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Objective: To assess oral antihyperglycemic agents (OAHA) and/or statin treatment initiation in patients with type 2 diabetes (T2D) and time from diagnosis to both types of treatment initiation and intensification. Research design and methods: We reviewed 662 retrospective medical records of patients with T2D diagnosed by 31 general practitioner or specialist sites across Mexico, Argentina, and Brazil. Demographic and clinical information was abstracted from patients’ medical records and summarized using descriptive statistics. Between-group differences were assessed with Student’s t-test for continuous variables and Fisher’s exact test for categorical variables. The starting time of each therapy (OAHA and statins, separately) was assessed using Kaplan-Meier estimates. Results: At diagnosis, patients’ mean age was 53 years; 44% had hypertension, 42% were obese, and 23% had dyslipidemia. During the 2-year follow-up, 95% of patients received OAHAs but only 29% of those eligible for statins received this prescription. Mean ± SD and median (Q1, Q3) time to first OAHA was 59 ± 141 days and 1 (1, 31) day, respectively, and 230 ± 232 days and 132 (30, 406) days, respectively, for a statin. During follow-up, 51–53% of patients with HbA1c/FPG values above target did not intensify hyperglycemia treatment. Conclusion: Dyslipidemia treatment in patients with T2D was delayed despite its known deleterious effect on atherosclerosis development and β-cell mass/function. Anti-hyperglycemic treatment was not intensified when targets were not attained. This prescriptive inertia needs to be corrected because attainment of HbA1c treatment goals becomes more difficult, favoring the development of diabetes complications. Keywords: Type 2 diabetes, Dyslipidemia, Treatment initiation, Clinical inertia, Antihyperglycemic agent, Statin

Abstract Background Veterinary clinic transaction records from the USA were examined to determine dog owner purchase patterns for three prescription ectoparasiticides. In-clinic purchases of formulations of fluralaner (with 12-week duration per dose) were compared with dog owner purchases of afoxolaner and spinosad (both with 4 week duration per dose) in a population of 231,565 dogs over a 12 month period. Prior studies in human and animal medicine have suggested that patients more closely adhere to prescriber dosing recommendations when they receive a longer-duration medication. Results Veterinary clinic transaction records were examined for the period June 2014 through March 2017 using records from approximately 650 veterinary clinics. Ectoparasiticide purchase patterns were compared for two products (afoxalaner and spinosad) with monthly dosing and one product (fluralaner) with an extended (12 week) dosing interval. The average dog owner who obtained fluralaner purchased significantly more months of flea/tick protection (5.7 months) over the 12-month study period than the average dog owner that selected either afoxolaner (4.6 months) or spinosad (3.3 months). The proportion of dog owners who obtained only one dose of ectoparasiticide per 12-month period was 42% for fluralaner, 30% for afoxolaner and 37% for spinosad. The proportion of dog owners who obtained 2 doses or less per 12-month period was 67% for fluralaner, 52% for afoxoalaner and 67% for spinosad. Owners that obtained fluralaner were significantly more likely to obtain 7.0–12.0 months of flea and tick protection and significantly less likely to purchase 1.0–6.9 months compared with dog owners who purchased afoxolaner or spinosad. Conclusions Dog owners who obtained a flea and tick medication with a longer duration of action acquired significantly more months of protection in a year than dog owners who obtained shorter duration (1 month) products. Dog owners were better able to adhere to veterinary recommendations on ectoparasites control with a longer-acting flea/tick medication.

Abstract Background Doses of flea and tick medication acquired by dog owners over a 12 month period were determined from veterinary hospital transaction records in Spain. The number of months of flea and tick protection potentially obtained by dog owners prescribed fluralaner, a flea and tick medication with a 12 week re-dosing interval, was compared with months of flea and tick protection obtained by dog owners prescribed monthly oral or spot-on products. Prior studies in human and veterinary medicine have suggested that longer-acting medications benefit patients by providing improved adherence to provider recommendations. Results Dog owners took home, on average, significantly more months of protection when they obtained the 12 week duration product fluralaner (4.3 months) than they did when they obtained other flea and tick products providing 1 month of protection [3.24 months (oral), 2.9 months (spot-on)]. Many dog owners (46–64%) obtained only one dose of flea and tick product each year, regardless of the duration of protection offered by the product. Significantly more dog owners obtained 7–12 months of protection when they were prescribed fluralaner (15.7%) by their veterinarians compared with dog owners prescribed monthly flea and tick products [6.8% (oral), 8.3% (spot-on)]. Conclusion Veterinary prescription of fluralaner delivers more months of potential flea and tick protection as shown by dog owner acquisition of flea and tick medication. The use of a longer-acting medication requires the administration of fewer doses and may translate into better adherence to veterinary ectoparasite control recommendations.

