Kidney function and appropriateness of device therapies in adults with implantable cardioverter defibrillators

OBJECTIVE

Patients with chronic kidney disease (CKD) have higher risk of sudden cardiac death; however, they may not receive implantable cardioverter defibrillators (ICDs), in part due to higher risk of complications. We evaluated whether CKD is associated with greater risk of device-delivered shocks/antitachycardia pacing (ATP) therapies among patients receiving a primary prevention ICD.

METHODS

We studied participants in the observational Cardiovascular Research Network Longitudinal Study of Implantable Cardioverter Defibrillators. CKD was defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m². Outcomes included all delivered shocks/ATPs therapies and type of shock/ATP therapies (inappropriate or appropriate, determined by physician adjudication) within the 3 years. We evaluated the associations between CKD and time to first device therapy, burden of device therapy, and inappropriate versus appropriate device therapy, adjusting for demographics, comorbidity, laboratory values and medication use.

RESULTS

Among 2161 participants, 1066 (49.3%) had CKD (eGFR 44±11 mL/min/1.73 m²) at ICD implantation. During mean of 2.26±0.89 years, 9.8% and 18.5% of participants had at least one inappropriate and appropriate shock/ATP therapies, respectively. CKD was not associated with time to first shock/ATP therapies (adjusted HR 0.87, 95% CI 0.73 to 1.05), overall burden of shock/ATP therapies (adjusted relative rate 0.93, 95% CI 0.74 to 1.17) or inappropriate versus appropriate shock/ATP therapies (adjusted relative risk 0.88, 95% CI 0.68 to 1.14) compared with not having CKD.

CONCLUSIONS

In adults receiving a primary prevention ICD, mild-to-moderate CKD was not associated with the timing, burden or appropriateness of subsequent device therapy. Potential concern for inappropriate ICD-delivered therapies should not preclude ICDs among eligible patients with CKD.

Identifying Unrecognized Peripheral Arterial Disease Among Asymptomatic Patients in the Primary Care Setting

National initiatives to enhance recognition of the detrimental impact of peripheral arterial disease on the health of adult Americans have been advocated. The objective of this study was to evaluate a strategy for identifying patients with unrecognized peripheral arterial disease from among persons without known atherosclerotic disease in the primary care setting. A cross-sectional design was used. Participants were patients receiving care from a multispecialty group practice in Massachusetts between July 2002 and July 2003, with a scheduled appointment with a primary care physician. Persons 70 years of age or older who were not already known to have atherosclerotic disease were enrolled. In addition, persons aged 50-69 with a diagnosis of diabetes mellitus, dyslipidemia, hypertension, and/or smoking based on information derived from administrative databases, and not known to have atherosclerotic disease, were enrolled. Before the scheduled appointment, potential study participants completed a telephone interview to ascertain their medical history. The ankle-brachial index (ABI) of eligible patients was measured at the time of the scheduled primary care office visit. Peripheral arterial disease was diagnosed if 1 or both legs had an ABI of ≤0.90. Also assessed was the time spent in performing ABI testing in a convenience sample of the study participants. ABI testing was performed on 717 patients. Among 359 study subjects aged ≥70 years, 45 (12.5%) were diagnosed with peripheral arterial disease. Nine (2.5%) of 358 subjects aged 50-69 years were diagnosed with peripheral arterial disease. The average total time (n=52) for ABI testing was 13.7 (SD: ±3.3) minutes. Patients aged ≥70 years required more time for ABI testing compared to those aged 50-69 (mean: 15.0 vs 13.0 minutes, p=0.04). Unrecognized asymptomatic peripheral arterial disease can be commonly detected among patients in the primary care setting who are not already known to have atherosclerotic disease. The yield from screening is substantially greater among unselected older patients compared with younger patients specifically identified as having risk factors for PAD. These findings should help inform the development and implementation of new initiatives to enhance the early detection of peripheral arterial disease among asymptomatic patients in the primary care setting.

New Initiation of Long-Acting Opioids in Long-Stay Nursing Home Residents

OBJECTIVES

To estimate the prevalence of new initiation of long-acting opioids since introduction of national efforts to increase prescriber and public awareness on safe use of transdermal fentanyl patches.

DESIGN

Cross-sectional.

