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Most Older Diabetics Not Getting Medicine to Protect
Kidneys and Heart
Even those with signs of problems arent on ACE
inhibitors or ARBs
April 18, 2006 - Only 43 percent of older people
with diabetes receive medicines that could protect their heart and
kidneys, despite the fact that virtually all of them could benefit from
those drugs, a new University of Michigan study finds. And even among
those with the most to gain from the medicines, the rate of use barely
reaches 53 percent.
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The classes of prescription medications, called ACE
inhibitors and ARBs for short, have been recommended by national
diabetes-treatment guidelines for years, because of the strong evidence
that they can prevent heart attacks, strokes, kidney failure and other
problems that disproportionately threaten older people who have
diabetes. The inexpensive drugs are especially recommended for diabetics
who already show signs of heart or kidney damage, or who have high blood
pressure.
But the first national study of their actual use in
diabetics over age 55 reveals a large gap between what should be and
what is.
The study, published in the April issue of the
Journal of General Internal Medicine, was conducted by U-M Medical
School researcher Allison Rosen, M.D., Sc.D., using data from the
federal National Health and Nutrition Examination Survey (NHANES).
"These are drugs that we know save lives and save
money, and still we're only using them in less than half of the people
who could benefit," says Rosen, an assistant professor of internal
medicine at U-M who also holds positions at the U-M School of Public
Health and the VA Ann Arbor Healthcare System. "It's especially striking
that their rate of use isn't much higher in people most likely to gain
that is, those with multiple clinical indications and risk factors."
Rosen notes that the study did not reveal the
reasons that use of the drugs was so low. But she says that lack of
awareness among physicians, the cost to patients and lack of effective
measures to track and encourage use of the drugs may all contribute.
Last year, Rosen and her colleagues published a
study showing that the Medicare system could actually save money while
saving thousands of lives by giving free ACE inhibitors and ARBs to its
diabetic participants in an effort to encourage more use of the drugs.
Such a program ultimately would save lives and
reduce spending by preventing cardiovascular and kidney-related health
complications -- and the costly hospitalizations, dialysis sessions,
operations and other treatments they would require.
Even if a free-medications program only increased
ACE inhibitor and ARB use to 50 percent of patients, the Medicare system
would still save money in the long run, the 2005 study found.
The newly published study is based on data from a
nationally representative sample of adults over age 55 with diabetes,
all of whom underwent a thorough health exam, medication review and
interview under the NHANES program.
Rosen assessed the percentage that were using any
drug in the ACE or ARB class, and tallied up each person's total number
of indications and risk factors that would increase the benefit that
they would receive from the drugs.
Three clinical indications were examined:
Cardiovascular disease of any sort including heart failure, history of
heart attack or stroke, or clogged coronary arteries; high blood
pressure, whether controlled by medication or not; and the presence of
protein in the patient's urine, a condition called albuminuria that
indicates impaired kidney function.
National guidelines say that any diabetic who has
even one of those clinical indications should be taking an ACE inhibitor
or ARB, except for a very small number may not be able to take them.
Studies also suggest that the drugs are beneficial to diabetics who
smoke or have high cholesterol, but who have not yet experienced
cardiovascular problems, high blood pressure or kidney problems.
In all, 92 percent of the participants in the new
study met at least one of the three clinical guideline indications, and
100 percent either had one of the clinical indications or an additional
risk factor for cardiovascular disease. Just over 34 percent had
cardiovascular disease, almost 47 percent had albuminuria, and nearly 83
percent had high blood pressure. Nearly 73 percent had high cholesterol
and 24 percent smoked.
"In other words, every one of the people in this
nationally representative survey probably should have been taking an ACE
inhibitor or an ARB, and most weren't," says Rosen. "The more risk
factors and indications someone had, the more likely they were to be on
one of these drugs, but still, even in people with four or more
indications to be treated with these life saving drugs, only 53 percent
were on them."
Rosen says she hopes the study results will
encourage physicians, insurers, hospitals and others to find new ways to
encourage ACE inhibitor and ARB use among people with diabetes. She
notes that the current "quality benchmarks" that are used to rate health
care providers and health plans do not typically include measurements of
ACE and ARB use. They do, however, often include a measure of how often
diabetics' receive urine tests -- but they do not measure what happens
after the results of those tests come back, especially if albuminuria is
found.
"The way we're measuring quality in this area is
not working," Rosen says. "We need to create incentives and benchmarks
that will encourage responsible prescribing of ACE inhibitors and ARBs,
while also creating conditions that will lower patients' barriers to
using these medications."
In the meantime, she adds, people with diabetes
should talk to their physicians about whether they should be taking one
or more of the drugs in the ACE inhibitor or ARB classes of drugs. Such
drugs are available as generic and brand-name medicines, and can cost
less than $300 a year.
About study:
The study was funded by an Agency on Healthcare
Research and Quality fellowship that Rosen held while she was at the
Harvard University School of Public Health. To read about the ACE/ARB
Medicare simulation study, published in the Annals of Internal Medicine
in July 2005, see
www.med.umich.edu/opm/newspage/2005/freemeds.htm. Reference: Journal
of General Internal Medicine, Vol. 21 Issue 4.
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