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Kapoor A, Patel P, Mbusa D, Pham T, Cicirale C, Tran W, Beavers C, Javed S, Wagner J, Swain D, Crawford S, Darling C, ItoFuKunaga M, McManus D, Mazor K, Gurwitz J. Multicomponent Pharmacist Intervention Did Not Reduce Clinically Important Medication Errors for Ambulatory Patients Initiating Direct Oral Anticoagulants. J Gen Intern Med 2023; 38:3526-3534. [PMID: 37758967 PMCID: PMC10713923 DOI: 10.1007/s11606-023-08315-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/30/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Anticoagulants including direct oral anticoagulants (DOACs) are among the highest-risk medications in the United States. We postulated that routine consultation and follow-up from a clinical pharmacist would reduce clinically important medication errors (CIMEs) among patients beginning or resuming a DOAC in the ambulatory care setting. OBJECTIVE To evaluate the effectiveness of a multicomponent intervention for reducing CIMEs. DESIGN Randomized controlled trial. PARTICIPANTS Ambulatory patients initiating a DOAC or resuming one after a complication. INTERVENTION Pharmacist evaluation and monitoring based on the implementation of a recently published checklist. Key elements included evaluation of the appropriateness of DOAC, need for DOAC affordability assistance, three pharmacist-initiated telephone consultations, access to a DOAC hotline, documented hand-off to the patient's continuity provider, and monitoring of follow-up laboratory tests. CONTROL Coupons and assistance to increase the affordability of DOACs. MAIN MEASURE Anticoagulant-related CIMEs (Anticoagulant-CIMEs) and non-anticoagulant-related CIMEs over 90 days from DOAC initiation; CIMEs identified through masked assessment process including two physician adjudication of events presented by a pharmacist distinct from intervention pharmacist who reviewed participant electronic medical records and interview data. ANALYSIS Incidence and incidence rate ratio (IRR) of CIMEs (intervention vs. control) using multivariable Poisson regression modeling. KEY RESULTS A total of 561 patients (281 intervention and 280 control patients) contributed 479 anticoagulant-CIMEs including 31 preventable and ameliorable ADEs and 448 significant anticoagulant medication errors without subsequent documented ADEs (0.95 per 100 person-days). Failure to perform required blood tests and concurrent, inappropriate usage of a DOAC with aspirin or NSAIDs were the most common anticoagulant-related CIMEs despite pharmacist documentation systematically identifying these issues when present. There was no reduction in anticoagulant-related CIMEs among intervention patients (IRR 1.17; 95% CI 0.98-1.42) or non-anticoagulant-related CIMEs (IRR 1.05; 95% CI 0.80-1.37). CONCLUSION A multi-component intervention in which clinical pharmacists implemented an evidence-based DOAC Checklist did not reduce CIMEs. NIH TRIAL NUMBER NCT04068727.
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Affiliation(s)
- Alok Kapoor
- UMass Chan Medical School, Worcester, MA, USA.
- UMass Memorial Medical Center, Worcester, MA, USA.
| | - Parth Patel
- UMass Chan Medical School, Worcester, MA, USA
| | | | - Thu Pham
- UMass Chan Medical School, Worcester, MA, USA
| | - Carrie Cicirale
- Barnes-Jewish Hospital, One Barnes Jewish Hospital Plaza, St. Louis, MO, USA
| | - Wenisa Tran
- UMass Memorial Medical Center, Worcester, MA, USA
| | | | - Saud Javed
- UMass Chan Medical School, Worcester, MA, USA
- UMass Memorial Medical Center, Worcester, MA, USA
| | | | - Dawn Swain
- Bouve College of Health Sciences, Northeastern University , Boston, MA, USA
- Beverly Hospital, Beverly, MA, USA
| | - Sybil Crawford
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, MA, USA
| | - Chad Darling
- UMass Chan Medical School, Worcester, MA, USA
- UMass Memorial Medical Center, Worcester, MA, USA
| | - Mayuko ItoFuKunaga
- UMass Chan Medical School, Worcester, MA, USA
- UMass Memorial Medical Center, Worcester, MA, USA
| | - David McManus
- UMass Chan Medical School, Worcester, MA, USA
- UMass Memorial Medical Center, Worcester, MA, USA
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2
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Castañeda-Avila MA, Lapane KL, Person SD, Zhou Y, Gurwitz J, Mazor KM, Epstein MM. Multi-trajectory models of serum biomarkers among patients with monoclonal gammopathy of undetermined significance. Hematol Oncol 2022; 40:409-416. [PMID: 35304925 PMCID: PMC9378561 DOI: 10.1002/hon.2992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/08/2022] [Accepted: 03/03/2022] [Indexed: 11/10/2022]
Abstract
Understanding the progression of monoclonal gammopathy of undetermined significance (MGUS) to multiple myeloma (MM) is needed to identify patients who would benefit from closer clinical surveillance. Given that two of the defining criteria of MM are renal failure and anemia, we described the trajectories of creatinine (Cr) and hemoglobin (Hgb) over time in patients with a diagnosis of MGUS. Patients diagnosed with MGUS (n = 424) were identified by a previously validated case-finding algorithm using health claims and electronic health record data (2007-2015) and followed through 2018. Group-based trajectory modeling identified patients with distinct laboratory value trajectories of Cr (mg/dl) and Hgb (g/dl). Most patients were non-Hispanic White (97.6%) with a mean age of 75 years at MGUS diagnosis. Three multi-trajectory groups were identified: (1) Normal Cr/Hgb (n = 225; 53.1%)-stable serum Cr levels and decreasing, normal Hgb levels; (2) Normal Cr/lower-normal Hgb group (n = 188; 44.3%)-stable, slightly elevated levels of Cr and decreasing levels of Hgb; and (3) High Cr/borderline Hgb group (n = 11; 2.6%)-increased Cr levels and stable low levels of Hgb. Patients with MGUS in Group 2 were older than patients in other groups, and patients in group 3 had more comorbidities than participants in all other groups. Few patients developed MM during the study period. We were able to identify distinct biomarker trajectories in patients with MGUS over time. Future research should investigate how these trajectories may be related to the risk of progression to MM, including M-protein levels.
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Affiliation(s)
- Maira A Castañeda-Avila
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Kate L Lapane
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Sharina D Person
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Yanhua Zhou
- Meyers Health Care Institute, a Joint Endeavor of the University of Massachusetts Chan Medical School, Fallon Health, and Reliant Medical Group, Worcester, Massachusetts, USA
| | - Jerry Gurwitz
- Meyers Health Care Institute, a Joint Endeavor of the University of Massachusetts Chan Medical School, Fallon Health, and Reliant Medical Group, Worcester, Massachusetts, USA.,Department of Medicine, Division of Geriatric Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Kathleen M Mazor
- Meyers Health Care Institute, a Joint Endeavor of the University of Massachusetts Chan Medical School, Fallon Health, and Reliant Medical Group, Worcester, Massachusetts, USA.,Department of Medicine, Division of Geriatric Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Mara M Epstein
- Meyers Health Care Institute, a Joint Endeavor of the University of Massachusetts Chan Medical School, Fallon Health, and Reliant Medical Group, Worcester, Massachusetts, USA.,Department of Medicine, Division of Geriatric Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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Rampam S, Sadiq H, Patel J, Meyer D, Uy K, Yates J, Schanzer A, Movahedi B, Lindberg J, Crawford S, Gurwitz J, Mazor K, Stefan M, White D, Walz M, Kapoor A. Supervised preoperative walking on increasing early postoperative stamina and mobility in older adults with frailty traits: A pilot and feasibility study. Health Sci Rep 2022; 5:e738. [PMID: 35873397 PMCID: PMC9301296 DOI: 10.1002/hsr2.738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/17/2022] [Accepted: 06/27/2022] [Indexed: 12/18/2022] Open
Abstract
Background and Aims Frail older adults are more than twice as likely to experience postoperative complications. Preoperative exercise may better prepare these patients through improved stamina and mobility experienced in the days following surgery. We measured the impact of a walking intervention using an activity tracker and coaching on postoperative stamina, and mobility in older adults with frailty traits. Methods We included patients aged 60+ and scoring 4+ on the Edmonton Frailty Scale. We then randomized patients to intervention versus control stratified by anticipated hospital stay (1 night vs. 2+ night) and baseline stamina (i.e., 6-min walk distance [6MWD]). Intervention patients received an activity tracker and linked smart phone. An athletic trainer (AT) prescribed a daily step count goal and titrated this up after checking in with patients during weekly telephone calls. Controls received general walking recommendations. We then measured postoperative 6MWD 1-3 days after surgery. We also assessed postoperative mobility by measuring steps walked the day after surgery using a thigh-worn monitor. Because many patients could not walk postoperatively, we compared intervention-control difference in both 6MWD and steps using Wilcoxon rank testing and Tobit and ordinal logistic regression adjusting for several patient characteristics. Results We randomized 104 eligible patients; 80 patients remained for final analysis. There was no difference in intervention versus control postoperative 6MWD (median 72 vs. 74 m Wilcoxon p = 0.54) or postoperative steps taken (median 128 vs. 51 steps Wilcoxon p = 0.76). Analysis adjusting for patient characteristics was consistent with these findings. Conclusion Our intervention consisting of goal setting with an activity tracker and telephonic coaching by an AT did not appear to improve stamina or mobility measured in the days after surgery. Small sample size limited our ability to examine this impact in subsets defined by surgical specialty or baseline stamina.
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Affiliation(s)
- Sanjeev Rampam
- Department of Medicine UMass Chan Medical School Worcester Massachusetts USA
| | - Hammad Sadiq
- Department of Medicine UMass Chan Medical School Worcester Massachusetts USA
| | - Jay Patel
- Department of Medicine UMass Chan Medical School Worcester Massachusetts USA
| | - David Meyer
- Hospital Medicine UMass Memorial Health Worcester Massachusetts USA.,Department of Surgery UMass Chan Medical School Worcester MA USA
| | - Karl Uy
- Department of Surgery UMass Chan Medical School Worcester MA USA.,Thoracic Surgery UMass Memorial Health Worcester MA USA
| | - Jennifer Yates
- Department of Urology UMass Chan Medical School Worcester MA USA.,Urology UMass Memorial Health Worcester MA USA
| | - Andres Schanzer
- Department of Surgery UMass Chan Medical School Worcester MA USA.,Vascular Surgery UMass Memorial Health Worcester MA USA
| | - Babak Movahedi
- Department of Surgery UMass Chan Medical School Worcester MA USA.,Transplant Surgery UMass Memorial Health Worcester MA USA
| | - James Lindberg
- Department of Surgery UMass Chan Medical School Worcester MA USA.,Surgical Oncology UMass Memorial Health Worcester MA USA
| | - Sybil Crawford
- Department of Medicine UMass Chan Medical School Worcester Massachusetts USA
| | - Jerry Gurwitz
- Department of Medicine UMass Chan Medical School Worcester Massachusetts USA.,Department of Medicine Meyers Health Care Institute Worcester Massachusetts USA
| | - Kathleen Mazor
- Department of Medicine UMass Chan Medical School Worcester Massachusetts USA.,Department of Medicine Meyers Health Care Institute Worcester Massachusetts USA
| | - Mihaela Stefan
- Department of Medicine UMass Chan Medical School Worcester Massachusetts USA.,Medicine Baystate Medical Center Springfield Massachusetts USA
| | - Daniel White
- Department of Physical Therapy University of Delaware Newark Delaware USA
| | - Matthias Walz
- Department of Anesthesiology and Perioperative Medicine UMass Chan Medical School Worcester MA USA.,Anesthesiology UMass Memorial Health Worcester MA USA
| | - Alok Kapoor
- Department of Medicine UMass Chan Medical School Worcester Massachusetts USA.,Hospital Medicine UMass Memorial Health Worcester Massachusetts USA.,Department of Medicine Meyers Health Care Institute Worcester Massachusetts USA
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4
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Tisminetzky M, Delude C, Allore HG, Anzuoni K, Bloomstone S, Charpentier P, Hepler JP, Kitzman DW, McAvay GJ, Miller M, Pajewski NM, Gurwitz J. The geriatrics research instrument library: A resource for guiding instrument selection for researchers studying older adults with multiple chronic conditions. Journal of Multimorbidity and Comorbidity 2022; 12:26335565221081200. [PMID: 35586036 PMCID: PMC9106318 DOI: 10.1177/26335565221081200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 01/31/2021] [Indexed: 11/15/2022]
Abstract
Background After the passage of the 21st Century Cures Act in the U.S., the Inclusion Across the Lifespan policy eliminates upper-age limits for research participation unless risk justified. Broader inclusion will necessitate the use of reliable instruments in research that characterize the health status and function of older adults with multiple chronic conditions. As there is a plethora of such instruments, the Geriatrics Research Instrument Library (GRIL) was developed as freely available online resource of data collection instruments commonly used in gerontological research. GRIL has been revised and updated by the Advancing Geriatrics Infrastructure and Network Growth (AGING) Initiative, a joint endeavor of the Health Care Systems Research Network (HCSRN) and the Older Americans Independence Centers (OAICs). Methods Extensive PubMed literature searches and domain expert feedback were utilized to inventory and update GRIL through the addition of instruments and compiling of instrument metadata. GRIL is hosted on the National Institute on Aging OAIC Coordinating Center website with a platform utilizing Microsoft Structured Query Language (SQL) and an Adobe ColdFusion application server. Tracking statistics are collected using Google Analytics. Results Presently, GRIL includes 175 instruments across 18 domains, including instrument metadata such as instrument description, copyright information, completion time estimates, keywords, available translations, and a link and reference to the original manuscript describing the instrument. The GRIL website includes user-friendly features such as mobile platforming and resource links. Conclusions GRIL provides a user-friendly public resource that facilitates clinical researchers in efficiently selecting appropriate instruments to measure clinical outcomes relevant to older adults across a full range of domains.