SETTING

U.S. nursing homes (NHs).

PARTICIPANTS

Medicare-enrolled long-stay NH residents (N = 22,253).

MEASUREMENTS

Minimum Data Set 3.0 was linked with Medicare enrollment, hospital claims, and prescription drug transaction data (January-December 2011) and used to determine the prevalence of new initiation of a long-acting opioid prescribed to residents in NHs.

RESULTS

Of NH residents prescribed a long-acting opioid within 30 days of NH admission (n = 12,278), 9.4% (95% confidence interval = 8.9-9.9%) lacked a prescription drug claim for a short-acting opioid in the previous 60 days. The most common initial prescriptions of long-acting opioids were fentanyl patch (51.9% of opioid-naïve NH residents), morphine sulfate (28.1%), and oxycodone (17.2%).

CONCLUSION

New initiation of long-acting opioids-especially fentanyl patches, which have been the subject of safety communications-persists in NHs.

Antipsychotic medication utilization in nonpsychiatric hospitalizations

BACKGROUND

Although antipsychotics are used for treatment of delirium/agitation in hospitalized patients, their scope of use has not been investigated in a large, multicenter cohort.

OBJECTIVE

To determine rates of use and hospital variation in use of antipsychotics in nonpsychiatric admissions.

DESIGN, SETTING, PATIENTS

Cohort study of adult, nonpsychiatric admissions to 300 US hospitals contributing data to the Premier database, from July 1, 2009 to June 30, 2010.

MEASUREMENTS

Antipsychotic exposure defined using pharmacy charges. Potentially excessive dosing defined using guidelines for long-term care facilities.

RESULTS

Our cohort included 2,695,081 admissions (median age, 63 years; 56% female). Antipsychotic exposure occurred in 160,773 (6%) admissions; 102,148 (64%) received atypical antipsychotics, 76,979 (48%) received typical, and 18,354 (11%) received both. Among exposed admissions, 47% received ≥1 potentially excessive daily dose. Among the variables we analyzed, the strongest predictors of antipsychotic receipt were delirium (relative risk [RR]: 2.93, 95% CI: 2.88-2.98) and dementia (RR: 2.78, 95% CI: 2.72-2.83). After adjustment for patient characteristics, patients admitted to hospitals in the highest antipsychotic prescribing quintile were more than twice as likely to be exposed compared to patients admitted to hospitals in the lowest prescribing quintile (RR: 2.56, 95% CI: 2.50-2.61). This relationship was similar across subgroups of admissions with delirium and dementia.

CONCLUSIONS

Antipsychotic medication exposure is common in nonpsychiatric admissions to US hospitals. The observed variation in antipsychotic prescribing was not fully explained by measured patient characteristics, suggesting the possibility of differing hospital prescribing cultures. Additional research and guidelines are necessary to define appropriate use of these potentially harmful medications in the hospital setting. Journal of Hospital Medicine 2016;11:543-549. © 2016 Society of Hospital Medicine.

Medication affordability gains following Medicare Part D are eroding among elderly with multiple chronic conditions

Elderly Americans, especially those with multiple chronic conditions, face difficulties paying for prescriptions, which results in worse adherence to and discontinuation of therapy, called cost-related medication nonadherence. Medicare Part D, implemented in January 2006, was supposed to address issues of affordability for prescriptions. We investigated whether the gains in medication affordability attributable to Part D persisted during the six years that followed its implementation. Overall, we found continued incremental improvements in medication affordability in the period 2007-09 that eroded during the period 2009-11. Among elderly beneficiaries with four or more chronic conditions, we observed an increase in the prevalence of cost-related nonadherence from 14.4 percent in 2009 to 17.0 percent in 2011, reversing previous downward trends. Similarly, the prevalence among the sickest elderly of forgoing basic needs to purchase medicines decreased from 8.7 percent in 2007 to 6.8 percent in 2009 but rose to 10.2 percent in 2011. Our findings highlight the need for targeted policy efforts to alleviate the persistent burden of drug treatment costs on this vulnerable population.

Antipsychotic Use in Hospitalized Adults: Rates, Indications, and Predictors

OBJECTIVES

To investigate patterns and predictors of use of antipsychotics in hospitalized adults.

DESIGN

Retrospective cohort study.

