Alyce S. Adams

The Top Patient Safety Strategies That Can Be Encouraged for Adoption Now

Over the past 12 years, since the publication of the Institute of Medicines report, “To Err is Human: Building a Safer Health System,” improving patient safety has been the focus of considerable public and professional interest. Although such efforts required changes in policies; education; workforce; and health care financing, organization, and delivery, the most important gap has arguably been in research. Specifically, to improve patient safety we needed to identify hazards, determine how to measure them accurately, and identify solutions that work to reduce patient harm. A 2001 report commissioned by the Agency for Healthcare Research and Quality, “Making Health Care Safer: A Critical Analysis of Patient Safety Practices” (1), helped identify some early evidence-based safety practices, but it also highlighted an enormous gap between what was known and what needed to be known.

Advancing the science of patient safety

Despite a decades worth of effort, patient safety has improved slowly, in part because of the limited evidence base for the development and widespread dissemination of successful patient safety practices. The Agency for Healthcare Research and Quality sponsored an international group of experts in patient safety and evaluation methods to develop criteria to improve the design, evaluation, and reporting of practice research in patient safety. This article reports the findings and recommendations of this group, which include greater use of theory and logic models, more detailed descriptions of interventions and their implementation, enhanced explanation of desired and unintended outcomes, and better description and measurement of context and of how context influences interventions. Using these criteria and measuring and reporting contexts will improve the science of patient safety.

Elevated rates of diabetes in Pacific Islanders and Asian subgroups: The Diabetes Study of Northern California (DISTANCE).

OBJECTIVE We estimated the prevalence and incidence of diabetes among specific subgroups of Asians and Pacific Islanders (APIs) in a multiethnic U.S. population with uniform access to care. RESEARCH DESIGN AND METHODS This prospective cohort analysis included 2,123,548 adult members of Kaiser Permanente Northern California, including 1,704,363 with known race/ethnicity (white, 56.9%; Latino, 14.9%; African American, 8.0%; Filipino, 4.9%; Chinese, 4.0%; multiracial, 2.8%; Japanese, 0.9%; Native American, 0.6%; Pacific Islander, 0.5%; South Asian, 0.4%; and Southeast Asian, Korean, and Vietnamese, 0.1% each). We calculated age-standardized (to the 2010 U.S. population) and sex-adjusted diabetes prevalence at baseline and incidence (during the 2010 calendar year). Poisson models were used to estimate relative risks. RESULTS There were 210,632 subjects with prevalent diabetes as of 1 January 2010 and 15,357 incident cases of diabetes identified during 2010. The crude diabetes prevalence was 9.9% and the incidence was 8.0 cases per 1,000 person-years and, after standardizing by age and sex to the 2010 U.S. Census, 8.9% and 7.7 cases per 1,000 person-years. There was considerable variation among the seven largest API subgroups. Pacific Islanders, South Asians, and Filipinos had the highest prevalence (18.3, 15.9, and 16.1%, respectively) and the highest incidence (19.9, 17.2, and 14.7 cases per 1,000 person-years, respectively) of diabetes among all racial/ethnic groups, including minorities traditionally considered high risk (e.g., African Americans, Latinos, and Native Americans). CONCLUSIONS High rates of diabetes among Pacific Islanders, South Asians, and Filipinos are obscured by much lower rates among the large population of Chinese and several smaller Asian subgroups.

Health literacy and antidepressant medication adherence among adults with diabetes: the diabetes study of Northern California (DISTANCE).

ABSTRACTBACKGROUNDPrevious studies have reported that health literacy limitations are associated with poorer disease control for chronic conditions, but have not evaluated potential associations with medication adherence.OBJECTIVETo determine whether health literacy limitations are associated with poorer antidepressant medication adherence.DESIGNObservational new prescription cohort follow-up study.PARTICIPANTSAdults with type 2 diabetes who completed a survey in 2006 and received a new antidepressant prescription during 2006–2010 (Nu2009=u20091,366) at Kaiser Permanente Northern California.MAIN MEASURESValidated three-item self-report scale measured health literacy. Discrete indices of adherence based on pharmacy dispensing data according to validated methods: primary non-adherence (medication never dispensed); early non-persistence (dispensed once, never refilled); non-persistence at 180 and 365xa0days; and new prescription medication gap (NPMG; proportion of time that the person is without medication during 12xa0months after the prescription date).KEY RESULTSSeventy-two percent of patients were classified as having health literacy limitations. After adjusting for sociodemographic and clinical covariates, patients with health literacy limitations had significantly poorer adherence compared to patients with no limitations, whether measured as early non-persistence (46xa0% versus 38xa0%, pu2009<u20090.05), non-persistence at 180xa0days (55xa0% versus 46xa0%, pu2009<u20090.05), or NPMG (41xa0% versus 36%, pu2009<u20090.01). There were no significant associations with primary adherence or non-persistence at 365xa0days.CONCLUSIONSPoorer antidepressant adherence among adults with diabetes and health literacy limitations may jeopardize the continuation and maintenance phases of depression pharmacotherapy. Findings underscore the importance of national efforts to address health literacy, simplify health communications regarding treatment options, improve public understanding of depression treatment, and monitor antidepressant adherence.