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Affiliation(s)
- Mayra Tisminetzky
- University of Massachusetts Medical School and Meyers Health Care Institute, Worcester, MA, USA
| | | | - Heather G Allore
- Yale School of Medicine and Yale School of Public Health, New Haven, CT, USA
| | | | | | | | - John P Hepler
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Gail J McAvay
- Yale School of Medicine and Yale School of Public Health, New Haven, CT, USA
| | | | | | - Jerry Gurwitz
- University of Massachusetts Medical School and Meyers Health Care Institute, Worcester, MA, USA
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5
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Bamgbade B, McManus D, Briesacher B, Lessard D, Mehawej J, Tisminestzky M, Gurwitz J, Saczynski J. Cost Reduction Behaviors and Cost-Related Medication Nonadherence in Older Adults with Atrial Fibrillation. Innov Aging 2021. [PMCID: PMC8681516 DOI: 10.1093/geroni/igab046.2342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
While factors such as forgetfulness may result in medication nonadherence, 2.7 million older adults in the US experience cost-related nonadherence (CRN). Limited research has explored CRN and associated cost-reduction behaviors (CRB) in older adults with atrial fibrillation. The objectives of this study were to 1) describe the prevalence of CRN, CRB and spending less on basic needs to afford medication and 2) examine factors associated with CRB among older adults with atrial fibrillation. Data were drawn from the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF), a prospective cohort of older adults with atrial fibrillation (>65 years). Using a self-administered survey, all participants completed a validated CRN measure. Chi-square and t-tests were used to evaluate differences in participant characteristics across CRB and significant characteristics (p<0.05) were entered into a logistic regression model. Participants (N=1244) were on average 76 years and 49% were female. Among all participants, 4.2% reported CRN; 69.1% reported CRB; and 5.9% reported spending less on basic needs. Compared to participants who did not engage in CRB, participants who engaged in CRB were less likely to be cognitively impaired and more likely to be a race/ethnicity other than non-Hispanic white; have Medicare insurance; and have comorbidities. CRB were common among older adults with atrial fibrillation and was associated with in-tact cognitive function, the presence of medical comorbidities and non-White race. Clinicians might consider providing patients with cognitive impairment additional support such as patient assistance programs or referrals to pharmacists for medication therapy management to assist with CRB.
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Affiliation(s)
- Benita Bamgbade
- Northeastern University, Boston, Massachusetts, United States
| | - David McManus
- University of Massachusetts Medical School, Worcester, Massachusetts, United States
| | | | - Darleen Lessard
- University of Massachusetts Medical School, Worcester, Massachusetts, United States
| | - Jordy Mehawej
- University of Massachusetts Medical School, Worcester, Massachusetts, United States
| | - Mayra Tisminestzky
- University of Massachusetts Medical School, Worcester, Massachusetts, United States
| | - Jerry Gurwitz
- University of Massachusetts Medical School, Worcester, Massachusetts, United States
| | - Jane Saczynski
- Northeastern University, Boston, Massachusetts, United States
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6
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Kapoor A, Patel J, Chen Z, Crawford S, McManus D, Gurwitz J, Shireman TI, Zhang N. Geriatric conditions do not predict stroke or bleeding in long-term care residents with atrial fibrillation. J Am Geriatr Soc 2021; 70:1218-1227. [PMID: 34902164 DOI: 10.1111/jgs.17605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 11/05/2021] [Accepted: 11/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Long-term care (LTC) providers prescribe anticoagulation (AC) less frequently in residents with atrial fibrillation (AF) and geriatric conditions independent of CHA2 DS2 -VASc stroke risk score. Geriatric conditions include recent fall, activities of daily living dependency, mobility impairment, cognitive impairment, low body mass index, and weight loss. Multiple publications have suggested that patients with geriatric conditions are at increased risk for stroke. Understanding better the risk of stroke and bleeding in residents with AF and geriatric conditions would be valuable to LTC providers for AC decision-making. METHODS AND RESULTS We measured the association of geriatric conditions with composite of stroke/transient ischemic attack (TIA)/systemic embolism and bleeding in residents with AF and elevated stroke risk (CHA2 DS2 -VASc score ≥ 2) living in American LTC facilities in 2015. After merging nursing home assessments (Minimum Data Set) with medication and hospital utilization records, we identified 209,413 eligible residents. Using generalized estimating equations, we found that the incidence of stroke/TIA/systemic embolism ranged from 0.13% to 0.26% over 30 days (1.43%-3.08%/year) in residents off AC with and without geriatric conditions adjusting for other resident characteristics including CHA2 DS2 -VASc score and propensity to receive AC. Similarly, the monthly incidence of bleeding on AC ranged from 0.22% to 0.28% (2.61%-3.31%/year) without increased risk with geriatric conditions. Residents with a CHA2 DS2 -VASc score of ≥7 had a 2.4-fold increased risk of stroke compared with those with score of 2-4 (0.30% vs. 0.12%/month). CONCLUSION Calculating a CHA2 DS2 -VASc score can be helpful in AC decision-making for residents with and without geriatric conditions.
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Affiliation(s)
- Alok Kapoor
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Jay Patel
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Zhiyong Chen
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA.,Zem Data Science, LLC, North Potomac, Maryland, USA
| | - Sybil Crawford
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - David McManus
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Jerry Gurwitz
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Theresa I Shireman
- Department of Health Services, Policy and Practice, Center for Gerontology & Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Ning Zhang
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA.,Department of Health Policy and Promotion, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
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7
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Kapoor A, Sadiq H, Patel J, Zhang N, Mazor K, Crawford S, Chen Z, Gurwitz J, McManus D, Hanchate A. Disparities in Anticoagulation Use by Race and Ethnicity in Long-Term Care Residents With Atrial Fibrillation. J Am Heart Assoc 2021; 10:e023428. [PMID: 34816732 PMCID: PMC9075411 DOI: 10.1161/jaha.121.023428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alok Kapoor
- University of Massachusetts Medical SchoolWorcesterMA
- University of Massachusetts Memorial Medical CenterWorcesterMA
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
| | - Hammad Sadiq
- University of Massachusetts Medical SchoolWorcesterMA
| | - Jay Patel
- University of Massachusetts Medical SchoolWorcesterMA
| | - Ning Zhang
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
- Department of Health Policy and PromotionSchool of Public Health and Health SciencesUniversity of Massachusetts AmherstAmherstMA
| | - Kathleen Mazor
- University of Massachusetts Medical SchoolWorcesterMA
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
| | - Sybil Crawford
- University of Massachusetts Medical SchoolWorcesterMA
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
| | - Zhiyong Chen
- University of Massachusetts Medical SchoolWorcesterMA
- Zem Data Science, LLCNorth PotomacMD
| | - Jerry Gurwitz
- University of Massachusetts Medical SchoolWorcesterMA
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
| | - David McManus
- University of Massachusetts Medical SchoolWorcesterMA
- A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthMeyers Primary Care InstituteWorcesterMA
| | - Amresh Hanchate
- Department of Social Sciences and HealthWake Forest School of MedicineWinston‐SalemNC
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Zhang N, Patel J, Chen Z, Zhou Y, Crawford S, McManus DD, Gurwitz J, Shireman TI, Kapoor A. Geriatric Conditions Are Associated With Decreased Anticoagulation Use in Long-Term Care Residents With Atrial Fibrillation. J Am Heart Assoc 2021; 10:e021293. [PMID: 34387127 PMCID: PMC8475043 DOI: 10.1161/jaha.121.021293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Anticoagulation is the mainstay for stroke prevention in patients with atrial fibrillation, but concerns about bleeding inhibit its use in residents of long‐term care facilities. Risk‐profiling algorithms using comorbid disease information (eg, CHADS2 and ATRIA [Anticoagulation and Risk Factors in Atrial Fibrillation]) have been available for years. In the long‐term care setting, however, providers and residents may place more value on geriatric conditions such as mobility impairment, activities of daily living dependency, cognitive impairment, low body mass index, weight loss, and fall history. Methods and Results Using a retrospective cohort design, we measured the association between geriatric conditions and anticoagulation use and type. After merging nursing home assessments containing information about geriatric conditions (Minimum Data Set 2015) with Medicare Part A 2014 to 2015 claims and prescription claims (Medicare Part D) 2015 to 2016, we identified 228 741 residents with atrial fibrillation and elevated stroke risk (CHA2DS2‐VASc score ≥2) for our main analysis. Recent fall, activities of daily living dependency, moderate and severe cognitive impairment, low body mass index, and unintentional weight loss were all associated with lower anticoagulation use even after adjustment for multiple predictors of stroke and bleeding (odds ratios ranging from 0.51 to 0.91). Residents with recent fall, low body mass index, and unintentional weight loss were more likely to be using a direct oral anticoagulant, although the magnitude of this effect was smaller. Conclusions Geriatric conditions were associated with lower anticoagulation use. Preventing stroke in these residents with potential for further physical and cognitive impairment would appear to be of paramount significance, although the net benefit of anticoagulation in these individuals warrants further research.