SETTING

Academic medical center.

PARTICIPANTS

Individuals aged 18 and older hospitalized from August 2012 to August 2013, excluding those admitted to obstetrics and gynecology or psychiatry or with a psychotic disorder.

MEASUREMENTS

Use was ascertained from pharmacy charges. Potentially excessive dosing was defined using guidelines for long-term care facilities. A review of 100 records was performed to determine reasons for use.

RESULTS

The cohort included 17,775 admissions with a median age 64; individuals could have been admitted more than once during the study period. Antipsychotics were used in 9%, 55% of which were initiations. The most common reasons for initiation were delirium (53%) and probable delirium (12%). Potentially excessive dosing occurred in 16% of admissions exposed to an antipsychotic. Of admissions with antipsychotic initiation, 26% were discharged on these medications. Characteristics associated with initiation included age 75 and older (relative risk (RR) = 1.4, 95% confidence interval (CI) = 1.2-1.7), male sex (RR = 1.2, 95% CI = 1.1-1.4), black race (RR = 0.8, 95% CI = 0.6-0.96), delirium (RR = 4.8, 95% CI = 4.2-5.7), dementia (RR = 2.1, 95% CI = 1.7-2.6), admission to a medical service (RR = 1.2, 95% CI = 1.1-1.4), intensive care unit stay (RR = 2.1, 95% CI = 1.8-2.4), and mechanical ventilation (RR = 2.0, 95% CI = 1.7-2.4). In individuals who were initiated on an antipsychotic, characteristics associated with discharge on antipsychotics were age 75 and older (RR = 0.6, 95% CI = 0.4-0.7), discharge to any location other than home (RR = 2.5, 95% CI = 1.8-3.3), and class of in-hospital antipsychotic exposure (RR = 1.6, 95% CI = 1.1-2.3 for atypical vs typical; RR = 2.7, 95% CI = 1.9-3.8 for both vs typical).

CONCLUSION

Antipsychotic initiation and use were common during hospitalization, most often for delirium, and individuals were frequently discharged on these medications. Several predictors of use on discharge were identified, suggesting potential targets for decision support tools that would be used to prompt consideration of ongoing necessity.

A Pilot Health Information Technology-Based Effort to Increase the Quality of Transitions From Skilled Nursing Facility to Home: Compelling Evidence of High Rate of Adverse Outcomes

OBJECTIVES

Older adults are often transferred from hospitals to skilled nursing facilities (SNFs) for post-acute care. Patients may be at risk for adverse outcomes after SNF discharges, but little research has focused on this period.

DESIGN

Assessment of the feasibility of a transitional care intervention based on a combination of manual information transmission and health information technology to provide automated alert messages to primary care physicians and staff; pre-post analysis to assess potential impact.

SETTING

A multispecialty group practice.

PARTICIPANTS

Adults aged 65 and older, discharged from SNFs to home; comparison group drawn from SNF discharges during the previous 1.5 years, matched on facility, patient age, and sex.

MEASUREMENTS

For the pre-post analysis, we tracked rehospitalization within 30 days after discharge and adverse drug events within 45 days.

RESULTS

The intervention was developed and implemented with manual transmission of information between 8 SNFs and the group practice followed by entry into the electronic health record. The process required a 5-day delay during which a large portion of the adverse events occurred. Over a 1-year period, automated alert messages were delivered to physicians and staff for the 313 eligible patients discharged from the 8 SNFs to home. We compared outcomes to those of individually matched discharges from the previous 1.5 years and found similar percentages with 30-day rehospitalizations (31% vs 30%, adjusted HR 1.06, 95% CI 0.80-1.4). Within the adverse drug event (ADE) study, 30% of the discharges during the intervention period and 30% of matched discharges had ADEs within 45 days.

CONCLUSION

Older adults discharged from SNFs are at high risk of adverse outcomes immediately following discharge. Simply providing alerts to outpatient physicians, especially if delivered multiple days after discharge, is unlikely to have any impact on reducing these rates.

Comparative Effectiveness of Statin Therapy in Chronic Kidney Disease and Acute Myocardial Infarction: A Retrospective Cohort Study

BACKGROUND

Whether there is a kidney function threshold to statin effectiveness in patients with acute myocardial infarction is poorly understood. Our study sought to help fill this gap in clinical knowledge.

