Venous thromboembolism in the elderly. A community-based perspective

While the magnitude of venous thromboembolism (VTE) increases dramatically with advancing age, relatively little is known about the contemporary management of VTE in the elderly and the impact of age on associated short- and long-term outcomes. The objectives of this population-based study were to compare the clinical characteristics, treatment practices, and outcomes of subjects > or = 65 years with VTE to those of younger patients. The medical records of residents of the Worcester (MA, USA) metropolitan area with ICD-9 codes consistent with VTE during 1999, 2001, and 2003 were independently validated and reviewed by trained data abstractors. Information about patients' demographic and clinical characteristics, hospital management practices, and hospital and long-term outcomes was collected. There were a total of 1,897 validated events of VTE - 1,048 (55%) occurred in patients > or = 65 years of age. Patients > or = 65 years were less likely to have "unprovoked" VTE than younger patients. They were less likely to receive parenteral anticoagulation or warfarin as acute treatment. Rates of recurrent VTE did not differ significantly between patients 65 years of age or older compared to younger patients but the adjusted rates of major bleeding were increased approximately two-fold in older patients. In conclusion, advancing age is not a predictor of recurrent VTE but is associated with a significant increase in major bleeding episodes. Physicians treating elderly patients with VTE should continue to base their decisions on clinical characteristics previously shown to impact the risk of recurrent VTE. These decisions must be tempered by our observation that major bleeding occurs frequently in these patients.

Medicare beneficiaries and free prescription drug samples: a national survey

BACKGROUND

New policies regulating physician/pharmaceutical company relationships propose to eliminate access to free prescription drug samples. Little is known about the prevalence of patient activity in requesting or receiving free prescription drug samples, or the characteristics of patients who access drug samples.

OBJECTIVE

To determine the prevalence of free sample access and to examine demographic, clinical, and insurance characteristics of Medicare beneficiaries who access free samples.

DESIGN

Cross-sectional study.

PARTICIPANTS

A national sample of 13,847 Medicare beneficiaries participating in the fall 2004 Medicare Current Beneficiary Survey.

MEASUREMENTS AND MAIN RESULTS

Prevalence of free prescription drug sample access (self-reported request for or receipt of free drug samples) and the demographic, clinical, and insurance characteristics of Medicare beneficiaries who accessed drug samples. Overall, 48.3% (95% confidence of interval [CI]: 46.6%, 49.9%) of Medicare beneficiaries reported accessing free drug samples. Access was higher among beneficiaries reporting cost-related medication nonadherence compared to those without (77.7% (95% CI: 74.5%, 80.6%) vs 43.0% (95% CI: 41.4%, 44.7%)). Multivariable analysis revealed cost-related medication nonadherence (CRN) to have the strongest relationship with accessing drug samples (adjusted odds ratio [AOR] 4.43 [95% CI: 3.64, 5.39]). Compared to beneficiaries with generous drug benefits from Medicaid, beneficiaries who lacked prescription drug benefits were more likely to access drug samples (AOR 2.42 [95% CI: 2.06, 2.85]). Beneficiaries with drug coverage from employer-sponsored plans or partial coverage (Medicare HMO, self-purchased Medicare supplement, or state-sponsored low-income plans) were also more likely to access drug samples (AOR 2.02, 1.74, respectively). Having 2-3 or > or = 4 comorbidities (vs 0-1 comorbidities) also increased the likelihood of accessing drug samples (AOR 1.60 (95% CI: 1.44, 1.79) and 2.00 (95% CI: 1.74, 2.29).

CONCLUSIONS

Accessing free prescription drug samples is prevalent among many categories of beneficiaries, especially among individuals with cost-related medication nonadherence and poor health status. Policies restricting or prohibiting drug sample distribution may adversely impact access to medications among patients in high-risk groups.

Antipsychotic therapy and short-term serious events in older adults with dementia

BACKGROUND

Antipsychotic therapy is widely used to treat behavioral problems in older adults with dementia. Cohort studies evaluating the safety of antipsychotic therapy generally focus on a single adverse event. We compared the rate of developing any serious event, a composite outcome defined as an event serious enough to lead to an acute care hospital admission or death within 30 days of initiating antipsychotic therapy, to better estimate the overall burden of short-term harm associated with these agents.

