Predicting performance in health professions education programs from admissions information - Comparisons of other health professions with pharmacy

BACKGROUND

The goal of the present review was to assess the state of performance prediction in healthcare programs generally, versus performance prediction in pharmacy schools, using didactic and non-didactic admissions measures. This is important because clinical success represents a combination of skills that are not fully predicted by either type of measure alone.

METHODS

PubMed searches were conducted focusing on work published from 2000 onwards, since it is during this period that non-didactic admissions measures have come to be incorporated into the applicant evaluation process. Relevant free full text papers available were used. When these papers were not available by direct import into EndNote, we went directly to the journal to try to retrieve the paper.

RESULTS

We acknowledge that health professions programs have been successful in recruiting excellent candidates into their schools. However, based on the modest amount of healthcare program performance accounted for by didactic measures, admissions committees should consider expanding their holistic evaluation of applicants. Schools would benefit from using two-step screening phases in the application process - perhaps evaluating didactic potential in phase 1 and experiential in phase 2. Using combination measures throughout the admission process should help ensure admission of students more likely to be successful throughout their healthcare practice.

IMPLICATIONS

Future investigations of the prediction of healthcare program performance by formal combinations of didactic and non-didactic admissions measures are imperative. In addition, it is likely that combination admission measures will incorporate more metrics of critical thinking than do simpler approaches. Furthermore, systematic evaluation of the usefulness of the two-step screening approaches to admissions used by most competitive health professions programs also needs to be done.

Shift to community-onset Clostridium difficile infection in the national Veterans Health Administration, 2003-2014

BACKGROUND

Clostridium difficile infection (CDI) occurs frequently in inpatient settings; however, community-onset cases have been reported more frequently in recent years. This study evaluated hospital-onset and community-onset CDI in the national Veterans Health Administration (VHA) population over a 12-year period.

METHODS

This was a retrospective cohort study of all adult VHA beneficiaries with CDI between October 1, 2002, and September 30, 2014. Data were obtained from the Veterans Affairs Informatics and Computing Infrastructure. CDI was categorized into community-associated CDI (CA-CDI); community-onset, health care facility-associated CDI; and health care facility-onset CDI (HCFO-CDI). Each type was described longitudinally and was assessed as an independent risk factor for health outcomes using multivariable logistic regression.

RESULTS

Overall, 30,326 patients with a first CDI episode were included. HCFO-CDI was the predominant type (60.2%), followed by CO-HCFA-CDI (20.6%) and CA-CDI (19.2%). The proportion of patients with HCFO-CDI decreased from 73.5% during fiscal year 2003 to 53.2% during fiscal year 2014, whereas CA-CDI increased from 8.3% to 26.7%. HCFO-CDI was a positive predictor of severe CDI (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.59-1.84) and 30-day mortality (OR, 1.46; 95% CI, 1.32-1.61), but a negative predictor of 60-day recurrence (OR, 0.41; 95% CI, 0.37-0.46).

CONCLUSIONS

HCFO-CDI was the predominant CDI type. The proportion of patients with CA-CDI increased and HCFO-CDI decreased in recent years. Patients with HCFO-CDI experienced higher rates of severe CDI and mortality.

Derivation and Validation of a Clostridium difficile Infection Recurrence Prediction Rule in a National Cohort of Veterans

STUDY OBJECTIVE

Prior studies have identified risk factors for recurrent Clostridium difficile infection (CDI), but few studies have integrated these factors into a clinical prediction rule that can aid clinical decision-making. The objectives of this study were to derive and validate a CDI recurrence prediction rule to identify patients at risk for first recurrence in a national cohort of veterans.

DESIGN

Retrospective cohort study.

DATA SOURCE

Veterans Affairs Informatics and Computing Infrastructure.

PATIENTS

A total of 22,615 adult Veterans Health Administration beneficiaries with first-episode CDI between October 1, 2002, and September 30, 2014; of these patients, 7538 were assigned to the derivation cohort and 15,077 to the validation cohort.

MEASUREMENTS AND MAIN RESULTS

A 60-day CDI recurrence prediction rule was created in a derivation cohort using backward logistic regression. Those variables significant at p<0.01 were assigned an integer score proportional to the regression coefficient. The model was then validated in the derivation cohort and a separate validation cohort. Patients were then split into three risk categories, and rates of recurrence were described for each category. The CDI recurrence prediction rule included the following predictor variables with their respective point values: prior third- and fourth-generation cephalosporins (1 point), prior proton pump inhibitors (1 point), prior antidiarrheals (1 point), nonsevere CDI (2 points), and community-onset CDI (3 points). In the derivation cohort, the 60-day CDI recurrence risk for each score ranged from 7.5% (0 points) to 57.9% (8 points). The risk score was strongly correlated with recurrence (R²  = 0.94). Patients were split into low-risk (0-2 points), medium-risk (3-5 points), and high-risk (6-8 points) classes and had the following recurrence rates: 8.9%, 20.2%, and 35.0%, respectively. Findings were similar in the validation cohort.

CONCLUSION

Several CDI and patient-specific factors were independently associated with 60-day CDI recurrence risk. When integrated into a clinical prediction rule, higher risk scores and risk classes were strongly correlated with CDI recurrence. This clinical prediction rule can be used by providers to identify patients at high risk for CDI recurrence and help guide preventive strategy decisions, while accounting for clinical judgment.

