Arlene S. Bierman

Association of ICU or Hospital Admission With Unintentional Discontinuation of Medications for Chronic Diseases

CONTEXT Patients discharged from acute care hospitals may be at risk for unintentional discontinuation of medications prescribed for chronic diseases. The intensive care unit (ICU) may pose an even greater risk because of the focus on acute events and the presence of multiple transitions in care. OBJECTIVE To evaluate rates of potentially unintentional discontinuation of medications following hospital or ICU admission. DESIGN, SETTING, AND PATIENTS A population-based cohort study using administrative records from 1997 to 2009 of all hospitalizations and outpatient prescriptions in Ontario, Canada; it included 396,380 patients aged 66 years or older with continuous use of at least 1 of 5 evidence-based medication groups prescribed for long-term use: (1) statins, (2) antiplatelet/anticoagulant agents, (3) levothyroxine, (4) respiratory inhalers, and (5) gastric acid-suppressing drugs. Rates of medication discontinuation were compared across 3 groups: patients admitted to the ICU, patients hospitalized without ICU admission, and nonhospitalized patients (controls). Odds ratios (ORs) were calculated and adjusted for patient demographics, clinical factors, and health services use. MAIN OUTCOME MEASURES The primary outcome was failure to renew the prescription within 90 days after hospital discharge. RESULTS Patients admitted to the hospital (n = 187,912) were more likely to experience potentially unintentional discontinuation of medications than controls (n = 208,468) across all medication groups examined. The adjusted ORs (AORs) ranged from 1.18 (95% CI, 1.14-1.23) for discontinuing levothyroxine in 12.3% of hospitalized patients (n = 6831) vs 11.0% of controls (n = 7114) to an AOR of 1.86 (95% CI, 1.77-1.97) for discontinuing antiplatelet/anticoagulant agents in 19.4% of hospitalized patients (n = 5564) vs 11.8% of controls (n = 2535). With ICU exposure, the AORs ranged from 1.48 (95% CI, 1.39-1.57) for discontinuing statins in 14.6% of ICU patients (n = 1484) to an AOR of 2.31 (95% CI, 2.07-2.57) for discontinuing antiplatelet/anticoagulant agents in 22.8% of ICU patients (n = 522) vs the control group. Admission to an ICU was associated with an additional risk of medication discontinuation in 4 of 5 medication groups vs hospitalizations without an ICU admission. One-year follow-up of patients who discontinued medications showed an elevated AOR for the secondary composite outcome of death, emergency department visit, or emergent hospitalization of 1.07 (95% CI, 1.03-1.11) in the statins group and of 1.10 (95% CI, 1.03-1.16) in the antiplatelet/anticoagulant agents group. CONCLUSIONS Patients prescribed medications for chronic diseases were at risk for potentially unintentional discontinuation after hospital admission. Admission to the ICU was generally associated with an even higher risk of medication discontinuation.

Calcium supplementation in premenstrual syndrome

Objective:To determine the efficacy of calcium supplementation in women with premenstrual syndrome (PMS).Design:Randomized, double-blind crossover trial.Setting:Outpatient medical clinic of a large city hospital.Particlpants:Seventy-eight women were initially screened. Trial selection was based on a history of recurrent PMS symptoms and on the results of a prospective assessment of daily symptom scores. Only women with symptom scores during the late luteal phase that were at least 50% greater than those during the intermenstrual phase were selected. Thirty-three women completed the trial.Intervention:A preliminary evaluation included physical examination, routine laboratory tests, dietary assessment, and psychiatric evaluation. Each participant received six months of treatment involving three months of daily calcium supplementation (1,000 mg of calcium carbonate) and three months of placebo.Measurements:Efficacy was assessed prospectively by changes in daily symptom scores over a six-month period and retrospectively by an overall global assessment. Multivariate repeated measures analysis of variance on symptom ratings derived from daily PMS symptom scores demonstrated a reduction in symptoms on calcium treatment during both the luteal (p=0.011) and the menstrual phases (p=0.032) of the reproductive cycle. Calcium supplementation had no effect during the intermenstrual phase. Retrospective assessment of overall symptoms confirmed this reduction: 73% of the women reported fewer symptoms during the treatment phase on calcium, 15% preferred placebo, and 12% had no clear preference. Three premenstrual factors (negative affect [p=0.045]; water retention [p=0.003]; pain [p=0.036]) and one menstrual factor (pain [p=0.02]) were significantly alleviated by calcium.Conclusion:Calcium supplementation is a simple and effective treatment for premenstrual syndrome, but further studies will be needed to determine its precise role in PMS.

Suboptimal Prescribing in Elderly Outpatients: Potentially Harmful Drug-Drug and Drug-Disease Combinations

Objectives: To assess the prevalence and correlates of potentially harmful drug‐drug combinations and drug‐disease combinations prescribed for elderly patients at outpatient settings.

