Angela M. Wisniewski

The epidemiologic association between opioid prescribing, non-medical use, and emergency department visits.

Abstract Introduction: Since the 1990s prescriptions for and the non-medical use of opioids have increased. This study examines associations between opioid prescribing, non-medical use, and emergency department (ED) visits. Methods: Data were abstracted from four federally sponsored, nationally representative, annual surveys (National Hospital Ambulatory Medical Care Survey, National Ambulatory Medical Care Survey, National Survey on Drug Use and Health, and Drug Abuse Warning Network). Results: For hydrocodone and oxycodone, associations between prescribing and non-medical use, and prescribing and ED visits were statistically significant (p-values < 0.04) and strongly associated (correlation coefficient range 0.73 to 0.87). Male gender, White race, and age ≥ 35 were all statistically significant (p-values < 0.0001) predictors of receiving a hydrocodone or oxycodone-containing prescription. Conclusion: The increased number of prescriptions written for hydrocodone and oxycodone between 1995 and 2004 was associated with similar increases in non-medical use and the number of ED visits during this time period.

Experience with a trigger tool for identifying adverse drug events among older adults in ambulatory primary care

Objective: To evaluate the performance of a trigger tool for identifying adverse drug events (ADEs) among older adults in ambulatory primary care practices. Methods: Manual 12-month retrospective chart review at six practices using a 39-item trigger tool. Patients aged 65 or above with cardiovascular diagnoses were included. Charts with triggers underwent detailed review by a physician and pharmacist to identify ADEs. Results: Of 1289 charts reviewed, 645 (50%) had at least one trigger. A random sample of 383 of these charts underwent further review (mean 64 charts per practice). Among the 908 triggers in these charts, 232 were deemed to represent ADEs, of which 92 were deemed preventable and 30% of these were severe. The most common triggers and their positive predictive values (PPVs) for ADEs were “Medication stop” (26.3%), “Hospitalisation” (21.8%) and “Emergency Room” visit (14.9%). Only nine of the triggers had PPVs >5%. These nine triggers accounted for 94.4% (219/232) of the ADEs detected. Discussion: Trigger tools have a potential role in driving quality improvement in ambulatory primary care. In our study using a 39-item ADE trigger tool, most triggers had very low PPVs. Nine of the 39 triggers accounted for 94.4% of ADEs detected, suggesting the possibility of a much briefer tool. Practical issues related to adoption of such tools by practising physicians should be further explored.

Physician–Pharmacist Collaborative Management of Asthma in Primary Care

To determine if asthma control improves in patients who receive physician–pharmacist collaborative management (PPCM) during visits to primary care medical offices.

Knowledge and Use of Ethnomedical Treatments for Asthma Among Puerto Ricans in an Urban Community

PURPOSE Puerto Ricans have higher lifetime and current asthma prevalence than other racial and ethnic groups in the United States. A great many Hispanics use ethnomedical therapies for asthma. This study elicited participant knowledge of ethnomedical therapies, developed a typology of the therapies, and considered whether some types are used or deemed efficacious based, in part, on information source. METHODS Eligible participants were randomly selected from the medical records of an inner-city primary care clinic serving a predominantly Hispanic community in Buffalo, New York. Thirty adult Puerto Ricans who had asthma or were care-givers of children with asthma were interviewed in person using a semistructured instrument. Qualitative data analysis followed a content-driven immersion-crystallization approach. Outcome measures were ethnomedical treatments for asthma known to participants, whether these treatments were used or perceived effective, and the participant’s information source about the treatment. RESULTS Participants identified 75 ethnomedical treatments for asthma. Behavioral strategies were significantly more likely to be used or perceived effective compared with ingested and topical remedies (P <.001). Among information sources for ingested and topical remedies, those recommended by community members were significantly less likely to be used or perceived effective (P <.001) compared with other sources. CONCLUSIONS This sample of Puerto Ricans with a regular source of medical care was significantly more likely to use or perceive as effective behavioral strategies compared with ingested and topical remedies. Allopathic clinicians should ask Puerto Rican patients about their use of ethnomedical therapies for asthma to better understand their health beliefs and to integrate ethnomedical therapies with allopathic medicine.

