Alaska DHSS/ SDS/ Senior Services

9/11/2007

Area / Services Region 1 Aniak
Contact / Title / Phone / Email

Provider Agency

Olga Perterson Kuskokwim Native Association 675-4387 Congregate & Home Delivered Meals, Assisted & Unassisted Transportation, Adult Day Services Thelma Kaganak, Director Senior Services Orutsaramiut Native Council 543-3989 tkaganak@nativecouncil.org Congregate & Home Delivered Meals, Assisted & Unassisted Transportation, Adult Day Services-Chrissie Shantz Ctr Marlis Fox, Food Service Technician marlis_fox@lksd.org 543-4844 Liz Lee, Coordinator 543-6123 Liz_Lee@ykhc.org Lower Kuskokwim School District

Bethel

Lower Kuskokwim Area
Congregate & Home Delivered Meals Lower Kuskokwim Area Chore, Respite Region 2 Fairbanks North Star Borough Homemaker Fairbanks Jodi Irvine Program Director 456-8901 jodi@fra-alaska.net Adult Day Services, Care Coordination, Respite, Extended Respite, Chore Fairbanks Resource Agency Freda Williams, Community Service Director 452-5225 commsvs1@alaska.net Fairbanks Native Association Yukon Kuskokwim Health Corporation
Fairbanks North Star Borough
Lou Gross, Executive Director 452-1735 lgross@alaska.net Congregate & Home Delivered Meals, Assisted & Unassisted Transportation
North Star Council on Aging, Inc

Fairbanks

Dulce Nobre Alzheimer's Disease Resource Agency 452-2277 or 1-800-478-1080 dnobre@alzalaska.org Care Coordination, Respite, Extended Respite, Chore, Alz Disease and Related Disorders Education, Support and Mini Grants, Family Caregiver Support. Sylvia Frank 798-7311 mintovillagecouncil@hotmail.com

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Minto Lakeview Lodge Congregate Meals

Minto Village Council

Nenana
Vickie Moyle, Director/Grant Administrator 832-5818 nenana_seniors@yahoo.com Congregate & Home Delivered Meals, Assisted & Unassisted Transportation
Nenana Tortella Council on Aging

Tanana

Josephine Grant, Health Director 366-7160 slnicholia@aol.com Congregate Meals, Senior Residential Services
Tanana Tribal Council / Elders Residence

Upper Tanana, SC Region

Betty Denny, Program Director Upper Tanana Development 883-5157 bdenny@aptalaska.net Corporation Congregate & Home Delivered Meals, Assisted & Unassisted Transportation, Homemaker Tanana Chiefs Conference, Inc ext. 3443
Interior Villages Served by TCC Lisa Donat, RN, Director Home Care 452-8251 lisa.donat@tananachiefs.org Care Coordination, Family Caregiver Support, Respite, Chore Region 3 Barrow Cynthia Troop 852-0366 cynthia.troop@north-slope.org Assisted & Unassisted Transportation Region 4 Anchorage Celeste Benson, Executive Director 258-7823 asc-director@ak.net Nutrition & Health Education and Counseling Dulce Nobre, Executive Director 561-3313 dnobre@alzalaska.org
North Slope Borough/ Department of Health & Social Services

Anchor-Age Center

Anchorage & Mat Su
Alzheimer's Disease Resource Agency
Care Coordination, Respite, Extended Respite, Chore, Alz Disease & Related Disorders Education, Support & Mini Grants, Family Caregiver Support Program Anchorage Liz Hunt, Program Director 346-2234 daybreak@alaska.net Jan Engan 349-0613 Anchorage Community Mental Health, Inc. Salvation Army, Older Alaskans Program
Adult Day Services - Daybreak Anchorage Jan_Engan@uswsalvationarmy.org
Congregate & Home Delivered Meals, Assisted Transportation, Homemaker

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Anchorage
Jesalyn Stanton, Executive Director 279-0501 jstanton@ak.net Adult Day Services - Serendipty Jody Karcz, Transportation Director 343-8484 KarczJM@muni.org

Salvation Army

Municipality Bowl Area Unassisted Transportation Anchorage and Mat-Su Valley
Municipality of Anchorage, Public Transportation Volunteers Of America, Alaska, Inc
Barbara Campbell, RSVP Program Director 279-9674 bcampbell@ak.net Retired Senior Volunteers Program Pat Cochran, Program Director 279-9634 voa-allstars@voaak.org Grandparents Raising Grandchildren