Associations Between Antidepressant Adherence and Shared Decision-Making, Patient–Provider Trust, and Communication Among Adults with Diabetes: Diabetes Study of Northern California (DISTANCE)

ABSTRACTBACKGROUNDDepression and adherence to antidepressant treatment are important clinical concerns in diabetes care. While patient–provider communication patterns have been associated with adherence for cardiometabolic medications, it is unknown whether interpersonal aspects of care impact antidepressant medication adherence.OBJECTIVETo determine whether shared decision-making, patient–provider trust, or communication are associated with early stage and ongoing antidepressant adherence.DESIGNObservational new prescription cohort study.SETTINGKaiser Permanente Northern California.PATIENTSOne thousand five hundred twenty-three adults with type 2 diabetes who completed a survey in 2006 and received a new antidepressant prescription during 2006–2010.MEASUREMENTSExposures included items based on the Trust in Physicians and Interpersonal Processes of Care instruments and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) communication scale. Measures of adherence were estimated using validated methods with physician prescribing and pharmacy dispensing data: primary non-adherence (medication never dispensed), early non-persistence (dispensed once, never refilled), and new prescription medication gap (NPMG; proportion of time without medication during 12xa0months after initial prescription).RESULTSAfter adjusting for potential confounders, patients’ perceived lack of shared decision-making was significantly associated with primary non-adherence (RRu2009=u20092.42, pu2009<u20090.05), early non-persistence (RRu2009=u20091.34, pu2009<u20090.01) and NPMG (estimated 5xa0% greater gap in medication supply, pu2009<u20090.01). Less trust in provider was significantly associated with early non-persistence (RRs 1.22–1.25, psu2009<u20090.05) and NPMG (estimated NPMG differences 5–8xa0%, psu2009<u20090.01).LIMITATIONSAll patients were insured and had consistent access to and quality of care.CONCLUSIONSPatients’ perceptions of their relationships with providers, including lack of shared decision-making or trust, demonstrated strong associations with antidepressant non-adherence. Further research should explore whether interventions for healthcare providers and systems that foster shared decision-making and trust might also improve medication adherence.

New Jersey’s Efforts To Improve Postpartum Depression Care Did Not Change Treatment Patterns For Women On Medicaid

Identification and treatment of postpartum depression are the increasing focus of state and national legislation, including portions of the Affordable Care Act. Some state policies and proposals are modeled directly on programs in New Jersey, the first state to require universal screening for postpartum depression among mothers who recently delivered babies. We examined the impact of these policies on a particularly vulnerable population, Medicaid recipients, and found that neither the required screening nor the educational campaign that preceded it was associated with improved treatment initiation, follow-up, or continued care. We argue that New Jerseys policies, although well intentioned, were predicated on an inadequate base of evidence and that efforts should now be undertaken to build that base. We also argue that to improve detection and treatment, policy makers contemplating or implementing postpartum depression mandates should consider additional measures. These could include requiring mechanisms to monitor and enforce the screening requirement; paying providers to execute screening and follow-up; and preliminary testing of interventions before policy changes are enacted.