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Affiliation(s)
- Ning Zhang
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,Department of Health Policy and Promotion School of Public Health and Health Sciences University of Massachusetts Amherst Amherst MA
| | - Jay Patel
- University of Massachusetts Medical School Worcester MA
| | - Zhiyong Chen
- University of Massachusetts Medical School Worcester MA.,Zem Data Science North Potomac MD
| | - Yanhua Zhou
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| | - Sybil Crawford
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| | - David D McManus
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| | - Jerry Gurwitz
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
| | - Theresa I Shireman
- Department of Health Services, Policy and Practice Center for Gerontology & Healthcare Research School of Public Health Brown University Providence RI
| | - Alok Kapoor
- Meyers Primary Care Institute a joint endeavor of University of Massachusetts Medical SchoolReliant Medical Group, and Fallon Health Worcester MA.,University of Massachusetts Medical School Worcester MA
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9
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Avila MAC, Lapane KL, Pearson S, Gurwitz J, Zhou Y, Epstein M. Abstract 895: Multi-trajectory models of multiple myeloma progression among patients with monoclonal gammopathy of undetermined significance. Cancer Res 2021. [DOI: 10.1158/1538-7445.am2021-895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Understanding the progression of monoclonal gammopathy of undetermined significance (MGUS) to multiple myeloma is needed to identify patients who would benefit from closer clinical surveillance. Given that two of the defining criteria of multiple myeloma are renal failure and anemia, we described the trajectories of creatinine and hemoglobin over time in patients with a diagnosis of MGUS.
Methods: We analyzed data from 429 patients who were diagnosed with MGUS at a large provider group in central Massachusetts between 2007 and 2015 and were followed up through 2018. Patients diagnosed with MGUS were identified by a previously validated case-finding algorithm using health claims and electronic health record data. Group-based trajectory modeling was used to identify groups of patients with distinct laboratory value trajectories of creatinine (mg/dL) and hemoglobin (mg/dL).
Results: The study sample was mostly non-Hispanic white (85.1%) with a mean age of 75 years at MGUS diagnosis. Three multi-trajectory groups were identified. Patients in Group 1 (54.3%) and Group 2 (43.1%) had increasing serum levels of creatinine and decreasing levels of hemoglobin over time, with group 2 having higher increments. Group 3 (2.6%) patients had increasing levels of creatinine and stable low levels of hemoglobin. Patients with MGUS in group 2 were older, less likely to have a prior cancer diagnosis, and had fewer comorbidities than other groups. Twenty-one patients (4.9%) developed multiple myeloma during the study period, with incidence proportions of 0.5%, 1.5%, and 1.6%, respectively for patients in groups 1, 2, and 3.
Conclusion: The data suggest that certain subpopulations of patients with MGUS can be characterized by biomarker trajectories over time. Future research should further investigate how these trajectories may be related to risk of progression to multiple myeloma.
Citation Format: Maira A. Castaneda Avila, Kate L. Lapane, Sharina Pearson, Jerry Gurwitz, Yanhua Zhou, Mara Epstein. Multi-trajectory models of multiple myeloma progression among patients with monoclonal gammopathy of undetermined significance [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 895.
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Affiliation(s)
| | - Kate L. Lapane
- University of Massachusetts Medical School, Worcester, MA
| | | | - Jerry Gurwitz
- University of Massachusetts Medical School, Worcester, MA
| | - Yanhua Zhou
- University of Massachusetts Medical School, Worcester, MA
| | - Mara Epstein
- University of Massachusetts Medical School, Worcester, MA
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10
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Mehawej J, Bamgbade B, Saczynski J, Gurwitz J, Trymbulak K, Saleeba C, Abu H, Wang W, Kiefe C, Goldberg R, McManus D. PERCEIVED VERSUS ESTIMATED RISK OF STROKE AND BLEEDING AMONG OLDER ADULTS WITH ATRIAL FIBRILLATION. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01620-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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11
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Callahan KE, Boustani M, Ferrante L, Forman DE, Gurwitz J, High KP, McFarland F, Robinson T, Studenski S, Yang M, Schmader KE. Embedding and Sustaining a Focus on Function in Specialty Research and Care. J Am Geriatr Soc 2020; 69:225-233. [PMID: 33064303 DOI: 10.1111/jgs.16860] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 07/21/2020] [Accepted: 07/25/2020] [Indexed: 12/12/2022]
Abstract
Function and the independent performance of daily activities are of critical importance to older adults. Although function was once a domain of interest primarily limited to geriatricians, transdisciplinary research has demonstrated its value across the spectrum of medical and surgical care. Nonetheless, integrating a functional perspective into medical and surgical therapeutics has yet to be implemented consistently into clinical practice. This article summarizes the presentations and discussions from a workshop, "Embedding/Sustaining a Focus on Function in Specialty Research and Care," held on January 31 to February 1, 2019. The third in a series supported by the National Institute on Aging and the John A. Hartford Foundation, the workshop aimed to identify scientific gaps and recommend research strategies to advance the implementation of function in care of older adults. Transdisciplinary leaders discussed implementation of mobility programs and functional assessments, including comprehensive geriatric assessment; integrating cognitive and sensory functional assessments; the role of culture, environment, and community in incorporating function into research; innovative methods to better identify functional limitations, techniques, and interventions to facilitate functional gains; and the role of the health system in fostering integration of function. Workshop participants emphasized the importance of aligning goals and assessments and adopting a team science approach that includes clinicians and frontline staff in the planning, development, testing, and implementation of tools and initiatives. This article summarizes those discussions.
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Affiliation(s)
- Kathryn E Callahan
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Malaz Boustani
- Center for Aging Research and Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lauren Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniel E Forman
- Section of Geriatric Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jerry Gurwitz
- Division of Geriatric Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Kevin P High
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA.,Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Frances McFarland
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Thomas Robinson
- Department of Surgery, University of Colorado School of Medicine and the Denver Veterans Affairs Medical Center, Denver, Colorado, USA
| | - Stephanie Studenski
- Section of Geriatric Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,National Institute on Aging, Bethesda, Maryland, USA
| | - Mia Yang
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Kenneth E Schmader
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
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12
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Madden J, Bayapureddy S, Briesacher B, Zhang F, Ross‐Degnan D, Soumerai S, Gurwitz J, Galbraith A. National Prevalence of Problems Paying Medical Bills and Cost‐Related Delays in Care Among Medicare Enrollees. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- J. Madden
- School of Pharmacy Northeastern University Boston MA United States
- Department of Population Medicine Harvard Medical School and Harvard Pilgrim Health Care Institute Boston MA United States
| | - S. Bayapureddy
- School of Pharmacy Northeastern University Boston MA United States
| | - B. Briesacher
- School of Pharmacy Northeastern University Boston MA United States
| | - F. Zhang
- Department of Population Medicine Harvard Medical School and Harvard Pilgrim Health Care Institute Boston MA United States
| | - D. Ross‐Degnan
- Department of Population Medicine Harvard Medical School and Harvard Pilgrim Health Care Institute Boston MA United States
| | - S. Soumerai
- Department of Population Medicine Harvard Medical School and Harvard Pilgrim Health Care Institute Boston MA United States
| | - J. Gurwitz
- University of Massachusetts Medical School and Meyers Primary Care Institute Worcester MA United States
| | - A. Galbraith
- Department of Population Medicine Harvard Medical School and Harvard Pilgrim Health Care Institute Boston MA United States
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13
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Kapoor A, Foley G, Zhang N, Zhou Y, Crawford S, McManus D, Gurwitz J. Geriatric Conditions Predict Discontinuation of Anticoagulation in Long-Term Care Residents With Atrial Fibrillation. J Am Geriatr Soc 2020; 68:717-724. [PMID: 31967319 DOI: 10.1111/jgs.16335] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/25/2019] [Accepted: 12/27/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Anticoagulation (AC) for stroke prevention in long-term care (LTC) residents with atrial fibrillation (AF) involves a challenging risk-benefit evaluation. We measured the association of geriatric conditions with discontinuation of AC. DESIGN Retrospective cohort analysis. SETTING LTC facilities across the United States. PARTICIPANTS A total of 48 545 individuals residing in LTC facilities in 2015 with AF and sufficient information to establish their status as someone who stopped AC vs someone who continued AC. MEASUREMENTS We measured the association of six geriatric conditions-recent fall, severe activity of daily living (ADL) dependency (21-28 on a 28-point scale), mobility impairment, cognitive impairment, body mass index (BMI) less than 18.5 kg/m2 , and weight loss (≥5% in 1 month or ≥10% in 6 months)-with discontinuation of AC. To identify cases of discontinuation, we required a pattern of being on AC over two consecutive recordings of the Minimum Data Set, the nursing home quality control data set recorded every 90 days, followed by two assessments being off AC-pattern of "on-on-off-off." By contrast, we required a pattern of "on-on-on-on" for continuers. We then constructed six logistic regression models to measure the independent association between each geriatric condition and discontinuation of AC, adjusted for CHA2 DS2 -VASc stroke risk score, recent bleeding hospitalization, and other confounders. RESULTS There were 4172 discontinuers and 44 373 continuers. Recent fall predicted a 1.9-fold increase in the odds of discontinuation (odds ratio = 1.91; 95% confidence interval = 1.66-2.20), whereas mobility and cognitive impairment only increased the odds by 14% to 17%. Severe ADL dependency, BMI less than 18.5 kg/m2 , and weight loss of 10% each increased odds of discontinuation by 55% to 68%. CHA2 DS2 -VASc score did not predict discontinuation. CONCLUSION Several geriatric conditions predicted discontinuation of AC, whereas CHA2 DS2 -VASc score did not. Future research should examine the association of geriatric conditions and discontinuation of warfarin discrete from newer anticoagulants and association of geriatric conditions with development of stroke and bleeding. J Am Geriatr Soc 68:717-724, 2020.
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Affiliation(s)
- Alok Kapoor
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts.,University of Massachusetts Medical School, Worcester, Massachusetts
| | - Gray Foley
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts
| | - Ning Zhang
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts.,Department of Health Policy and Promotion, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts
| | - Yanhua Zhou
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts
| | - Sybil Crawford
- University of Massachusetts Medical School, Worcester, Massachusetts
| | - David McManus
- University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jerry Gurwitz
- Meyers Primary Care Institute, A Joint Endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts
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Anzuoni K, Field T, Mazor K, Zhou Y, Konola T, Kapoor A, Garber L, Gurwitz J. A TRIAL TO IMPROVE MEDICATION SAFETY IN OLDER ADULTS: RECRUITMENT CHALLENGES HAVE GENERALIZABILITY IMPLICATIONS. Innov Aging 2019. [PMCID: PMC6841060 DOI: 10.1093/geroni/igz038.2611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
For older adults, the transition from hospital to home is a high-risk period for adverse drug events, functional decline, and hospital readmission. Randomized trials of interventions to improve this transition must recruit potential subjects immediately after hospital discharge, when people are recovering and tired. Within a randomized trial assessing the impact of a pharmacist home visit to provide medication assistance immediately post-discharge, we determined whether individuals who enrolled were comparable to those who were invited but did not enroll, and described reasons for not enrolling. Individuals ≥50 years of age discharged from the hospital and prescribed a high-risk medication were eligible. We attempted to recruit individuals by phone within 3 days of discharge, and recorded reasons for not enrolling. Of 3,606 eligible individuals reached, 3,147 (87%) declined, 361 (10%) were enrolled, and 98 (3%) were initially recruited but did not complete a consent form. Individuals ≥80 years of age (odds ratio 0.45, CI 0.25, 0.78) and those with an assigned visiting nurse (odds ratio 0.64, CI 0.48, 0.85) were least likely to enroll. Among those who provided a reason for declining (2,473) the most common reason given was the belief they did not need medication assistance (22%). An additional 332 (13%) declined because they were receiving visiting nurse services. Recruiting older adults recently discharged from the hospital is difficult and may under-enroll the oldest individuals, limiting the ability to generalize findings across older patient populations. Researchers planning RCTs among newly discharged older adults may need creative approaches to overcome resistance.
