Context.-Although clinical trials have demonstrated the benefits of lipidlowering therapy, little is known about how these drugs are prescribed or used in the general population. Objective.-To estimate predictors of persistence with therapy for lipid-lowering drug regimens in typical populations of patients in the United States and Canada. Design.-A cohort study defining all prescriptions filled for lipid-lowering drugs during 1 year, as well as patients' demographic and clinical characteristics. Setting.-New Jersey's Medicaid and Pharmacy Assistance for the Aged and Disabled programs and Quebec's provincial medical care program. Patients.-All continuously enrolled patients older than 65 years who filled 1 or more prescriptions for lipid-lowering drugs (N = 5611 in the US programs, and N = 1676 drawn from a 10% sample in Quebec). Main Outcome Measures.-Proportion of days during the study year for which patients had filled prescriptions for lipid-lowering drugs; predictors of good vs poor persistence with therapy. Results.-In both populations, patients failed to fill prescriptions for lipid-lowering drugs for about 40% of the study year. Persistence rates with 3-hydroxy-3methylglutaryl coenzyme A reductase inhibitors were significantly higher than those seen with cholestyramine (64.3% vs 36.6% of days with drug available, respectively). Patients with hypertension, diabetes, or coronary artery disease had significantly higher rates of persistence with lipid-lowering regimens. In New Jersey, multivariable analysis indicated that the poorest patients (those enrolled in Medicaid) had lower rates of drug use than less indigent patients (those enrolled in Pharmacy Assistance for the Aged and Disabled) after adjusting for possible confounders, despite virtually complete drug coverage in both programs. When rates of use were measured in the US population for the 5 years following the study year, only 52% of surviving patients who were initially prescribed lipid-lowering drugs were still filling prescriptions for this drug class. Conclusion.-In all populations studied, patients who were prescribed lipidlowering drug regimens remained without filled prescriptions for over a third of the study year on average. Rates of persistence varied substantially with choice of agent prescribed, comorbidity, and socioeconomic status, despite universal coverage of prescription drug costs. After 5 years, about half of the surviving original cohort in the United States had stopped using lipid-lowering therapy altogether.

Even at modest doses, including some low doses currently advocated in prescribing guidelines for older patients, treatment with benzodiazepines appears to increase the risk of hip fracture. Patients appear to be particularly vulnerable immediately after initiating therapy and after more than 1 month of continuous use. Benzodiazepines with shorter half-lives appear to be no safer than longer half-life agents. Clinicians should be aware of these risks and weigh them against potential benefits when prescribing for elderly patients.

This exploratory analysis suggests that the use of gabapentin, lamotrigine, oxcarbazepine, and tiagabine, compared with the use of topiramate, may be associated with an increased risk of suicidal acts or violent deaths.

Abstract-Hypertension remains poorly controlled in the United States. Improvement of its management will require an understanding of the patient characteristics and treatment factors associated with uncontrolled hypertension. We studied antihypertensive medication use, comorbidity, and blood pressure measurements for 525 hypertensive patients in 3 different healthcare systems over a 1-year period. We concomitantly conducted comprehensive patient interviews covering demographic factors, knowledge of hypertension and its treatment, and medication side effects. Ordinal logistic regression was used to identify factors associated with poor blood pressure control. 1 However, in a recent national study, only 29% of people with hypertension had their blood pressure controlled Ͻ140/90 mm Hg. 2 A study of older men at 5 Department of Veterans Affairs sites found even worse blood pressure control, with fewer than 25% of patients having a blood pressure Ͻ140/90 mm Hg, despite an average of Ͼ6 hypertension-related visits per year. 3 Similar results were found in a study of unionized healthcare workers with hypertension. 4 The reasons for this epidemic of uncontrolled hypertension are unclear, and several explanations have been considered. In a study of innercity patients with uncontrolled hypertension, lack of a primary care physician and noncompliance were both associated with poor blood pressure control. 5 There is also some evidence that intensity of medical therapy is related to blood pressure control; however, this is difficult to measure accurately. The cost of antihypertensive medication has also been linked to poor blood pressure control. 6 In addition to the underlying pathophysiology, blood pressure control is potentially determined by multiple other factors, including compliance behavior, the presence of comorbid illness, and patient knowledge, as well as patterns of treatment and systems of care. Much of the literature on blood pressure control is focused on antihypertensive medication adherence, and good adherence has been associated with good blood pressure control. 7 However, blood pressure is also determined by other factors, including age, severity of disease, health habits, and intensity of care.The current study was designed to test several issues related to blood pressure control that have not been extensively examined in prior studies. First, we sought to assess the role of patient-specific factors in blood pressure control, as well as to explore the relationship between age and blood pressure control. 8 -11 We also wanted to measure the relationship between patient knowledge of target blood pressure goals and blood pressure control, as lack of such knowledge has been associated with poor compliance with medications and clinic visits. 12 Second, we wished to examine the impact of different healthcare systems on blood pressure control, an especially important issue at a time when systems of care are in such rapid flux. Systems that emphasize regular, ongoing primary