Reimbursement and Practice Policies Among Providers of Buprenorphine-Naloxone Treatment

ABSTRACT Background: Physician acceptance of cash payment and low adherence to practice guidelines may contribute to buprenorphine-naloxone diversion. The purpose of this study was to investigate the clinical practice policies of physicians who provide office-based treatment for opioid dependence with buprenorphine-naloxone. Methods: Data were obtained from 31 of 71 practices surveyed (response rate 43.7%) that provided answers to at least some of the survey questions. Results: Of these practices, 28 (90.3%) accepted cash as payment and 6 (19.4%) accepted only cash for treatment services. Analysis of open-ended responses to questions about office policies revealed wide variation among practices and overall suboptimal adherence to recommended treatment guidelines. Conclusions: These results underscore the need for continuing education for physicians who prescribe buprenorphine-naloxone.

A Practice Facilitation and Academic Detailing Intervention Can Improve Cancer Screening Rates in Primary Care Safety Net Clinics

Background: Despite the current evidence of preventive screening effectiveness, rates of breast, cervical, and colorectal cancer in the United States fall below national targets. We evaluated the efficacy and feasibility of combining practice facilitation and academic detailing quality improvement (QI) strategies to help primary care practices increase breast, cervical, and colorectal cancer screening among patients. Methods: Practices received a 1-hour academic detailing session addressing current cancer screening guidelines and best practices, followed by 6 months of practice facilitation to implement evidence-based interventions aimed at increasing patient screening. One-way repeated measures analysis of variance compared screening rates before and after the intervention, provider surveys, and TRANSLATE model scores. Qualitative data were gathered via participant focus groups and interviews. Results: Twenty-three practices enrolled in the project: 4 federally qualified health centers, 10 practices affiliated with larger health systems, 4 physician-owned practices, 4 university hospital clinics, and 1 nonprofit clinic. Average screening rates for breast cancer increased by 13% (P = .001), and rates for colorectal cancer increased by 5.6% (P = .001). Practices implemented a mix of electronic health record data cleaning workflows, provider audits and feedback, reminder systems streamlining, and patient education and outreach interventions. Practice facilitators assisted practices in tailoring interventions to practice-specific priorities and constraints and in connecting with community resources. Practices with resource constraints benefited from the engagement of all levels of staff in the quality improvement processes and from team-based adaptations to office workflows and policies. Many practices aligned quality improvement interventions in this project with patient-centered medical home and other regulatory reporting targets. Conclusions: Combining practice facilitation and academic detailing is 1 method through which primary care practices can achieve systems-level changes to better manage patient population health.

Improving quality of NSAID prescribing by internal medicine trainees with an educational intervention.

Background: Prescribing nonsteroidal anti-inflammatory drugs (NSAIDs) for older adults is a safety concern. Education innovations in postgraduate training designed to improve patient safety should comply with the Accreditation Council for Graduate Medical Education (ACGME). Purpose: The objective is to evaluate a seven-component education program for internal medicine trainees designed to change prescribing practices while addressing ACGME competencies. Methods: Pretest, posttest data collection. Results: The baseline chart review found that 28.7% (79/275) patients age 70 or older were prescribed NSAIDs. Approximately 1 year later, the proportion of patients prescribed NSAIDs had declined to 16.4% (30/183; p= .002). The proportion of patients prescribed NSAIDs in conjunction with a diuretic similarly declined from 13.6% (38/278) to 7% (13/187; p= .024). Conclusion: A systematically applied education program targeted to a specific prescribing pattern produced significant improvement among internal medicine trainees. This model may assist training programs in reducing polypharmacy, or in other areas of trainee practice.

Practice facilitation and academic detailing improves colorectal cancer screening rates in safety net primary care clinics

Objective SUNY Upstate Medical University entered a contract with Health Research, Inc. and the New York State Department of Health to implement an intervention using academic detailing and practice facilitation to increase colorectal cancer screening rates within primary care practices, and to assess the outcomes and barriers to intervention success. The project was conducted within a large multiorganizational framework, led by the Studying-ActingLearning-Teaching Network (SALT-Net, SUNY Upstate Medical University) in partnership with the Upstate New York Network (UNYNET -University at Buffalo) and the Greater Rochester PBRN (GR-PBRN -University of Rochester Medical Center), under the auspices of the Upstate New York Translational Research Network (UNYTE).