METHODS

We undertook a new-user cohort study of the effectiveness of statin therapy by level of estimated glomerular filtration rate (eGFR) in adults who were hospitalized for myocardial infarction between 2000 and 2008. Data came from the Cardiovascular Research Network. The primary clinical outcomes were 1-year all-cause mortality and cardiovascular hospitalizations, with adverse outcomes of myopathy and development of diabetes mellitus. We calculated incidence rates, the number needed to treat, and used Cox proportional hazards regression with propensity score matching and adjustment to control for confounding, with testing for variation of effect by level of kidney function.

RESULTS

Compared with statin non-initiators (n = 5583), statin initiators (n = 5597) had a lower propensity score-adjusted risk for death (hazard ratio 0.79; 95% confidence interval [CI], 0.71-0.88) and cardiovascular hospitalizations (hazard ratio 0.90; 95% CI, 0.82-1.00). We found little evidence of variation in effect by level of eGFR (P = .86 for death; P = .77 for cardiovascular hospitalization). Adverse outcomes were similar for statin initiators and statin non-initiators. The number needed to treat to prevent 1 additional death over 1 year of follow-up ranged from 15 (95% CI, 11-28) for eGFR <30 mL/min/1.73 m(2) requiring statin treatment over 2 years to prevent 1 additional death, to 67 (95% CI, 49-118) for patients with eGFR >90 mL/min/1.73 m(2).

CONCLUSIONS

Our findings suggest that there is potential for important public health gains by increasing the routine use of statin therapy for patients with lower levels of kidney function.

Pain management in nursing home residents with cancer

OBJECTIVES

To assess improvements in pain management of nursing home (NH) residents with cancer since the implementation of pain management quality indicators.

DESIGN

Cross-sectional.

SETTING

One thousand three hundred eighty-two U.S. NHs (N = 1,382).

PARTICIPANTS

Newly admitted, Medicare-eligible NH residents with cancer (N = 8,094).

MEASUREMENTS

Nationwide data on NH resident health from Minimum Data Set 2.0 linked to all-payer pharmacy dispensing records (February 2006-June 2007) were used to determine prevalence of pain, including frequency and intensity, and receipt of nonopioid and opioid analgesics. Multinomial logistic regression was used to evaluate resident-level correlates of pain and binomial logistic regression to identify correlates of untreated pain.

RESULTS

More than 65% of NH residents with cancer had any pain (28.3% daily, 37.3% <daily), 13.5% of whom had severe and 61.3% had moderate pain. Women; residents admitted from acute care or who were bedfast; and those with compromised activities of daily living, depressed mood, an indwelling catheter, or a terminal prognosis were more likely to have pain. More than 17% of residents in daily pain (95% confidence interval (CI) = 16.0-19.1%) received no analgesics, including 11.7% with daily severe pain (95% CI = 8.9-14.5%) and 16.9% with daily moderate pain (95% CI = 15.1-18.8%). Treatment was negatively associated with age of 85 and older (adjusted OR (aOR) = 0.67, 95% CI = 0.55-0.81 vs aged 65-74), cognitive impairment (aOR = 0.71, 95% CI = 0.61-0.82), presence of feeding tube (aOR = 0.77, 95% CI = 0.60-0.99), and restraints (aOR = 0.50, 95% CI = 0.31-0.82).

CONCLUSION

Untreated pain is still common in NH residents with cancer and persists despite pain management quality indicators.

Dissemination of Evidence-Based Antipsychotic Prescribing Guidelines to Nursing Homes: A Cluster Randomized Trial

OBJECTIVES

To evaluate the effectiveness of efforts to translate and disseminate evidence-based guidelines about atypical antipsychotic use to nursing homes (NHs).

DESIGN

Three-arm, cluster randomized trial.

SETTING

NHs.

PARTICIPANTS

NHs in the state of Connecticut.

MEASUREMENTS

Evidence-based guidelines for atypical antipsychotic prescribing were translated into a toolkit targeting NH stakeholders, and 42 NHs were recruited and randomized to one of three toolkit dissemination strategies: mailed toolkit delivery (minimal intensity); mailed toolkit delivery with quarterly audit and feedback reports about facility-level antipsychotic prescribing (moderate intensity); and in-person toolkit delivery with academic detailing, on-site behavioral management training, and quarterly audit and feedback reports (high intensity). Outcomes were evaluated using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.

