1
|
Kröger E, Wilchesky M, Marcotte M, Voyer P, Morin M, Champoux N, Monette J, Aubin M, Durand PJ, Verreault R, Arcand M. Medication Use Among Nursing Home Residents With Severe Dementia: Identifying Categories of Appropriateness and Elements of a Successful Intervention. J Am Med Dir Assoc 2015; 16:629.e1-17. [DOI: 10.1016/j.jamda.2015.04.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 04/02/2015] [Accepted: 04/02/2015] [Indexed: 12/20/2022]
|
2
|
Moore KL, Boscardin WJ, Steinman MA, Schwartz JB. Patterns of chronic co-morbid medical conditions in older residents of U.S. nursing homes: differences between the sexes and across the agespan. J Nutr Health Aging 2014; 18:429-36. [PMID: 24676326 PMCID: PMC4099251 DOI: 10.1007/s12603-014-0001-y] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE There are limited data on combinations of co-morbid conditions to guide efforts to improve therapeutic strategies in patients with multiple co-morbid conditions. To some extent, this may be due to limited data on combinations of co-morbid conditions in patient groups. Our goal was to determine the most common co-morbid medical conditions in older residents of U.S. nursing homes and identify sex differences in prevalences and changes across the agespan of nursing residents. DESIGN Cross sectional analysis of National Nursing Home Survey (NNHS)--a nationally representative sample with comprehensive medical data on nursing home residents. SETTING 1174 Nursing homes. PARTICIPANTS Long term stay residents of U.S. Nursing Homes aged 65 years and older (11,734 :8745 women, 2989 men). MEASUREMENTS Determination of the prevalences of the most frequent two and three disease combinations identified using Clinical Classifications Software (CCS) for ICD-9-CM and a composite vascular disease diagnosis (atherosclerosis and/or coronary artery disease, and/or peripheral arterial disease, and/or cerebrovascular disease or stroke) from the most recent and only NNHS survey with comprehensive medical diagnosis information. RESULTS Frequent 2-disease combinations were: hypertension (HTN) + dementia (DEM) in 27%, HTN + any Vascular (Vasc) disease (26%), HTN + depression(DEP) 21%, HTN + arthritis(ARTH) 20%, DEM + Vasc (21%), DEM+Depression 19%, Arthritis + DEM 17%, DEP + Vasc (16%), ARTH + Vasc (15%), followed by HTN + GERD (14%) and ARTH + DEP (14%). Frequent 3-disease combinations: HTN +VASC+ DEP in 13%, HTN +DEM +DEP (11%), and HTN+Arthritis+DEM (10%). HTN was in 80% of the top 3-disease combinations, Vasc in 50%, HTN+VASC in 35%, DEM or DEP in 40%, ARTH in 25% and GERD in 20%. Combinations with anemia, arthritis, dementia, heart failure, osteroporosis, thyroid disease were higher in women, COPD combinations higher in men. As age increased, dementia, depression, arthritis, and anemia with hypertension were common co-morbid combinations, diabetes and heart failure were not. CONCLUSIONS Hypertension, vascular disease, dementia, arthritis, depression, and gastro-esophageal reflux disease were part of the most prevalent co-morbid conditions. Multimorbidity patterns can be identified in nursing home residents and vary with age and by sex.
