Alan Lyles

Comparison of Prescribing Criteria to Evaluate the Appropriateness of Drug Treatment in Individuals Aged 65 and Older: A Systematic Review

Because inappropriate prescribing is prevalent in individuals aged 65 and older, various criteria to assess it have been developed. This studys aim was to systematically review articles that describe criteria for assessing inappropriate prescribing in individuals aged 65 and older and to define the circumstances of their use (explicit/implicit), origins, development processes, and content. A systematic search was conducted on MEDLINE and PubMed (1990–2010) and augmented with a manual search. Original articles written in English were included if they described the development of the criteria and were aimed at people aged 65 and older. Articles that described criteria applicable only in hospital settings, specific drugs, or a particular disease or condition were excluded. Sixteen of 535 articles met the inclusion criteria. They described 14 criteria, half originating in the United States. The English‐language restriction limited the search results. Most criteria were explicit, consensus validated, based totally or partly on Beers criteria, and focused on pharmacological appropriateness of prescribing and some were old. Drug‐ and disease‐oriented explicit criteria require regular updating and are country specific. Implicit, person‐specific criteria are universal and do not need updating, although their use requires up‐to‐date professional skills. Unlike explicit criteria, implicit criteria have been validated in people. Some of the 14 criteria were noncomprehensive, mainly because of the intended purpose. To conclude, different criteria exist for optimizing prescribing for individuals aged 65 and older. Possible deficiencies must be recognized and trade‐offs made when selecting criteria for use. In the future, more‐comprehensive and ‐timely criteria are needed.

Obesity, Business and Public Policy

The effects of obesity have become practically ubiquitous in the US. This book aims to provide an alternative framework through which to explore the important and controversial obesity debate that has spilled over from the medical community. This book is not about obesity as a medical condition, nor does it offer a wide-ranging discussion on the health effects of obesity or the role of the ‘right’ diet.

Potentially inappropriate medication use among Finnish non-institutionalized people aged ≥65 years: a register-based, cross-sectional, national study.

BackgroundThe Beers criteria and their modifications are the most frequently used tools for measuring potentially inappropriate medication (PIM) use among older people. The prevalence of such use in various settings has been high, but no data have been reported for an entire national non-institutionalized elderly population, nor is there information on the reimbursement costs for those medications.ObjectiveTo determine the prevalence of PIM use according to the Beers 2003 criteria, independent of diagnoses, among Finnish non-institutionalized people aged ≥65 years, and the reimbursement costs for these medications.MethodsA register-based cross-sectional national study used drug reimbursement data from Finland’s Social Insurance Institution (SII). These data cover the entire non-institutionalized population aged ≥65 years in 2007. The number of persons who received reimbursements for each PIM according to the Beers 2003 criteria and the total annual reimbursement costs for PIMs were calculated. Indirect costs were excluded.ResultsOf the non-institutionalized population aged ≥65 years in Finland (n = 841 509), 14.7% (n = 123 545) had received PIMs according to the Beers 2003 criteria. Temazepam >15 mg/day was clearly the most commonly reimbursed PIM (4.4% of the population aged ≥65 years), followed by amitriptyline (2.0%) and diazepam (1.8%). The SII paid drug reimbursements of €2.9 million for PIMs, which was 0.7% of the total drug reimbursements (€421 million) for people aged ≥65 years in Finland in 2007.ConclusionsThe use of PIMs among outpatients aged ≥65 years in Finland (14.7%) was less than in several earlier large-scale studies in other countries (17–42%) and reimbursement costs were modest, mainly as a result of the limited availability in Finland of medicines identified as PIMs by the Beers 2003 criteria. However, benzodiazepines were commonly used and actions to improve medication safety should target reducing their use.

Opioids, antiepileptic and anticholinergic drugs and the risk of fractures in patients 65 years of age and older: a prospective population-based study

BACKGROUND in men, the concomitant use of two or more benzodiazepines or two or more antipsychotics is associated with an increased risk of fracture(s). Potential associations between the concomitant use of drugs with central nervous system effects and fracture risk have not been studied. OBJECTIVE the purpose was to describe the gender-specific risk of fractures in a population aged 65 years or over associated with the use of an opioid, antiepileptic or anticholinergic drug individually; or, their concomitant use with each other; or the concomitant use of one of these with a psychotropic drug. METHODS this study was part of a prospective, population-based study performed in Lieto, Finland. Information about fractures in 1,177 subjects (482 men and 695 women) was confirmed with radiology reports. RESULTS at 3 years of follow-up, the concomitant use of an opioid with an antipsychotic was associated with an increased risk of fractures in men. During the 6-year follow-up, the concomitant use of an opioid with a benzodiazepine was also related to the risk of fractures for males. No significant associations were found for females. CONCLUSION the concomitant use of an opioid with an antipsychotic, or with a benzodiazepine may increase the risk of fractures in men aged 65 years and older.