METHODS

In this population-based, retrospective cohort study, we identified 20 682 matched older adults with dementia living in the community and 20 559 matched individuals living in a nursing home between April 1, 1997, and March 31, 2004. Propensity-based matching was used to balance differences between the drug exposure groups in each setting. To examine the effects of antipsychotic drug use on the composite outcome of any serious event we used a conditional logistic regression model. We also estimated adjusted odds ratios using models that included all covariates with a standard difference greater than 0.10.

RESULTS

Relative to those who received no antipsychotic therapy, community-dwelling older adults newly dispensed an atypical antipsychotic therapy were 3.2 times more likely (95% confidence interval, 2.77-3.68) and those who received conventional antipsychotic therapy were 3.8 times more likely (95% confidence interval, 3.31-4.39) to develop any serious event during the 30 days of follow-up. The pattern of serious events was similar but less pronounced among older adults living in a nursing home.

CONCLUSIONS

Serious events, as indicated by a hospital admission or death, are frequent following the short-term use of antipsychotic drugs in older adults with dementia. Antipsychotic drugs should be used with caution even when short-term therapy is being prescribed.

Cost-related medication nonadherence and spending on basic needs following implementation of Medicare Part D

CONTEXT

Cost-related medication nonadherence (CRN) has been a persistent problem for individuals who are elderly and disabled in the United States. The impact of Medicare prescription drug coverage (Part D) on CRN is unknown.

OBJECTIVE

To estimate changes in CRN and forgoing basic needs to pay for drugs following Part D implementation.

DESIGN, SETTING, AND PARTICIPANTS

In a population-level study design, changes in study outcomes between 2005 and 2006 before and after Medicare Part D implementation were compared with historical changes between 2004 and 2005. The community-dwelling sample of the nationally representative Medicare Current Beneficiary Survey (unweighted unique n = 24,234; response rate, 72.3%) was used, and logistic regression analyses were controlled for demographic characteristics, health status, and historical trends.

MAIN OUTCOME MEASURES

Self-reports of CRN (skipping or reducing doses, not obtaining prescriptions) and spending less on basic needs to afford medicines.

RESULTS

The unadjusted, weighted prevalence of CRN was 15.2% in 2004, 14.1% in 2005, and 11.5% after Part D implementation in 2006. The prevalence of spending less on basic needs was 10.6% in 2004, 11.1% in 2005, and 7.6% in 2006. Adjusted analyses comparing 2006 with 2005 and controlling for historical changes (2005 vs 2004) demonstrated significant decreases in the odds of CRN (ratio of odds ratios [ORs], 0.85; 95% confidence interval [CI], 0.74-0.98; P = .03) and spending less on basic needs (ratio of ORs, 0.59; 95% CI, 0.48-0.72; P < .001). No significant changes in CRN were observed among beneficiaries with fair to poor health (ratio of ORs, 1.00; 95% CI, 0.82-1.21; P = .97), despite high baseline CRN prevalence for this group (22.2% in 2005) and significant decreases among beneficiaries with good to excellent health (ratio of ORs, 0.77; 95% CI, 0.63-0.95; P = .02). However, significant reductions in spending less on basic needs were observed in both groups (fair to poor health: ratio of ORs, 0.60; 95% CI, 0.47-0.75; P < .001; and good to excellent health: ratio of ORs, 0.57; 95% CI, 0.44-0.75; P < .001).

CONCLUSIONS

In this survey population, there was evidence for a small but significant overall decrease in CRN and forgoing basic needs following Part D implementation. However, no net decrease in CRN after Part D was observed among the sickest beneficiaries, who continued to experience higher rates of CRN.

The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: a systematic review

CONTEXT

Computerized physician order entry (CPOE) with clinical decision support (CDS) has been promoted as an effective strategy to prevent the development of a drug injury defined as an adverse drug event (ADE).

OBJECTIVE

To systematically review studies evaluating the effects of CPOE with CDS on the development of an ADE as an outcome measure.

DATA SOURCES

PUBMED versions of MEDLINE (from inception through March 2007) were searched to identify relevant studies. Reference lists of included studies were also searched.

METHODS

We searched for original investigations, randomized and nonrandomized clinical trials, and observational studies that evaluated the effect of CPOE with CDS on the rates of ADEs. The studies identified were assessed to determine the type of computer system used, drug categories being evaluated, types of ADEs measured, and clinical outcomes assessed.