Collapse
Affiliation(s)
- K L Moore
- J.B. Schwartz, MD, Research Department, 302 Silver Avenue, San Francisco, CA 94112; (415) 406-1573, fax (415) 406-1577;
| | | | | | | |
Collapse
|
3
|
Abstract
BACKGROUND Overuse of unnecessary medications in frail older adults with limited life expectancy remains an understudied challenge. OBJECTIVE To identify intervention studies that reduced use of unnecessary medications in frail older adults. A secondary goal was to identify and review studies focusing on patients approaching end of life. We examined criteria for identifying unnecessary medications, intervention processes for medication reduction, and intervention effectiveness. METHODS A systematic review of English articles using MEDLINE, EMBASE, and International Pharmaceutical Abstracts from January 1966 to September 2012. Additional studies were identified by searching bibliographies. Search terms included prescription drugs, drug utilization, hospice or palliative care, and appropriate or inappropriate. A manual review of 971 identified abstracts for the inclusion criteria (study included an intervention to reduce chronic medication use; at least 5 participants; population included patients aged at least 65 years, hospice enrollment, or indication of frailty or risk of functional decline-including assisted living or nursing home residence, inpatient hospitalization) yielded 60 articles for full review by 3 investigators. After exclusion of review articles, interventions targeting acute medications, or studies exclusively in the intensive care unit, 36 articles were retained (including 13 identified by bibliography review). Articles were extracted for study design, study setting, intervention description, criteria for identifying unnecessary medication use, and intervention outcomes. RESULTS The studies included 15 randomized controlled trials, 4 non-randomized trials, 6 pre-post studies, and 11 case series. Control groups were used in over half of the studies (n = 20). Study populations varied and included residents of nursing homes and assisted living facilities (n = 16), hospitalized patients (n = 14), hospice/palliative care patients (n = 3), home care patients (n = 2), and frail or disabled community-dwelling patients (n = 1). The majority of studies (n = 21) used implicit criteria to identify unnecessary medications (including drugs without indication, unnecessary duplication, and lack of effectiveness); only one study incorporated patient preference into prescribing criteria. Most (25) interventions were led by or involved pharmacists, 4 used academic detailing, 2 used audit and feedback reports targeting prescribers, and 5 involved physician-led medication reviews. Overall intervention effect sizes could not be determined due to heterogeneity of study designs, samples, and measures. CONCLUSIONS Very little rigorous research has been conducted on reducing unnecessary medications in frail older adults or patients approaching end of life.
Collapse
|
4
|
Vale L, Thomas R, MacLennan G, Grimshaw J. Systematic review of economic evaluations and cost analyses of guideline implementation strategies. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2007; 8:111-21. [PMID: 17347844 DOI: 10.1007/s10198-007-0043-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2005] [Accepted: 01/31/2007] [Indexed: 05/14/2023]
Abstract
To appraise the quality of economic studies undertaken as part of evaluations of guideline implementation strategies, we conducted a systematic review of such studies published between 1966 and 1998. Studies were assessed against BMJ economic evaluations guidelines for each stage (guideline development, implementation and treatment). Of 235 studies identified, 63 reported some information on cost. Only 3 studies provided evidence that their guideline was effective and efficient, 38 reported treatment costs only, 12 implementation and treatment costs, 11 implementation costs alone, and 2 guideline development, implementation and treatment costs. No study gave reasonably complete information on costs. Thus, very few satisfactory economic evaluations of guideline implementation strategies have been performed. Current evaluations have numerous methodological defects and rarely consider all relevant costs and benefits. Future evaluations should focus on evaluating the implementation of evidence-based guidelines.
Collapse
Affiliation(s)
- Luke Vale
- Health Services Research Unit and Health Economics Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, Scotland.
| | | | | | | |
Collapse
|
5
|
Zuckerman IH, Lee E, Wutoh AK, Xue Z, Stuart B. Application of regression-discontinuity analysis in pharmaceutical health services research. Health Serv Res 2006; 41:550-63. [PMID: 16584464 PMCID: PMC1702511 DOI: 10.1111/j.1475-6773.2005.00487.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To demonstrate how a relatively underused design, regression-discontinuity (RD), can provide robust estimates of intervention effects when stronger designs are impossible to implement. DATA SOURCES/STUDY SETTING Administrative claims from a Mid-Atlantic state Medicaid program were used to evaluate the effectiveness of an educational drug utilization review intervention. STUDY DESIGN Quasi-experimental design. DATA COLLECTION/EXTRACTION METHODS A drug utilization review study was conducted to evaluate a letter intervention to physicians treating Medicaid children with potentially excessive use of short-acting beta(2)-agonist inhalers (SAB). The outcome measure is change in seasonally-adjusted SAB use 5 months pre- and postintervention. To determine if the intervention reduced monthly SAB utilization, results from an RD analysis are compared to findings from a pretest-posttest design using repeated-measure ANOVA. PRINCIPAL FINDINGS Both analyses indicated that the intervention significantly reduced SAB use among the high users. Average monthly SAB use declined by 0.9 canisters per month (p<.001) according to the repeated-measure ANOVA and by 0.2 canisters per month (p<.001) from RD analysis. CONCLUSIONS Regression-discontinuity design is a useful quasi-experimental methodology that has significant advantages in internal validity compared to other pre-post designs when assessing interventions in which subjects' assignment is based on cutoff scores for a critical variable.