Symptom Burden of Adults with Type 2 Diabetes Across the Disease Course: Diabetes & Aging Study

ABSTRACTBACKGROUNDReducing symptom burden is paramount at the end-of-life, but typically considered secondary to risk factor control in chronic disease, such as diabetes. Little is known about the symptom burden experienced by adults with type 2 diabetes and the need for symptom palliation.OBJECTIVETo examine pain and non-pain symptoms of adults with type 2 diabetes over the disease course – at varying time points before death and by age.DESIGNSurvey follow-up study.PARTICIPANTS13,171 adults with type 2 diabetes, aged 30–75xa0years, from Kaiser Permanente, Northern California, who answered a baseline symptom survey in 2005–2006.MAIN MEASURESPain and non-pain symptoms were identified by self-report and medical record data. Survival status from baseline was categorized into ≤6, >6–24, or alive >24xa0months.KEY RESULTSMean age was 60xa0years; 48xa0% were women, and 43xa0% were non-white. Acute pain was prevalent (41.8xa0%) and 39.7xa0% reported chronic pain, 24.6xa0% fatigue, 23.7xa0% neuropathy, 23.5xa0% depression, 24.2xa0% insomnia, and 15.6xa0% physical/emotional disability. Symptom burden was prevalent in all survival status categories, but was more prevalent among those with shorter survival, pu2009<u2009.001. Adults ≥60xa0years who were alive >24xa0months reported more physical symptoms such as acute pain and dyspnea, whereas participants <60xa0years reported more psychosocial symptoms, such as depressed mood and insomnia. Adjustment for duration of diabetes and comorbidity reduced the association between age and pain, but did not otherwise change our results.CONCLUSIONSIn a diverse cohort of adults with type 2 diabetes, pain and non-pain symptoms were common among all patients, not only among those near the end of life. However, symptoms were more prevalent among patients with shorter survival. Older adults reported more physical symptoms, whereas younger adults reported more psychosocial symptoms. Diabetes care management should include not only good cardiometabolic control, but also symptom palliation across the disease course.

Impact of prior authorization on the use and costs of lipid-lowering medications among Michigan and Indiana dual enrollees in Medicaid and Medicare: results of a longitudinal, population-based study.

BACKGROUNDnSome Medicaid programs have adopted prior-authorization (PA) policies that require prescribers to request approval from Medicaid before prescribing drugs not included on a preferred drug list.nnnOBJECTIVEnThis study examined the association between PA policies for lipid-lowering agents in Michigan and Indiana and the use and cost of this drug class among dual enrollees in Medicare and Medicaid.nnnMETHODSnMichigan and Indiana claims data from the Centers for Medicare and Medicaid Services were assessed. Michigan Medicaid instituted a PA requirement for several lipid-lowering medications in March 2002; Indiana implemented a PA policy for drugs in this class in September 2002. Although the PA policies affected some statins, they predominantly targeted second-line treatments, including bile acid sequestrants, fibrates, and niacins. Individuals aged ≥18 years who were continuously dually enrolled in both Medicare and Medicaid from July 2000 through September 2003 were included in this longitudinal, population-based study, which included a 20-month observation period before the implementation of PA in Michigan and a 12-month follow-up period after the Indiana PA policy was initiated. Interrupted time series analysis was used to examine changes in prescription rates and pharmacy costs for lipid-lowering drugs before and after policy implementation.nnnRESULTSnA total of 38,684 dual enrollees in Michigan and 29,463 in Indiana were included. Slightly more than half of the cohort were female (Michigan, 53.3% [20,614/38,684]; Indiana, 56.3% [16,595/29,463]); nearly half were aged 45 to 64 years (Michigan, 43.7% [16,921/38,684]; Indiana, 45.2% [13,321/29,463]). Most subjects were white (Michigan, 77.4% [29,957/38,684]; Indiana: 84.9% [25,022/29,463]). The PA policy was associated with an immediate 58% reduction in prescriptions for nonpreferred medications in Michigan and a corresponding increase in prescriptions for preferred agents. However, the PA policy had no apparent effect in Indiana, where there had been little use of nonpreferred medications before the policy was implemented (3.3%). The policies were associated with an immediate reduction of

Health-plan and employer-based wellness programs to reduce diabetes risk: The Kaiser Permanente Northern California NEXT-D Study.

24,548 in prescription expenditures in Michigan and an immediate reduction of

Ethnic Differences in Geriatric Conditions and Diabetes Complications Among Older, Insured Adults With Diabetes: The Diabetes and Aging Study.

16,070 in Indiana.nnnCONCLUSIONSnThe PA policy was associated with substantially lower use of nonpreferred lipid-lowering drugs in Michigan, offset by increases in the use of preferred medications, but there was less change in Indiana. Data limitations did not permit the evaluation of the impact of policy-induced switching on clinical outcomes such as cholesterol levels. The monetary benefit of PA policies for lipid-lowering agents should be weighed against administrative costs and the burden on patients and health care providers.