Economic Burden of Attention-Deficit/Hyperactivity Disorder among Pediatric Patients in the United States

OBJECTIVES

To determine the adjusted incremental total costs (direct and indirect) for patients (aged 3-17 years) with attention-deficit/hyperactivity disorder (ADHD) and the differences in the adjusted incremental direct expenditures with respect to age groups (preschoolers, 0-5 years; children, 6-11 years; and adolescents, 12-17 years).

METHODS

The 2011 Medical Expenditure Panel Survey was used as the data source. The ADHD cohort consisted of patients aged 0 to 17 years with a diagnosis of ADHD, whereas the non-ADHD cohort consisted of subjects in the same age range without a diagnosis of ADHD. The annual incremental total cost of ADHD is composed of the incremental direct expenditures and indirect costs. A two-part model with a logistic regression (first part) and a generalized linear model (second part) was used to estimate the incremental costs of ADHD while controlling for patient characteristics and access-to-care variables.

RESULTS

The 2011 Medical Expenditure Panel Survey database included 9108 individuals aged 0 to 17 years, with 458 (5.0%) having an ADHD diagnosis. The ADHD cohort was 4.90 times more likely (95% confidence interval [CI] 2.97-8.08; P < 0.001) than the non-ADHD cohort to have an expenditure of at least $1, and among those with positive expenditures, the ADHD cohort had 58.4% higher expenditures than the non-ADHD cohort (P < 0.001). The estimated adjusted annual total incremental cost of ADHD was $949.24 (95% CI $593.30-$1305.18; P < 0.001). The adjusted annual incremental total direct expenditure for ADHD was higher among preschoolers ($989.34; 95% CI $402.70-$1575.98; P = 0.001) than among adolescents ($894.94; 95% CI $428.16-$1361.71; P < 0.001) or children ($682.71; 95% CI $347.94-$1017.48; P < 0.001).

CONCLUSIONS

Early diagnosis and use of evidence-based treatments may address the substantial burden of ADHD.

Health care-associated pneumonia in the intensive care unit: Guideline-concordant antibiotics and outcomes

PURPOSE

Recent data have not demonstrated improved outcomes when guideline-concordant (GC) antibiotics are given to patients with health care-associated pneumonia (HCAP). This study was designed to evaluate the relationship between health outcomes and GC therapy in patients admitted to an intensive care unit (ICU) with HCAP.

MATERIALS AND METHODS

We performed a population-based cohort study of patients admitted to greater than 150 hospitals in the US Veterans Health Administration system to compare baseline characteristics, bacterial pathogens, and health outcomes in ICU patients with HCAP receiving GC-HCAP therapy, GC community-acquired pneumonia (GC-CAP) therapy, or non-GC therapy. The primary outcome was 30-day patient mortality. Risk factors for the primary outcome were assessed in a multivariable logistic regression model.

RESULTS

A total of 3593 patients met inclusion criteria and received GC-HCAP therapy (26%), GC-CAP therapy (23%), or non-GC therapy (51%). Patients receiving GC-HCAP had higher 30-day patient mortality compared to GC-CAP patients (34% vs 22%; P< .0001). After controlling for confounders, risk factors for 30-day patient mortality were vasopressor use (odds ratio, 1.67; 95% confidence interval, 1.30-2.13), recent hospital admission (1.53; 1.15-2.02), and receipt of GC-HCAP therapy (1.51; 1.20-1.90).

CONCLUSIONS

Our data do not demonstrate improved outcomes among ICU patients with HCAP who received GC-HCAP therapy.

A prospective observational cohort study in primary care practices to identify factors associated with treatment failure in Staphylococcus aureus skin and soft tissue infections

Background

The incidence of outpatient visits for skin and soft tissue infections (SSTIs) has substantially increased over the last decade. The emergence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has made the management of S. aureus SSTIs complex and challenging. The objective of this study was to identify risk factors contributing to treatment failures associated with community-associated S. aureus skin and soft tissue infections SSTIs.

Methods

This was a prospective, observational study among 14 primary care clinics within the South Texas Ambulatory Research Network. The primary outcome was treatment failure within 90 days of the initial visit. Univariate associations between the explanatory variables and treatment failure were examined. A generalized linear mixed-effect model was developed to identify independent risk factors associated with treatment failure.

Results

Overall, 21% (22/106) patients with S. aureus SSTIs experienced treatment failure. The occurrence of treatment failure was similar among patients with methicillin-resistant S. aureus and those with methicillin-susceptible S. aureus SSTIs (19 vs. 24%; p = 0.70). Independent predictors of treatment failure among cases with S. aureus SSTIs was a duration of infection of ≥7 days prior to initial visit [aOR, 6.02 (95% CI 1.74–19.61)] and a lesion diameter size ≥5 cm [5.25 (1.58–17.20)].

Conclusions

Predictors for treatment failure included a duration of infection for ≥7 days prior to the initial visit and a wound diameter of ≥5 cm. A heightened awareness of these risk factors could help direct targeted interventions in high-risk populations.