RESULTS

Of the 543 citations identified, 10 studies met our inclusion criteria. These studies were grouped into categories based on their setting: hospital or ambulatory; no studies related to the long-term care setting were identified. CPOE with CDS contributed to a statistically significant (P < or = .05) decrease in ADEs in 5 (50.0%) of the 10 studies. Four studies (40.0%) reported a nonstatistically significant reduction in ADE rates, and 1 study (10.0%) demonstrated no change in ADE rates.

CONCLUSIONS

Few studies have measured the effect of CPOE with CDS on the rates of ADEs, and none were randomized controlled trials. Further research is needed to evaluate the efficacy of CPOE with CDS across the various clinical settings.

Patient education about anticoagulant medication: is narrative evidence or statistical evidence more effective?

OBJECTIVE

To determine the relative impact of incorporating narrative evidence, statistical evidence or both into patient education about warfarin, a widely used oral anticoagulant medication.

METHODS

600 patients receiving anticoagulant therapy were randomly assigned to view one of three versions of a video depicting a physician-patient encounter where anticoagulation treatment was discussed, or usual care (no video). The videos differed in whether the physician used narrative evidence (patient anecdotes), statistical evidence, or both to highlight key information. 317 patients completed both the baseline and post-test questionnaires. Questions assessed knowledge, beliefs and adherence to medication and laboratory monitoring regimens.

RESULTS

All three approaches positively effected patients' warfarin-related knowledge, and beliefs in the importance of lab testing; there was also some indication that viewing a video strengthened belief in the benefits of warfarin. There was some indication that narrative evidence had a greater impact than statistical evidence on beliefs about the importance of lab testing and on knowledge. No other evidence of the differential effectiveness of either approach was found. No statistically significant effect was found on intent to adhere, or documented adherence to lab monitoring.

CONCLUSION

Videos depicting a physician-patient dialogue about warfarin were effective in educating patients about anticoagulant medication, and had a positive impact on their beliefs. The use of narrative evidence in the form of patient anecdotes may be more effective than statistical evidence for some patient outcomes.

PRACTICE IMPLICATIONS

Patients on oral anticoagulant therapy may benefit from periodic educational efforts reinforcing key medication safety information, even after initial education and ongoing monitoring. Incorporating patient anecdotes into physician-patient dialogues or educational materials may increase the effectiveness of the message.

Computerized physician order entry with clinical decision support in long-term care facilities: costs and benefits to stakeholders

Nursing homes are the setting of care for growing numbers of our nation's older people, and adverse drug events are an increasingly recognized safety and quality concern in this population. Health information technology, including computerized physician/provider order entry (CPOE) with clinical decision support (CDS), has been proposed as an important systems-based approach for reducing medication errors and preventable drug-related injuries. This article describes the costs and benefits of CPOE with CDS for the various stakeholders involved in long-term care (LTC), including nurses, physicians, the pharmacy, the laboratory, the payer (e.g., the insurer), nursing home residents, and the LTC facility. Critical barriers to adoption of these systems are discussed, primarily from an economic perspective. The analysis suggests that multiple stakeholders will incur the costs related to implementation of CPOE with CDS in the LTC setting, but the costs incurred by each may not be aligned with the benefits, which may present a major barrier to broad adoption. Physicians and LTC facilities are likely to bear a large burden of the costs, whereas residents and payers will enjoy a large portion of the benefits. Consideration of these costs and benefits suggests that financial incentives to physicians and facilities may be necessary to encourage and accelerate widespread use of these systems in the LTC setting.

Cluster Randomized Trials

BACKGROUND

Cluster randomized trials (CRTs) offer unique advantages over standard randomized controlled clinical trials (RCTs) and observational methodologies, and may provide a cost-efficient alternative for answering questions about the best treatments for common conditions.

OBJECTIVES

To describe health plan leaders' views on CRTs, identify barriers to conducting CRTs, and solicit recommendations for increasing the acceptability of CRTs.

RESEARCH DESIGN

Qualitative in-depth telephone interviews with leaders from 8 health plans.

SUBJECTS

: Thirty-four health plan leaders (medical directors, pharmacy directors, Institutional Review Board leaders, ethics leaders, compliance leaders, and others).

MEASURES

Qualitative analysis of interview transcripts to identify barriers, factors influencing leaders' views, ethical issues, aspects of CRTs that appeal to leaders, and recommendations for increasing acceptability of CRTs.

