Use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in high-risk clinical and ethnic groups with diabetes
UMass Chan AffiliationsDepartment of Quantitative Health Sciences
Document TypeJournal Article
Angiotensin II Type 1 Receptor Blockers
*Angiotensin Receptor Antagonists
Angiotensin-Converting Enzyme Inhibitors
Diabetes Mellitus, Type 2
Kidney Failure, Chronic
Managed Care Programs
Quality of Health Care
Health Services Research
MetadataShow full item record
AbstractBACKGROUND: Diabetes causes 45% of incident end-stage renal disease (ESRD). Risk of progression is higher in those with clinical risk factors (albuminuria and hypertension), and in ethnic minorities (including blacks, Asians, and Latinos). Angiotensin-converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) slow the progression of diabetic nephropathy, yet little is known about their use among patients at high risk for progression to ESRD. OBJECTIVES: To examine the prevalence of ACE or ARB (ACE/ARB) use overall and within patients with high-risk clinical indications, and to assess for ethnic disparities in ACE/ARB use. DESIGN: Observational cohort study. SETTING: Kaiser Permanente Northern California (KPNC) Diabetes Registry, a longitudinal registry that monitors quality and outcomes of care for all KPNC patients with diabetes. PATIENTS: Individuals (N= 38887) with diabetes who were continuously enrolled with pharmacy benefits during the year 2000, and had self-reported ethnicity data on survey. INTERVENTIONS AND MEASUREMENTS: Pharmacy dispensing of ACE/ARB. RESULTS: Forty-one percent of the cohort had both hypertension and albuminuria, 30% had hypertension alone, and 12% had albuminuria alone. Fourteen percent were black, 11% Latino, 13% Asian, and 63% non-Latino white. Overall, 61% of the cohort received an ACE/ARB. ACE/ARB was dispensed to 74% of patients with both hypertension and albuminuria, 64% of those with hypertension alone, and 54% of those with albuminuria alone. ACE/ARB was dispensed to 61% of whites, 63% of blacks, 59% of Latinos, and 60% of Asians. Among those with albuminuria alone, blacks were significantly (P =.0002) less likely than whites to receive ACE/ARB (47% vs 56%, respectively). No other ethnic disparities were found. CONCLUSIONS: In this cohort, the majority of eligible patients received indicated ACE/ARB therapy in 2000. However, up to 45% to 55% of high-risk clinical groups (most notably individuals with isolated albuminuria) were not receiving indicated therapy. Additional targeted efforts to increase use of ACE/ARB could improve quality of care and reduce ESRD incidence, both overall and in high-risk ethnic groups. Policymakers might consider use of ACE/ARB for inclusion in diabetes performance measurement sets.
SourceJ Gen Intern Med. 2004 Jun;19(6):669-75. Link to article on publisher's site
Permanent Link to this Itemhttp://hdl.handle.net/20.500.14038/47773
Related ResourcesLink to Article in PubMed
Showing items related by title, author, creator and subject.
Prescription Trends of Angiotensin Converting Enzyme Inhibitors (ACEi) and Angiotensin Receptor Blockers (ARBs) as Estimated in the National Ambulatory Medical Care Survey (NAMCS)Prentiss, Benjamin (2004-06-01)Background:Hypertension, whether isolated systolic, or combined systolic and diastolic, affects greater than 50% of people aged 65 or older and is the second most common reason for physician visits and medication prescriptions in the United States. The recent discoveries of the deleterious effects of intrinsic angiotensin II (ATII) activity on the cardiovascular system have opened the door for therapeutic agents which block angiotensin II activity in the primary and secondary treatment of hypertension and cardiovascular disease. While not considered first line agents for the treatment of hypertension, angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) are used for this indication especially in the presence of heart failure and diabetes mellitus. Methods:We analyzed the National Ambulatory Medical Care Survey (NAMCS) database for the years 1994-2000 and identified all patients given a diagnosis of essential hypertension. From this patient sample, we then identified patients with comorbid diagnoses CHF or diabetes mellitus. These data sets were then analyzed for ACEi or ARB use. Results:Hypertension was listed as a diagnosis in an average of 6.7% of patient visits during 1994 to 2000. The percentage of patients in the NAMCS database with a diagnosis of hypertension who were prescribed either an ACEi or ARB showed a steady increase from 20.4% in 1994 to 34.8% in 2000. Diabetes mellitus and hypertension were listed together as diagnoses in an average of 3.8% of patient visits during the same period. The percentage of patients with both hypertension and diabetes mellitus who were prescribed ACEi or ARB was consistently greater than for those patients with hypertension alone, increasing from 28.4% in 1994 to 44.6% in 2000. Patients with a diagnosis of hypertension and CHF demonstrated the highest percentage of ACEi/ARB use with an increase from 35.1% to 46.2% during the years studied. As a percentage of the total ACEi/ARB prescriptions, ARBs showed an increase from 0% to 24.1%. Conclusion:ACEi and ARB usage for the treatment of hypertension, especially with comorbidities of CHF and diabetes, is increasing. However, the usage of these classes of medications as of the 2000 NAMCS data, fall far short of optimal levels. ARB usage has increased to account for almost one-quarter of the total ACEi/ARB prescriptions.