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Affiliation(s)
- Kathryn Anzuoni
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, United States
| | - Terry Field
- University of Massachusetts Medical School, Worcester, Massachusetts, United States
| | - Kathleen Mazor
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, United States
| | - Yanhua Zhou
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, United States
| | - Timothy Konola
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, United States
| | - Alok Kapoor
- University of Massachusetts Medical School, Worcester, Massachusetts, United States
| | - Lawrence Garber
- Reliant Medical Group, Worcester, Massachusetts, United States
| | - Jerry Gurwitz
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, United States
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15
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McManus DD, Kiefe C, Lessard D, Waring ME, Parish D, Awad HH, Marino F, Helm R, Sogade F, Goldberg R, Hayward R, Gurwitz J, Wang W, Mailhot T, Barton B, Saczynski J. Geriatric Conditions and Prescription of Vitamin K Antagonists vs. Direct Oral Anticoagulants Among Older Patients With Atrial Fibrillation: SAGE-AF. Front Cardiovasc Med 2019; 6:155. [PMID: 31737647 PMCID: PMC6831524 DOI: 10.3389/fcvm.2019.00155] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/11/2019] [Indexed: 12/18/2022] Open
Abstract
Background: Geriatric conditions are common among patients with atrial fibrillation (AF) and relate to complications of oral anticoagulation (OAC). Objective: To examine the prevalence of geriatric conditions among older patients with AF on OAC and relate type of OAC to geriatric conditions. Methods: Participants had a diagnosis of AF, were aged ≥65 years, CHA2DS2VASC ≥ 2, and had no OAC contraindications. Participants completed a 6-component geriatric assessment that included validated measures of frailty (CHS Frailty Scale), cognitive function (MoCA), social support (MOS), depressive symptoms (PHQ9), vision, and hearing. Type of OAC prescribed was documented in medical records. Results: 86% of participants were prescribed an OAC. These participants were on average aged 75.7 (SD: 7.1) years, 49% were women, two thirds were frail or pre-frail, and 44% received a DOAC. DOAC users were younger, had lower CHA2DS2VASC and HAS-BLED scores, and were less likely to be frail. In Massachusetts, pre-frailty was associated with a significantly lower odds of DOAC vs. VKA use (OR = 0.64, 95%CI 0.45, 0.91). Pre-frailty (OR = 0.33, 95%CI 0.18–0.59) and social isolation (OR = 0.38, 95%CI 0.14–0.99) were associated with lower odds of DOAC receipt in patients aged 75 years or older. Social isolation was associated with higher odds of DOAC use (OR = 2.13, 95%CI 1.05–4.29) in patients aged 65–74 years. Conclusions: Geriatric conditions were common and related to type of OAC prescribed, differentially by age group. Research is needed to evaluate whether a geriatric examination can be used clinically to better inform OAC decision-making in older patients with AF.
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Affiliation(s)
- David D McManus
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.,Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Catarina Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.,Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Molly E Waring
- Department of Allied Health Sciences, University of Connecticut, Mansfield, MA, United States
| | - David Parish
- Department of Community Medicine/Internal Medicine, Mercer University School of Medicine, Macon, GA, United States
| | - Hamza H Awad
- Department of Community Medicine/Internal Medicine, Mercer University School of Medicine, Macon, GA, United States
| | - Francesca Marino
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Robert Helm
- Department of Medicine, Boston University School of Medicine, Boston, MA, United States
| | - Felix Sogade
- Department of Medicine, Mercer University School of Medicine, Macon, GA, United States
| | - Robert Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Robert Hayward
- Department of Electrophysiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, United States
| | - Jerry Gurwitz
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Tanya Mailhot
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, United States.,Montreal Heart Institute Research Center, Montreal, QC, Canada
| | - Bruce Barton
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Jane Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, United States
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16
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Saczynski JS, Sanghai SR, Kiefe CI, Lessard D, Marino F, Waring ME, Parish D, Helm R, Sogade F, Goldberg R, Gurwitz J, Wang W, Mailhot T, Bamgbade B, Barton B, McManus DD. Geriatric Elements and Oral Anticoagulant Prescribing in Older Atrial Fibrillation Patients: SAGE-AF. J Am Geriatr Soc 2019; 68:147-154. [PMID: 31574165 DOI: 10.1111/jgs.16178] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/23/2019] [Accepted: 08/23/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Oral anticoagulants are the cornerstone of stroke prevention in high-risk patients with atrial fibrillation (AF). Geriatric elements, such as cognitive impairment and frailty, commonly occur in these patients and are often cited as reasons for not prescribing oral anticoagulants. We sought to systematically assess geriatric impairments in patients with AF and determine whether they were associated with oral anticoagulant prescribing. DESIGN Cross-sectional analysis of baseline data from the ongoing Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF) prospective cohort study. SETTING Multicenter study with site locations in Massachusetts and Georgia that recruited participants from cardiology, electrophysiology, and primary care clinics from 2016 to 2018. PARTICIPANTS Participants with AF age 65 years or older, CHA2 DS2 -VASc (congestive heart failure; hypertension; aged ≥75 y [doubled]; diabetes mellitus; prior stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65-74; female sex) score of 2 or higher, and no oral anticoagulant contraindications (n = 1244). MEASUREMENTS A six-component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Oral anticoagulant use was abstracted from the medical record. RESULTS A total of 1244 participants (mean age = 76 y; 49% female; 85% white) were enrolled; 42% were cognitively impaired, 14% frail, 53% pre-frail, 12% socially isolated, and 29% had depressive symptoms. Oral anticoagulants were prescribed to 86% of the cohort. Oral anticoagulant prescribing did not vary according to any of the geriatric elements (adjusted odds ratios [ORs] for oral anticoagulant prescribing and cognitive impairment: OR = .75; 95% confidence interval [CI] = .51-1.09; frail OR = .69; 95% CI = .35-1.36; social isolation OR = .90; 95% CI = .52-1.54; depression OR = .79; 95% CI = .49-1.27; visual impairment OR = .98; 95% CI = .65-1.48; and hearing impairment OR = 1.05; 95% CI = .71-1.54). CONCLUSION Geriatric impairments, particularly cognitive impairment and frailty, were common in our cohort, but treatment with oral anticoagulants did not differ by impairment status. These geriatric impairments are commonly cited as reasons for not prescribing oral anticoagulants, suggesting that prescribers may either be unaware or deliberately ignoring the presence of these factors in clinical settings. J Am Geriatr Soc 68:147-154, 2019.
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Affiliation(s)
- Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts
| | - Saket R Sanghai
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Darleen Lessard
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Francesca Marino
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Molly E Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, Connecticut
| | - David Parish
- Department of Community Medicine/ Internal Medicine, Mercer University School of Medicine, Macon, Georgia
| | - Robert Helm
- Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Felix Sogade
- Department of Medicine, Mercer University School of Medicine, Mercer, Georgia
| | - Robert Goldberg
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jerry Gurwitz
- Geriatric Medicine Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Tanya Mailhot
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts.,Montreal Heart Institute Research Center, Montreal, Quebec, Canada
| | - Benita Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts
| | - Bruce Barton
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D McManus
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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17
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High KP, Zieman S, Gurwitz J, Hill C, Lai J, Robinson T, Schonberg M, Whitson H. Use of Functional Assessment to Define Therapeutic Goals and Treatment. J Am Geriatr Soc 2019; 67:1782-1790. [PMID: 31081938 DOI: 10.1111/jgs.15975] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 04/10/2019] [Accepted: 04/16/2019] [Indexed: 12/13/2022]
Abstract
This article summarizes the presentations and discussions from a workshop, "Using Functional Assessment to Define Therapeutic Goals and Treatment," which took place on November 30 to December 1, 2017. This workshop brought together transdisciplinary leaders in the fields of function and disability and clinical investigators engaged in research on geriatric populations to outline opportunities and challenges for incorporating measures of function in clinical research. Topics addressed included reliable and clinically feasible measures of function and key domains of health (eg, musculoskeletal, cognitive, and sensory) that are most strongly associated with patients' perceptions of well-being, independence, and quality of life across a wide array of diseases and interventions. The workshop also focused on the importance of function in medical decision making to inform communications between specialty physicians and patients about prognosis and goals of care. Workshop participants called for more research on the role of function as a predictor of an intervention's effectiveness and an important treatment outcome. Such research would be facilitated by development of a core set of simple, short, functional measures that can be used by all specialties in the clinical setting to allow "big data" analytics and a pragmatic research. J Am Geriatr Soc 67:1782-1790, 2019.
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Affiliation(s)
- Kevin P High
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | | | - Jerry Gurwitz
- University of Massachusetts Medical School, Worcester, Massachusetts
| | - Carl Hill
- National Institute on Aging, Bethesda, Maryland
| | - Jennifer Lai
- University of California, San Francisco, San Francisco, California
| | - Thomas Robinson
- Denver VA Medical Center, Veterans Affairs, Denver, Colorado
| | - Mara Schonberg
- Beth Israel Deaconess Medical Center, Brookline, Massachusetts
| | - Heather Whitson
- Duke University School of Medicine and Durham VA Geriatrics Research, Education, and Clinical Center, Durham, North Carolina
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18
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Aldrugh S, Sanghai S, Waring M, Kiefe C, Goldberg R, Gurwitz J, Lessard D, Parish D, Helm R, Sogade F, Hayward R, Mailhot T, Barton B, Saczynski J, McManus D. GERIATRIC ELEMENTS AND PRESCRIPTION OF WARFARIN VERSUS DIRECT ORAL ANTICOAGULANTS AMONG OLDER PATIENTS WITH AF: THE SAGE-AF STUDY. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)31046-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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19
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Sanghai S, Aldrugh S, Waring M, Kiefe C, Goldberg R, Gurwitz J, Lessard D, Parish DC, Awad HH, Sogade F, Helm R, Hayward R, McManus D, Saczynski J. ASSOCIATION BETWEEN GERIATRIC ELEMENTS AND ORAL ANTICOAGULANT PRESCRIBING AMONG OLDER ADULTS WITH ATRIAL FIBRILLATION: DATA FROM THE SAGE-AF STUDY. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)31013-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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20
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Tisminetzky M, Gurwitz J, Fan D, Reynolds K, Smith D, Sung S, Murphy T, Go A. MULTIMORBIDITY BURDEN AND ADVERSE OUTCOMES IN OLDER ADULTS WITH HEART FAILURE. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - J Gurwitz
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts
| | - D Fan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - K Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - D Smith
- Center for Health Research, Kaiser Permanente Northwest, Portland Oregon
| | - S Sung
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - T Murphy
- Department of Internal Medicine, Section of Geriatrics, Yale University School of Medicine, New Haven, CT, USA
| | - A Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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21
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Tisminetzky M, Wang TY, Gurwitz J, Kaltenbach LA, McManus D, Gore J, Peterson E, Goldberg RJ. Magnitude and Characteristics of Patients Who Survived an Acute Myocardial Infarction. J Am Heart Assoc 2017; 6:JAHA.117.006373. [PMID: 28947562 PMCID: PMC5634289 DOI: 10.1161/jaha.117.006373] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The purpose of this study was to describe the magnitude and characteristics of patients who did not experience any significant major adverse cardiovascular event early (within 6 weeks) and late (during the first year) after hospital discharge for an acute myocardial infarction (AMI). METHODS AND RESULTS Data from 12 243 patients discharged after an AMI from 233 sites across the United States in the TRANSLATE-ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) study were analyzed. Multivariable adjusted regression analyses modeled factors associated with 6-week and 1-year survivors who did not experience a recurrent AMI, stroke, unplanned coronary revascularization, or rehospitalization for unstable angina/chest pain during these time periods. The average age of this study population was 60.0 years, 72.0% were men, and 87.9% were white. In this population, 92.4% were classified as early low-risk survivors and 76.3% were classified as late low-risk survivors of an AMI. Factors associated with being an early and late postdischarge survivor included being male and having single-vessel coronary artery disease at the patient's index hospitalization. Patients who were not first seen with any chronic health condition, had an index hospital stay of ≤3 days, and had high baseline quality-of-life scores were more likely to be late low-risk survivors. CONCLUSIONS Identifying low-risk survivors of an AMI may permit healthcare providers to focus more intensive efforts and interventions on those at higher risk of experiencing adverse cardiovascular events during the postdischarge transition period. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01088503.