RESULTS

Toolkit awareness of 30% (7/23) of leadership of low-intensity NHs, 54% (19/35) of moderate-intensity NHs, and 82% (18/22) of high-intensity NHs reflected adoption and implementation of the intervention. Highest levels of use and knowledge among direct care staff were reported in high-intensity NHs. Antipsychotic prescribing levels declined during the study period, but there were no statistically significant differences between study arms or from secular trends.

CONCLUSION

RE-AIM indicators suggest some success in disseminating the toolkit and differences in reach, adoption, and implementation according to dissemination strategy but no measurable effect on antipsychotic prescribing trends. Further dissemination to external stakeholders such as psychiatry consultants and hospitals may be needed to influence antipsychotic prescribing for NH residents.

A 35-Year Perspective (1975 to 2009) into the Long-Term Prognosis and Hospital Management of Patients Discharged from the Hospital After a First Acute Myocardial Infarction

There are limited population-based data available describing trends in the long-term prognosis of patients discharged from the hospital after an initial acute myocardial infarction (AMI). Our objectives were to describe multidecade trends in post-discharge mortality and their association with hospital management practices in patients discharged from all medical centers in Central Massachusetts after a first AMI. Residents of the Worcester, Massachusetts, metropolitan area discharged from all hospitals in Central Massachusetts after a first AMI from 1975 to 2009 comprised the study population (n = 8,728). Multivariable-adjusted logistic regression analyses were used to examine the association between year of hospitalization and 1-year post-discharge mortality. The average age of this population was 66 years, and 40% were women. Patients hospitalized in 1999 to 2009, compared with those discharged in 1975 to 1984, were older, more likely to be women, and have multiple previously diagnosed co-morbidities. Hospital use of invasive cardiac interventions and medications increased markedly over time. Unadjusted 1-year mortality rates were 12.9%, 12.5%, and 15.8% for patients discharged during 1975 to 1984, 1986 to 1997, and 1999 to 2009, respectively. After adjusting for several demographic characteristics, clinical factors, and inhospital complications, there were no significant differences in the odds of dying at 1-year post-discharge during the years under study. After further adjustment for hospital treatment practices, the odds of dying at 1 year post-discharge was 2.43 (95% confidence interval = 1.83 to 3.23) times higher in patients hospitalized in 1999 to 2009 than in 1975 to 1984. In conclusion, the increased use of invasive cardiac interventions and pharmacotherapies was associated with enhanced long-term survival in patients hospitalized for a first AMI.

Did Medicare Part D Affect National Trends in Health Outcomes or Hospitalizations? A Time-Series Analysis

BACKGROUND

Medicare Part D increased economic access to medications, but its effect on population-level health outcomes and use of other medical services remains unclear.

OBJECTIVE

To examine changes in health outcomes and medical services in the Medicare population after implementation of Part D.

DESIGN

Population-level longitudinal time-series analysis with generalized linear models.

SETTING

Community.

PATIENTS

Nationally representative sample of Medicare beneficiaries (n = 56,293 [unweighted and unique]) from 2000 to 2010.

MEASUREMENTS

Changes in self-reported health status, limitations in activities of daily living (ADLs) (ADLs and instrumental ADLs), emergency department visits and hospital admissions (prevalence, counts, and spending), and mortality. Medicare claims data were used for confirmatory analyses.

RESULTS

Five years after Part D implementation, no clinically or statistically significant reductions in the prevalence of fair or poor health status or limitations in ADLs or instrumental ADLs, relative to historical trends, were detected. Compared with trends before Part D, no changes in emergency department visits, hospital admissions or days, inpatient costs, or mortality after Part D were seen. Confirmatory analyses were consistent.

LIMITATIONS

Only total population-level outcomes were studied. Self-reported measures may lack sensitivity.

CONCLUSION

Five years after implementation, and contrary to previous reports, no evidence was found of Part D's effect on a range of population-level health indicators among Medicare enrollees. Further, there was no clear evidence of gains in medical care efficiencies.