Abstract Background Heartworm medications and many oral or topical flea and tick products are provided as monthly doses while a newer oral flea/tick product, fluralaner (BRAVECTO® Chew), is re-dosed at a 12-week interval. This study focused on whether there was a difference in the number of heartworm medication doses that were purchased in the 12-months follow-up period for dogs that receive either fluralaner or other flea/tick medications that are dosed monthly. Methods Clinic transaction records of heartworm medication purchases for over 200,000 dogs were examined to compare the purchase of heartworm preventative protection by dog owners that also receive flea and tick medications of differing efficacy durations. Results Annual purchases of heartworm medication for dogs by owners that receive a flea and tick medication dosed at 12-week intervals was incrementally higher than the number of doses purchased for dogs receiving monthly flea and tick medications. The average number of monthly doses per year was slightly over 7 months for both categories of product. The distribution of purchases of monthly doses was also similar between groups. Conclusions Dog owners who purchase a longer-acting flea and tick medication purchase as much heartworm medication annually for their dogs as dog owners who purchase monthly flea and tick medication. On average, dog owners who gave their dog fluralaner obtained significantly more months of heartworm preventative protection compared with dog owners who gave their dog a monthly flea and tick medication, although the biological significance of this increase in doses is very small.

Abstract Background South African veterinarians report the perception of a multi-year decline in the number of dogs presenting with clinical babesiosis, a common and serious disease of dogs in the country. This study tested this observation through analysis of veterinary hospital medical records from 2011 through 2016. Methods Medical records were collected from 44 participating South African veterinary hospitals. The collected medical records were searched to enumerate the number of Babesia-specific medication treatments administered to dogs at all participating hospitals. A healthcare use rate was calculated for canine babesiosis treatment for each calendar year from 2011 to 2016. The healthcare use rate numerator was the total number of canine babesiosis treatments and the denominator was the total dog visits to all participating veterinary practices over the same period. Results There were 2.6 million dog visits to 44 participating veterinary practices between 2011 and 2016. The number of canine babesiosis treatments for each year in chronological order starting with 2011 was: 2957; 2679; 2456; 2746; 2272; and 1592. South African regions with the highest number of canine babesiosis treatments were Gauteng, Free State and Mpumalanga. The overall calculated healthcare use rate for canine babesiosis treatment declined 72% over the study period from 1.18% in 2011 to 0.33% in 2016. The steepest decline of 31% was observed between 2015 and 2016. Conclusions South African veterinary practices saw a decline in canine babesiosis treatment administration from 2011 to 2016 with the steepest decline beginning in 2015.

Abstract Background Adherence to a prescribed therapeutic regimen is a critical factor for achieving medication effectiveness and therefore treatment success. In the case of companion animal ectoparasite control, suboptimal owner adherence to medication recommendations is thought to be a common cause of treatment failure, and previous reports have found pet owners applying an average of 4.0–4.6 monthly flea and tick treatments per year to their dogs. This study investigated: US veterinary hospital self-reported flea and tick prevention recommendations; dog owner recollection of these recommendations; dog owner opinion on flea/tick recommendations and estimated owner flea and tick medication adherence based on veterinary hospital purchase records. Results Veterinarians at 24 veterinary hospitals in 4 United States regions provided their flea and tick prevention recommendations. Five hundred fifty-nine dog owners, clients of the 24 hospitals, completed a survey evaluating their recollection of the hospitals’ recommendations and their opinions regarding required treatment frequency. Almost all veterinary hospitals in this study recommended 12 months of flea and tick prevention but only 62% of participating dog owners recalled this recommendation. The average owner response was that their dogs require 10.5 months of flea and tick prevention annually. Owner opinions were significantly different among U.S. regions with pet owners in the northeast U.S. believing that they needed significantly less canine flea and tick protection than pet owners in other parts of the United States. The estimated actual flea and tick prevention coverage was 6.1 months based on owner medication purchases over a 12-month period. Conclusions In the United States, dog owner opinions and actions show that their flea and tick treatment adherence falls short of veterinarians’ recommendations.

Introduction. Whether changes in adherence are associated with changes in HbA1c is assumed but not known. Methods. We conducted a observational study of 2,844 type 2 diabetes patients who initiated metformin as their first antihyperglycemic drug. Using HbA1c measures before, 6–12 months after, and up to 3 years after metformin initiation, we analyzed HbA1c change as a function of initial adherence and change in adherence. Results. Compared with no adherence, initial adherence of 50–79% was associated with an adjusted reduction in HbA1c of 0.45% while adherence ≥80% was associated with HbA1c reduction of 0.73%. Change from some initial adherence (1–79%) to total nonadherence was associated with 0.25% increase in HbA1c. Change from some to full adherence was associated with an HbA1c decrease of 0.15%. Those associations were accentuated among patients not in glycemic control: change from some to no adherence was associated with an HbA1c increase of 0.63% and change from some to full adherence was associated with an HbA1c decrease of 0.40%. Conclusions. Initial adherence to newly prescribed metformin therapy produces substantial HbA1c reduction. Among those with modest adherence but suboptimal glycemic control, the difference between moving to full adherence versus nonadherence results in lower HbA1c of one percentage point.