RESULTS

Multiple barriers were identified, including financial costs, concerns about stakeholders' perceptions of CRTs, impact on physicians' prescribing habits, and formulary changes. Most leaders recognized the potential value of studying the comparative effectiveness of therapeutics, and many stressed the need for head-to-head trials. Leaders' views would be influenced by variations in study design and implementation. Recommendations for increasing acceptability of CRTs included ensuring that the fiscal impact of a CRT be budget neutral, and that researchers educate stakeholders and decision-makers about CRTs.

CONCLUSIONS

Overall, health plan leaders recognized the need for studies of the comparative effectiveness of therapeutics under real world conditions, and many expressed support for CRTs. However, researchers seeking to conduct CRTs in health plans are likely to face numerous barriers, and preparatory work will be essential.

Comparative effectiveness of beta-adrenergic antagonists (atenolol, metoprolol tartrate, carvedilol) on the risk of rehospitalization in adults with heart failure

Placebo-controlled randomized trials have demonstrated the efficacy of selected beta blockers on outcomes in chronic heart failure (HF), but the relative effectiveness of different beta blockers in usual clinical care is poorly understood. We compared 12-month risk of rehospitalization for HF associated with receipt of different beta blockers in 7,883 adults hospitalized for HF within 2 large health plans between January 1, 2001 and December 31, 2002. Beta-blocker use was ascertained from electronic pharmacy databases and readmissions within 12 months were identified from hospital discharge databases. Extended Cox regression was used to examine the association between receipt of different beta blockers and risk of readmission for HF after adjustment for potential confounders. During follow-up, there were 3,234 person-years of exposure to beta blockers (39.3% atenolol, 42.0% metoprolol tartrate, 12.3% carvedilol, and 6.4% other). Crude 12-month rates of readmissions for HF were high overall (42.6 per 100 person-years). After adjustment for potential confounders, cumulative exposure to each beta blocker, and propensity to receive carvedilol compared with atenolol, adjusted risks of readmission were not significantly different for metoprolol tartrate (adjusted hazard ratio 0.95, 95% confidence interval 0.85 to 1.05) or for carvedilol (adjusted hazard ratio 0.92, 95% confidence interval 0.74 to 1.14). In conclusion, in a contemporary cohort of high-risk patients hospitalized with HF, we found that adjusted risks of rehospitalization for HF within 12 months were not significantly different in patients receiving atenolol, shorter-acting metoprolol tartrate, or carvedilol.

Antipsychotic drug use and mortality in older adults with dementia

BACKGROUND

Antipsychotic drugs are widely used to manage behavioral and psychological symptoms in dementia despite concerns about their safety.

OBJECTIVE

To examine the association between treatment with antipsychotics (both conventional and atypical) and all-cause mortality.

DESIGN

Population-based, retrospective cohort study.

SETTING

Ontario, Canada.

PATIENTS

Older adults with dementia who were followed between 1 April 1997 and 31 March 2003.

MEASUREMENTS

The risk for death was determined at 30, 60, 120, and 180 days after the initial dispensing of antipsychotic medication. Two pairwise comparisons were made: atypical versus no antipsychotic use and conventional versus atypical antipsychotic use. Groups were stratified by place of residence (community or long-term care). Propensity score matching was used to adjust for differences in baseline health status.

RESULTS

A total of 27,259 matched pairs were identified. New use of atypical antipsychotics was associated with a statistically significant increase in the risk for death at 30 days compared with nonuse in both the community-dwelling cohort (adjusted hazard ratio, 1.31 [95% CI, 1.02 to 1.70]; absolute risk difference, 0.2 percentage point) and the long-term care cohort (adjusted hazard ratio, 1.55 [CI, 1.15 to 2.07]; absolute risk difference, 1.2 percentage points). Excess risk seemed to persist to 180 days, but unequal rates of censoring over time may have affected these results. Relative to atypical antipsychotic use, conventional antipsychotic use was associated with a higher risk for death at all time points. Sensitivity analysis revealed that unmeasured confounders that increase the risk for death could diminish or eliminate the observed associations.

LIMITATIONS

Information on causes of death was not available. Many patients did not continue their initial treatments after 1 month of therapy. Unmeasured confounders could affect associations.