Age and sex differences in long-term outcomes following implantable cardioverter-defibrillator placement in contemporary clinical practice: findings from the Cardiovascular Research Network

Background

Patient sex and age may influence rates of death after receiving an implantable cardioverter-defibrillator for primary prevention. Differences in outcomes other than mortality and whether these differences vary by heart failure symptoms, etiology, and left ventricular ejection fraction are not well characterized.

Methods and Results

We studied 2954 patients with left ventricular ejection fraction ≤0.35 undergoing first-time implantable cardioverter-defibrillator for primary prevention within the Cardiovascular Research Network; 769 patients (26%) were women, and 2827 (62%) were aged >65 years. In a median follow-up of 2.4 years, outcome rates per 1000 patient-years were 109 for death, 438 for hospitalization, and 111 for heart failure hospitalizations. Procedure-related complications occurred in 8.36%. In multivariable models, women had significantly lower risks of death (hazard ratio 0.67, 95% CI 0.56 to 0.80) and heart failure hospitalization (hazard ratio 0.82, 95% CI 0.68 to 0.98) and higher risks for complications (hazard ratio 1.38, 95% CI 1.01 to 1.90) than men; patients aged >65 years had higher risks of death (hazard ratio 1.55, 95% CI 1.30 to 1.86) and heart failure hospitalization (hazard ratio 1.25, 95% CI 1.05 to 1.49) than younger patients. Age and sex differences were generally consistent in strata according to symptoms, etiology, and severity of left ventricular systolic dysfunction, except the higher risk of complications in women, which differed by New York Heart Association classification (P=0.03 for sex–New York Heart Association interaction), and the risk of heart failure hospitalization in older patients, which differed by etiology of heart failure (P=0.05 for age–etiology interaction).

Conclusions

The burden of adverse outcomes after receipt of an implantable cardioverter-defibrillator for primary prevention is substantial and varies according to patient age and sex. These differences in outcome generally do not vary according to baseline heart failure characteristics.

Abstract 165: In-hospital Serum HbA1c and Glucose Levels and 30-Day Hospital Readmissions Among Adults Hospitalized with an Acute Coronary Syndrome: TRACE-CORE

Objective: Abnormalities in glucose metabolism may worsen the prognosis of patients hospitalized with an acute coronary syndrome (ACS). We examined the association of in-hospital serum glucose and glycated hemoglobin (HbA1c) levels with the occurrence of 30-day hospital readmissions among adults discharged from the hospital after an ACS.

Methods: Using data from the Transitions, Risks, and Action in Coronary Events - Center for Outcomes Research and Education (TRACE-CORE) study, we reviewed the medical records of 2,187 patients discharged from 6 hospitals in MA and GA after an ACS between 2011 and 2013. We stratified patients according to diabetes mellitus (DM) status at baseline, as defined by medical history of DM, admission medications, or a serum HbA1c > 6.5%. Using logistic regression models, we calculated crude and adjusted odds ratios to estimate the association between serum HbA1c and glucose levels during hospitalization with 30-day all-cause readmissions. We controlled for prior and inpatient insulin use, age, body mass index, ACS classification, length of stay, and hospital site.

Results: Data on serum HbA1c and glucose levels were available for 1,102 (50%) participants. This study sample had a mean age of 60 (SD: 11) years, 68% were male, 77% were non-Hispanic white, and 52% had DM. The mean in-hospital serum HbA1c and maximum and minimum serum glucose levels were 8.2%, 277 mg/dL, and 101 mg/dL, respectively, for those with known DM (n = 526) and 5.7%, 155 mg/dL, and 92 mg/dL for those without known DM (n = 576). A higher, but non-significant, proportion of patients with DM (14%) were readmitted to an area medical center within 30 days of discharge compared to those without DM (11%, p = 0.27). Neither serum HbA1c levels, nor minimum or maximum glucose values during hospitalization were associated with all-cause 30-day readmissions among those with and without DM (Table).

Conclusions: In this prospective study of adults with an ACS, we found no significant association between serum HbA1c or glucose levels with the occurrence of 30-day hospital readmissions. The low proportion of subjects with serum HbA1c testing may have biased the study results. Further investigation should examine the in-hospital management of ACS patients with varying serum glucose and HBA1C levels and their post-discharge outcomes.

