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Effective glycemic control in type 2 diabetes generally requires addition of 2[sup nd] and 3[sup rd] agents over time to the initially-prescribed hypoglycemic medicine. However, increasing regimen complexity may have a negative impact on medication adherence. We examined medication adherence according to the number of concurrently prescribed hypoglycemic medicines. We identified a cohort of 3082 commercially-insured type 2 diabetes patients receiving primary care within our health care network. We calculated quarterly medication adherence for each prescribed oral hypoglycemic agent using pharmacy claim refills from 01/01/04 to 12/31/05. Adherence was calculated as the % days with available pills per 90-day Interval. For patients on more than one oral hypoglycemic agent, we calculated their mean adherence to all concurrently prescribed hypoglycemic medicines. Insulins were excluded from these calculations. After excluding patients with no pharmacy claim refills during the study period, there were 1813 patients for analysis. Patients had mean age 54.5 ± 9.8 years, 57% were men, and the mean enrollment period was 18 ± 8 months. Within this cohort, 56% patients were on one, 34% on two, and 10% on three or more oral hypoglycemic medicines for at least one 90-day adherence interval. The figure shows the average per-patient adherence for all hypoglycemic medicines by quarter of study enrollment, for intervals that patients were on 1, 2, or 3 hypoglycemic drugs. Adherence was significantly higher among patients taking 3 drugs vs. 1 or 2 drugs (P < 0.02). In a cohort of insured primary care patients, the overall adherence to hypoglycemic medicines was consistently higher in quarters that patients were prescribed 3 hypoglycemic drugs compared to quarters during which 1 or 2 hypoglycemic drugs were prescribed. ADA-Funded Research [ABSTRACT FROM AUTHOR]

Prior genome-wide association studies (GWAS) of major depressive disorder (MDD) have met with limited success. We sought to increase statistical power to detect disease loci by conducting a GWAS mega-analysis for MDD. In the MDD discovery phase, we analyzed more than 1.2 million autosomal and X chromosome single-nucleotide polymorphisms (SNPs) in 18 759 independent and unrelated subjects of recent European ancestry (9240 MDD cases and 9519 controls). In the MDD replication phase, we evaluated 554 SNPs in independent samples (6783 MDD cases and 50 695 controls). We also conducted a cross-disorder meta-analysis using 819 autosomal SNPs with P<0.0001 for either MDD or the Psychiatric GWAS Consortium bipolar disorder (BIP) mega-analysis (9238 MDD cases/8039 controls and 6998 BIP cases/7775 controls). No SNPs achieved genome-wide significance in the MDD discovery phase, the MDD replication phase or in pre-planned secondary analyses (by sex, recurrent MDD, recurrent early-onset MDD, age of onset, pre-pubertal onset MDD or typical-like MDD from a latent class analyses of the MDD criteria). In the MDD-bipolar cross-disorder analysis, 15 SNPs exceeded genome-wide significance (P<5 × 10(-8)), and all were in a 248 kb interval of high LD on 3p21.1 (chr3:52 425 083-53 822 102, minimum P=5.9 × 10(-9) at rs2535629). Although this is the largest genome-wide analysis of MDD yet conducted, its high prevalence means that the sample is still underpowered to detect genetic effects typical for complex traits. Therefore, we were unable to identify robust and replicable findings. We discuss what this means for genetic research for MDD. The 3p21.1 MDD-BIP finding should be interpreted with caution as the most significant SNP did not replicate in MDD samples, and genotyping in independent samples will be needed to resolve its status.

Objectives: To examine patient and physician factors affecting utilization of diagnostic imaging in primary care., Data Sources/study Setting: Patient-level data from a large academic group practice over the period July 1, 2007, through June 30, 2009., Study Design: This is a retrospective cohort study of 85,277 patients cared for by 148 primary care physicians (PCPs). The dependent variable is the number of outpatient imaging exams ordered by each patient's PCP over the study period. Independent variables include 17 patient factors describing both clinical need and demographic characteristics and 7 physician factors., Data Collection: Data were collected from the electronic medical record and associated administrative databases., Principal Findings: Patient factors having a statistically significant effect on both the probability race, more than 10 medications, congestive heart failure, diabetes, hypertension, other problems, visits to the PCP, visits to specialists, and imaging exams ordered by specialists. For physician factors, experience, gender, and having another degree were statistically significant in both portions of the model., Conclusions: Both patient and physician factors have a substantial effect on primary care outpatient diagnostic imaging utilization. Several of these significantly influence both the probability that any images will be ordered and the intensity (number) of imaging.

Objective: To determine the costs of antidepressant medications used during inadequate treatment., Study Design: Retrospective database analysis of pharmacy claims made by patients who were treated under routine clinical conditions from July 1, 1999, through September 30, 2002., Patients and Methods: Our participants included 21,632 patients enrolled in a commercial HMO who had a primary care physician associated with our healthcare system. Patients never receiving at least a minimum likely effective antidepressant dose for at least 90 days were defined as having inadequate treatment. This study calculated the costs of antidepressants involved with inadequate treatment at the level of the patient and the medication trial., Results: A majority of patients (51%) received inadequate treatment. Of overall antidepressant costs, 16% were incurred during trials for patients never adequately treated. The majority of inadequate trials were short and unlikely to have been effective. Most patients (64%) had only a single trial of antidepressants. Venlafaxine, fluoxetine, and sertraline had significantly lower first-trial inadequacy rates compared with the most commonly prescribed agent, citalopram., Conclusions: Improved patient care quality and lower antidepressant costs could result if clinicians and healthcare systems focus on reducing short trial rates. Initiating treatment with agents least likely to be discontinued prematurely may be helpful.