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Affiliation(s)
- Mayra Tisminetzky
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA.,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA.,Division of Geriatrics, University of Massachusetts Medical School, Worcester, MA
| | | | - Jerry Gurwitz
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA.,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA.,Division of Geriatrics, University of Massachusetts Medical School, Worcester, MA
| | | | - David McManus
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA.,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA.,Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Joel Gore
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA.,Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | | | - Robert J Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA .,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA
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22
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Kapoor A, Matheos T, Walz M, McDonough C, Maheswaran A, Ruppell E, Mohamud D, Shaffer N, Zhou Y, Kaur S, Heard S, Crawford S, Cabral H, White DK, Santry H, Jette A, Fielding R, Silliman RA, Gurwitz J. Self-Reported Function More Informative than Frailty Phenotype in Predicting Adverse Postoperative Course in Older Adults. J Am Geriatr Soc 2017; 65:2522-2528. [PMID: 28926087 DOI: 10.1111/jgs.15108] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND/OBJECTIVE Current preoperative assessment tools such as the American College of Surgeons Surgical Risk Calculator (ACS Calculator) are suboptimal for evaluating older adults. The objective was to evaluate and compare the performance of the ACS Calculator for predicting risk of serious postoperative complications with the addition of self-reported physical function versus a frailty score. DESIGN Prospective cohort. SETTING Two tertiary care academic medical centers in Massachusetts. PARTICIPANTS Individuals aged 65 and older undergoing any surgery with a risk of serious complication of 5% or greater (N = 403). MEASUREMENTS We measured self-reported physical function using the Late-Life Function and Disability Instrument (LLFDI FUNCTION) and frailty phenotype (FP), which has a score ranging from 0 to 5 based on slow gait speed, weak handgrip, exhaustion, weight loss, or low activity. Using c-statistic and net classification improvement (NRI), we then analyzed capability of LLFDI-FUNCTION versus FP to improve the ACS Calculator for predicting an adverse postoperative course (serious complication, discharge to nursing home, readmission, death within 30 days of surgery). Increase in c-statistic and net reclassification improvement (NRI) for LLFDI-FUNCTION versus FP in addition to the ACS Calculator for predicting an adverse postoperative course (serious complication, discharge to nursing home, readmission, death within 30 days of surgery) RESULTS: Over 30 days, 26% of participants developed an adverse postoperative course. The increase in c-statistic for the ACS Calculator (baseline value 0.645) was slightly greater with LLFDI-FUNCTION (0.076) than with FP (0.058), with a bootstrapped difference in c-statistic of 0.005 (95% confidence interval = 0.002-0.007). NRI was also better with LLFDI-FUNCTION. CONCLUSION The LLFDI-FUNCTION predicted postoperative complications slightly better than the FP. Further studies are needed to confirm these findings and validate the use of the LLFDI-FUNCTION with the ACS Calculator for preoperative assessments of older adults.
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Affiliation(s)
- Alok Kapoor
- Division of Hospital Medicine, Department of Medicine, School of Medicine, University of Massachusetts, Worcester, Massachusetts.,Department of Medicine and Meyers Primary Care Institute, School of Medicine, University of Massachusetts, Worcester, Massachusetts.,Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Theofilos Matheos
- Department of Anesthesiology & Perioperative Medicine, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Matthias Walz
- Department of Anesthesiology & Perioperative Medicine, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Christine McDonough
- Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, Massachusetts
| | - Abiramy Maheswaran
- Department of Medicine, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Evan Ruppell
- Department of Radiology, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Deeqo Mohamud
- Department of Medicine, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Nicholas Shaffer
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Yanhua Zhou
- Department of Medicine and Meyers Primary Care Institute, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Shubjeet Kaur
- Department of Anesthesiology & Perioperative Medicine, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Stephen Heard
- Department of Anesthesiology & Perioperative Medicine, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Sybil Crawford
- Department of Medicine and Meyers Primary Care Institute, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Howard Cabral
- Department of Biostatistics, School of Public Health, Boston University, Boston, Massachusetts
| | - Daniel K White
- Department of Physical Therapy, University of Delaware, Newark, Delaware
| | - Heena Santry
- Department of Surgery & Quantitative Health Sciences, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Alan Jette
- Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, Massachusetts
| | - Roger Fielding
- Nutrition, Exercise Physiology, and Sarcopenia Laboratory, Tufts University, Boston, Massachusetts
| | - Rebecca A Silliman
- Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Jerry Gurwitz
- Department of Medicine and Meyers Primary Care Institute, School of Medicine, University of Massachusetts, Worcester, Massachusetts
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23
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Tisminetzky M, Anzuoni K, Shirley B, Magaziner J, Bayliss E, Gurwitz J. Research Priorities to Advance the Science of Multiple Chronic Conditions in Older Adults From the AGING Initiative Steering and Advisory Committees. J Patient Cent Res Rev 2017. [DOI: 10.17294/2330-0698.1465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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24
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Tisminetzky M, Gurwitz J, Nguyen H, Goldberg R. Age and Sex Differences in the Magnitude of, and Hospital Death Rates Associated With, Multiple Chronic Conditions in Older Adults Hospitalized With Acute Myocardial Infarction. J Patient Cent Res Rev 2017. [DOI: 10.17294/2330-0698.1464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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25
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Zhang N, Rodriguez-Monguio R, Barenberg A, Gurwitz J. Are Obese Residents More Likely to Be Admitted to Nursing Homes That Have More Deficiencies in Care? J Am Geriatr Soc 2017; 64:1085-90. [PMID: 27225360 DOI: 10.1111/jgs.14105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine whether obese older adults who qualify for nursing home (NH) placement are as likely as nonobese adults to be admitted to NHs that provide adequate quality of care. DESIGN Retrospective study. SETTING NHs in New York State. PARTICIPANTS Individuals aged 65 and older newly admitted to a NH in New York State in 2006-07. MEASUREMENTS Total and healthcare-related deficiency citations for each facility were obtained from the Online Survey, Certification, and Reporting file. Bivariate and multivariate regression analyses were used to assess the association between obesity (body mass index (BMI) 30.0-39.9 kg/m(2) ) and morbid obesity (BMI ≥ 40.0 kg/m(2) ) separately and admission to facilities with more deficiencies. RESULTS NHs that admitted a higher proportion of morbidly obese residents were more likely to have more deficiencies, whether total or healthcare related. These NHs also had greater odds of having severe deficiencies, or falling in the top quartile ranking of total deficiencies. After sequentially controlling for the choice of facilities within the inspection region, resident characteristics, and facility covariates, the association between morbid obesity and admission to higher-deficiency NHs persisted. CONCLUSION Residents with morbid obesity were more likely to be admitted to NHs of poorer quality based on deficiency citations. The factors driving these disparities and their impact on the care of obese NH residents require further elucidation.
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Affiliation(s)
- Ning Zhang
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts.,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Rosa Rodriguez-Monguio
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts
| | - Andrew Barenberg
- Department of Economics, University of Massachusetts Amherst, Amherst, Massachusetts
| | - Jerry Gurwitz
- Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, Massachusetts
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26
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Kapoor A, Ellis A, Shaffer N, Gurwitz J, Chandramohan A, Saulino J, Ishak A, Okubanjo T, Michota F, Hylek E, Trikalinos TA. Comparative effectiveness of venous thromboembolism prophylaxis options for the patient undergoing total hip and knee replacement: a network meta-analysis. J Thromb Haemost 2017; 15:284-294. [PMID: 28102615 PMCID: PMC5305416 DOI: 10.1111/jth.13566] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 10/24/2016] [Indexed: 12/20/2022]
Abstract
Essentials Despite trial data, guidelines have not endorsed direct oral Xa inhibitors above other options. We provide profiles of venous thromboembolism and hemorrhage risk for 12 options. Direct oral Xa inhibitors had a favorable profile compared with low-molecular-weight heparin. Other options did not have favorable profiles compared with low-molecular-weight heparin. SUMMARY Background There are numerous trials and several meta-analyses comparing venous thromboembolism (VTE) prophylaxis options after total hip and knee replacement (THR and TKR). None have included simultaneous comparison of new with older options. Objective To measure simultaneously the relative risk of VTE and hemorrhage for 12 prophylaxis options. Methods We abstracted VTE and hemorrhage information from randomized controlled trials published between January 1990 and June 2016 comparing 12 prophylaxis options. We then constructed networks to compute the relative risk for each option, relative to once-daily dosing with low-molecular-weight heparin (LMWH) Low. Results Main: Relative to LMWH Low, direct oral Xa inhibitors had the lowest risk of total deep vein thrombosis (DVT)-asymptomatic and symptomatic- (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.35-0.57), translating to 53-139 fewer DVTs per 1000 patients. Vitamin K antagonists (VKAs) titrated to International Normalized Ratio [INR] 2-3 predicted 56% more DVT events (OR, 1.56; 95% CI, 1.14-2.14). Aspirin performed similarly (OR, 0.80; 95% CI, 0.34-1.86), although small numbers prohibit firm conclusions. Direct oral Xa inhibitors did not lead to significantly more bleeding (OR, 1.21; 95% CI, 0.79-1.90). Secondary: Relative to LMWH Low, direct oral Xa inhibitors prevented 4-fold more symptomatic DVTs (OR, 0.25; 95% CI, 0.13-0.47). Conclusions Relative to LMWH Low, direct oral Xa inhibitors had a more favorable profile of VTE and hemorrhage risk, whereas VKAs had a less favorable profile. The profile of other agents was not more or less favorable. Clinicians should consider these profiles when selecting prophylaxis options.
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Affiliation(s)
- Alok Kapoor
- University of Massachusetts Medical School, Biotech 1, Suite 100, Worcester, MA 01605
- Meyers Primary Care Institute, 630 Plantation St, Worcester, MA, USA, 01605
- Boston University School of Medicine, 72 E Concord St, Boston, MA, USA, 02118
| | - Alexandra Ellis
- Brown University School of Public Health, 121 S Main St, Providence, RI, USA, 02903
| | - Nicholas Shaffer
- University of Texas Health Science Center at San Antonio School of Medicine, San Antonio, TX, USA, 78229
| | - Jerry Gurwitz
- Meyers Primary Care Institute, 630 Plantation St, Worcester, MA, USA, 01605
- University of Massachusetts Medical School, 55 North Lake Avenue, Worcester, MA, USA, 01655
| | | | - Justin Saulino
- Boston Medical Center, 840 Harrison Ave, Boston, MA, USA, 02118
- Biogen Idec, 14 Cambridge Center, Cambridge, MA, USA, 02412
| | - Anthony Ishak
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, USA, 02215
| | - Temitayo Okubanjo
- Cox Health Department of Pharmacy, 1423 N Jefferson Ave, Springfield, MO, USA, 65802
| | | | - Elaine Hylek
- Boston University School of Medicine, 72 E Concord St, Boston, MA, USA, 02118
| | - Thomas A Trikalinos
- Brown University School of Public Health, 121 S Main St, Providence, RI, USA, 02903
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27
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Li W, Procter-Gray E, Churchill L, Crouter SE, Kane K, Tian J, Franklin PD, Ockene JK, Gurwitz J. Gender and Age Differences in Levels, Types and Locations of Physical Activity among Older Adults Living in Car-Dependent Neighborhoods. J Frailty Aging 2017; 6:129-135. [PMID: 28721428 PMCID: PMC5612373 DOI: 10.14283/jfa.2017.15] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND A thorough understanding of gender differences in physical activity is critical to effective promotion of active living in older adults. OBJECTIVES To examine gender and age differences in levels, types and locations of physical activity. DESIGN Cross-sectional observation. SETTING Car-dependent urban and rural neighborhoods in Worcester County, Massachusetts, USA. PARTICIPANTS 111 men and 103 women aged 65 years and older. MEASUREMENTS From 2012 to 2014, participants were queried on type, frequency and location of physical activity. Participants wore an accelerometer for 7 consecutive days. RESULTS Compared to women, men had a higher mean daily step count (mean (SD) 4385 (2122) men vs. 3671(1723) women, p=0.008). Men reported higher frequencies of any physical activity and moderate-to-vigorous physical activity, and a lower frequency of physical activity inside the home. Mean daily step counts and frequency of physical activity outside the home decreased progressively with age for both men and women. Women had a sharper decline in frequencies of self-reported physical activity. Men had a significant decrease in utilitarian walking, which women did not (p=0.07). Among participants who reported participation in any physical activity (n=190), more women indicated exercising indoors more often (59% vs. 44%, p=0.04). The three most commonly cited locations for physical activity away from home for both genders were streets or sidewalks, shopping malls, and membership-only facilities (e.g., YMCA or YWCA). The most common types of physical activity, performed at least once in a typical month, with over 40% of both genders reporting, included light housework, brisk walking, leisurely walking, and stretching. CONCLUSION Levels, types and location preferences of physical activity differed substantially by gender. Levels of physical activity decreased progressively with age, with greater decline among women. Consideration of these gender differences is necessary to improve the effectiveness of active living promotion programs among older adults.
