Antibiotic use in children who have asthma: results of retrospective database analysis

OBJECTIVE

Inappropriate antibiotic use is a well-recognized public health problem because of its association with the emergence of resistant bacteria. It also is a source of unnecessary health care costs and of potentially severe adverse drug reactions. Although there are no evidence-based indications for the use of antibiotics in the treatment of asthma in the absence of comorbid bacterial conditions, physicians might feel more pressure to prescribe them to children with this common chronic disease. The objectives of this study were to (a) determine if antimicrobial prescription utilization rates are higher for pediatric patients with asthma than a matched comparison group and (b) identify common variables (gender and age) that might explain higher antibiotic utilization rates in children.

METHODS

Using administrative claims data, we conducted a retrospective cohort study of children with asthma (age range 5 to 18 years) who were members of a large health plan from January 1, 2000, to December 31, 2002, in the southeastern United States. A comparison group was created that was matched according to age, sex, regional codes, and insurance product line. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to identify asthmatic patients (493.xx), as well as to link antibiotic prescriptions to diagnosis codes from claims for medical office visits.

RESULTS

Asthmatics consistently received significantly more services, including a mean of 1.74 (SD 1.82) antibiotics per patient per year (PPPY) compared with a mean of 0.96 (SD 1.32) antibiotics PPPY for nonasthmatics (t=25.71, P <0.001). Asthmatics received antibiotics more often for all diagnoses. The more frequent receipt of antibiotics was true for conditions related to the respiratory tract (e.g., upper respiratory infection and bronchitis) as well as for conditions unrelated to the respiratory tract (e.g., urinary tract infection and acne). A diagnosis of asthma significantly increased the likelihood of a prescribed antibiotic by 26% to 86%.

CONCLUSION

This study demonstrated that pediatric asthmatic patients received significantly more antibiotic prescriptions than nonasthmatics for conditions caused by bacteria as well as for conditions more likely to be viral in origin. In this era of concern about the widespread use of antibiotics and consequent antimicrobial resistance, further research needs to be conducted concerning the appropriateness of antibiotics in the treatment of asthma. Studies on the appropriate use of antibiotics in asthma could help reduce the overall use of antibiotics in children.

Delirium superimposed on dementia in a community-dwelling managed care population: a 3-year retrospective study of occurrence, costs, and utilization

BACKGROUND

Dementia is a growing public health problem and a well-described risk factor for delirium. Yet little is known about delirium superimposed on dementia in community-dwelling populations. The purpose of this study was to examine the 3-year occurrence, healthcare utilization, and costs associated with delirium superimposed on dementia in community-dwelling persons.

METHODS

We used a 3-year cross-sectional, retrospective design with an administrative database from a large managed care organization. Four individually matched samples of 699 individuals each were selected for comparison purposes: delirium superimposed on dementia (DSD), dementia alone, delirium alone, and a control group with neither delirium nor dementia. The occurrence rate of DSD was calculated by measuring those individuals with a dementia diagnosis that were also coded with an International Classification of Diseases, Ninth Edition Clinical Modification (ICD-9 CM) code for delirium or delirium with dementia.

RESULTS

Of the total sample of 76,688 persons aged 65 years or older in the managed care organization, 7347 (10%) were coded as having dementia, and an additional 763 (1%) as having delirium alone. Among the 7347 with dementia, 976 (13%) had DSD, representing 1.3% of the total sample. After log transformation of total costs and adjustment for multiple covariates, the adjusted mean total health care costs remained significantly higher for the DSD group than for all other groups.

CONCLUSIONS

This study is the first to report the occurrence rate of DSD in a community-dwelling population, and to demonstrate the substantial health care costs and utilization associated with DSD.

A randomized study to decrease the use of potentially inappropriate medications among community-dwelling older adults in a southeastern managed care organization

BACKGROUND

Despite progress in describing the problem of potentially inappropriate medication (PIM) use, there have been few prospective studies demonstrating that interventions with specific medication criteria can make a difference in decreasing the use of problematic drugs in older adults.

OBJECTIVE

To design an intervention study to change physician behavior regarding PIM prescribing to older patients.

STUDY DESIGN AND METHODS

A prospective randomized block design was used during an 18-month period from January 2001 to June 2002. The study population was primary care physicians (n = 355) in the Medicare + Choice product line of a southeastern managed care organization and their patients 65 years and older. There were 170 physicians in the treatment group and 185 in the control group. Physicians were assigned to the treatment or usual-care, groups using a randomization table, and each group included physicians who had and had not prescribed a PIM.

RESULTS

Approximately 71% (84/118) of the physicians in the intervention group who prescribed a PIM completed and faxed back at least 1 potentially inappropriate medication form to the managed care organization. On 15.4% (260/1692) of the medication forms, physicians made some change regarding PIM use.