Chugiak-Eagle River

Konni Halford, Grants Management 688-2683 opsdir@mtaonline.net Congregate & Home Delivered Meals, Assisted & Unassisted Transportation Adult Day Services Region 5 Sharon Butler, Program Coordinator 688-2691 cscads@mtaonline.net
Chugiak Senior Citizens, Inc

Cordova

Shelley Balint, Project Director

Cordova Senior Services

424-8271 sbalint@cdvcmc.com Congregate & Home Delivered Meals, Assisted & Unassisted Transportation Greater Mat-Su Borough Richard Tubbs, Program Director 745-5454 rtubbs@mtaonline.net Palmer Senior Citizens Center, inc
Congregate & Home Delivered Meals & Assisted Transportation, Care Coordination, Family Caregiver Support, Adult Day Services Homer & 20 mile radius Fred Lau, Administrator Homer Senior Citizens, Inc
235-7655 fred@homerseniors.org Congregate & Home Delivered Meals, Adult Day Services - The Friendship Center

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Houston, Big & Meadow Lakes
Leslie Wheeler, Director 892-6114 mvsc@mtaonline.net Congregate & Home Delivered Meals Rachael Craig, Director 283-4156 rcraig@ci.kenai.ak.us Congregate & Home Delivered Meals, Assisted & Unassisted Transportation Leigh Hagstrom-Sanger, Executive Director leigh@nikiskiseniorcenter.org 776-7654 Homemaker, Care Coordination, Chore

Mid-Vally Seniors, Inc

City of Kenai /Senior Services
Nikiski & Kenai Peninsula
Nikiski Senior Citizens, Inc

Kenai & Soldotna

Linda Flowers, Program Director 283-7294 lflowers@cpcservices.org Adult Day Services-Forget Me Not Gail Spence or Annie Heintzman 746-3413 gspence@alzalaska.org
Central Peninsula Counseling Services, Inc

Mat-Su

Care Coordination, Respite, Extended Respite, Chore, Alz Disease and Related Disorders Education, Support and Mini Grants, Family Caregiver Support. Seldovia Marcia Patrick, Program Manager 234-7898 mpatrick@svt.org Congregate & Home Delivered Meals Dana Paperman, Executive Director Seldovia Village Tribe
Seward, Lowell Point, Crown
Seward Senior Citizens, Inc
Point & point in between 224-5604 ssc@seward.net Congregate & Home Delivered Meals, Unaasisted Transportation Soldotna, Funny River

3/4 of Ridgeway area

Jan Fena, Executive Director
Soldotna Area Senior Citizens, Inc
262-2322 solsrctr@alaska.net Congregate & Home Delivered Meals, Assisted & Unassisted Transportation, Family Caregiver Support, Respite Renee Graham, Program Contact renee_graham@fcsonline.org

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Soldotna & Kenai Peninsula
Frontier Community Services
262-6331 Care Coordination, Chore, Respite
Sterling & 77square mile vicinity Judy Warren, Director 262.6826 sterlingseniorcenter@alaska.net Information & Assistance Valdez Sharon Keese, Program Manager 835-5032 vsccsr@gci.net Congregate & Home Delivered Meals, Assisted & Unassisted Transportation Robin Hall, Executive Director 376-3104 robinh@alaskaseniors.com Congregate & Home Delivered Meals Region 6 Unalaska and Dutch Harbor
Sterling Area Senior Citizens, Inc
Valdez Senior Citizens Center, Inc

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Community Connections
Elena Rath, Program Director 247-1961 rendezvous@kpunet.net
Rendezvous Senior Day Services
Mt View Food Services, Inc
Petersburg, Wrangell, & Northern Prince of Wales Metlakatla
Shanda Gregoroff 874-3375 shanda.gregoroff@akics.org
Alaska Island Community Services
Care Coordination, Chore, Respite, Extended Respite Janet Guthrie, Metlakatla Elderly Program micsr@aptalaska.net 886-7191 Congregate & Home Delivered Meals Metlakatla Indian Community
Wilma Gauthier, Program Director Haines, Hoonah, Metlakatla 747-6960 wgauthier@cfc.org Care Coordination, Chore, Respite
Sitka, Juneau, Kake, Angoon

Center for Community

Statewide Services Statewide
Norm Brennan, Business Manager Alaska Community Services 375-2202 nbrennan@akcommunityservices.org Senior Companion, Retired Senior Volunteer, Foster Grandparent/Elder Mentor Programs Alaska Legal Services Corporation