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Affiliation(s)
- W Li
- Wenjun Li, PhD, Associate Professor, Director, Health Statistics and Geography Lab, Division of Preventive and Behavioral Medicine, Departments of Medicine, University of Massachusetts Medical School, School Building S4-314, 55 Lake Avenue North, Worcester, MA 01655, Phone: 774-455-4215, Fax: 508-856-4543,
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28
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Andrade S, Bartels DB, Lange R, Sandford L, Gurwitz J. Safety of metamizole: a systematic review of the literature. J Clin Pharm Ther 2016. [DOI: '10.1111/jcpt.12422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Affiliation(s)
- S. Andrade
- Meyers Primary Care Institute and University of Massachusetts Medical School; Worcester MA USA
| | - D. B. Bartels
- Corporate Department Global Epidemiology; Boehringer Ingelheim GmbH; Ingelheim am Rhein Germany
- Institute of Epidemiology; Social Medicine and Health Systems Research; Hannover Medical School; Hannover Germany
| | - R. Lange
- Consumer Health Care Development, Medicine, and Regulatory Affairs; Boehringer Ingelheim GmbH; Ingelheim am Rhein Germany
| | - L. Sandford
- Meyers Primary Care Institute and University of Massachusetts Medical School; Worcester MA USA
| | - J. Gurwitz
- Meyers Primary Care Institute and University of Massachusetts Medical School; Worcester MA USA
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29
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Tjia J, Lemay CA, Bonner A, Compher C, Paice K, Field T, Mazor K, Hunnicutt JN, Lapane KL, Gurwitz J. Informed Family Member Involvement to Improve the Quality of Dementia Care in Nursing Homes. J Am Geriatr Soc 2016; 65:59-65. [PMID: 27550398 DOI: 10.1111/jgs.14299] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To describe the extent to which nursing homes engaged families in antipsychotic initiation decisions in the year before surveyor guidance revisions were implemented. DESIGN Mixed-methods study based on semistructured interviews. SETTING U.S. nursing homes (N = 20) from five CMS regions (III, IV, VI, VIII, IX). PARTICIPANTS Family members of nursing home residents (N = 41). MEASUREMENTS Family member responses to closed- and open-ended questions regarding involvement in resident care and antipsychotic initiation. Two researchers used a content analytical approach to code open responses to themes of family involvement in behavior management, decision-making, knowledge of risks and benefits, and informed consent. RESULTS Fifty-four percent of family members felt highly involved in decisions about behavior management. Forty-two percent recalled being asked how to manage resident behavior without medication, and 17% recalled receipt of information about antipsychotic risks and benefits. Sixty-six percent felt highly involved in the process of initiating antipsychotic medication; 24% reported being asked for input into the antipsychotic initiation decision and knowing before the antipsychotic was started. CONCLUSION Under existing federal regulations but before guidance revisions were implemented in 2013, more than 40% of families reported being involved in nonpharmacological behavior management of family members, but fewer than one in four reported being involved throughout the entire antipsychotic prescribing process. Interventions that standardize family engagement and promote adherence to existing federal regulations are needed. This discussion builds on these findings to weigh the policy options of greater enforcement of existing regulations versus enactment of new legislation to address this challenging issue.
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Affiliation(s)
- Jennifer Tjia
- Division of Epidemiology, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Celeste A Lemay
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Alice Bonner
- School of Nursing, Northeastern University, Boston, Massachusetts
| | | | - Kelli Paice
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Terry Field
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Meyers Primary Care Institute, Worcester, Massachusetts
| | - Kathleen Mazor
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Meyers Primary Care Institute, Worcester, Massachusetts
| | - Jacob N Hunnicutt
- Division of Epidemiology, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Kate L Lapane
- Division of Epidemiology, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jerry Gurwitz
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Meyers Primary Care Institute, Worcester, Massachusetts
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30
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Tisminetzky M, Gurwitz J, McManus DD, Saczynski JS, Waring ME, Erskine N, Anatchkova M, Parish DC, Lessard D, Kiefe C, Goldberg R. Multiple Chronic Conditions and Psychosocial Limitations in a Contemporary Cohort of Patients Hospitalized With an Acute Coronary Syndrome. J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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31
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Tabano H, Gill T, Anzuoni K, Allore H, Gruber-Baldini A, Dublin S, Elliott T, Ganz D, Tai-Seale M, Gurwitz J, Bayliss E. Patient-Reported Outcomes Collected as Part of the Medicare Annual Wellness Visit in the Health Care Systems Research Network. J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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32
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Andrade S, Bartels DB, Lange R, Sandford L, Gurwitz J. Safety of metamizole: a systematic review of the literature. J Clin Pharm Ther 2016; 41:459-77. [PMID: 27422768 DOI: 10.1111/jcpt.12422] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 06/17/2016] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Metamizole was withdrawn from the market in the United States and several European countries following reports of fatal agranulocytosis among users, but is still available in many countries in Europe, South America and Asia. Over the past several decades, a number of epidemiologic studies have been conducted to quantify the risk of agranulocytosis and other adverse effects associated with metamizole and other non-narcotic analgesics. The objective of this study was to perform a systematic review of the safety of metamizole. METHODS Epidemiologic studies published between 1 January 1980 and 15 December 2014 were identified through systematic searches of PubMed and Google Scholar; the reference sections of selected articles were also reviewed to identify potentially relevant studies. Studies included in this review focused on the safety of metamizole, that is on outcomes such as haematologic abnormalities, gastrointestinal bleeding, anaphylaxis and hepatotoxicity. Two study investigators independently reviewed the abstracts and articles to determine relevant studies according to prespecified criteria. RESULTS AND DISCUSSION A total of 22 articles met the criteria for evaluation. The majority of studies that evaluated agranulocytosis indicated an increased risk associated with metamizole, with relative risk (RR) estimates ranging from 1·5 (95% CI, 0·8-2·7) to 40·2 (95% CI, 14·7-113·3). Findings of three case-control studies do not suggest an association between metamizole and aplastic anaemia. Of the five case-control studies that evaluated the risk of upper gastrointestinal bleeding, four found a statistically significant increased risk associated with metamizole (RR estimates ranging from 1·4 to 2·7). There is insufficient evidence to determine whether metamizole increases the risk of other outcomes (e.g. hepatic effects, anaphylaxis, congenital anomalies). Few studies evaluated the effects of dose, route of administration or duration of therapy. WHAT IS NEW AND CONCLUSION Published studies reported differences in the magnitude of risk of adverse outcomes associated with metamizole use and often had small sample sizes and a number of other limitations that may have biased the results. Further research is needed to better quantify the potential risks associated with metamizole compared to other non-narcotic analgesics.
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Affiliation(s)
- S Andrade
- Meyers Primary Care Institute and University of Massachusetts Medical School, Worcester, MA, USA
| | - D B Bartels
- Corporate Department Global Epidemiology, Boehringer Ingelheim GmbH, Ingelheim am Rhein, Germany.,Institute of Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | - R Lange
- Consumer Health Care Development, Medicine, and Regulatory Affairs, Boehringer Ingelheim GmbH, Ingelheim am Rhein, Germany
| | - L Sandford
- Meyers Primary Care Institute and University of Massachusetts Medical School, Worcester, MA, USA
| | - J Gurwitz
- Meyers Primary Care Institute and University of Massachusetts Medical School, Worcester, MA, USA
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33
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Tisminetzky M, Gurwitz J, McManus DD, Saczynski JS, Erskine N, Waring ME, Anatchkova M, Awad H, Parish DC, Lessard D, Kiefe C, Goldberg R. Multiple Chronic Conditions and Psychosocial Limitations in Patients Hospitalized with an Acute Coronary Syndrome. Am J Med 2016; 129:608-14. [PMID: 26714211 PMCID: PMC4879087 DOI: 10.1016/j.amjmed.2015.11.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/19/2015] [Accepted: 11/19/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND As adults live longer, multiple chronic conditions have become more prevalent over the past several decades. We describe the prevalence of, and patient characteristics associated with, cardiac- and non-cardiac-related multimorbidities in patients discharged from the hospital after an acute coronary syndrome. METHODS We studied 2174 patients discharged from the hospital after an acute coronary syndrome at 6 medical centers in Massachusetts and Georgia between April 2011 and May 2013. Hospital medical records yielded clinical information including presence of eight cardiac-related and eight non-cardiac-related morbidities on admission. We assessed multiple psychosocial characteristics during the index hospitalization using standardized in-person instruments. RESULTS The mean age of the study sample was 61 years, 67% were men, and 81% were non-Hispanic whites. The most common cardiac-related morbidities were hypertension, hyperlipidemia, and diabetes (76%, 69%, and 31%, respectively). Arthritis, chronic pulmonary disease, and depression (20%, 18%, and 13%, respectively) were the most common noncardiac morbidities. Patients with ≥4 morbidities (37% of the population) were slightly older and more frequently female than those with 0-1 morbidity; they were also heavier and more likely to be cognitively impaired (26% vs 12%), have symptoms of moderate/severe depression (31% vs 15%), high perceived stress (48% vs 32%), a limited social network (22% vs 15%), low health literacy (42% vs 31%), and low health numeracy (54% vs 42%). CONCLUSION Multimorbidity, highly prevalent in patients hospitalized with an acute coronary syndrome, is strongly associated with indices of psychosocial deprivation. This emphasizes the challenge of caring for these patients, which extends well beyond acute coronary syndrome management.
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Affiliation(s)
- Mayra Tisminetzky
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester; Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester; Division of Geriatric Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Jerry Gurwitz
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester; Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester; Division of Geriatric Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
| | - David D McManus
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester; Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester; Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Jane S Saczynski
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester; Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester; Division of Geriatric Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Nathaniel Erskine
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Molly E Waring
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Milena Anatchkova
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Hamza Awad
- Department of Community Medicine, Mercer University School of Medicine, Macon, Ga
| | - David C Parish
- Department of Community Medicine, Mercer University School of Medicine, Macon, Ga
| | - Darleen Lessard
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Catarina Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Robert Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester; Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester; Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester.