CONCLUSIONS

Atypical antipsychotic use is associated with an increased risk for death compared with nonuse among older adults with dementia. The risk for death may be greater with conventional antipsychotics than with atypical antipsychotics.

The safety of warfarin therapy in the nursing home setting

PURPOSE

We examined the preventability of adverse warfarin-related events and potential adverse warfarin-related events ("near misses") in the nursing home setting.

METHODS

We performed a cohort study of all long-term care residents of 25 nursing homes (bed size range, 90-360) in Connecticut during a 12-month observation period. The total number of residents in these facilities ranged from 2946 to 3212 per quarter. There were 490 residents who received warfarin therapy. Possible warfarin-related incidents were detected by quarterly retrospective review of nursing home records by trained nurse abstractors. Each incident was independently classified by 2 physician-reviewers to determine whether it constituted a warfarin-related event, its severity, and its preventability. The primary outcome was an adverse warfarin-related event, defined as an injury associated with the use of warfarin. Potential adverse warfarin-related events were defined as situations in which the international normalized ratio (INR) was noted to be 4.5 or greater, an error in management was noted, but no injury occurred. We also assessed time in specified INR ranges per nursing home resident day on warfarin.

RESULTS

Over the 12-month observation period, 720 adverse warfarin-related events and 253 potential adverse warfarin-related events were identified. Of the adverse warfarin-related events, 625 (87%) were characterized as minor, 82 (11%) were deemed serious, and 13 (2%) were life-threatening or fatal. Overall, 29% of the adverse warfarin-related events were judged to be preventable. Serious, life-threatening, or fatal events occurred at a rate of 2.49 per 100 resident-months; 57% of these more severe events were considered preventable. Errors resulting in preventable events occurred most often at the prescribing and monitoring stages of warfarin management. The percentages of time in the less than 2, 2 to 3, and more than 3 INR ranges were 36.5%, 49.6%, and 13.9%, respectively.

CONCLUSIONS

The use of warfarin in the nursing home setting presents substantial safety concerns for patients. Adverse events associated with warfarin therapy are common and often preventable in the nursing home setting. Prevention strategies should target the prescribing and monitoring stages of warfarin management.

Patients at-risk for cost-related medication nonadherence: a review of the literature

OBJECTIVE

Up to 32% of older patients take less medication than prescribed to avoid costs, yet a comprehensive assessment of risk factors for cost-related nonadherence (CRN) is not available. This review examined the empirical literature to identify patient-, medication-, and provider-level factors that influence the relationship between medication adherence and medication costs.

DESIGN

We conducted searches of four databases (MEDLINE, CINAHL, Sciences Citations Index Expanded, and EconLit) from 2001 to 2006 for English-language original studies. Articles were selected if the study included an explicit measure of CRN and reported results on covarying characteristics.

MAIN RESULTS

We found 19 studies with empirical support for concluding that certain patients may be susceptible to CRN: research has established consistent links between medication nonadherence due to costs and financial burden, but also to symptoms of depression and heavy disease burden. Only a handful of studies with limited statistical methods provided evidence on whether patients understand the health risks of CRN or to what extent clinicians influence patients to keep taking medications when faced with cost pressures. No relationship emerged between CRN and polypharmacy.

CONCLUSION

Efforts to reduce cost-related medication nonadherence would benefit from greater study of factors besides the presence of prescription drug coverage. Older patients with chronic diseases and mood disorders are at-risk for CRN even if enrolled in Medicare's new drug benefit.

Variation in Nursing Home Antipsychotic Prescribing Rates

BACKGROUND

Excessive prescribing of antipsychotic therapy is a concern owing to their potential to cause serious adverse events. We explored variation in the use of antipsychotic therapy across nursing homes in Ontario, Canada, and determined if prescribing decisions were based on clinical indications.

METHODS

A point-prevalence study of antipsychotic therapy use in 47 322 residents of 485 provincially regulated nursing homes in December 2003. Facilities were classified into quintiles according to their mean antipsychotic prescribing rates. Residents were grouped into those with a potential clinical indication or no identified clinical indication for antipsychotic therapy.

