure patients, and perhaps and the focus of quality improvement should be optimal prescribing of evidence-based therapies, and continued adherence over time.

The main objectives of this dissertation were to examine the effects of bariatric surgery on medication and health services utilization among a cohort of Commercial and Medicare insured members from a large health benefits organization in the U.S.. A total of 1,492 members with morbid obesity underwent gastric bypass (n=785) or gastric banding (n=707) procedure between January 2005 and June 2008. Administrative claims databases were accessed and three data files including a member file, a medical file and a pharmacy file were merged at the member level. Non-parametric Wilcoxon signed rank tests revealed that the average number of all prescription claims were significantly lower during the 12 months post-surgery, compared to the 12 months pre surgery (p<0.0001). Moreover, McNemar’s Chi Square analyses showed that after the surgery, there was a statistically significant (p=<0001) decline in the proportion of members utilizing antihypertensives, antidiabetics and antihyperlipidemics. Our results also showed that the average number of prescription claims for each of these medication groups significantly declined during the 12-month post-surgery period, among members who had at least one prescription for these medications before the surgery (p<0.0001). Logistic regression modeling revealed that members who underwent bypass procedures were more likely to discontinue antihypertensives (OR=2.04; 95% CI= 1.30-3.23) , antihyperlipidemics (OR=3.25; 95% CI 1.96-5.40) and antidiabetics (OR=1.89; 95% CI 1.13–3.08) post-surgery than members who underwent banding procedures. In terms of medical services utilization, our results showed a significant decline in the average number of medical claims for all outpatient services overall from the 12 months pre to the 12 months post-surgery (p<0.0001). In contrast, the average number of medical claims for emergency room and inpatient hospitalizations were significantly increased from the pre to the post-surgery period (p<0.01). Logistic regression modeling revealed that the type of bariatric surgery was a significant positive predictor for inpatient hospitalizations post-surgery (OR =2.33; 95% CI= 1.76-3.08; p<0.0001) but not for emergency room visits (OR=1.23; 95% CI 0.97–1.56). The implications of the findings from a managed care perspective are discussed, along with limitation and future directions.

Background: In 2007, Saskatchewan’s Ministry of Health launched the Seniors’ Drug Plan (SDP), whereby provincial beneficiaries at or above the age of 65 receive medications at a maximum self-payment of $15. The purpose of this study was to document the impact of the SDP using provincial health-administrative databases. Methods: Aggregate medication utilization and costs were described using the prescription drug database starting two years before the implementation of the SDP and continuing for two years after. Interrupted time series analysis using segmented regression models were developed to test the impact of the SDP. Also, the probability of achieving optimal medication adherence was examined among cohorts receiving medications after SDP implementation versus similar patients receiving medications before the SDP and also a group of patients <65 years who were not eligible for the SDP at all. The impact of the SDP on the outcome of optimal adherence was estimated using logistic regression models with generalized estimating equations (GEE). Results: Monthly government spending on medications increased by 47.5% following implementation of the SDP, while total medication dispensations only increased by 5.8%. The SDP was associated with more dispensations per month among prevalent users (+5.4%, 95% CI: 1.3% to 9.5%) but not incident users who did not receive the study medication in the previous 365 days (+1.3%, 95% CI: -8.0% to 10.7%). Similarly, the SDP did not appear to impact the use of blood-glucose-lowering agents, (-0.5%, 95% CI: -6.2% to 5.2%). A small but significant increase in the odds of optimal medication adherence was observed after the SDP compared with before (OR=1.08, 95% CI 1.04 to 1.11). However, the impact was only observed in prevalent users (OR=1.08, 95% CI 1.04 to 1.12), but not incident users (OR=1.05, 95% CI 0.98 to 1.13). Also, the impact of the SDP on medication adherence was not consistent for all medication classes examined. Discussion: In summary, the SDP resulted in substantially higher government investment into drug costs without a major effect on medication utilization and adherence. However, cost reduction for seniors must have provided substantial relief independent of the impact on adherence and utilization.