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Tisminetzky M, Gurwitz J, Chen HY, Erskine N, Yarzebski J, Gore J, Lessard D, Goldberg R. Identification and Characteristics of Low-Risk Survivors of an Acute Myocardial Infarction. Am J Cardiol 2016; 117:1552-1557. [PMID: 27013386 DOI: 10.1016/j.amjcard.2016.02.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 02/16/2016] [Accepted: 02/16/2016] [Indexed: 11/28/2022]
Abstract
There are limited contemporary data available describing the characteristics of patients who neither died nor were readmitted to the hospital during the first year after hospital discharge for an acute myocardial infarction (AMI) in comparison with those who died and/or were readmitted to the hospital during this high-risk period. Residents of the Worcester, Massachusetts, metropolitan area discharged after an AMI from 3 central Massachusetts hospitals on a biennial basis from 2001 to 2011 comprised the study population. The average age of this population (n = 4,268) was 69 years, 62% were men, and 92% were white. From 2001 to 2011, 43.5% of patients were classified as low-risk survivors of an AMI, 12.3% died, and 44.2% did not die but had at least 1 rehospitalization during the subsequent year. The proportion of low-risk survivors increased from 42.6% to 46.4%, whereas the proportion of those who died within a year after hospital discharge decreased from 14.3% to 10.5%, respectively, during the years under study. After adjusting for several patient characteristics, younger (≤65 years) persons, men, those who were married, those who did not present with multimorbidities, and patients who did not develop in-hospital clinical complications were more likely to be classified as a low-risk AMI survivor. Identifying low-risk survivors of an AMI may help health care providers to focus more intensive efforts and interventions on those at higher risk for dying and/or being readmitted to the hospital during the postdischarge transition period after an AMI.
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Zhang N, Lu SF, Xu B, Wu B, Rodriguez-Monguio R, Gurwitz J. Health Information Technologies: Which Nursing Homes Adopted Them? J Am Med Dir Assoc 2016; 17:441-7. [DOI: 10.1016/j.jamda.2016.02.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 02/23/2016] [Indexed: 10/21/2022]
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Makam RP, Erskine N, Yarzebski J, Lessard D, Lau J, Allison J, Gore JM, Gurwitz J, McManus DD, Goldberg RJ. Decade Long Trends (2001-2011) in Duration of Pre-Hospital Delay Among Elderly Patients Hospitalized for an Acute Myocardial Infarction. J Am Heart Assoc 2016; 5:e002664. [PMID: 27101833 PMCID: PMC4843528 DOI: 10.1161/jaha.115.002664] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early intervention with medical and/or coronary revascularization treatment approaches remains the cornerstone of the management of patients hospitalized with acute myocardial infarction (AMI). However, several patient groups, especially the elderly, are known to delay seeking prompt medical care after onset of AMI-associated symptoms. Current trends, and factors associated with prolonged prehospital delay among elderly patients hospitalized with AMI, are incompletely understood. METHODS AND RESULTS Data from a population-based study of patients hospitalized at all 11 medical centers in central Massachusetts with a confirmed AMI on a biennial basis between 2001 and 2011 were analyzed. Information about duration of prehospital delay after onset of acute coronary symptoms was abstracted from hospital medical records. In patients 65 years and older, the overall median duration of prehospital delay was 2.0 hours, with corresponding median delays of 2.0, 2.1, and 2.0 hours in those aged 65 to 74 years, 75 to 84 years, and in patients 85 years and older, respectively. There were no significant changes over time in median delay times in each of the age strata examined in both crude and multivariable adjusted analyses. A limited number of patient characteristics were associated with prolonged delay in this patient population. CONCLUSIONS The results of this community-wide study demonstrate that delay in seeking prompt medical care continues to be a significant problem among elderly patients hospitalized with AMI. The lack of improvement in the timeliness of patients' care-seeking behavior during the years under study remains of considerable clinical and public health concern.
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Affiliation(s)
- Raghavendra P Makam
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Nathaniel Erskine
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Jorge Yarzebski
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Darleen Lessard
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Jason Lau
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Jeroan Allison
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Joel M Gore
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | | | - David D McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Robert J Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
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Tisminetzky M, Erskine N, Chen HY, Gore J, Gurwitz J, Yarzebski J, Joffe S, Shaw P, Goldberg R. Changing Trends in, and Characteristics Associated with, Not Undergoing Cardiac Catheterization in Elderly Adults Hospitalized with ST-Segment Elevation Acute Myocardial Infarction. J Am Geriatr Soc 2015; 63:925-31. [PMID: 25940950 PMCID: PMC4439287 DOI: 10.1111/jgs.13399] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe decade- long trends (1999-2009) in the rates of not undergoing cardiac catheterization and percutaneous coronary intervention (PCI) in individuals aged 65 and older presenting with an ST-segment elevation acute myocardial infarction (STEMI) and factors associated with not undergoing these procedures. DESIGN Observational population-based study. SETTING Worcester, Massachusetts, metropolitan area. PARTICIPANTS Individuals aged 65 and older hospitalized for an STEMI in six biennial periods between 1999 and 2009 at 11 central Massachusetts medical centers (N=960). MEASUREMENTS Analyses were conducted to examine the characteristics of people who did not undergo cardiac catheterization overall and stratified into two age strata (65-74, ≥75). RESULTS Between 1999 and 2009, dramatic declines (from 59.4% to 7.5%) were observed in the proportion of older adults who did not undergo cardiac catheterization at all greater Worcester hospitals. These declines were observed in individuals aged 65 to 74 (58.4-6.7%) and in those aged 75 and older (69.4-13.5%). The proportion of individuals not undergoing PCI after undergoing cardiac catheterization decreased from 36.6% in 1999 to 6.5% in 2009. Women, individuals with a prior MI, those with do-not-resuscitate orders, and those with various comorbidities were less likely to have undergone these procedures than comparison groups. CONCLUSION Older adults who develop an STEMI are increasingly likely to undergo cardiac catheterization and PCI, but several high-risk groups remain less likely to undergo these procedures.
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Affiliation(s)
- Mayra Tisminetzky
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Nathaniel Erskine
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Han-Yang Chen
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Joel Gore
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jerry Gurwitz
- Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, Massachusetts
- Division of Geriatric Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jorge Yarzebski
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Samuel Joffe
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Peter Shaw
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Robert Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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McManus DD, Saczynski JS, Waring ME, Anatchkova M, McManus R, Allison J, Goldberg RJ, Parish DC, Awad HH, Gurwitz J, Ash A, Kiefe CI. Abstract 126: In-hospital Depression Predicts Early Hospital Readmission after an Acute Coronary Syndrome: Preliminary Data from TRACE-CORE. Circ Cardiovasc Qual Outcomes 2014. [DOI: 10.1161/circoutcomes.7.suppl_1.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Hospital systems, patients and providers seek to avert rehospitalizations within 30 days for patients admitted with an acute coronary syndrome (ACS). Rehospitalizations within 30 days of discharge are often considered preventable and to reflect poor in-hospital management or discharge practices. However, independent associations of psychosocial factors with early rehospitalization in patients admitted with an ACS have not been examined.
Methods:
A multi-racial cohort of 1,540 patients admitted with an ACS reported psychosocial factors via standardized questionnaires in an in-hospital interview. One month following discharge, patients were interviewed via phone and reported hospital readmissions. We used logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of the association between in-hospital psychosocial characteristics (depression, anxiety, and perceived stress), health literacy and numeracy, and cognitive status, with self-reported readmission within 30 days.
Results:
Participants were 34% female and 17% non-white, with a mean age of 62 years and a mean length of stay of 4.1 days. Rehospitalization was reported for 14% (n=208) of participants, 77% of which were due to CVD. In univariate analyses, in-hospital severe depression, anxiety, and high stress were associated with higher odds of early readmission, whereas low health numeracy was associated with lower odds of early readmission (Table 1). Severe depression remained associated with higher odds and low health numeracy remained associated with lower odds of early readmission in a multivariable model including covariates associated on univariate testing with rehospitalization.
Conclusions:
Early readmission after hospitalization for an ACS was common and associated with in-hospital depression and health numeracy. Notably, depression and health numeracy were the only predictors independently associated with readmission in multivariable analyses. We speculate that the lower likelihood of readmission for those with low numeracy may be related to less engagement with the healthcare system. In-hospital screening for depression and characterization of health numeracy may help stratify risk for early rehospitalization after an ACS.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Arlene Ash
- Univ of Massachusetts Med Sch, Worcester, MA
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Goldberg R, Gore JM, Barton B, Gurwitz J. Individual and composite study endpoints: separating the wheat from the chaff. Am J Med 2014; 127:379-84. [PMID: 24486289 PMCID: PMC4019929 DOI: 10.1016/j.amjmed.2014.01.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 01/14/2014] [Accepted: 01/14/2014] [Indexed: 01/08/2023]
Abstract
We provide an overview of the individual and combined clinical endpoints and patient-reported outcomes typically used in clinical trials and prospective epidemiological investigations. We discuss the strengths and limitations associated with the utilization of aggregated study endpoints and surrogate measures of important clinical endpoints and patient-centered outcomes. We hope that the points raised in this overview will lead to the collection of clinically rich, relevant, measurable, and cost-efficient study outcomes.
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Affiliation(s)
- Robert Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Mass; Meyers Primary Care Institute, Worcester, Mass.
| | - Joel M Gore
- Department of Medicine, University of Massachusetts Medical School, Worcester, Mass
| | - Bruce Barton
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Mass
| | - Jerry Gurwitz
- Meyers Primary Care Institute, Worcester, Mass; Department of Medicine, University of Massachusetts Medical School, Worcester, Mass
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Abstract
This study developed a new measure of medication affordability that examines out-of-pocket drug expenses relative to available household resources. The authors assessed the spending patterns of approximately 2.1 million poor households (< or =100% federal poverty level) of adults aged 51 and older by Medicaid status. The data were drawn from the 2000-2001 Health and Retirement Study. Household spending was categorized into three broad types: basic living, health care, and discretionary. Older (aged 51 or older) poor households without Medicaid allocated about 72% of their total resources ($17,421, SE $783) to basic living needs. In comparison, those with Medicaid had scarcer total resources ($12,498, SE $423) and allocated 85% to basic living needs. Medication costs consumed the largest proportion of health care expenses for both types of poor households (Medicaid: $463, SE $67; non-Medicaid: $970, SE $102). After paying for basic living needs and health care costs, these families had, on average, only $16 left each week. Poor families have very few resources available for anything beyond basic living needs, even when they have Medicaid coverage. There is no great reservoir of discretionary funds to pay for increases in cost-sharing under Medicaid and Medicare Part D.
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Affiliation(s)
- Becky Briesacher
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worchester, Massachusetts 01605, USA.
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Field TS, Rochon P, Lee M, Gavendo L, Subramanian S, Hoover S, Baril J, Gurwitz J. Costs associated with developing and implementing a computerized clinical decision support system for medication dosing for patients with renal insufficiency in the long-term care setting. J Am Med Inform Assoc 2008; 15:466-72. [PMID: 18436908 DOI: 10.1197/jamia.m2589] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
A team of physicians, pharmacists, and informatics professionals developed a CDSS added to a commercial electronic medical record system to provide prescribers with patient-specific maximum dosing recommendations based on renal function. We tracked the time spent by team members and used US national averages of relevant hourly wages to estimate costs. The team required 924.5 hours and $48,668.57 in estimated costs to develop 94 alerts for 62 drugs. The most time intensive phase of the project was preparing the contents of the CDSS (482.25 hours, $27,455.61). Physicians were the team members with the highest time commitment (414.25 hours, $25,902.04). Estimates under alternative scenarios found lower total cost estimates with the existence of a valid renal dosing database ($34,200.71) or an existing decision support add-on for renal dosing ($23,694.51). Development of a CDSS for a commercial computerized prescriber order entry system requires extensive commitment of personnel, particularly among clinical staff.
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Affiliation(s)
- Terry S Field
- Meyers Primary Care Institute, 630 Plantation Street, Worcester, MA 01605, USA.