Statewide

Gregory Peters, Attorney 222-4509 gpeters@alsc-law.org Legal Services, Family Caregiver Support
Dulce Nobre Alzheimer's Disease Resource Agency 1-800-478-1080 or 561-3313 dnobre@alzalaska.net Care Coordination, Respite, Extended Respite, Chore, Alz Disease and Related Disorders Education, Support and Mini Grants, Family Caregiver Support (for communities with no local program) Ray Clements, Executive Director execdiropag@gci.net 276-1059 Senior Voice Monthly Publication Tami Eller, Grandfamilies Network Coordinator 522-9866 grands@voaak.org Family Caregiver Support- Grandparents Raising Grandchildren Older Persons Action Group, Inc
Volunteers of America / Alaska

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NORTHSTAR HEALTHCARE CONSULTING

CLINICAL COMPASS

VOLUME 2 , ISSUE 3 JUSTIFICATION FOR THE USE OF STATINS IN PRIMARY PREVENTION: AN INTERVENTION TRIAL EVALUATING ROSUVASTATIN
SUMMARY OF ROSUVASTATIN TO PREVENT VASCULAR EVENTS IN MEN AND WOMEN WITH
ELEVATED C-REACTIVE PROTEIN
C-reactive protein is an acute phase plasma protein used as a marker for inflammation in infections and arthritis.1 Levels of high-sensitivity C-reactive protein are used to determine a patients risk for heart disease and can independently predict future events.2 Normally, there is no C-reactive protein in the blood and as the level increases, there is a correlated increase in the risk of a cardiovascular event. Patients may have elevated highsensitivity C-reactive protein without any common risks, such as vascular disease, diabetes, or hyperlipidemia. The rationale for the study is based on the premise that 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) reductase inhibitors or statins reduce levels of Creactive protein and may be useful in preventing myocardial infarctions, strokes, and death from cardiovascular causes.2 Justification for the Use of Statins in Prevention: an Intervention Trail Evaluating Rosuvastatin (JUPITER) was a randomized, double-blind, placebo-controlled, multicenter trial whose primary objective was to determine if rosuvastatin 20mg decreased the rate of primary cardiovascular events compared to placebo.2 To be included in the trial participants must have been a male 50 years or older or a female 60 years or older without history of cardiovascular disease and with low-density lipoprotein (LDL) cholesterol less than 130mg/dL, triglyceride level less than 500mg/dL, and high-sensitivity Creactive protein level greater than or equal to 2mg/L. Additional requirements were written informed consent and willingness to participate, which was tested with a 4-week run in of placebo.
Only patients with good compliance, defined as greater than 80%, during this phase were enrolled in the trial. Exclusion criteria included use of cholesterol lowering medications and/or postmenopausal hormone replacement, hepatic or kidney dysfunction, diabetes, uncontrolled hypertension, uncontrolled hypothyroidism, history of cancer within the past 5 years, history of alcohol or drug abuse, and patients with inflammatory diseases. Participants were randomly assigned in a one to one ratio to receive rosuvastatin 20mg once daily or placebo, and assessments were scheduled at 13 weeks and every 6 months from randomization for 60 months. Each assessment measured compliance, lipid levels, renal and hepatic function, blood glucose and hemoglobin A1C and monitored for outcomes and adverse effects.2 The primary endpoint was the occurrence of the first cardiovascular event from the following list: nonfatal myocardial infarction, nonfatal stroke, hospitalization for unstable angina, arterial revascularization, or confirmed death from cardiovascular causes. Secondary endpoints for the study were the individual rates of the components of the primary endpoint. The trial was designed to continue until 520 primary endpoints have been recorded providing the ability to detect a 25% reduction in the rate of primary events. However, findings of an interim efficacy analysis determined that the OBrien-Fleming stopping boundary had been crossed and the study was discontinued after a median follow-up time of 1.9 years. Analysis was conducted on an intent-to-treat basis. Hazard ratios were calculated based on the Cox proportional-hazards models with 95% confidence intervals. Subgroup analysis was conducted based on predetermined groups.2 From the initial screening of 89,890 men and women, 72,088 (80.2%) were deemed ineligible mainly for LDL cholesterol that was too high (N=37,611) and high-sensitivity C-reactive protein levels that were too low (N=25,993). The remaining 19.8% of screened patients underwent a 4 week run-in phase in which 1,521 more participants were dismissed due to poor compliance. The remaining 17,802 participants were randomized equally with 8,901 patients in each study group. Each study population was equally distributed in terms of age, gender, race, body mass index, cholesterol levels, high-sensitivity C-reactive protein levels, and blood glucose level. The study was designed to be diverse in terms of race and gender; women comprised 38.2% of the study population, while Hispanics or Blacks made up 25.2% of the population.2 At the time the study was terminated, there were 142 primary endpoints documented in the rosuvastatin group and 251 in the placebo group. The rates of a primary endpoint per 100 personyears were 0.77 and 1.36 in the rosuvastatin and placebo groups, respectively. Rosuvastatins hazard ratio was 0.56 with a 95% confidence interval (p<0.00001; Table 1). The number needed to treat to prevent one primary endpoint is 95 over a 2 year period and 31 over a 4 year period. The results of the secondary endpoints were also significant in preventing the first major cardiovascular event. The results of the primary and secondary endpoints are highlighted in Table 1.2