Collapse
Affiliation(s)
- Ilene H Zuckerman
- Department of Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | | | | | | | | |
Collapse
|
6
|
Ramsay CR, Matowe L, Grilli R, Grimshaw JM, Thomas RE. Interrupted time series designs in health technology assessment: lessons from two systematic reviews of behavior change strategies. Int J Technol Assess Health Care 2004; 19:613-23. [PMID: 15095767 DOI: 10.1017/s0266462303000576] [Citation(s) in RCA: 487] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES In an interrupted time series (ITS) design, data are collected at multiple instances over time before and after an intervention to detect whether the intervention has an effect significantly greater than the underlying secular trend. We critically reviewed the methodological quality of ITS designs using studies included in two systematic reviews (a review of mass media interventions and a review of guideline dissemination and implementation strategies). METHODS Quality criteria were developed, and data were abstracted from each study. If the primary study analyzed the ITS design inappropriately, we reanalyzed the results by using time series regression. RESULTS Twenty mass media studies and thirty-eight guideline studies were included. A total of 66% of ITS studies did not rule out the threat that another event could have occurred at the point of intervention. Thirty-three studies were reanalyzed, of which eight had significant preintervention trends. All of the studies were considered "effective" in the original report, but approximately half of the reanalyzed studies showed no statistically significant differences. CONCLUSIONS We demonstrated that ITS designs are often analyzed inappropriately, underpowered, and poorly reported in implementation research. We have illustrated a framework for appraising ITS designs, and more widespread adoption of this framework would strengthen reviews that use ITS designs.
Collapse
Affiliation(s)
- Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Foresterhill, UK.
| | | | | | | | | |
Collapse
|
7
|
Medication Errors and Adverse Drug Events in Nursing Homes: Problems, Causes, Regulations, and Proposed Solutions. J Am Med Dir Assoc 2002. [DOI: 10.1016/s1525-8610(04)70439-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
8
|
Dodd MJ, Miaskowski C. The PRO-SELF Program: a self-care intervention program for patients receiving cancer treatment. Semin Oncol Nurs 2000; 16:300-8; discussion 308-16. [PMID: 11109273 DOI: 10.1053/sonu.2000.16586] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To describe the development, testing, and refinement of the PRO-SELF Program as used in randomized clinical trials. DATA SOURCES Research studies and articles. CONCLUSIONS The PRO-SELF Program has made an important contribution in enhancing patients' self-care and reducing morbidity. It has the potential to contribute to self-care abilities of children and adolescents who have cancer. IMPLICATIONS FOR NURSING PRACTICE It is imperative that patients and their families have the essential information, skills, and support to carry out effective self-care symptom management.
Collapse
Affiliation(s)
- M J Dodd
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco 94143-0610, USA
| | | |
Collapse
|
9
|
Gurwitz JH, Field TS, Avorn J, McCormick D, Jain S, Eckler M, Benser M, Edmondson AC, Bates DW. Incidence and preventability of adverse drug events in nursing homes. Am J Med 2000; 109:87-94. [PMID: 10967148 DOI: 10.1016/s0002-9343(00)00451-4] [Citation(s) in RCA: 378] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Adverse drug events, especially those that may have been preventable, are among the most serious concerns about medication use in nursing homes. We studied the incidence and preventability of adverse drug events and potential adverse drug events in nursing homes. METHODS We performed a cohort study of all long-term care residents of 18 community-based nursing homes in Massachusetts during a 12-month observation period. Potential drug-related incidents were detected by stimulated self-report by nursing home staff and by periodic review of the records of nursing home residents by trained nurse and pharmacist investigators. Each incident was classified by 2 independent physician-reviewers, using a structured implicit review process, by whether or not it constituted an adverse drug event or potential adverse drug event (those that may have caused harm, but did not because of chance or because they were detected), by the severity of the event (significant, serious, life-threatening, or fatal), and by whether it was preventable. Examples of significant events included nonurticarial rashes, falls without associated fracture, hemorrhage not requiring transfusion or hospitalization, and oversedation; examples of serious events included urticaria, falls with fracture, hemorrhage requiring transfusion or hospitalization, and delirium. RESULTS During 28,839 nursing home resident-months of observation in the 18 participating nursing homes, 546 adverse drug events (1.89 per 100 resident-months) and 188 potential adverse drug events (0.65 per 100 resident-months) were identified. Of the adverse drug events, 1 was fatal, 31 (6%) were life-threatening, 206 (38%) were serious, and 308 (56%) were significant. Overall, 51% of the adverse drug events were judged to be preventable, including 171 (72%) of the 238 fatal, life-threatening, or serious events and 105 (34%) of the 308 significant events (P < 0.001). Errors resulting in preventable adverse drug events occurred most often at the stages of ordering and monitoring; errors in transcription, dispensing, and administration were less commonly identified. Psychoactive medications (antipsychotics, antidepressants, and sedatives/hypnotics) and anticoagulants were the most common medications associated with preventable adverse drug events. Neuropsychiatric events were the most common types of preventable adverse drug events. CONCLUSIONS Adverse drug events are common and often preventable in nursing homes. More serious adverse drug events are more likely to be preventable. Prevention strategies should target the ordering and monitoring stages of pharmaceutical care.