Primary care providers' assessment of older latino patients' instrumental activities of daily living ability: Implications for improving quality of care

ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. Author Contributions: Olga Vriz: concept and design. Stefano Martina, Lucio Mos, Franco Pertoldi, Daniela Pavan, Francesco Antonini-Canterin: acquisition of subjects and data, analysis and interpretation of data. Rodolfo Citro, Roberto Manfredini, Eduardo Bossone: preparation of manuscript. Sponsor’s Role: None.

CROSS-SECTIONAL SURVEY OF SUBOPTIMAL PRESCRIBING TO COMMUNITY-DWELLING OLDER ADULTS

To the Editor: Use of benzodiazepines and nonsteroidal anti-inflammatory drugs (NSAIDs) may be suboptimal in older adults. Benzodiazepines have been associated with risk of single, recurrent, and injurious falls and fractures. For patients with a history of falls, practice guidelines recognize the association between benzodiazepine use and falls and recommend their discontinuation. In addition to gastrointestinal complications (bleeding, perforation, ulceration), NSAIDs have been associated with the development of acute renal failure, cardiovascular events, and congestive heart failure. The concomitant use of NSAIDs with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) and NSAIDs with diuretics has been associated with risk of acute renal failure. To manage persistent pain in older adults, practice guidelines specifically discourage the use of NSAIDs and recommend the use of opioids instead. A cross-sectional survey was conducted to determine the current prevalence of suboptimal medication prescribing to community-dwelling older adults who were patients at community-based primary care academic training sites. As part of the clinical clerkship in family medicine, medical students attended didactic sessions that addressed the topics of polypharmacy and patient safety. Students were then assigned to review the first five charts of patients aged 70 and older scheduled for a visit with the students’ preceptors during a clinic session. Medical students were instructed not to review the charts of patients whom they had seen or were scheduled to see. A standardized data collection instrument was used to abstract data from the medical record. Date of the medical record review, site, age, sex, and number of prescribed medications were recorded. The medication list was the primary source of information on medications currently prescribed for the patient. Categorical information collected on medications specifically included long-acting benzodiazepines and other benzodiazepines, anticholinergic antidepressants and other antidepressants, antihistamines, ACEIs and ARBs, diuretics, NSAIDs other than aspirin, gastric protection (if an NSAID was prescribed), and digoxin doses greater than 0.125 mg. To the extent that they were included on the medication list or elsewhere in the medical record, the use of over-thecounter products was noted (e.g., antihistamines, NSAIDs). Medication indication, dose, frequency, and duration of use were not recorded. Students and their preceptors reviewed and discussed the findings of the site-specific chart audit. The results were then uploaded to a central data collection system. Data collection took place from January through June 2007. Data were entered into an Excel worksheet (Microsoft Corporation, Redmond, WA) and analyzed using SPSS version 16.0 (SPSS, Inc., Chicago, IL). The medical records of 303 patients at 30 different community-based primary care academic training sites in western New York were reviewed. Approximately twothirds of the sample was female, and the mean age standard deviation was 78.8 6 (Table 1). One-fifth of patients were prescribed a benzodiazepine: almost 6% a long-acting Q1. History of stumbling within 1 year Q2. Can you climb stairs without help? Q3. Do you feel your walking speed declined recently? Q4. Can you cross the road within the green signal interval? Q5. Can you walk 1 km continuously? Q6. Can you stand on one foot for approximately 5 seconds? Q7. Do you use cane when you walk? Q8. Can you squeeze the towel tightly? Q9. Do you feel dizzy? Q10. Is your back bent? Q11. Do you have knee pain? Q12. Do you have a vision problem? Q13. Do you have a hearing problem? Q14. Do you think you are forgetful? Q15. Do you worry that you will fall when you walk? Q16. Do you take more than five kinds of prescribed medicines? Q17. Do you feel dark walking within your home? Q18. Are there any obstacles within the house? Q19. Is there any level difference within your home? Q20. Do you have to use stairs in daily living? Q21. Do you walk steep slope around the house?