Improving Aspirin Prophylaxis
Study Objective: To evaluate and improve adherence to American Diabetes Association guidelines for prophylactic aspirin therapy in ambulatory patients with diabetes using a pharmacy-directed intervention.
Design: Unblinded, single intervention.
Setting: Rural, primary care clinic.
Subjects: Eighty-five patients with a diagnosis of diabetes mellitus.
Intervention: Patients with diabetes were identified from database searches and routine clinic visits. Medical records were screened for aspirin use, allergies, adverse events, and contraindications. During routine clinic visits or structured telephone interviews, patients with indications for aspirin therapy were advised to begin enteric-coated aspirin 81 mg/day. A follow-up survey assessed adherence.
Measurements and Main Results: At baseline, 28 (33%) of 85 patients were receiving aspirin therapy. An additional 8 patients had contraindications to aspirin, and 2 patients had no indications for aspirin therapy. Aspirin was recommended to 27 patients during clinic interventions and to 15 patients during telephone interventions. Two patients declined the recommendation. At the completion of this intervention, 70 (82%) of 85 patients were receiving daily aspirin or had accepted the recommendation to begin therapy.
Conclusions: A pharmacy-directed intervention increased prophylactic aspirin therapy in patients with diabetes from 33% of patients at baseline to 82% at the end of the study. The intervention, which has a simple, patient-focused design, serves as a template for improving aspirin prophylaxis among patients with diabetes in other ambulatory settings.
Cardiovascular disease (CVD) is a common, often fatal complication of diabetes mellitus, a condition that has been diagnosed in an estimated 16 million United States residents. Cardiovascular disease-related mortality rate is 2-4 times higher in patients with diabetes than in patients without diabetes. Annual medical costs for patients with both diabetes and a history of major cardiovascular events are 360% higher than for patients without diabetes and with similar cardiovascular events. One simple, often overlooked, readily available preventive therapy can reduce these alarming statistics. Daily aspirin therapy in patients with diabetes reduces myocardial infarction by 17-44%, nonfatal stroke by 25%, total CVD mortality by 5-17%, and major CVD events by 15%.
Since 1997, the American Diabetes Association (ADA) has endorsed aspirin prophylaxis for high-risk patients with diabetes. Despite the ADA guidelines, however, most patients with diabetes do not receive aspirin therapy. The third National Health and Nutrition Examination Survey (NHANES-3) estimated that from 1988-1994, 20% of adult patients with a reported history of diabetes were taking aspirin on a regular basis, compared with 37% of adult patients with a history of CVD. Data from the National Ambulatory Medical Care (NAMC) survey database corroborates the NHANES-3 estimates, indicating that 21.9% of adult patients with concurrent CVD and diabetes mellitus reported regular aspirin therapy.
Other preventive measures for patients with diabetes, including annual eye examinations, hemoglobin A1c (A1C) measurements, and foot care, also demonstrate suboptimal adherence to ADA guidelines. Medical record review of 2865 patients with diabetes from 55 Midwestern community health centers found that 26% obtained dilated eye examinations, 51% received proper foot care, and 70% had documented A1C measurements.
Interventions to improve adherence to specific ADA guidelines have proved effective. For example, nurse managers practicing in a health maintenance organization significantly improved rates of microalbuminuria screening in patients with diabetes over a 12-month period: 52% of patients in the nurse manager group received quantitative screening for microalbuminuria compared with 32% in the usual care group. No published studies report improvements in adherence to ADA aspirin guidelines.
To address this issue, an intervention designed to improve adherence to daily aspirin therapy was conducted in a diabetic population from an internal medicine-pediatric practice in New York State. This two-phase, targeted intervention sought to evaluate and improve prophylactic aspirin therapy. The practice's multidisciplinary approach to care and established patient-provider relationship made it an ideal location for this intervention.
Study Objective: To evaluate and improve adherence to American Diabetes Association guidelines for prophylactic aspirin therapy in ambulatory patients with diabetes using a pharmacy-directed intervention.
Design: Unblinded, single intervention.
Setting: Rural, primary care clinic.
Subjects: Eighty-five patients with a diagnosis of diabetes mellitus.
Intervention: Patients with diabetes were identified from database searches and routine clinic visits. Medical records were screened for aspirin use, allergies, adverse events, and contraindications. During routine clinic visits or structured telephone interviews, patients with indications for aspirin therapy were advised to begin enteric-coated aspirin 81 mg/day. A follow-up survey assessed adherence.
Measurements and Main Results: At baseline, 28 (33%) of 85 patients were receiving aspirin therapy. An additional 8 patients had contraindications to aspirin, and 2 patients had no indications for aspirin therapy. Aspirin was recommended to 27 patients during clinic interventions and to 15 patients during telephone interventions. Two patients declined the recommendation. At the completion of this intervention, 70 (82%) of 85 patients were receiving daily aspirin or had accepted the recommendation to begin therapy.
Conclusions: A pharmacy-directed intervention increased prophylactic aspirin therapy in patients with diabetes from 33% of patients at baseline to 82% at the end of the study. The intervention, which has a simple, patient-focused design, serves as a template for improving aspirin prophylaxis among patients with diabetes in other ambulatory settings.
Cardiovascular disease (CVD) is a common, often fatal complication of diabetes mellitus, a condition that has been diagnosed in an estimated 16 million United States residents. Cardiovascular disease-related mortality rate is 2-4 times higher in patients with diabetes than in patients without diabetes. Annual medical costs for patients with both diabetes and a history of major cardiovascular events are 360% higher than for patients without diabetes and with similar cardiovascular events. One simple, often overlooked, readily available preventive therapy can reduce these alarming statistics. Daily aspirin therapy in patients with diabetes reduces myocardial infarction by 17-44%, nonfatal stroke by 25%, total CVD mortality by 5-17%, and major CVD events by 15%.
Since 1997, the American Diabetes Association (ADA) has endorsed aspirin prophylaxis for high-risk patients with diabetes. Despite the ADA guidelines, however, most patients with diabetes do not receive aspirin therapy. The third National Health and Nutrition Examination Survey (NHANES-3) estimated that from 1988-1994, 20% of adult patients with a reported history of diabetes were taking aspirin on a regular basis, compared with 37% of adult patients with a history of CVD. Data from the National Ambulatory Medical Care (NAMC) survey database corroborates the NHANES-3 estimates, indicating that 21.9% of adult patients with concurrent CVD and diabetes mellitus reported regular aspirin therapy.
Other preventive measures for patients with diabetes, including annual eye examinations, hemoglobin A1c (A1C) measurements, and foot care, also demonstrate suboptimal adherence to ADA guidelines. Medical record review of 2865 patients with diabetes from 55 Midwestern community health centers found that 26% obtained dilated eye examinations, 51% received proper foot care, and 70% had documented A1C measurements.
Interventions to improve adherence to specific ADA guidelines have proved effective. For example, nurse managers practicing in a health maintenance organization significantly improved rates of microalbuminuria screening in patients with diabetes over a 12-month period: 52% of patients in the nurse manager group received quantitative screening for microalbuminuria compared with 32% in the usual care group. No published studies report improvements in adherence to ADA aspirin guidelines.
To address this issue, an intervention designed to improve adherence to daily aspirin therapy was conducted in a diabetic population from an internal medicine-pediatric practice in New York State. This two-phase, targeted intervention sought to evaluate and improve prophylactic aspirin therapy. The practice's multidisciplinary approach to care and established patient-provider relationship made it an ideal location for this intervention.
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