Use of Statins and the Risk of Incident Diabetes: A Retrospective Cohort Study

INTRODUCTION

Even though several landmark statin trials have demonstrated the beneficial effects of statin therapy in both primary and secondary prevention of cardiovascular disease, several studies have suggested that statins are associated with a moderate increase in risk of new-onset diabetes. These observations prompted the US FDA to revise statin labels to include a warning of an increased risk of incident diabetes mellitus as a result of increases in glycosylated hemoglobin (HbA1c) and fasting plasma glucose. However, few studies have used US-based data to investigate this statin-associated increased risk of diabetes.

OBJECTIVE

The primary objective of our study was to examine whether the use of statins increases the risk of incident diabetes mellitus using data from the Thomson Reuters MarketScan (®) Commercial Claims and Encounters Database.

METHOD

This study was a retrospective cohort analysis utilizing data for the period 2003-2004. The study population included new statin users aged 20-63 years at index who did not have a history of diabetes.

RESULTS

The proportion (3.4 %) of statin users (N = 53,212) who had incident diabetes was higher than the proportion (1.2 %) of non-statin users (N = 53,212) who had incident diabetes. Compared with no statin use and controlling for demographic and clinical covariates, statin use was significantly associated with increased risk of incident diabetes (hazard ratio 2.01; 99 % confidence interval 1.74-2.33; p < 0.0001). In addition, risk of diabetes was highest among users of lovastatin, atorvastatin, simvastatin, and fluvastatin. Diabetes risk was lowest among pravastatin and rosuvastatin users.

DISCUSSION

Because the potential for diabetogenicity differs among different statin types, healthcare professionals should individualize statin therapy by identifying patients who would benefit more from less diabetogenic statin types.

Health Costs and Outcomes Associated with Medicare Part D Prescription Drug Cost-Sharing in Beneficiaries on Dialysis

BACKGROUND

High out-of-pocket costs for prescription medications have been associated with poor patient outcomes. A previous study found that the Part D coverage gap was significantly associated with decreases in adherence and persistence for medications frequently used in patients undergoing dialysis. It is not known what effect the decreased use of prescription drugs associated with the coverage gap had on utilization and spending for other medical care. 

OBJECTIVE

To determine the relationship between the Part D prescription drug cost-sharing structure and health and economic outcomes in Medicare beneficiaries on dialysis.

METHODS

A retrospective analysis using data from the United States Renal Data System (2006-2008) was conducted for Medicare-eligible patients receiving dialysis. Patients were grouped in 1 of 4 cohorts based on low-income subsidy (LIS) receipt and benefit phase in 2007: Cohort 1 (non-LIS and did not reach the coverage gap); Cohort 2 (non-LIS and reached the coverage gap); Cohort 3 (non-LIS and reached catastrophic coverage after the gap); and Cohort 4 (received an LIS, and none of the LIS patients reached the coverage gap). Outcomes included medical care utilization, direct medical costs, and mortality. 

RESULTS

A total of 11,732 subjects met the inclusion criteria. Patients in Cohorts 1, 2, and 3 had $3,222 lower, $2,457 lower, and $1,182 higher adjusted pharmacy costs (P  less than  0.001), but their adjusted hospitalization costs were $1,499 (P = 0.09), $2,287 (P = 0.01), and $2,959 (P = 0.01) higher, respectively, compared with Cohort 4 (LIS). In the propensity score-matched cohorts, patients who reached the coverage gap (Cohort 2) had higher rates of hospitalization (relative risk [RR] = 1.02, 95% CI = 0.94-1.10), outpatient visits (RR = 1.16, 95% CI = 1.08-1.25), and other visits (RR = 1.17, 95% CI = 1.03-1.32) compared with those who had an LIS (Cohort 4). Patients in Cohort 3 had a higher rate of outpatient visits compared with those in Cohort 4 (RR = 1.14, 95% CI = 1.03-1.25). There were no differences in medical care utilization between patients in Cohort 1 and Cohort 4. Compared with patients in Cohort 4 (LIS), patients in Cohort 2 (those who reached the coverage gap) had 9% higher hospitalization costs (RR = 1.09, 95% CI = 1.01-1.18) and 6% higher outpatient costs (RR = 1.06, 95% CI = 0.97-1.17), respectively. During the 1-year follow-up period, patients in Cohort 2 had a 20% (HR = 1.20, 95% CI = 1.05-1.37) and a 22% (HR = 1.22, 95% CI = 1.01-1.47) increased risk of all-cause and cardiovascular-related mortality compared with those in Cohort 4, respectively. 

CONCLUSIONS

Our findings suggest that reaching the Part D coverage gap was associated with unfavorable clinical and economic outcomes in patients undergoing dialysis.