Reducing the Use of H2-Receptor Antagonists in the Long-Term-Care Setting

OBJECTIVES

To examine the patterns of H2 blocker use in the long-term-care setting and to assess the effect of educational interventions designed to improve H2 blocker utilization patterns.

DESIGN

Time-series quasi-experimental study and retrospective chart review.

SETTING

A large academically-oriented long-term-care facility.

PATIENTS

Institutionalized elderly patients with a mean age of 88 years receiving H2 blocker therapy.

INTERVENTIONS

Two interventions involving group discussions with the medical staff, supporting educational materials, and physician-specific listings of patients receiving H2 blockers were employed sequentially over a 32-month period.

RESULTS

Each intervention resulted in substantial reductions in medication use (59.6% and 32.1%, respectively). Indications for H2 blocker use were determined retrospectively for patients identified as receiving therapy prior to the interventions (n = 110). Forty-one percent were found to be receiving therapy for reasons unsubstantiated by the medical literature. These patients were more likely to be discontinued from therapy than those receiving therapy for substantiated indications (P less than 0.01), consistent with the primary focus of the educational interventions.

CONCLUSIONS

These results suggest that the excessive use of H2 blocker therapy in the long-term care setting responds to educational interventions with therapeutically appropriate reductions in utilization. Repeated interventions are necessary to maintain such reductions over time although there may be some reduction in the effectiveness of the intervention with repetition.

Use of atypical antipsychotics in nursing homes and pharmaceutical marketing

OBJECTIVES

To describe the current extent and type of pharmaceutical marketing in nursing homes (NHs) in one state and to provide preliminary evidence for the potential influence of pharmaceutical marketing on the use of atypical antipsychotics in NHs.

DESIGN

Nested mixed-methods, cross-sectional study of NHs in a cluster randomized trial.

SETTING

Forty-one NHs in Connecticut.

PARTICIPANTS

NH administrators, directors of nursing, and medical directors (n = 93, response rate 75.6%).

MEASUREMENTS

Quantitative data, including prescription drug dispensing data (September 2009-August 2010) linked with Nursing Home Compare data (April 2011), were used to determine facility-level prevalence of atypical antipsychotic use, facility-level characteristics, NH staffing, and NH quality. Qualitative data, including semistructured interviews and surveys of NH leaders conducted in the first quarter of 2011, were used to determine encounters with pharmaceutical marketing.

RESULTS

Leadership at 46.3% of NHs (n = 19) reported pharmaceutical marketing encounters, consisting of educational training, written and Internet-based materials, and sponsored training. No association was detected between level of atypical antipsychotic prescribing and reports of any pharmaceutical marketing by at least one NH leader.

CONCLUSION

NH leaders frequently encounter pharmaceutical marketing through a variety of ways, although the impact on atypical antipsychotic prescribing is unclear.

Rationales that providers and family members cited for the use of antipsychotic medications in nursing home residents with dementia

OBJECTIVES

To describe the rationales that providers and family members cite for the use of antipsychotic medications in people with dementia living in nursing homes (NHs).

DESIGN

Qualitative, descriptive study.

SETTING

Twenty-six medium-sized and large facilities in five Centers for Medicare and Medicaid Services regions.

PARTICIPANTS

Individuals diagnosed with dementia who received an antipsychotic medication.

MEASUREMENTS

Data were collected from medical record abstraction and interviews with prescribers, administrators, direct care providers, and family members. Textual data from medical record abstraction and responses to open-ended interview questions were analyzed using directed content analysis techniques. A coding scheme was developed, and coded reasons for antipsychotic prescribing were summarized across all sources.

RESULTS

Major categories of reasons for use of antipsychotic medications in the 204 NH residents in the study sample were behavioral (n = 171), psychiatric (n = 159), emotional states (n = 105), and cognitive diagnoses or symptoms (n = 114). The most common behavioral reasons identified were verbal (n = 91) and physical (n = 85) aggression. For the psychiatric category, psychosis (n = 95) was most frequently described. Anger (n = 93) and sadness (n = 20) were the most common emotional states cited.

CONCLUSION

The rationale for use of antipsychotic drug therapy frequently relates to a wide variety of indications for which these drugs are not approved and for which evidence of efficacy is lacking. These findings have implications for clinical practice and policy.