Trends in Incidence of Diabetes in Pregnancy and Serious Perinatal Outcomes: A Large, Population-Based Study in Ontario, Canada, 1996–2010

OBJECTIVE Women with diabetes in pregnancy have high rates of pregnancy complications. Our aims were to explore trends in the incidence of diabetes in pregnancy and examine whether the risk of serious perinatal outcomes has changed. RESEARCH DESIGN AND METHODS We performed a population-based cohort study of 1,109,605 women who delivered in Ontario, Canada, between 1 April 1996 and 31 March 2010. We categorized women as gestational diabetes (GDM) (n = 45,384), pregestational diabetes (pre-GDM) (n = 13,278), or no diabetes (n = 1,050,943). The annual age-adjusted rates of diabetes in pregnancy were calculated, and rates of serious perinatal outcomes were compared between groups and by year using Poisson regression. RESULTS The age-adjusted rate of both GDM (2.7–5.6%, P < 0.001) and pre-GDM (0.7–1.5%, P < 0.001) doubled from 1996 to 2010. The rate of congenital anomalies declined by 23%, whereas the rate of perinatal mortality did not change significantly. However, compared with women with no diabetes, women with pre-GDM and GDM faced an increased risk of congenital anomalies (relative risk 1.86 [95% CI 1.49–2.33] and 1.26 [1.09–1.45], respectively), and perinatal mortality remained elevated in women with pre-GDM (2.33 [1.59–3.43]). CONCLUSIONS The incidence of both GDM and pre-GDM in pregnancy has doubled over the last 14 years, and the overall burden of diabetes in pregnancy on society is growing. Although congenital anomaly rates have declined in women with diabetes, perinatal mortality rates remain unchanged, and the risk of both remains significantly elevated compared with nondiabetic women. Increased efforts are needed to reduce these adverse outcomes.

Potentially inappropriate prescribing in elderly veterans: Are we using the wrong drug, wrong dose, or wrong duration?

Objectives: To identify the extent of inappropriate prescribing using criteria for proper use developed by the Agency for Healthcare Research and Quality (AHRQ) and dose‐limitation criteria defined by Beers, as well as to describe duration of use and patient characteristics associated with inappropriate prescribing for older people.

All-Cause Mortality and Serious Cardiovascular Events in People with Hip and Knee Osteoarthritis: A Population Based Cohort Study

Background Because individuals with osteoarthritis (OA) avoid physical activities that exacerbate symptoms, potentially increasing risk for cardiovascular disease (CVD) and death, we assessed the relationship between OA disability and these outcomes. Methods In a population cohort aged 55+ years with at least moderately severe symptomatic hip and/or knee OA, OA disability (Western Ontario McMaster Universities (WOMAC) OA scores; Health Assessment Questionnaire (HAQ) walking score; use of walking aids) and other covariates were assessed by questionnaire. Survey data were linked to health administrative data to determine the relationship between baseline OA symptom severity to all-cause mortality and occurrence of a composite CVD outcome (acute myocardial infarction, coronary revascularization, heart failure, stroke or transient ischemic attack) over a median follow-up of 13.2 and 9.2 years, respectively. Results Of 2156 participants, 1,236 (57.3%) died and 822 (38.1%) experienced a CVD outcome during follow-up. Higher (worse) baseline WOMAC function scores and walking disability were independently associated with a higher all-cause mortality (adjusted hazard ratio, aHR, per 10-point increase in WOMAC function score 1.04, 95% confidence interval, CI 1.01–1.07, p = 0.004; aHR per unit increase in HAQ walking score 1.30, 95% CI 1.22–1.39, p<0.001; and aHR for those using versus not using a walking aid 1.51, 95% CI 1.34–1.70, p<0.001). In survival analysis, censoring on death, risk of our composite CVD outcome was also significantly and independently associated with greater baseline walking disability ((aHR for use of a walking aid  = 1.27, 95% CI 1.10–1.47, p = 0.001; aHR per unit increase in HAQ walking score  = 1.17, 95% CI 1.08–1.27, p<0.001). Conclusions Among individuals with hip and/or knee OA, severity of OA disability was associated with a significant increase in all-cause mortality and serious CVD events after controlling for multiple confounders. Research is needed to elucidate modifiable mechanisms.