Attitudes Toward Medications and the Relationship to Outcomes in Patients with Schizophrenia

The determinants of attitudes toward medication (ATM) are not well elucidated. In particular, literature remains equivocal regarding the influence of cognition, adverse events, and psychiatric symptomatology. This study evaluated relationships between those outcomes in schizophrenia and ATM. This is a retrospective analysis of data collected during the Texas Medication Algorithm Project (TMAP, n=307 with schizophrenia-related diagnoses), in outpatient clinics at baseline and every 3 months for ≥1 year (for cognition: 3rd and 9th month only). The Drug Attitude Inventory (DAI-30) measured ATM, and independent variables were: cognition (Trail Making Test [TMT], Verbal Fluency Test, Hopkins Verbal Learning Test), adverse events (Systematic Assessment for Treatment-Emergent Adverse Events, Barnes Akathisia Rating Scale), psychiatric symptomatology (Brief Psychiatric Rating Scale, Scale for Assessment of Negative Symptoms [SANS]), and medication adherence (Medication Compliance Scale). Analyses included binary logistic regression (cognition, psychiatric symptoms) and chi-square (adverse events, adherence) for baseline comparisons, and linear regression (cognition) or ANOVA (adverse events, adherence) for changes over time. Mean DAI-30 scores did not change over 12 months. Odds of positive ATM increased with higher TMT Part B scores (p=0.03) and lower SANS scores (p=0.02). Worsening of general psychopathology (p<0.001), positive symptoms (p<0.001), and negative symptoms (p=0.007) correlated with negative changes in DAI-30 scores. Relationships between cognition, negative symptoms, and ATM warrant further investigation. Studies evaluating therapies for cognitive deficits and negative symptoms should consider including ATM measures as endpoints. Patterns and inconsistencies in findings across studies raise questions about whether some factors thought to influence ATM have nonlinear relationships.

Adherence and persistence to prescribed medication therapy among Medicare part D beneficiaries on dialysis: comparisons of benefit type and benefit phase

BACKGROUND

The implementation of Medicare Part D provided insurance coverage for outpatient medications, but when persons reach the "gap," they have very limited or no medication insurance coverage until they reach a second threshold for catastrophic coverage. In addition, some patients have a low-income subsidy (LIS), and their out-of-pocket costs do not reach the threshold for the gap. Little is known about how these Part D types (LIS versus non-LIS) and benefit phases (before the gap, during the gap, after the gap) affect medication adherence and persistence of dialysis patients. 

OBJECTIVE

To examine medication use, adherence, and persistence for Medicare-eligible dialysis patients by Part D benefit type and benefit phase. 

METHODS

A retrospective cohort study using data from the U.S. Renal Data System (USRDS) was conducted for Medicare-eligible dialysis patients. Outcomes included medication use, adherence, and persistence. Patients were categorized into 4 cohorts based on their Part D benefit phase that the beneficiaries reached at the end of the year and LIS receipt in 2007: Cohort 1 = non-LIS and did not reach the coverage gap; Cohort 2 = non-LIS and reached the coverage gap; Cohort 3 = non-LIS and reached catastrophic coverage after the gap; and Cohort 4 = received an LIS and none of the LIS patients reached the coverage gap. Outcomes were measured separately for 5 therapeutic classes of outpatient prescription drugs: antihyperglycemics, antihypertensives, antilipidemics, phosphate binders, and calcimimetics. 

RESULTS

A total of 11,732 patients met the study inclusion criteria. Patients were distributed among the cohorts as follows: 3,678 (31.3%) patients in Cohort 1 who did not reach the coverage gap; 4,349 (37.1%) patients in Cohort 2 who reached the coverage gap but not catastrophic coverage; 1,310 (11.2%) patients in Cohort 3 who reached catastrophic coverage; and 2,395 (20.4%) patients in Cohort 4 who had an LIS (none of whom reached the gap). Overall, the percentage of patients who were adherent to their medications (≥ 80% medication possession ratio) was low: 39% for antihyperglycemics, 59% for antihypertensives, 54% for antilipidemics, 22% for phosphate binders, and 35% for cinacalcet. There were wide ranges in adherence rates depending on the cohort. For patients on antihyperglycemics, antihypertensives, antilipidemics, phosphate binders, and cinacalcet, the odds ratios for adherence to therapy were 0.76 (95% C I =0.63-0.92), 1.06 (0.94-1.19), 0.80 (0.67-0.95), 0.65 (0.55-0.76), and 0.39 (0.30-0.49), respectively; the hazard ratios for discontinuation of therapy were 1.18 (95% CI 1.06-1.31), 1.01 (0.93-1.10), 1.25 (1.12-1.40), 1.13 (1.05-1.21), and 1.61 (1.75-1.82), respectively, for Cohort 2 patients who reached the coverage gap compared with those in Cohort 4 who received an LIS. In addition, when comparing adherence before and after the benefit gap, patients in Cohort 2 were significantly more likely to be nonadherent to medications for diabetes (relative risk (RR) = 1.71, 95% CI = 1.48-1.99), hypertension (RR = 1.69, 95% CI = 1.54-1.85), hyperlipidemia (RR = 2.01, 95% CI = 1.76-2.29), hyperphosphatemia (RR = 1.74, 95% CI = 1.55-1.95), and hyperparathyroidism (RR = 2.08, 95% CI = 1.66-2.60) after reaching the coverage gap. 

CONCLUSIONS

More than half of Medicare beneficiaries on dialysis reached the Part D coverage gap in 2007. Our findings suggest that the Part D coverage gap was significantly associated with decreases in adherence and persistence for medications frequently used in patients undergoing dialysis. Patients who reached the coverage gap (Cohort 2) often decreased use of or discontinued critical medications after reaching the coverage gap. Compared with patients who had an LIS (Cohort 4), patients in Cohort 2 had significantly lower medication adherence and persistence levels. The negative impact of the Part D coverage gap (high out-of-pocket cost sharing) on medication adherence and persistence for Medicare-eligible dialysis patients has implications for currently proposed Medicare end-stage renal disease bundled reimbursement payment and requires more research.

