Dual renin‐angiotensin‐aldosterone blockade: Implementation of published research and Dear Doctor letters in ambulatory care: A retrospective observational study using prescription data

Abstract

PurposeThis study aims to assess the implementation of published research, contraindications, and warnings on the prescription of dual renin‐angiotensin‐hormone system (RAS) blockade in ambulatory care in Germany.MethodsCohort study based on health claims data of 6.7 million subjects from 2008 to 2015. Yearly prevalence and incidence for dual RAS blockade with (a) angiotensin‐converting enzyme inhibitors and angiotensin‐receptor blockers (ACEI + ARB) and (b) aliskiren and ACEI or ARB (aliskiren + ACEI/ARB) were calculated. We assessed prescriber specialty and associations between discontinuing dual RAS blockade with specialist (internal medicine, cardiology, nephrology) visits and hospital discharge in the previous year.ResultsA total of 2 984 517 patients were included (age 51.4 ± SD 18.4 y, 48.5% male). Prescription rates for ACEI + ARB decreased from 0.6% (n = 17 907) to 0.4% (n = 12 237) and for aliskiren + ACEI/ARB from 0.23% (n = 6634) to 0.03% (n = 818). Incident prescriptions decreased from 0.23% (n = 6705) to 0.19% (n = 5055) (ACE + ARB) and from 0.1% (n = 2796) to 0.005% (n = 142) (aliskiren + ACE/ARB); 59% of ACEI + ARB and 48% of aliskiren + ACE/ARB combinations were prescribed only by one physician. Of those, 73% (ACEI + ARB) and 58% (aliskiren + ACE/ARB) were primary care providers (PCPs). Discontinuing dual RAS blockade was associated with specialist care and hospital discharge in the previous year (specialist care: RR 1.4, 95% CI, 1.3‐1.6; hospital visit: RR 1.5, 95% CI, 1.3‐1.6).ConclusionsOur results suggest a delayed uptake of treatment recommendation for ACEI + ARB and a higher impact of Dear Doctor letters addressing PCPs directly compared with published research, contraindications, and warnings. Targeted continuous medical education, practice software alerts, and stronger involvement of pharmacists might improve the implementation of medication safety recommendations in ambulatory care.

Development of quality indicators for the care of patients with chronic kidney disease

“…Die gleichzeitige Gabe von ACE-Hemmern und ARB kann jedoch zu vermehrten Nebenwirkungen (Hyperkaliämie, Hypotonie, Nierenschädigung) führen und zeigt keinen positiven Effekt auf die Mortalität (QI 23; [ 25 , 26 ]). Zwar sinkt inzwischen die Häufigkeit solcher Doppelverordnungen in Hausarztpraxen, sie tritt aber weiterhin auf [ 27 ].…”

Dear Doctor Letters regarding citalopram and escitalopram: guidelines vs real-world data

“…to reduce these risks [1]. However, the effectiveness of DDLs has been challenged [2][3][4][5], in part due to insufficient quality of warning instructions in DDLs [6]. Furthermore, a Dutch study found that DDLs regarding the risk of hospitalization are less effective than DDLs related to the risk of death or disability [7].…”

“…Dear Doctor Letters (DDLs), also known as Direct Healthcare Professional Communications (DHPCs), are paper-based warning letters with the intention of informing physicians about newly detected drug risks and recommendations to reduce these risks [ 1 ]. However, the effectiveness of DDLs has been challenged [ 2 – 5 ], in part due to insufficient quality of warning instructions in DDLs [ 6 ]. Furthermore, a Dutch study found that DDLs regarding the risk of hospitalization are less effective than DDLs related to the risk of death or disability [ 7 ].…”