Table 1: Outcomes According to Study Group2 End Point Rosuvastatin (N=8,901) # of Rate per 100 pts person-yr 16 0.77 0.12 0.17 0.16 0.18 0.38 0.09 Placebo (N=8,901) # of Rate per 100 pts person-yr 27 1.36 0.33 0.37 0.31 0.34 0.71 0.14 Hazard Ratio (95% CI)

P Value

Primary end point Nonfatal myocardial infarction Any myocardial infarction Nonfatal stroke Any stroke Arterial revascularization Hospitalization for unstable angina Arterial revascularization or hospitalization for unstable angina Myocardial infarction, stroke, or confirmed death from cardiovascular causes Death on known date Any death

Pts=patients

0.56 (0.46-0.69) 0.35 (0.22-0.58) 0.46 (0.30-0.70) 0.52 (0.33-0.80) 0.52 (0.34-0.79) 0.54 (0.41-0.72) 0.59 (0.32-1.10)
<0.00001 <0.00001 0.0002 0.003 0.002 <0.0001 0.09

0.53 (0.40-0.70)

<0.00001

0.53 (0.40-0.69)

190 198

0.96 1.00

235 247

1.19 1.25

0.81 (0.67-0.98) 0.80 (0.67-0.97)

0.03 0.02

CI=confidence interval
The occurrence of adverse events was similar in the rosuvastatin and placebo groups (1,352 and 1,377, respectively; p=0.60).2 Myopathy was observed in 10 rosuvastatin patients and 9 placebo patients (p=0.82) and only one case of rhabdomyolysis was reported in the rosuvastatin group. There was a statistically significant number of physician reported newly diagnosed diabetes in the rosuvastatin as compared to the placebo group (270 and 216, respectively; p=0.01). There also was a
statistically significant increase in hemoglobin A1C in the treatment group; however, this is not clinically significant as each study group remained less than 6% as recommended by the American Diabetes Association.3 See Table 2 for a complete listing of adverse events.2 Table 2: Monitored Adverse Events, Measured Laboratory Values, and Other Reported Events of Interests during the Follow-up Period.2 Event Rosuvastatin (N=8,901) Placebo (N=8,901) 1377 (15.5%) 1375 (15.4%) 9 (0.1%) (3.5%) 58 (0.7%) 480 (5.4%) 275 (3.1%) 186 (2.1%) 10 (0.1%) 66.(02%) 5.8 P Value
Monitored Adverse Effects Any serious adverse 1352 (15.2%) event Muscular weakness, 1421 (16.0%) stiffness, or pain Myopathy 10 (0.1%) Rhabdomyolysis 1 (<0.1%) Newly diagnosed 298 (3.4%) cancer Death from cancer 35 (0.4%) Renal disorder 535 (6.0%) Bleeding 258 (2.9%) Hepatic disorder 216 (2.4%) Laboratory Values >100% increase in 16 (0.2%) serum creatinine Median glomerular 66.8 filtration rate at 12 months ALT >3xULN at 23 (0.3%) consecutive visits Median glycated 5.9 hemoglobin at 24 months Other Events Newly diagnosed 270 (3.0%) diabetes Hemorrhagic stroke 6 (0.1%)

0.60 0.34 0.82 -0.51 0.02 0.08 0.45 0.13 0.24 0.24 0.34 0.001

216 (2.4%) 9 (0.1%)