Collapse
Affiliation(s)
- J H Gurwitz
- Meyers Primary Care Institute, the Fallon Healthcare System, and the University of Massachusetts Medical School (JHG, TSF, DM, SJ, ME, MB), Worcester, Massachusetts, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Gill PS, Mäkelä M, Vermeulen KM, Freemantle N, Ryan G, Bond C, Thorsen T, Haaijer-Ruskamp FM. Changing doctor prescribing behaviour. PHARMACY WORLD & SCIENCE : PWS 1999; 21:158-67. [PMID: 10483603 DOI: 10.1023/a:1008719129305] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The aim of this overview was to identify interventions that change doctor prescribing behaviour and to derive conclusions for practice and further research. Relevant studies (indicating prescribing as a behaviour change) were located from a database of studies maintained by the Cochrane Collaboration on Effective Professional Practice. This register is kept up to date by searching the following databases for reports of relevant research: DHSS-DATA; EMBASE; MEDLINE; SIGLE; Resource Database in Continuing Medical Education (1975-1994), along with bibliographies of related topics, hand searching of key journals and personal contact with content area experts. Randomised controlled trials and non-equivalent group designs with pre- and post-intervention measures were included. Outcome measures were those used by the study authors. For each study we determined whether these were positive, negative or inconclusive. Positive studies (+) were those that demonstrated a statistically significant change in the majority of outcomes measured at level of p < or = 0.05 between the intervention and control groups. Negative studies (-) showed a significant change in the opposite direction and inconclusive studies (approximately) showed no significant change compared to control or no overall positive findings. We identified 79 eligible studies which described 96 separate interventions to change prescribing behaviour. Of these interventions, 49 (51%, 41%-61%) showed a positive significant change compared to the control group but interpretation of specific interventions is limited due to wide and overlapping confidence intervals.
Collapse
Affiliation(s)
- P S Gill
- Department of Primary Care and General Practice, University of Birmingham, UK.
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Perron AD, Huff JS, Ullrich CG, Heafner MD, Kline JA. A multicenter study to improve emergency medicine residents' recognition of intracranial emergencies on computed tomography. Ann Emerg Med 1998; 32:554-62. [PMID: 9795317 DOI: 10.1016/s0196-0644(98)70032-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
STUDY OBJECTIVE Cranial computed tomography (CT) has assumed a critical role in the practice of emergency medicine for the evaluation of intracranial emergencies. Several recent studies have documented a deficiency in the emergency physician's ability to interpret these studies. The purpose of this study was to quantify the baseline ability of emergency medicine residents to interpret cranial CTs, and to test a novel method of cranial CT interpretation designed for the emergency physician in training. METHODS A standardized pretest was administered to assess baseline ability to interpret CT scans. A standardized posttest was given 3 months after the course. Each test consisted of 12 CT scans with a short accompanying history. All scans were validated by 3 expert reviewers for difficulty and diagnosis. A 2-hour course based on the mnemonic "Blood Can Be Very Bad" was then administered. "Blood" reminds the examiner to search for blood, "Can" prompts the examiner to identify 4 key cisterns, "Be" denotes the need to examine the brain, "Very" prompts a review of the 4 ventricles, and finally "Bad" reminds the examiner to evaluate the bones of the cranium. RESULTS Eighty-three residents at 5 institutions were initially examined. The mean percentage correct before the course was 60% (95% confidence interval [CI] 58%-64%) on the standardized pretest. At retesting 3 months after the course, the accuracy rate increased to 78% (n=61, 95% CI 75%-81%, P<.001 paired t test). CONCLUSION Emergency medicine residents are deficient in their ability to interpret cranial CT scans. A novel educational course was demonstrated to significantly improve this ability.