CONCLUSIONS

Although many studies have addressed medication use among older adults, intervention studies aimed at influencing physician prescribing in this population are limited. This study describes a low-cost, replicable method to contact and educate physicians on drug therapy issues in older adults.

Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts

BACKGROUND

Medication toxic effects and drug-related problems can have profound medical and safety consequences for older adults and economically affect the health care system. The purpose of this initiative was to revise and update the Beers criteria for potentially inappropriate medication use in adults 65 years and older in the United States.

METHODS

This study used a modified Delphi method, a set of procedures and methods for formulating a group judgment for a subject matter in which precise information is lacking. The criteria reviewed covered 2 types of statements: (1) medications or medication classes that should generally be avoided in persons 65 years or older because they are either ineffective or they pose unnecessarily high risk for older persons and a safer alternative is available and (2) medications that should not be used in older persons known to have specific medical conditions.

RESULTS

This study identified 48 individual medications or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and medications to be avoided in older adults with these conditions. Of these potentially inappropriate drugs, 66 were considered by the panel to have adverse outcomes of high severity.

CONCLUSIONS

This study is an important update of previously established criteria that have been widely used and cited. The application of the Beers criteria and other tools for identifying potentially inappropriate medication use will continue to enable providers to plan interventions for decreasing both drug-related costs and overall costs and thus minimize drug-related problems.

Delirium superimposed on dementia: a systematic review

Delirium in a patient with preexisting dementia is a common problem that may have serious complications and poor prognostic implications. The purpose of this paper was to conduct a systematic review of the medical literature on delirium superimposed on dementia, specifically to review studies on prevalence, associated features, outcomes, and management. Areas of controversy and gaps in our knowledge of this problem are highlighted. Finally, an agenda for future research is proposed. Fourteen studies were reviewed, including seven prospective studies, three retrospective studies, two cross-sectional studies, and two clinical trials. For the review of the literature on delirium superimposed on dementia, we searched MEDLINE from January 1966 through February 2002 for research studies with primary sources of data. Selection criteria for inclusion of articles in this study were inclusion of data on subjects with delirium superimposed on dementia, inclusion of a validated operational definition/measures of dementia and delirium, actual data on persons with delirium and dementia reported in the paper, and reporting of primary data. MEDLINE was searched using the following key search terms: delirium, acute confusion, cognitive impairment, Alzheimer's disease, dementia, delirium superimposed on dementia, and elderly. The prevalence of delirium superimposed on dementia ranged from 22% to 89% of hospitalized and community populations aged 65 and older with dementia. To date, only one reported study systematically identified associated factors and interventions for delirium superimposed on dementia, but several studies examining outcomes have found that adverse events are associated with delirium in persons with dementia, including accelerated and long-term cognitive and functional decline, need for institutionalization, rehospitalization, and increased mortality. This paper highlights the dearth of research on delirium superimposed on dementia and stresses the importance of early recognition and prevention of delirium in persons with dementia.

Comparison of 2 systems for clinical practice profiling in diabetic care: medical records versus claims and administrative data

OBJECTIVES

To (1) describe the rate of glycosylated hemoglobin (HbA1c) testing and control in a primary care clinic at an academic medical center; (2) compare academic medical center and health maintenance organization (HMO) data for a subgroup of the same patients; and (3) discuss the challenges to accurate clinical practice profiling.

STUDY DESIGN

Retrospective analysis of medical records and claims and administrative data.

PATIENTS AND METHODS

We reviewed the medical records of 300 patients with diabetes mellitus from the Primary Care practice at an academic medical center (AMC). The HMO and AMC were in the southeastern United States. The study adhered to the National Committee for Quality Assurance's Health Plan Employer Data and Information Set 3.0 (1998) guidelines for collection of the numerator and denominator data.

RESULTS

Overall, 275 (91.7%) of 300 patients underwent a documented HbA1c test (range, 77.8%-98.0% across the 5 Primary Care Associates clinic physicians). Of these 275 patients, 206 (74.9%; range, 52.4%-84.7%) were under "good control" (defined by the National Committee for Quality Assurance as an HbA1c level of < or = 9.5%). The mean (SD) HbA1c level was 8.45% (1.98%). Data from the HMO documented a rate of HbA1c testing of 36.3% (45/124) compared with 92.7% (115/124) based on case note review at the academic medical center.

CONCLUSIONS

Current administrative and claims-based information systems have inherent weaknesses if used for performance measurement. Reliance solely on medical record review is time and cost prohibitive. To ensure complete reporting of mandated "quality measures" will necessitate the tracking of data across different healthcare systems.