0.01 0.44
The trial successfully demonstrated that rosuvastatin significantly reduces the occurrence of cardiovascular events in participants who are at low risk by the current treatment guidelines, but have elevated levels of high-sensitivity C-reactive protein.2,4 This trial exceeded the expectations of the authors by reducing the hazard ratio by almost twice what was predicted. The therapy used in the trial was considered safe demonstrated by the adverse effect profile being very similar to placebo.2
LIMITATIONS While C-reactive protein is useful as a marker for predicting cardiovascular disease, its role as a diagnostic tool has yet to proven clinically. More studies are needed in order to determine the diagnostic value of C-reactive protein as well as other cardiovascular markers. The study did not include patients with low levels of high-sensitivity C-reactive protein because they felt those patients would be less likely to see a benefit from the therapy. However, these patients would have been useful as a comparative arm in the study. The trial was stopped early due to the results and their ethical implications; even still longer-term data is needed to ensure safety and efficacy due to that fact that patients in practice will be taking the medication for many years. Based on currently available data, the patients enrolled in this study are at lower risk for events and as such there must be strong justification for recommending long term therapy. More studies with varying doses should be conducted to determine if the therapy decreases the risk enough to warrant nearly life long therapy as some participants in the interquartile had highsensitivity C-reactive protein levels at 12 months that are categorized as high risk.1 Also, the long term effects and ramifications of low LDL cholesterol levels must also be investigated. At 12 months, the average level was 55mg/dL and the long term effects of such levels are unknown. Participants in this trial were screened for compliance, were followed between visits with phone calls, and assessed on their compliance at each assessment. This high level of compliance may not be applicable to the average patient and results may not be duplicated in the practice setting. Meta-regression analysis was used to determine that the risk reduction seen with rosuvastatin was greater than expected. However, the use of this method has been called into question. This combined with the early termination of the trial may have lead to exaggerated results.5 IMPLICATIONS TO CLINICAL GUIDELINES Current National Cholesterol Education Program guidelines site LDL cholesterol as the primary target for lipid-lowering therapy.6 A patients target LDL cholesterol is determined by his/her coronary heart disease (CHD) status and/or CHD equivalents, such as diabetes, atherosclerotic disease, as well as other risk factors such as, age, gender, family history, hypertension, and smoking status.6 Screening for C-reactive protein is not in the current guidelines as a clear causative link has yet to be confirmed.1,5 Current guidelines concerning C-reactive protein levels recommend testing patients with intermediate risk if the result of the test would change the course of therapy.5 If results from this trial are used to elevate C-reactive protein testing to a more prominent place in practice, there may be an increase in healthcare costs for medical and pharmaceutical providers. Additional laboratory tests will increase medical costs; however, this may or may not be substantial given that other bloods tests are being drawn concurrently to check for LDL cholesterol levels. Additionally, the cost spent in testing may be recovered by decreasing the number of

hospitalizations long term. However, testing will qualify more patients to be eligible for drug therapy leading to an increase in prescription costs. CONCLUSION Recommendations concerning expanding the use of rosuvastatin to patients with elevated levels of high-sensitivity C-reactive protein without other risks for cardiovascular events must be carefully considered based upon the results of this one study. The absolute risk reduction must justify the additional cost and potential risk of exposing low risk patients to medication. More studies are needed to confirm the benefit of statin therapy in this patient population. Moreover, until studies proving a causative relationship between C-reactive protein levels and cardiovascular events are conducted and confirmed, C-reactive protein testing should only be used as a marker for cardiovascular risk. REFERENCES
1. 2. 3. Borigini, Mark James. C-Reactive Protein. Medline Plus Medical Encyclopedia. http://www.nlm.nih.gov/medlineplus/ency/article/003356.htm. Updated January 16, 2007. Accessed November 19, 2008. Ridker, Paul M, Danielson, Eleanor, Fonseca, Francisco A.H., Genest, Jacques, et al. Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein. N Engl J Med 2008;359: 2195-2207. American Diabetes Association. Standards of Medical Care in Diabetes 2008. Diabetes Care 31: S12-54S. http://care.diabetesjournals.org/cgi/content/full/31/Supplement_1/S12?maxtoshow=&H ITS= 1 0&hits=10&RESULTFORMAT=&fulltext=a1c&searchid=1&FIRSTINDEX=0&volume=31&issue=Supplement +1%0D%0A&resourcetype=HWCIT#otherarticles. Accessed November 21, 2008. Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004;110:227-39. Hlatky, Mark. Expanding the Orbit of Primary Prevention- Moving beyond JUPITER. N Engl J Med 2008;359:2208-2282. Executive summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on the Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-97.