This study examined the effect of job-related health insurance on employment transitions (labor force exits, reductions in hours, and job changes) of older working cancer survivors. Using multivariate models, we compared longitudinal data for the period 1997–2002 from the Penn State Cancer Survivor Study to similar data for workers with no cancer history in the Health and Retirement Study, who were also ages 55 to 64 at follow-up. The interaction of cancer survivorship with health insurance at diagnosis was negative and significant in predicting labor force exits, job changes, and transitions to part-time employment for both genders. The differential effect of jobrelated health insurance on the labor market dynamics of cancer survivors represents an additional component of the economic and psychosocial burden of cancer on survivors.

Objective:To systematically review and analyse evidence for cholesterol-lowering efficacy of at least 4 weeks of add-on ezetimibe vsdoubling statin dose, in adults with primary hypercholesterolaemia.Research design and methods:MEDLINE, EMBASE and Cochrane databases were searched to identify randomised controlled trials of ezetimibe––statin combination vsstatin titration (January 1993 –– March 2010). Studies were selected using predefined criteria. Two reviewers conducted screening of articles, critical appraisal and data extraction; a third reviewer resolved disagreements. The difference between treatments was analysed for four co-primary outcomes: mean percentage change from baseline in low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and total cholesterol (TC); and proportion of patients achieving LDL-C treatment goal. Data were combined by two sets of direct comparison fixed and random effects meta-analysis: (1) compared data in the same treatment period between groups; (2) compared the incremental change in lipid levels of add-on ezetimibe vsdoubling statin dose. Heterogeneity was assessed using the I2statistic.Results:Thirteen studies including 5080 patients were included in the meta-analyses. Data on simvastatin, atorvastatin and rosuvastatin were analysed. Results for primary and secondary outcomes were in favour of the ezetimibe––statin combination. A significantly greater percentage reduction in LDL-C levels was achieved in patients treated with ezetimibe––statin vsstatin monotherapy (weighted mean difference [WMD]: −−14.1% [−−16.1, −−12.1], p  <  0.001). Reduction in LDL-C levels attributed to add-on ezetimibe was significantly greater than that for statin dose doubling (WMD: −−15.3% [−−19.1, −−11.4], p  <  0.001). Achievement of LDL-C goal favoured add-on ezetimibe over statin titration and was statistically significant (odds ratio: LDL-C treatment goal 2.45 [1.95, 3.08], p  =  0.007).Conclusions:Meta-analyses were restricted by the limited number of studies with similar trial design and method of statin titration. Results indicate that add-on ezetimibe is significantly more effective in reducing LDL-C levels than doubling statin dose, enabling more patients to achieve LDL-C goal. [ABSTRACT FROM AUTHOR]

AbstractObjective:To evaluate the cost-effectiveness of generic atorvastatin 20mg (A20), branded rosuvastatin 10mg (R10), generic simvastatin 40mg (S40) and the combination of generic S40  branded ezetimibe 10mg (S40EZ10) for the secondary prevention of coronary heart disease (CHD) in Finnish patients not meeting the target goal of low-density lipoprotein cholesterol (LDL-C) with S40.Research design and methods:A probabilistic Markov model was employed to evaluate the costs and health outcomes of the different therapies based on the cardiovascular events avoided. The model included Framingham risk equations, Finnish population characteristics, event rates, quality of life estimates, resource use and unit costs. The LDL-C lowering efficacies were gathered from a systematic literature review, based on a search of Medline carried out in June 2008 (no time limit).Main outcome measures:Incremental cost per quality-adjusted life year (QALY) gained and incremental cost per life year gained (LYG).Results:The efficacy (LDL-C decrease) gained from switching S40 to S40EZ10 was consistent in the literature review, whereas the LDL-C decrease gained from switching S40 to A20/R10 was uncertain. The incremental cost per QALY gained from switching generic S40 was lowest for S40EZ10 (€22,841 [€24,017] and €26,595 [€46,686] for diabetic and non-diabetic men [women], respectively). The respective incremental cost per QALY gained for S40EZ10 vs. A20 were €19,738 (€21,405) and €23,596 (€40,087). A20 dominated R10. Based on the cost-effectiveness acceptability frontier with a willingness-to-pay value of €30,000 per QALY gained, the probability of cost-effectiveness for switching generic S40 to S40EZ10 was 100 for men and diabetic women. Sensitivity analyses showed that results were robust.Conclusions:In the Finnish secondary prevention population that is not at goal on S40, switching generic S40 to S40EZ10 is more cost-effective than switching S40 to generic A20 or R10. [ABSTRACT FROM AUTHOR]