CNS Medications as Predictors of Precipitous Cognitive Decline in the Cognitively Disabled Aged: A Longitudinal Population-Based Study

Background/Aims: Psychotropics and antiepileptics (AE) are medications commonly used among the aged with cognitive decline or dementia, although they may precipitate further cognitive decline. Our aim was to analyze the relationships between the use of (i) psychotropics (i.e. benzodiazepines or related drugs, BZD, antipsychotics, AP, or antidepressants, AD), opioids (Op), anticholinergics (ACh) or AEs or the concomitant use of two of these drugs, and (ii) the risk of precipitous cognitive decline in an older (≧65 years) cognitively disabled population. Methods: A longitudinal population-based study of general aged community-dwelling patients was executed in two phases (1990–1991 and 1998–1999) in Lieto, Finland. Fifty-two individuals cognitively disabled (MMSE score 0–23) at the 1990–1991 baseline form this study’s sample. Cognitive abilities were assessed in each phase with the Mini-Mental State Examination (MMSE) and medication utilization data were collected in both phases. The mean follow-up time was 7.6 years. Multivariate models were used to analyze the change in MMSE total score between medication users and non-users. Results: BZD or any psychotropic use was associated with greater cognitive decline in elders aged ≧75 years compared to non-users (change in MMSE sum score: –8.6 ± 7.0 vs. –3.3 ± 5.6 and –5.9 ± 7.0 vs. –2.7 ± 6.4, respectively). A greater decline was also associated specifically with the concomitant use of BZD and AP (–16 vs. –1.4 ± 7.8); as were BZD and any drug with CNS effects (–9.6 ± 9.9 vs. –1.3 ± 7.2) compared to non-users. The concomitant use of BZD and AD (–10.7 ± 4.7 vs. –3.2 ± 5.6) or ACh (–15.0 ± 8.5 vs. –3.3 ± 5.6) or any drug with CNS effects (–13.3 ± 6.5 vs. –3.3 ± 5.6) was associated with cognitive decline in patients ≧75 years compared to non-users of any drug with CNS effects. Conclusion: The use of a BZD or any psychotropic medication may be an independent risk factor for cognitive decline in the cognitively disabled aged, and patients co-prescribed psychotropic medications had greater cognitive decline. Studies with larger sample sizes and studies on possible pathophysiologic mechanisms are needed.

Decision-makers' use of pharmacoeconomics: What does the research tell us?

Governments, organizations and industry routinely make decisions regarding the value of pharmaceuticals. The perspectives, techniques, decision constraints and available information differ across these decision–makers and sometimes within categories. Although pharmacoeconomics is consistent with the international trend toward evidence-based decisions in medicine and could benefit all of these decision-makers, the potential impact of these studies has been largely unrealized. Why is it that a field to which so much research funding has been devoted, has produced so little of clear use to major decision-makers? Would inflexible organizational barriers surrounding narrowly defined performance incentives and line item budget accountability limit the usefulness of even impeccably performed pharmacoeconomic studies? Or, are methodological and logistical considerations impeding the usefulness of pharmacoeconomics?

A Policy Framework for Confronting Obesity

The effects of obesity have become practically ubiquitous in the US. This book aims to provide an alternative framework through which to explore the important and controversial obesity debate that has spilled over from the medical community. This book is not about obesity as a medical condition, nor does it offer a wide-ranging discussion on the health effects of obesity or the role of the ‘right’ diet.

Pharmacy Benefit Management Companies: Do They Create Value in the US Healthcare System?

Pharmacy benefit management companies (PBMs) perform functions in the US market-based healthcare system that may be performed by public agencies or quasi-public institutions in other nations. By aggregating lives covered under their many individual contracts with payers, PBMs have formidable negotiating power. They influence pharmaceutical insurance coverage, design the terms of coverage in a plan’s drug benefit, and create competition among providers for inclusion in a plan’s network. PBMs have, through intermediation, the potential to secure lower drug prices and to improve rational prescribing. Whether these potential outcomes are realized within the relevant budget is a function of the healthcare system and the interaction of benefit design and clinical processes—not just individually vetted components. Efficiencies and values achieved in price discounts and cost sharing can be nullified if there is irrational prescribing (over-utilization, under-utilization and mis-utilization), variable patient adherence to medication regimens, ineffective formulary processes, or fraud, waste and abuse. Rising prescription drug costs and the increasing prevalence of ‘high deductible health plans’, which require much greater patient out-of-pocket costs, is creating a crisis for PBM efforts towards an affordable pharmacy benefit. Since PBM rebate and incentive contracts are opaque to the public, whether they add value by restraining higher drug prices or benefit from them is debatable.

U.S. Public Administration Programs: Increasing Academic Achievement by Identifying and Utilizing Student Learning Styles.