RESULTS

A total of 15 317 residents (32.4%) were dispensed an antipsychotic agent. The mean rate of antipsychotic prescribing by home ranged from 20.9% in the quintile of facilities with the lowest mean prescribing rates (quintile 1) to 44.3% in facilities with the highest mean prescribing rates (quintile 5). Compared with individuals residing in nursing homes with the lowest mean antipsychotic prescribing rates, those residing in facilities with the highest rates were 3 times more likely to be dispensed an antipsychotic agent (adjusted odds ratio [AOR], 3.0; 95% confidence interval [CI], 2.74-3.19). Similar rates were observed among residents with psychoses with or without dementia (AOR, 2.7; 95% CI, 2.35-3.09) and residents without psychoses or dementia (AOR, 2.9; 95% CI, 2.19-3.81) who had no identifiable indication for an antipsychotic therapy.

CONCLUSION

Residents in facilities with high antipsychotic prescribing rates were about 3 times more likely than those in facilities with low prescribing rates to be dispensed an antipsychotic agent, irrespective of their clinical indication.

Racial differences in tumor stage and survival for colorectal cancer in an insured population

BACKGROUND

Despite declining death rates from colorectal cancer (CRC), racial disparities have continued to increase. In this study, the authors examined disparities in a racially diverse group of insured patients.

METHODS

This study was conducted among patients who were diagnosed with CRC from 1993 to 1998, when they were enrolled in integrated healthcare systems. Patients were identified from tumor registries and were linked to information in administrative databases. The sample was restricted to non-Hispanic whites (n = 10,585), non-Hispanic blacks (n = 1479), Hispanics (n = 985), and Asians/Pacific Islanders (n = 909). Differences in tumor stage and survival were analyzed by using polytomous and Cox regression models, respectively.

RESULTS

In multivariable regression analyses, blacks were more likely than whites to have distant or unstaged tumors. In Cox models that were adjusted for nonmutable factors, blacks had a higher risk of death from CRC (hazard ratio [HR], 1.17; 95% confidence interval [95% CI], 1.06-1.30). Hispanics had a risk of death similar to whites (HR, 1.04; 95% CI, 0.92-1.18), whereas Asians/Pacific Islanders had a lower risk of death from CRC (HR, 0.89; 95% CI, 0.78-1.02). Adjustment for tumor stage decreased the HR to 1.11 for blacks, and the addition of receipt of surgical therapy to the model decreased the HR further to 1.06. The HR among Hispanics and Asians/Pacific Islanders was stable to adjustment for tumor stage and surgical therapy.

CONCLUSIONS

The relation between race and survival from CRC was complex and appeared to be related to differences in tumor stage and therapy received, even in insured populations. Targeted interventions to improve the use of effective screening and treatment among vulnerable populations may be needed to eliminate disparities in CRC.

Adverse Drug Events Resulting from Patient Errors in Older Adults

OBJECTIVES

To characterize the types of patient-related errors that lead to adverse drug events (ADEs) and identify patients at high risk of such errors.

DESIGN

A subanalysis within a cohort study of Medicare enrollees.

SETTING

A large multispecialty group practice.

PARTICIPANTS

Thirty thousand Medicare enrollees followed over a 12-month period.

MEASUREMENTS

Primary outcomes were ADEs, defined as injuries due to a medication, and potential ADEs, defined as medication errors with the potential to cause an injury. The subset of these events that were related to patient errors was identified.

RESULTS

The majority of patient errors leading to adverse events (n=129) occurred in administering the medication (31.8%), modifying the medication regimen (41.9%), or not following clinical advice about medication use (21.7%). Patient-related errors most often involved hypoglycemic medications (28.7%), cardiovascular medications (21.7%), anticoagulants (18.6%), or diuretics (10.1%). Patients with medication errors did not differ from a comparison group in age or sex but were taking more regularly scheduled medications (compared with 0-2 medications, odds ratio (OR) for 3-4 medications=2.0, 95% confidence interval (CI)=0.9-4.2; OR for 5-6 medications=3.1, 95% CI=1.5-7.0; OR for >or=7 medications=3.3, 95% CI=1.5-7.0). The strongest association was with the Charlson Comorbidity Index (compared with a score of 0, OR for a score of 1-2=3.8, 95% CI=2.1-7.0; OR for a score of 3-4=8.6, 95% CI=4.3-17.0; OR for a score of >or=5=15.0, 95% CI=6.5-34.5).

CONCLUSION

The medication regimens of older adults present a range of difficulties with the potential for harm. Strategies are needed that specifically address the management of complex drug regimens.