Medication effectiveness with the use of tumor necrosis factor inhibitors among Texas Medicaid patients diagnosed with rheumatoid arthritis

BACKGROUND

Adalimumab (Humira [ADA]), etanercept (Enbrel [ETN]), and infliximab (Remicade [IFX]) are tumor necrosis factor (TNF) inhibitors indicated for the treatment of a variety of disorders. While their effectiveness has not been directly compared in a clinical trial, results from the majority of the indirect treatment comparisons suggest comparable efficacy and safety profiles. However, these TNF inhibitor agents differ in administration method and dosing flexibility, which may result in differences in medication use profiles (e.g., adherence, persistence, discontinuation, dose escalation, and switching to a new biologic rheumatoid arthritis drug) and effectiveness in clinical practice. 

OBJECTIVE

To estimate the effectiveness of ADA, ETN, and IFX in patients with rheumatoid arthritis (RA) using a validated, claims-based algorithm designed for large retrospective databases.

METHODS

Adult (aged 18-63 years) patients diagnosed with RA, and receiving ADA, ETN, or IFX, and insured by Texas Medicaid were included. The index date was the date of the first prescription claim for ADA or ETN or infusion record for IFX with no claim or infusion record of a biologic drug in the preceding 6 months (i.e., biologic naïve). The study time frame was from July 2003 to August 2011, and prescription and medical claims for each subject were analyzed over an 18-month period (6 months pre- and 12 months post-index). Based on a RA medication effectiveness algorithm (Curtis et al. 2011), a RA medication was classified as effective if each of the following 6 criteria were met: (1) high medication adherence (i.e., medication possession ratio [MPR] ≥ 80%, defined as the sum of days' supply for all fills or infusions divided by the number of days in the study period); (2) no switching to (or addition of) new biologic RA drugs; (3) no addition of new nonbiologic RA drugs; (4) no increase in dose or frequency of administration of the RA medication currently evaluated; (5) no more than 1 glucocorticoid (GC) joint injection; and (6) no increase in dose of a concurrent oral GC. Propensity score (PS) matching was employed, and paired tests (i.e., McNemar's) and multivariate conditional logistic regression analysis were used to compare groups. Demographic (i.e., age, gender, race) and clinical (i.e., use of nonbiologic disease-modifying antirheumatic drugs [DMARDs], pain medication use, GC medication use, RA-related and non-RA-related health care visits [i.e., ambulatory and inpatient visits], number of nonstudy RA medications, and comorbidity index) characteristics, including total health care utilization cost at baseline, served as study covariates.

RESULTS

After PS matching, 822 patients (n = 274 per group) were included. The majority of the sample (69.2%) was between 45-63 years, female (88%), and Hispanic (53.7%). Results for each TNF inhibitor differed significantly for 2 of the 6 effectiveness criteria (i.e., medication adherence and dose escalation). A significantly higher proportion of patients on IFX were adherent compared with patients on ETN or ADA (38.3% vs. 16.4% and 21.2%, P  less than  0.0001 for both). Adherence rates between ETN and ADA were not significantly different. A significantly higher (P  less than  0.0001) proportion of patients on ETN had no dose escalation compared with patients on ADA or IFX (98.2% vs. 88.7% and 80.3%, P  less than  0.0001). Dose escalation rate was also significantly lower (P = 0.0106) for ADA compared with IFX. The multivariate conditional logistic regression analysis indicated no significant difference in overall effectiveness using the claims-based algorithm among the 3 TNF inhibitors nor any significant relationship between effectiveness and the study covariates. 

CONCLUSION

The study results suggest that when using a medication effectiveness algorithm, IFX, ETN, and ADA have comparable effectiveness in patients with RA. Patient adherence to therapy may be higher if given IFX, and patients who receive ETN are less likely to have a dose escalation.

Outpatient antibiotic prescribing in the United States: 2000 to 2010

BACKGROUND

The use of antibiotics is the single most important driver in antibiotic resistance. Nevertheless, antibiotic overuse remains common. Decline in antibiotic prescribing in the United States coincided with the launch of national educational campaigns in the 1990s and other interventions, including the introduction of routine infant immunizations with the pneumococcal conjugate vaccine (PCV-7); however, it is unknown if these trends have been sustained through recent measurements.

METHODS

We performed an analysis of nationally representative data from the Medical Expenditure Panel Surveys from 2000 to 2010. Trends in population-based prescribing were examined for overall antibiotics, broad-spectrum antibiotics, antibiotics for acute respiratory tract infections (ARTIs) and antibiotics prescribed during ARTI visits. Rates were reported for three age groups: children and adolescents (<18 years), adults (18 to 64 years), and older adults (≥65 years).