Single item measures of self-rated mental health: a scoping review

BackgroundA single-item measure of self-rated mental health (SRMH) is being used increasingly in health research and population health surveys. The item asks respondents to rate their mental health on a five-point scale from excellent to poor. This scoping study presents the first known review of the SRMH literature.MethodsElectronic databases of Medline, CINAHL, PsycINFO, EMBASE and Cochrane Reviews were searched using keywords. The databases were also searched using the titles of surveys known to include the SRMH single item. The search was supplemented by manually searching the bibliographic sections of the included studies. Two independent reviewers coded articles for inclusion or exclusion based on whether articles included SRMH. Each study was coded by theme and data were extracted about study design, sample, variables, and results.ResultsFifty-seven studies included SRMH. SRMH correlated moderately with the following mental health scales: Kessler Psychological Distress Scale, Patient Health Questionnaire, mental health subscales of the Short-Form Health Status Survey, Behaviour and Symptom Identification Scale, and World Mental Health Clinical Diagnostic Interview Schedule. However, responses to this item may differ across racial and ethnic groups. Poor SRMH was associated with poor self-rated health, physical health problems, increased health service utilization and less likelihood of being satisfied with mental health services. Poor or fair SRMH was also associated with social determinants of health, such as low socioeconomic position, weak social connections and neighbourhood stressors. Synthesis of this literature provides important information about the relationships SRMH has with other variables.ConclusionsSRMH is associated with multi-item measures of mental health, self-rated health, health problems, service utilization, and service satisfaction. Given these relationships and its use in epidemiologic surveys, SRMH should continue to be assessed as a population health measure. More studies need to examine relationships between SRMH and clinical mental illnesses. Longitudinal analyses should look at whether SRMH is predictive of future mental health problems.

The relation between total joint arthroplasty and risk for serious cardiovascular events in patients with moderate-severe osteoarthritis: propensity score matched landmark analysis

Objective To examine whether total joint arthroplasty of the hip and knee reduces the risk for serious cardiovascular events in patients with moderate-severe osteoarthritis. Design Propensity score matched landmark analysis. Setting Ontario, Canada. Participants 2200 adults with hip or knee osteoarthritis aged 55 or more at recruitment (1996-98) and followed prospectively until death or 2011. Main outcome measure Rates of serious cardiovascular events for those who received a primary total joint arthroplasty compared with those did not within an exposure period of three years after baseline assessment. Results The propensity score matched cohort consisted of 153 matched pairs of participants with moderate-severe arthritis. Over a median follow-up period of seven years after the landmark date (start of the study), matched participants who underwent a total joint arthroplasty during the exposure period were significantly less likely than those who did not to experience a cardiovascular event (hazards ratio 0.56, 95% confidence interval 0.43 to 0.74, P<0.001). Within seven years of the exposure period the absolute risk reduction was 12.4% (95% confidence interval 1.7% to 23.1%) and number needed to treat was 8 (95% confidence interval 4 to 57 patients). Conclusions Using a propensity matched landmark analysis in a population cohort with advanced hip or knee osteoarthritis, this study found a cardioprotective benefit of primary elective total joint arthroplasty.

Potentially inappropriate prescribing for the elderly: Effects of geriatric care at the patient and health care system level

Background:Many studies have identified patient characteristics associated with potentially inappropriate prescribing in the elderly (PIPE), however, little attention has been directed toward how health care system factors such as geriatric care may affect this patient safety issue. Objective:This study examines the association between geriatric care and PIPE in a community dwelling elderly population. Research Design:Cross-sectional retrospective database study. Subjects:Veterans age ≥65 years who received health care in the VA system during Fiscal Years (FY99-00), and also received at medications from the Veterans Administration in FY00. Measures:PIPE was identified using the Zhan adaptation of the Beers criteria. Geriatric care penetration was calculated as the proportion of patients within a facility who received at least 1 geriatric outpatient clinic or inpatient visit. Analyses:Logistic regression models with generalized estimating equations were used to assess the relationship between geriatric care and PIPE after controlling for patient and health care system characteristics. Results:Patients receiving geriatric care were less likely to have PIPE exposure (odds ratio, 0.64; 95% confidence interval, 0.59–0.73). There was also a weak effect for geriatric care penetration, with a trend for patients in low geriatric care penetration facilities having higher risk for PIPE regardless of individual geriatric care exposure (odds ratio, 1.14; 95% confidence interval, 0.99–1.30). Conclusions:Although geriatric care is associated with a lower risk of PIPE, additional research is needed to determine if heterogeneity in the organization and delivery of geriatric care resulted in the weak effect of geriatric care penetration, or whether this is a result of low power.

Assessing access as a first step toward improving the quality of care for very old adults.

Understanding the barriers to obtaining care that the population of people age 80 and older (80+) experiences is one of the first steps toward developing organizational and clinical strategies aimed at improving care. This article reviews the data from the 80+ Projects survey to assess the prevalence of barriers to care and Identify the characteristics that place the 80+ population at risk. Barriers to access for older adults occur on many levels. Ultimately, the ability to improve health outcomes through reducing barriers to care is dependent on the effectiveness and quality of care received. By recognizing the barriers to care that limit access, health care professionals can begin to develop strategies to eliminate these barriers and improve the health care of older adult patients.