Effect of New York State regulatory action on benzodiazepine prescribing and hip fracture rates

BACKGROUND

Medicare Part D excludes benzodiazepines from coverage, and numerous state government policies limit use of benzodiazepines. No data indicate that such policies have decreased the incidence of hip fracture.

OBJECTIVE

To assess whether a statewide policy that decreased the use of benzodiazepines among elderly persons by more than 50% has decreased the incidence of hip fracture.

DESIGN

A quasi-experiment comparing changes in outcomes before and after a policy change in a study U.S. state (New York) and a control state (New Jersey).

SETTING

Two U.S. state Medicaid programs, 1988-1990.

PATIENTS

Medicaid enrollees in New York (n = 51 529) and New Jersey (n = 42 029) who received or did not receive a benzodiazepine.

MEASUREMENTS

Benzodiazepine prescribing and hazard ratios for hip fracture, adjusted for age and eligibility category.

INTERVENTION

A statewide policy, implemented in New York in 1989, that required triplicate forms for benzodiazepine prescribing to allow surveillance by health authorities.

RESULTS

The triplicate prescription policy immediately resulted in a 60.3% (95% CI, -66.3% to -54.2%) reduction in benzodiazepine use among women and 58.5% (-64.3% to -52.8%) among men. Benzodiazepine use in New Jersey remained stable. Hazard ratios for hip fracture that were adjusted for age and eligibility category did not change in New York or New Jersey when the periods before and after use of the triplicate prescription policy were compared (change from 1.2 to 1.1 among female benzodiazepine recipients [P = 0.70], 1.3 to 1.1 [P = 0.08] among female nonrecipients, 0.8 to 1.1 [P = 0.56] among male recipients, and 1.1 to 1.3 [P = 0.46] among male nonrecipients).

LIMITATIONS

Information was lacking on race, benzodiazepine dose, and other potential determinants of continued benzodiazepine prescribing.

CONCLUSIONS

Policies that lead to substantial reductions in the use of benzodiazepines among elderly persons do not necessarily lead to decreased incidence of hip fracture. Limitations on coverage of benzodiazepines under Medicare Part D may not achieve this widely assumed clinical benefit.

Statin therapy and risks for death and hospitalization in chronic heart failure

CONTEXT

Whether statin therapy has beneficial effects on clinical outcomes in patients with heart failure is unclear.

OBJECTIVE

To evaluate the association between initiation of statin therapy and risks for death and hospitalization among adults with chronic heart failure.

DESIGN, SETTING, AND PATIENTS

Propensity-adjusted cohort study of adults diagnosed with heart failure who were eligible for lipid-lowering therapy but had no previous known statin use, within an integrated health care delivery system in northern California between January 1, 1996, and December 31, 2004. Statin use was estimated from filled outpatient prescriptions in pharmacy databases.

MAIN OUTCOME MEASURES

All-cause death and hospitalization for heart failure during a median of 2.4 years of follow-up. We examined the independent relationships between statin therapy and risks for adverse events overall and stratified by the presence or absence of coronary heart disease after multivariable adjustment for potential confounders.

RESULTS

Among 24,598 adults diagnosed with heart failure who had no prior statin use, those initiating statin therapy (n = 12,648; 51.4%) were more likely to be younger, male, and have known cardiovascular disease, diabetes, and hypertension. There were 8235 patients who died. Using an intent-to-treat approach, incident statin use was associated with lower risks of death (age- and sex-adjusted rate of 14.5 per 100 person-years with statin therapy vs 25.3 per 100 person-years without statin therapy; adjusted hazard ratio, 0.76 [95% confidence interval, 0.72-0.80]) and hospitalization for heart failure (age- and sex-adjusted rate of 21.9 per 100 person-years with statin therapy vs 31.1 per 100 person-years without statin therapy; adjusted hazard ratio, 0.79 [95% confidence interval, 0.74-0.85]) even after adjustment for the propensity to take statins, cholesterol level, use of other cardiovascular medications, and other potential confounders. Incident statin use was associated with lower adjusted risks of adverse outcomes in patients with or without known coronary heart disease.

CONCLUSION

Among adults diagnosed with heart failure who had no prior statin use, incident statin use was independently associated with lower risks of death and hospitalization among patients with or without coronary heart disease.

Polypharmacy with oral antidiabetic agents: an indicator of poor glycemic control

OBJECTIVE

To evaluate antidiabetic drug treatment patterns and glycemic control among patients diagnosed with type 2 diabetes mellitus.