RESULTS

An estimated 1.4 billion antibiotics were dispensed over the study period. Overall antibiotic prescribing decreased 18% (risk ratio (RR) 0.82, 95% confidence interval (95% CI) 0.72 to 0.94) among children and adolescents, remained unchanged for adults, and increased 30% (1.30, 1.14 to 1.49) among older adults. Rates of broad-spectrum antibiotic prescriptions doubled from 2000 to 2010 (2.11, 1.81 to 2.47). Proportions of broad-spectrum antibiotic prescribing increased across all age groups: 79% (1.79, 1.52 to 2.11) for children and adolescents, 143% (2.43, 2.07 to 2.86) for adults and 68% (1.68, 1.45 to 1.94) for older adults. ARTI antibiotic prescribing decreased 57% (0.43, 0.35 to 0.52) among children and adolescents and 38% (0.62, 0.48 to 0.80) among adults; however, it remained unchanged among older adults. While the number of ARTI visits declined by 19%, patients with ARTI visits were more likely to receive an antibiotic (73% versus 64%; P <0.001) in 2010 than in 2000.

CONCLUSIONS

Antibiotic use has decreased among children and adolescents, but has increased for older adults. Broad-spectrum antibiotic prescribing continues to be on the rise. Public policy initiatives to promote the judicious use of antibiotics should continue and programs targeting older adults should be developed.

Adherence to oral diabetes medications among users and nonusers of antipsychotic medication

OBJECTIVE

This study compared adherence to oral diabetes medications among users and nonusers of oral antipsychotic medications. Adherence to oral antidiabetics and antipsychotics among antipsychotic users was also compared.

METHODS

Texas Medicaid prescription claims data from July 1, 2008, to December 31, 2011, were used to examine adherence to oral antidiabetics among users and nonusers of antipsychotics for 12 months after the first prescription for oral diabetes medication. Users and nonusers of antipsychotics were matched on the basis of their chronic disease score (CDS). Medication adherence was measured by proportion of days covered (PDC), and patients with a PDC value ≥.80 were considered to be adherent. Bivariate and multivariate analyses were used to compare adherence between cohorts.

RESULTS

A total of 1,821 patients from each group were matched. The mean PDC for oral antidiabetics was significantly higher among antipsychotic users (.63) than nonusers (.55) (p<.001). About 37% (N=678) of antipsychotic users and 24% (N=473) of nonusers were adherent to oral antidiabetics. After adjustment for age, gender, CDS, and number of prescriptions, antipsychotic users were 2.10 times more likely than nonusers to be adherent to oral antidiabetics (p<.001). Antipsychotic users had higher mean PDC values for antipsychotic medications than for oral antidiabetics (.78±.25 versus .63±.29, p<.001).

CONCLUSIONS

Adherence to oral antidiabetics in the Texas Medicaid population was better among antipsychotic medication users than nonusers, but overall adherence was poor for both groups. Low adherence rates highlight the need for interventions to help improve medication management.

Clinical Epidemiology of Carbapenem-Resistant Enterobacteriaceae in Community Hospitals

Background: The occurrence of carbapenem-resistant Enterobacteriaceae (CRE) has been increasing at an alarming rate worldwide. Despite that increase, there are limited data identifying risk factors. Objective: To evaluate risk factors associated with the acquisition of CRE among hospitalized patients. Methods: We performed a retrospective case-case-control study in 4 community hospitals from June 2007 through June 2012. Case group 1 (CG1) consisted of patients with CRE. Case group 2 (CG2) consisted of patients with carbapenem susceptible Enterobacteriaceae (CSE). CG2 patients were matched to CG1 patients by site of infection and species of Enterobacteriaceae. Hospitalized controls were matched 2:1 by date of admission and hospital location to patients in CG1. Two sets of analyses were conducted comparing demographics, comorbidities, and antibiotic exposures of CG1 and CG2 to controls and then contrasted to identify unique risk factors associated with CRE. Results: Overall, 104 patients (CG1, 25 patients; CG2, 29 patients, control, 50 patients) were evaluated. CRE and CSE consisted mostly of Klebsiella spp. (63%) from a urinary source (28%). In multivariable analyses, intensive care unit (ICU) stay (OR 12.48; 95% CI 1.14-136.62; p = 0.04) and cumulative number of antibiotic days (OR 1.47; 95% CI 1.02-2.16; p = 0.04) were distinct independent predictors of CRE isolation; whereas, cumulative health care exposures (OR 2.03; 95% CI 1.20-3.41; p < 0.01) and vancomycin exposure (OR 6.70; 95% CI 1.15- 38.91; p = 0.03) were predictors for CSE. Conclusions: CRE should be considered in patients requiring ICU admission, particularly those who have received multiple antibiotics. Antibiotic stewardship efforts should be directed at reducing all antibiotic exposures as opposed to any specific antibiotic class to reduce the risk of CRE.