Outpatient use of cardiovascular drugs during pregnancyAndrade, Susan E.; Raebel, Marsha A.; Brown, Jeffrey S.; Lane, Kimberly; Livingston, James; Boudreau, Denise M.; Rolnick, Sharon J.; Roblin, Douglas W.; Smith, David H.; Dal Pan, Gerald J.; et al. (2008-03-18)PURPOSE: To provide information on the prevalence of use of cardiovascular drugs, some of which may have fetotoxic or teratogenic effects, in the outpatient setting among pregnant women in the United States. METHODS: A retrospective study was conducted using the automated databases of seven health plans participating in the HMO Research Network Center for Education and Research on Therapeutics (CERT). Women who delivered an infant from 1 January 2001 to 31 December 2005 were identified. Cardiovascular drug use was evaluated assuming a gestational duration of 270 days. RESULTS: During the period 2001 through 2005, 118,935 deliveries were identified that met the criteria for study; 3.1% of women (N = 3672) were dispensed an antihypertensive medication and 0.12% of women (N = 146) were dispensed an antihyperlipidemic medication at any time during pregnancy. The most common antihypertensive drugs dispensed during pregnancy were nifedipine (1219 deliveries; 1.0%), methyldopa (961 deliveries; 0.8%), atenolol (593 deliveries; 0.5%), and labetalol (576 deliveries; 0.5%). Overall, 134 women (0.11%) received an angiotensin converting enzyme (ACE) inhibitor and 7 women (0.006%) received an angiotensin II receptor blocker (ARB) during pregnancy. Statins were the most commonly dispensed antihyperlipidemic drugs (71 deliveries; 0.06%). CONCLUSIONS: The prevalence of use of cardiovascular drugs that are suspected to be fetotoxic or teratogenic (ACE inhibitors, ARBs, and statins) was low in this cohort of pregnant women. Differing patterns of use across health plans suggests that further research is needed to evaluate the potential differential effects of cardiovascular drugs to assist prescribers and patients in making informed treatment decisions.
Indications for and utilization of ACE inhibitors in older individuals with diabetes. Findings from the National Health and Nutrition Examination Survey 1999 to 2002Rosen, Allison B. (2006-05-12)BACKGROUND: Angiotensin-converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) improve cardiovascular outcomes in high-risk individuals with diabetes. Despite the marked benefit, it is unknown what percentage of patients with diabetes would benefit from and what percentage actually receive this preventive therapy. OBJECTIVES: To examine the proportion of older diabetic patients with indications for ACE or ARB (ACE/ARB). To generate national estimates of ACE/ARB use. DESIGN AND PARTICIPANTS: Survey of 742 individuals> or =55 years (representing 8.02 million U.S. adults) self-reporting diabetes in the 1999 to 2002 National Health and Nutrition Examination Survey. MEASUREMENTS: Prevalence of guideline indications (albuminuria, cardiovascular disease, hypertension) and other cardiac risk factors (hyperlipidemia, smoking) with potential benefit from ACE/ARB. Prevalence of ACE/ARB use overall and by clinical indication. RESULTS: Ninety-two percent had guideline indications for ACE/ARB. Including additional cardiac risk factors, the entire (100%) U.S. noninstitutionalized older population with diabetes had indications for ACE/ARB. Overall, 43% of the population received ACE/ARB. Hypertension was associated with higher rates of ACE/ARB use, while albuminuria and cardiovascular disease were not. As the number of indications increased, rates of use increased, however, the maximum prevalence of use was only 53% in individuals with 4 or more indications for ACE/ARB. CONCLUSIONS: ACE/ARB is indicated in virtually all older individuals with diabetes; yet, national rates of use are disturbingly low and key risk factors (albuminuria and cardiovascular disease) are being missed. To improve quality of diabetes care nationally, use of ACE/ARB therapy by ALL older diabetics may be a desirable addition to diabetes performance measurement sets.