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Bambauer KZ, Safran DG, Ross-Degnan D, Zhang F, Adams AS, Gurwitz J, Pierre-Jacques M, Soumerai SB. Depression and cost-related medication nonadherence in Medicare beneficiaries. ACTA ACUST UNITED AC 2007; 64:602-8. [PMID: 17485612 DOI: 10.1001/archpsyc.64.5.602] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Treatment for depression can be expensive and depression can affect the use of other medical services, yet there is little information on how depression affects the prevalence of cost-related medication nonadherence (CRN) in elderly patients and patients with disabilities. OBJECTIVE To quantify the presence of CRN in depressed and nondepressed elderly Medicare beneficiaries and nonelderly Medicare beneficiaries with disabilities prior to the implementation of the Medicare Drug Benefit. DESIGN AND SETTING 2004 Medicare Current Beneficiary Survey. PARTICIPANTS Depressed and nondepressed elderly Medicare beneficiaries and beneficiaries with disabilities. MAIN OUTCOME MEASURES Cost-related medication nonadherence included taking smaller doses or skipping doses of a prescription to make it last longer, or failing to fill a prescription because of cost, controlling for health insurance status, comorbid conditions, age, race, sex, and functional status. RESULTS In a nationally representative sample of 13 835 noninstitutionalized elderly Medicare enrollees and Medicare enrollees with disabilities, 44% of beneficiaries with disabilities and 13% of elderly beneficiaries reported being depressed during the previous year. Among enrollees with disabilities reporting depressive symptoms, 38% experienced CRN compared with 22% of enrollees with disabilities who did not report depressive symptoms. Among elderly enrollees who reported depressive symptoms, 19% experienced CRN, compared with 12% of elderly enrollees who did not report such symptoms. In adjusted analyses, depressive symptoms remained a significant predictor of CRN in both groups (persons with disabilities: odds ratio, 1.7; 95% confidence interval, 1.3-2.3; elderly persons: odds ratio, 1.4; 95% confidence interval, 1.1-1.7). CONCLUSIONS Depressive symptoms were associated with CRN in elderly Medicare enrollees and Medicare enrollees with disabilities. Providers should elicit information on economic barriers that might interfere with treatment of Medicare beneficiaries with depression.
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Soumerai SB, Pierre-Jacques M, Zhang F, Ross-Degnan D, Adams AS, Gurwitz J, Adler G, Safran DG. Cost-related medication nonadherence among elderly and disabled medicare beneficiaries: a national survey 1 year before the medicare drug benefit. ACTA ACUST UNITED AC 2006; 166:1829-35. [PMID: 17000938 DOI: 10.1001/archinte.166.17.1829] [Citation(s) in RCA: 186] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Prior to implementation of the Medicare drug benefit, we estimated the prevalence of cost-related medication nonadherence (CRN) among Medicare enrollees, including elderly and nonelderly disabled beneficiaries. METHODS In the fall of 2004, detailed measures of CRN (skipping or reducing doses or not filling prescriptions because of cost) were added to the Medicare Current Beneficiary Survey. We examined the prevalence of CRN nationally and by Medicare eligibility subgroups (elderly vs nonelderly disabled beneficiaries), drug coverage status, socioeconomic status, self-rated health, and number of chronic medical conditions. RESULTS In a national sample of 13 835 noninstitutionalized Medicare enrollees, 29% of the disabled and 13% of the elderly beneficiaries reported CRN; those in fair to poor health with multiple comorbidities and without coverage were most at risk. Among the disabled enrollees with 4 or more morbidities, 52% (95% confidence interval [CI], 43.3%-60.3%) without drug coverage skipped prescriptions or doses compared with 26% (95% CI, 17.7%-34.8%) with Medicaid drug coverage. Those with partial drug coverage through Medigap policies or Medicare health maintenance organizations reported intermediate rates of CRN. The adjusted odds ratio of CRN among disabled enrollees in poor (vs good) health was 3.9 (95% CI, 1.7-9.2), whereas for those with 4 or more (vs <4) comorbidities, the odds ratio of CRN was 2.7 (95% CI, 1.7-4.1). CONCLUSIONS One year before Medicare Part D implementation, Medicare beneficiaries reported high rates of CRN. Rates are highest among nonelderly disabled beneficiaries, but among both elderly and disabled beneficiaries, CRN is exacerbated by poor health, multiple morbidities, and limited drug coverage. Given the high cost sharing under Part D, it is important to closely monitor CRN in high-risk subgroups.
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Affiliation(s)
- Stephen B Soumerai
- Department of Ambulatory Care and Prevention, Harvard Medical School & Harvard Pilgrim Health Care, Boston, Mass, USA.
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Halpern MT, Khan ZM, Schmier JK, Burnier M, Caro JJ, Cramer J, Daley WL, Gurwitz J, Hollenberg NK. Response to Compliance With Hypertension Therapy: Why Standards Are Needed. Hypertension 2006. [DOI: 10.1161/01.hyp.0000239675.88802.dc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | - Jerry Gurwitz
- University of Massachusetts Medical School, Worcester, Mass
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Doubeni C, Bigelow C, Lessard D, Spencer F, Yarzebski J, Gore J, Gurwitz J, Goldberg R. Trends and outcomes associated with angiotensin-converting enzyme inhibitors. Am J Med 2006; 119:616.e9-16. [PMID: 16828635 DOI: 10.1016/j.amjmed.2005.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2005] [Revised: 11/23/2005] [Accepted: 11/26/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND Limited recent data are available describing the patterns of use of angiotensin converting enzyme inhibitor (ACEI) therapy in patients with acute myocardial infarction (AMI), particularly from the more generalizable population-based setting. The purpose of this study was to examine trends in the receipt of ACEIs and associated short-term outcomes in patients hospitalized with AMI in a large Northeastern community. METHODS We conducted a community-wide study of 7991 patients hospitalized with AMI in all metropolitan Worcester, Massachusetts, medical centers during 8 annual periods between 1990 and 2003. RESULTS Among all patients, 44% received ACEI therapy during their acute hospitalization. There was a marked increase in the use of ACEIs between 1990 (23%) and 2003 (68%), particularly among those who were not on ACEIs before hospitalization. Patients who were previously on ACEIs were more likely to receive this therapy during hospitalization for AMI than were patients who were not previously on this therapy. Patients treated with ACEIs were significantly less likely to die (adjusted odds ratio [OR] 0.33; 95% confidence interval [CI] 0.27-0.41) during hospitalization than were patients who did not receive this therapy, with benefits observed across all subgroups examined. CONCLUSIONS The results of this observational study demonstrate marked increases in the use of ACEIs in patients with AMI in the community setting and demonstrate the benefits to be gained from use of this therapy. Despite these encouraging trends, there remains room for more optimal use of this therapy.
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Affiliation(s)
- Chyke Doubeni
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester 01655, USA
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Halpern MT, Khan ZM, Schmier JK, Burnier M, Caro JJ, Cramer J, Daley WL, Gurwitz J, Hollenberg NK. Recommendations for Evaluating Compliance and Persistence With Hypertension Therapy Using Retrospective Data. Hypertension 2006; 47:1039-48. [PMID: 16651464 DOI: 10.1161/01.hyp.0000222373.59104.3d] [Citation(s) in RCA: 147] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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McPhillips HA, Stille CJ, Smith D, Hecht J, Pearson J, Stull J, Debellis K, Andrade S, Miller M, Kaushal R, Gurwitz J, Davis RL. Potential medication dosing errors in outpatient pediatrics. J Pediatr 2005; 147:761-7. [PMID: 16356427 DOI: 10.1016/j.jpeds.2005.07.043] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2005] [Revised: 06/27/2005] [Accepted: 07/27/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the prevalence of potential dosing errors of medication dispensed to children for 22 common medications. STUDY DESIGN Using automated pharmacy data from 3 health maintenance organizations (HMOs), we randomly selected up to 120 children with a new dispensing prescription for each drug of interest, giving 1933 study subjects. Errors were defined as potential overdoses or potential underdoses. Error rate in 2 HMOs that use paper prescriptions was compared with 1 HMO that uses an electronic prescription writer. RESULTS Approximately 15% of children were dispensed a medication with a potential dosing error: 8% were potential overdoses and 7% were potential underdoses. Among children weighing <35 kg, only 67% of doses were dispensed within recommended dosing ranges, and more than 1% were dispensed at more than twice the recommended maximum dose. Analgesics were most likely to be potentially overdosed (15%), whereas antiepileptics were most likely potentially underdosed (20%). Potential error rates were not lower at the site with an electronic prescription writer. CONCLUSIONS Potential medication dosing errors occur frequently in outpatient pediatrics. Studies on the clinical impact of these potential errors and effective error prevention strategies are needed.
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Affiliation(s)
- Heather A McPhillips
- Department of Pediatrics and Epidemiology, University of Washington, and the Center for Health Studies, Group Health Cooperative, Seattle, Washington, 98105, USA.
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Briesacher B, Limcangco R, Simoni-Wastila L, Doshi J, Gurwitz J. Evaluation of Nationally Mandated Drug Use Reviews to Improve Patient Safety in Nursing Homes: A Natural Experiment. J Am Geriatr Soc 2005; 53:991-6. [PMID: 15935022 DOI: 10.1111/j.1532-5415.2005.53314.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To test whether nationally required drug use reviews reduce exposure to inappropriate medications in nursing homes. DESIGN Quasi-experimental, longitudinal study. SETTING Data source is the 1997-2000 Medicare Current Beneficiary Survey, a nationally representative survey of Medicare beneficiaries. PARTICIPANTS Nationally representative population sample of 8 million nursing home (NH) residents (unweighted n=2,242) and a comparative group of 2 million assisted living facility (ALF) residents (unweighted n=664). MEASUREMENTS Prevalence and incident use of 38 potentially inappropriate medications compared before and after the policy: 32 restricted for all NH residents and six for residents with certain conditions. Inappropriate medications were stratified by potential for legitimate exceptions: always avoid, rarely appropriate, or some acceptable indications. RESULTS In July 1999, the Centers for Medicare and Medicaid Services (CMS) mandated expansions to the drug use review policy for nursing home certification. Using explicit criteria, surveyors and consultant pharmacists must evaluate resident records for potentially inappropriate medication exposures and related adverse drug reactions. Nursing homes in noncompliance may receive citations for deficient care. Before the CMS policy, 28.8% (95% confidence interval (CI)=27.3-30.3) of Medicare beneficiaries in NHs and 22.4% (95% CI=19.8-25.0) in ALFs received potentially inappropriate medications. Nearly all prepolicy use came from medications with some acceptable indications: 23.4% in NHs (95% CI=20.4-26.4) and 18.0% in ALFs (95% CI=15.6-20.4). After the policy, exposures in NHs declined to 25.6% (95% CI=24.1-27.1, P<.05), but similar declines occurred in ALFs (19.0%, 95% CI=16.7-21.3, nonsignificant). Postpolicy use of inappropriate medications with exempted indications remained high, and more than half was incident use: 20.6% of NH residents (95% CI=19.0-22.0) and 15.6% of ALF residents (95% CI=15.2-15.7). Use of drugs that are restricted with certain diseases increased 33% in NHs between 1997 and 2000 (from 9.3% to 13.2%; P<.05). Multivariate results detected no postpolicy differences in inappropriate drug use between long-term care facilities with mandatory drug use reviews and those without. CONCLUSION Some postpolicy declines were noted in NH use of potentially inappropriate medications, but the decrease was uneven and could not be attributed to the national drug use reviews. This study is the first evaluation of the CMS policy, and it highlights the unclear effectiveness of drug use reviews to improve patient safety in NHs even though state and federal agencies have widely adopted this strategy.
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Affiliation(s)
- Becky Briesacher
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA 01605, USA.
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