Estimates of charges associated with emergency department and hospital inpatient care for opioid abuse-related events

The economic burden of prescription opioid abuse is substantial; however, no study has estimated the monetary burden of hospital services (emergency department [ED] and inpatient) using a single, nationally representative database. We sought to estimate total and average (adjusted for demographic and clinical factors) charges billed for opioid abuse-related events, and magnitude of difference in charges between ED visits resulting in inpatient admission to the same hospital and treat-and-release ED visits in the United States. We used the 2006, 2007, and 2008 files of the Healthcare Cost and Utilization Project's Nationwide Emergency Departments Sample (HCUP-NEDS) to identify events and charges assigned opioid abuse, dependence, or poisoning ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) diagnosis codes (304.0X, 304.7X, 305.5X, 965.00, 965.02, 965.09). Using methods to account for the complex sampling design of the NEDS and a log-linked gamma regression model, we estimated national total and mean charges (in 2010 USD). Total charges were $9.8, $9.6, and $9.5 billion for 2006, 2007, and 2008, respectively. Medicaid-covered events had the highest total charges ($3 billion), followed by events covered by Medicare ($2 billion) for each year. The national estimate of adjusted, mean, per-event charges, was $18,891 (95% confidence interval [CI] = $18,167-$19,616). Compared with events covered by private insurance, mean charges for Medicare- and Medicaid-covered events were higher (t = 28.14, P < .001; t = 6.42, P < .001, respectively), whereas self-paid events had significantly lower charges (t = -11.14, P < .001). ED visits resulting in subsequent inpatient admission had approximately 6 times higher charges than treat-and-release visits. This study provides estimates of differences in hospital costs of opioid abuse by insurance status, resulting in a better understanding of the economic burden of opioid abuse on the health care system.

Identifying patient characteristics associated with high schizophrenia-related direct medical costs in community-dwelling patients

BACKGROUND

Schizophrenia is a chronic, debilitating disease that affects approximately 1% of the U.S. population and has disproportionately high costs. Several factors, including age, gender, insurance status, and comorbid conditions, have been hypothesized to be associated with schizophrenia-
related costs. 

OBJECTIVE

To identify demographic and clinical characteristics of community-dwelling schizophrenia patients experiencing high schizophrenia-related direct medical costs. 

METHODS

Community-dwelling patients with a diagnosis for schizophrenic disorder (ICD-9-CM code 295) and other nonorganic psychoses (ICD-9-CM code 298) were identified from the 2005-2008 Medical Expenditure Panel Survey (MEPS). Schizophrenia-related direct medical costs were calculated for (a) inpatient hospitalizations; (b) prescription medications; and (c) outpatient, office-based physician, emergency room, and home health care visits. Using Andersen's Behavorial Model of Health Services Use and the literature, factors that could potentially affect schizophrenia-related direct medical costs were identified. Based on the distribution of their mean annual costs, patients were classified into high- and low-cost groups. Logistic regression was used to determine the likelihood of high-cost group membership based on age, sex, race, insurance status, marital status, region of residence, family income as a percentage of poverty line, number of medical comorbidities, number of mental health-related comorbidities, patient-perceived general health status, patient-perceived mental health status, and year of inclusion in MEPS. In addition, a generalized linear model (GLM) regression (gamma distribution with a log-link function) was used to evaluate the relationships between the independent variables and total schizophrenia-related direct medical costs as a continuous variable. 

RESULTS

From the MEPS database, we identified 317 patients with schizophrenia who represented 2.75 million noninstitutionalized, community-dwelling schizophrenia patients in the United States between 2005 and 2008. The logistic regression procedure showed that older patients (OR=0.933, 95% CI=0.902-0.966) and patients with a spouse (OR=0.150, 95% CI=0.041-0.555) were less likely to be in the high-cost group, while those who reported having "poor" perceived general health status (OR=15.548, 95% CI=1.278-189.127) were more likely to be in the high-cost group. The GLM regression procedure showed that younger patients (compared with older patients), African Americans (compared with Caucasions), patients with private insurance (compared with the uninsured), and those living in the northeastern United States (compared with those living in the southern United States) had higher schizophrenia-related direct medical costs. 

CONCLUSION

Identification of factors associated with a high-cost population may help decision makers in managed care, government, and other organizations allocate resources more efficiently and health care providers manage patients more effectively through assignment of these patients to case managers and appropriate monitoring and treatment. 

Factors associated with hospices' provision of complementary and alternative medicine

There is limited research about the provision of complementary and alternative (CAM) in US hospices. The purpose of this study was to assess the factors that influence hospices' likelihood of providing CAM therapies. Mail surveys were sent to 369 hospices in Texas; 61 were returned undelivered, yielding a total usable response rate of 35.7% (n = 110) after an initial and one follow-up mail out. Binary logistic regression was used to assess whether the likelihood of offering CAM is related to hospice's age, geographic location, agency type, profit orientation, Medicare certification, and number of patients served annually. Results showed that profit orientation and the number of patients served by hospices were significantly related to the probability that hospices will offer CAM. Specifically, the odds of offering CAM in not-for-profit hospices were approximately 4 times higher than that in for-profit hospices (odds ratio [OR] = 3.77, P = .022, 95% confidence interval [CI] = 1.2, 11.8). In addition, for every 100 patients served by the hospices, the odds of offering CAM increases by 13% (OR = 1.13, P = .015, 95% CI = 1.02, 1.25). In conclusion, CAM offering by hospices is related to hospices' profit orientation status and number of patients served but is not related to other measured characteristics of hospices.

Complementary and alternative medicine utilization in Texas hospices: prevalence, importance, and challenges

The purpose of this study was to describe the prevalence, importance, and challenges of complementary and alternative medicine (CAM) utilization in Texas hospices. Mail surveys were sent to 369 hospices in Texas, and 110 useful surveys were returned. Results showed that a majority (n = 62, 56.4%) of hospices offer CAM to their clients, with the most popularly offered CAMs being massage, music, and relaxation therapies. Despite the availability of CAM services in most hospices, and that the utilization of CAM has the potential to improve overall quality of life of patients, our results showed that a sizeable proportion of patients in these hospices are not utilizing the provided CAMs. Funding and personnel constraints were substantial obstacles to offering CAM.