Collapse
Affiliation(s)
- A D Perron
- Departments of Emergency Medicine, Radiology, and Neurosurgery, Carolinas Medical Center, Charlotte, NC, USA
| | | | | | | | | |
Collapse
|
12
|
Levitt MA, Dawkins R, Williams V, Bullock S. Abbreviated educational session improves cranial computed tomography scan interpretations by emergency physicians. Ann Emerg Med 1997; 30:616-21. [PMID: 9360572 DOI: 10.1016/s0196-0644(97)70079-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
STUDY OBJECTIVE Previously published research (phase I) demonstrated a concerning misinterpretation rate of cranial computed tomography (CT) scans by emergency physicians. This study (phase II) determined whether an abbreviated educational session would improve emergency physician interpretation skills of cranial CT scans. METHODS Participants in this prospective, interventional study in a county hospital ED were patients undergoing cranial CT scanning during ED evaluations and attending level emergency physicians. An abbreviated educational session on cranial CT interpretation skills was given to the same attending emergency physicians who participated in phase I. The educational session included basic CT interpretation skills and misinterpreted CT scans from phase I. We determined the postsession accuracy rate of the emergency physicians on 324 ED patient CT scans. The CT interpretation accuracy rates were then compared between phase I and phase II to determine the effectiveness of the educational session. RESULTS The radiology/ED CT scan concordance rate improved from 61.3% (kappa = .22) to 88.6% (kappa = .70; P < .0001). Potentially clinically significant CT scan misinterpretations decreased from 24.1% to 4.0% (P < .0001). Most importantly, major missed findings on CT scans decreased from 11.4% to 2.8% (P < .0001). Continuous quality improvement monitoring found no instance of clinically significant patient mismanagement. CONCLUSION Within the limits of this study, we conclude that emergency physicians' interpretation skills of cranial CT scans may be improved using a 1-hour educational session.
Collapse
Affiliation(s)
- M A Levitt
- Department of Emergency Medicine, Alameda County Medical Center, Oakland, CA, USA
| | | | | | | |
Collapse
|
13
|
Moride Y, Melnychuk D, Monette J, Abenhaim L. Determinants of initiation and suboptimal use of anti-ulcer medication: a study of the Quebec older population. J Am Geriatr Soc 1997; 45:853-6. [PMID: 9215338 DOI: 10.1111/j.1532-5415.1997.tb01514.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To describe the use of anti-ulcer medication in the Quebec older population; to examine determinants of initiation, suboptimal use, and switches between products. DESIGN Population-based retrospective cohort study. SETTING Universal health program for older adults in Quebec. PARTICIPANTS 5000 users and 5000 non-users of anti-ulcer medications were selected randomly. Use was defined as the presence in the 1991 prescription database of an anti-ulcer prescription. Among users, 1697 (34%) were new users and were considered as the exposure group. Subjects were followed for 365 days after inclusion. MEASUREMENTS Measured were patient's age, gender, prescribed duration of anti-ulcer medication, concomitant medications, and gastrointestinal diagnostic procedures. RESULTS A total of 17% of new users had unusually short courses; 18% were long-term users. There was no difference in duration for omeprazole compared with other anti-ulcer medications. First-time use of NSAIDs was the strongest predictor of initiation of anti-ulcer medication (odds ratio = 3.21; 95% CI, 2.66-3.88). Twenty-six percent of users switched brands. Only 9.5% of new users underwent a diagnostic procedure before initiation of therapy, and 49% of long-term users ever underwent such procedure. CONCLUSION Despite a relatively homogeneous recommended duration of therapy, patterns of use of anti-ulcer medication among older people are highly variable, and treatment is often not accompanied by a diagnostic procedure.