Global economic shifts are forcing universities to become more competitive and operationally efficient. As a result, universities emphasize access, affordability, and achievement. More specifically, U.S. universities have responded by emphasizing course assessment, retention rates, and graduation rates. Both university administrators and faculty members recognize that student cognitive styles are an important dimension in retention and graduation rates. Equally important, the Network of Schools of Public Policy, Affairs, and Administration requires graduate programs to meet universal core competencies and assess student learning outcomes. Within the context of U.S. higher education trends and new accreditation standards, we examine the demographic characteristics and cognitive styles of 130 Master of Public Administration (MPA) students currently enrolled at the University of Baltimore, which is one of the largest accredited MPA programs in the United States. Student cognitive styles are measured using a point in time Group Embedded Figures Test instrument. Key findings reveal that a stronger concentration in quantitative skills is essential in bolstering core competencies and student marketability in the global economy. Recommendations for course design and pedagogical modifications are discussed.

Improving Long-Term Weight Management: Social Capital and Missed Opportunities

Change is notoriously difficult and relapse is the norm for eating disorders. Access to and financing for medical services to treat eating disorders involve private resources, insurance, and=or government programs. Unfortunately, these are often insufficient for the support long-term recovery requires. However, social capital, the value created by members of society through voluntary networks, can supplement these resources without additional health care expenditures. Social capital, a concept first proposed by James Coleman in 1988, is broad and there is no single accepted definition. Its essence concerns ‘‘social organization such as networks, norms, and social trust that facilitate coordination and cooperation for mutual benefit.’’ Some examples are churchbased health promotional activities, civic associations, 12-step groups, and hospital volunteers. Beginning in the midtwentieth century, a striking feature of American society has been the long-term decline of social capital, with the surge and continuing vitality of 12-step programs being an exception. Surveys on the extent of social visiting, community involvement, and civic engagement in the United States track the rise and decline of social capital over decades. Informal resources that otherwise would have been available in communities and extended families to provide care, continuity, support, and guidance are gradually disappearing. Some have been replaced by formal structures and commercial entities that medicalize life, requiring individual, household, government, or health insurance expenditures for what previously was without financial cost. Medical services’ organization, financing, and delivery are not compatible with long-term treatment of behavioral disorders, nor are they particularly effective even for short-term episodic needs. Two examples will demonstrate these shortcomings. In 2005–2006, 34% of adults in the United States had a body mass index (BMI) 30 (ie, were obese), but just 42% of obese persons were advised by a health care professional to lose weight. Prevention, screening, and treatment for alcohol abuse are even more discouraging. Using RAND’s Quality Assessment Tools to identify evidencebased quality indicators, McGlynn et al screened for problem drinking, and assessment of and referral for treatment for alcohol dependence in usual community medical practice. Only 10.5% of persons with alcohol dependence received appropriate quality care between 1998 and 2000. The subjective features of these conditions reinforce stereotypical explanations such as an individual or group is weak willed or has moral failings. Dr. Paul McHugh, formerly psychiatrist-in-chief of The Johns Hopkins Hospital, provides professional insight into the patient’s experience: motivated behaviors are ‘‘more pressing and determinative than casual choices from among attractive alternatives...A person’s interests become progressively more dominated by aspects of a motivation, a domination reflected in his [sic] preoccupations ... The sense of choice may remain, but it is progressively narrowed as the drive increases...[to] a growing urge to act that can become so intense that its expression has almost a forced quality.’’ Those experiencing these conditions are more succinct. Overeaters Anonymous states, ‘‘We admitted we were powerless over food—that our lives had become unmanageable.’’ Motivated behaviors such as eating disorders, gambling, and alcohol and drug abuse have biological and social components; successful therapeutic outcomes require sustained changes in personal behavior in addition to medical services. However, fragmentation, gaps, and costs of health services jeopardize longand even short-term outcomes. Evidence-based treatments for eating disorders, gambling, and drug and alcohol abuse, though improving, lack rigor and specificity. What is clear is that high-quality results require frequent reinforcement, possibly extending over a person’s lifetime. Voluntary associations and social networks support positive outcomes for patients attempting behavioral change without increasing health care expenditures. Twelve-step programs are among the most recognized examples of social capital for initiating and sustaining change in motivated behaviors. These self-help support groups complement gaps in formal therapeutic contacts. They offer community-based continuity, and do so without cost to the health sector. However, the articulation between the formal health services delivery system and these nonprofessional groups occurs on terms established by the 12-step programs. They define boundaries for health care, institutional, and other professionals who would direct patients to them or use their programs. The central tenets that organize Overeaters Anonymous (OA), like other 12-step programs, are contained in their Twelve Traditions. Those most relevant to this discussion are: 4. Each group should be autonomous except in matters