STUDY DESIGN

Retrospective study using the automated databases of a 200 000-member HMO.

METHODS

The study population consisted of patients > or =18 years of age with documented type 2 diabetes mellitus from January 1, 2002, through December 31, 2002. We determined the proportion of patients who had optimal glycemic control (glycosylated hemoglobin <7%) during the 6 months after the initial documentation of diabetes during calendar year 2002 (index date).

RESULTS

Of the 4282 patients who met the inclusion criteria, 1050 (25%) received 1 oral agent, 486 (11%) received 2 oral agents, 56 (1%) received > or =3 oral agents, 84 (2%) received insulin and an oral agent, and 107 (2%) received insulin exclusively within 90 days after the index date. Among the 1075 patients receiving antidiabetic drug therapy who had a laboratory test result documented, 414 (39%) had optimal glycemic control. Optimal control was most frequent among patients receiving 1 oral agent (47%) and least frequent among patients receiving > or =3 oral agents (13%) (P <.01). Patients with a prior history of suboptimal glycemic control were less likely to have optimal glycemic control.

CONCLUSIONS

Multiple oral antidiabetic agents may serve as a marker for more severe, uncontrolled diabetes. The vast majority of patients treated with multiple oral antidiabetic agents had suboptimal glycemic control, suggesting a need for intensified efforts to treat this particular group of patients to recommended goal levels.

Disclosure of medical errors: what factors influence how patients respond?

BACKGROUND

Disclosure of medical errors is encouraged, but research on how patients respond to specific practices is limited.

OBJECTIVE

This study sought to determine whether full disclosure, an existing positive physician-patient relationship, an offer to waive associated costs, and the severity of the clinical outcome influenced patients' responses to medical errors.

PARTICIPANTS

Four hundred and seven health plan members participated in a randomized experiment in which they viewed video depictions of medical error and disclosure.

DESIGN

Subjects were randomly assigned to experimental condition. Conditions varied in type of medication error, level of disclosure, reference to a prior positive physician-patient relationship, an offer to waive costs, and clinical outcome.

MEASURES

Self-reported likelihood of changing physicians and of seeking legal advice; satisfaction, trust, and emotional response.

RESULTS

Nondisclosure increased the likelihood of changing physicians, and reduced satisfaction and trust in both error conditions. Nondisclosure increased the likelihood of seeking legal advice and was associated with a more negative emotional response in the missed allergy error condition, but did not have a statistically significant impact on seeking legal advice or emotional response in the monitoring error condition. Neither the existence of a positive relationship nor an offer to waive costs had a statistically significant impact.

CONCLUSIONS

This study provides evidence that full disclosure is likely to have a positive effect or no effect on how patients respond to medical errors. The clinical outcome also influences patients' responses. The impact of an existing positive physician-patient relationship, or of waiving costs associated with the error remains uncertain.

Frequency of high-risk use of QT-prolonging medications

PURPOSE

Prolongation of the QT interval has been associated with increased risk of torsades de pointes and death. Concurrent use of more than one QT-prolonging drug or a QT-prolonging drug with a drug that alters its pharmacokinetic profile is an important risk factor for adverse outcomes.

METHODS

Using a representative sample of 2 million health plan members from 10 health maintenance organizations with pharmacy benefits between January 1999 and July 2001, we identified potential drug interactions involving QT-prolonging medications. Prescription claims overlapping by at least 7 days for either 2 or more QT-prolonging drugs or a QT-prolonging drug with a drug that alters its clearance were considered potential drug interactions. We determined the number of drug interactions overall and the number of these interactions involving patients with other risk factors for torsades de pointes.

RESULTS

A total of 48 465 potential drug interactions were identified in 10 415 (4.6%) of the 228 550 patients with at least one prescription for a QT-prolonging drug. Amitriptyline was involved in 37 859 (78.1%) of the drug interactions. Of all potential drug interactions, 43 689 (90.1%) occurred in patients with at least one other risk factor for torsades de pointes, and 1053 (2.2%) were listed as a contraindicated combination in product labeling.

CONCLUSION

Potential drug interactions involving currently marketed QT-prolonging drugs occurred in 4.6% of patients who had a prescription for a QT-prolonging medication. The findings suggest several areas for targeted interventions to decrease the potential risk from QT-prolonging medications.