Collapse
Affiliation(s)
- Y Moride
- Centre for Clinical Epidemiology and Community Studies, McGill University S.M.B.D. Jewish General Hospital, Montreal, Quebec, Canada
| | | | | | | |
Collapse
|
14
|
Abstract
Many physicians prescribe more than one antiulcerative agent (AUA) simultaneously to the same patient, although there is little evidence to support this practice. The purposes of this study were to (a) determine patient factors associated with the concurrent use of these agents and (b) estimate the excess costs generated by the prescription of multiple rather than a single agent. We conducted a case-control study of concurrent AUA users among New Jersey Medicaid enrollees age 65 years and older. To evaluate the excess cost generated by the ongoing prescription of an additional AUA, we measured the additional drug expenditures associated with each regimen of concurrent use. Nearly 1 in 15 AUA users (6.6%) met our conservative definition of concurrent AUA use. In a multiple logistic regression model, previous gastrointestinal procedure, use of a nonsteroidal anti-inflammatory drugs, nursing home residency, and recent hospitalization for more than 20 days were all predictors of concurrent use of more than one AUA. No association was found with age, sex, or number of pharmacies used. The upper bound estimate of the cost generated by the concurrent prescription of a second AUA was $210 (range: $2-$942) over the 180-day study period, with a lower bound of $151 (range: $1-$449). Annually, such excess cost would range from $301 to $420 per patient. This would account for between $457 million and $637 million per year for the nation's elderly if these patterns are generalizable. Despite the lack of evidence of therapeutic benefit from multiple concurrent AUA use in most patients, this practice is fairly common. Besides introducing the risk of additional costs and side effects in the absence of additional efficacy, the costs of such duplicative prescribing are substantial.
Collapse
Affiliation(s)
- J Monette
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | | | | |
Collapse
|
15
|
Joseph CL. Alcohol and drug misuse in the nursing home. THE INTERNATIONAL JOURNAL OF THE ADDICTIONS 1995; 30:1953-84. [PMID: 8751325 DOI: 10.3109/10826089509071062] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The misuse of alcohol or drugs is a common and frequently neglected problem among nursing home residents. The misuse of prescription medications is particularly prevalent, but tobacco, alcohol, and illicit drugs are all subject of misuse by nursing home residents. This article reviews the epidemiologic and clinical aspects of substance misuse in nursing homes, including alcohol, illicit drugs, tobacco, and pyscho-active medications. Regulations regarding the prescription of psycho-active drugs in nursing homes is also discussed.
Collapse
Affiliation(s)
- C L Joseph
- Extended Care Services, Portland Veterans Affairs Medical Center, Oregon
| |
Collapse
|
16
|
Stichele RHV, Petri H. Utilization patterns of subsidized and nonsubsidized reimbursable peptic ulcer medication in Belgium. Pharmacoepidemiol Drug Saf 1995. [DOI: 10.1002/pds.2630040404] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
|
17
|
Evolution of histamine H2-receptor antagonist use in an ambulatory elderly population: A 14-year overview. Pharmacoepidemiol Drug Saf 1995. [DOI: 10.1002/pds.2630040310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
18
|
Pickering TD, Gurwitz JH, Zaleznik D, Noonan JP, Avorn J. The appropriateness of oral fluoroquinolone-prescribing in the long-term care setting. J Am Geriatr Soc 1994; 42:28-32. [PMID: 8277111 DOI: 10.1111/j.1532-5415.1994.tb06069.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To evaluate the appropriateness of ciprofloxacin-prescribing in the long-term care setting. DESIGN Retrospective chart review. SETTING A large academically oriented long-term care facility. PATIENTS Institutionalized elderly patients with a mean age of 88 years. METHODS One hundred orders were randomly selected for review from all ciprofloxacin orders initiated over a 3-year period. Criteria for appropriateness of ciprofloxacin-prescribing were developed based on a comprehensive review of the medical literature. Evaluation of appropriateness of prescribing was based on the indication for therapy and the availability of more effective and/or less expensive alternative antibiotic regimens. Only information available to the physician at the time of the order was used to judge appropriateness. Abstracted medical records were evaluated independently by a geriatrician and an infectious diseases specialist. RESULTS With respect to site of infection, the urinary tract accounted for 43% of all ciprofloxacin orders; the lower respiratory tract, 28%; and skin and soft-tissue infections, 17%. Only 25% of orders were judged appropriate. Twenty-three percent of orders were judged less than appropriate based on indication, and 49% due to the availability of a more effective and/or less expensive alternative antibiotic choice. There was insufficient information in the medical record to judge 3% of the orders. CONCLUSION These results indicate less than optimal prescribing of oral fluoroquinolones in the long-term care setting, with potential consequences including the development of resistant bacterial strains and increased health care costs.
Collapse
|
19
|
Katz J. The Use of H 2-Receptor Antagonists in the Nursing Home. J Am Geriatr Soc 1992; 40:425-6. [PMID: 1348257 DOI: 10.1111/j.1532-5415.1992.tb02149.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|