Pharmacist reporting of serious adverse drug events to the Food and Drug Administration

OBJECTIVE

To identify barriers to and facilitators of pharmacist reporting of serious adverse drug events (ADEs) to the Food and Drug Administration (FDA).

METHOD

Two focus groups consisting of practicing pharmacists were held in Austin, TX, in 2009. The following open-ended questions were used in the focus groups: (1) What do you think would make it easier to report serious ADEs to the FDA? (2) What do you think would make it more difficult to report serious ADEs to the FDA? A content analysis was performed on the generated transcripts.

RESULTS

13 pharmacists practicing in hospital and community settings in Texas participated. Pharmacists identified 27 barriers to and facilitators of reporting serious ADEs to FDA. Lack of patients' complete medical histories and lack of time were the barriers most frequently cited. Knowledge and awareness of ADEs and ADE reporting emerged as important factors that would facilitate reporting serious ADEs to FDA.

CONCLUSION

These findings highlight the factors that facilitate and/or inhibit pharmacist reporting of serious ADEs to FDA. Improved knowledge of ADEs and ADE reporting would facilitate reporting behaviors, while lack of time, lack of complete patient medical histories, and lack of compensation issues serve as important barriers to reporting. Interventions are needed to address these factors.

Hospitalizations for cardiovascular disease in African Americans and whites with HIV/AIDS

Therapeutic advances have resulted in an epidemiological shift in the predominant causes of hospitalization for patients with HIV/AIDS. An emerging cause for hospitalization in this patient population is cardiovascular disease (CVD); however, data are limited regarding how this shift affects different racial groups. The objective of this observational, retrospective study was to evaluate the association between race and hospitalization for CVD in African Americans and whites with HIV/AIDS and to compare the types of CVD-related hospitalizations between African Americans and whites with HIV/AIDS. Approximately 1.5 million hospital discharges from the US National Hospital Discharge Surveys for the years of 1996 to 2008 were identified. After controlling for potential confounders, the odds of CVD-related hospitalization in patients with HIV/AIDS were 45% higher for African Americans than whites (odds ratio [OR]=1.45, 95% CI, 1.39-1.51). Other covariates that were associated with increased odds of hospitalization for CVD included chronic kidney disease (OR=1.43, 95% CI, 1.36-1.51), age≥50 years (OR=3.22, 95% CI, 2.94-3.54), region in the Southern United States (OR=1.17, 95% CI, 1.11-1.23), and Medicare insurance coverage (OR=1.71, 95% CI, 1.60-1.83). Male sex was not significantly associated with the study outcome (OR=0.99, 95% CI, 0.96-1.02). Compared to whites with HIV/AIDS, African Americans with HIV/AIDS had more hospitalizations for heart failure and hypertension, but fewer hospitalizations for stroke and coronary heart disease. In conclusion, African Americans with HIV/AIDS have increased odds of CVD-related hospitalization as compared to whites with HIV/AIDS. Furthermore, the most common types of CVD-related hospitalizations differ significantly in African Americans and whites.

Effect of social influences on pharmacists' intention to report adverse drug events

OBJECTIVES

To identify the groups or individuals that influence pharmacists' decision making to report adverse drug events (ADEs), determine the differences in social influence or subjective norm between intenders and nonintenders, and determine the relationship between subjective norm toward reporting serious ADEs and practice and demographic characteristics.

DESIGN

Nonexperimental cross-sectional study.

SETTING

Texas during June and July 2009.

PARTICIPANTS

1,500 Texas pharmacists.

INTERVENTION

As part of a larger survey, 3 and 18 items were used to assess pharmacists' intentions and subjective norm, respectively, to report serious ADEs to the Food and Drug Administration (FDA).

MAIN OUTCOME MEASURE

Pharmacists' subjective norm toward reporting serious ADEs.

RESULTS

The survey had a response rate of 26.4% (n = 377). Most pharmacists intended to report serious ADEs that they would encounter (15.87 ± 4.22 [mean ± SD], possible range 3-21, neutral = 12). The mean subjective norm scores were moderately high and positive (28.75 ± 9.38, 1-49, 16), indicating that the referents had a moderate influence on pharmacists regarding reporting serious ADEs to FDA. FDA had the greatest (34.82 ± 12.16) and drug manufacturers the lowest (21.55 ± 13.83) social influence. The most important salient referents (important others) in pharmacists' decisions to report serious ADEs were FDA, patients, pharmacy associations, pharmacy managers/bosses, and hospitals and hospital groups. Gender (female equals higher), pharmacists' years of experience (negative correlation), and knowledge of ADE reporting (positive correlation) were associated with subjective norm.

CONCLUSION

Pharmacists had a moderately high subjective norm, suggesting that ADE reporting intentions is influenced by others and that the opinions of others are of great importance in pharmacists' intentions regarding ADE reporting. The main drivers of subjective norm were FDA, patients, pharmacy associations, and managers/bosses.