David A. Ganz

Monitoring Falls in Cohort Studies of Community-Dwelling Older People: Effect of the Recall Interval

Objectives: To determine whether the interval over which patients are asked to remember their falls affects fall reporting.

Multimorbidity is associated with better quality of care among vulnerable elders

Background: Older patients with multiple chronic conditions may be at higher risk of receiving poorer overall quality of care compared with those with single or no chronic conditions. Possible reasons include competing guidelines for individual conditions, burden of numerous recommendations, and difficulty implementing treatments for multiple conditions. Objectives: We sought to determine whether coexisting combinations of 8 common chronic conditions (hypertension, coronary artery disease, chronic obstructive pulmonary disease, osteoarthritis, diabetes mellitus, depression, osteoporosis, and having atrial fibrillation or congestive heart failure) are associated with overall quality of care among vulnerable older patients. Materials and Methods: Using an observational cohort study, we enrolled 372 community-dwelling persons 65 years of age or older who were at increased risk for death or functional decline within 2 years. We included (1) a comprehensive measure (% of quality indicators satisfied) of quality of medical and geriatric care that accounted for patient preference and appropriateness in light of limited life expectancy and advanced dementia, and (2) a measure of multimorbidity, either as a simple count of conditions or as a combination of specific conditions. Results: Multimorbidity was associated with greaer overall quality scores: mean proportion of quality indicators satisfied increased from 47% for elders with none of the prespecified conditions to 59% for those with 5 or 6 conditions (P < 0.0001), after controlling for number of office visits. Patients with greater multimorbidity also received care that was better than would be expected based on the specific set of quality indicators they triggered. Conclusions: Among older persons at increased risk of death or functional decline, multimorbidity results in better, rather than worse, quality of care.

Inpatient Fall Prevention Programs as a Patient Safety Strategy: A Systematic Review

Falls are common among inpatients. Several reviews, including 4 meta-analyses involving 19 studies, show that multicomponent programs to prevent falls among inpatients reduce relative risk for falls by as much as 30%. The purpose of this updated review is to reassess the benefits and harms of fall prevention programs in acute care settings and to identify factors associated with successful implementation of these programs. We searched for new evidence using PubMed from 2005 to September 2012. Two new, large, randomized, controlled trials supported the conclusions of the existing meta-analyses. An optimal bundle of components was not identified. Harms were not systematically examined, but potential harms included increased use of restraints and sedating drugs and decreased efforts to mobilize patients. Eleven studies showed that the following themes were associated with successful implementation: leadership support, engagement of front-line staff in program design, guidance of the prevention program by a multidisciplinary committee, pilot-testing interventions, use of information technology systems to provide data about falls, staff education and training, and changes in nihilistic attitudes about fall prevention. Future research would advance knowledge by identifying optimal bundles of component interventions for particular patients and by determining whether effectiveness relies more on the mix of the components or use of certain implementation strategies.

Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness

To systematically document the implementation, components, comparators, adherence, and effectiveness of published fall prevention approaches in U.S. acute care hospitals.

Use of risk stratification to identify patients with unstable angina likeliest to benefit from an invasive versus conservative management strategy

OBJECTIVES This study was designed to determine whether patient characteristics collected at presentation can identify which patients benefit from immediate coronary angiography and revascularization. BACKGROUND Risk stratification may offer a method for identifying which patients with unstable angina or non-Q-wave myocardial infarction (NQMI) are likeliest to benefit from invasive management strategies. METHODS The analysis was based on data from a randomized controlled trial that enrolled 1,473 patients presenting with unstable angina or NQMI who were randomly assigned to an early invasive or early conservative (medical) management strategy. We constructed a risk-stratification score for each patient based on adjusted odds ratios for clinical variables likely to predict adverse outcomes. We stratified all trial subjects by their risk scores and studied the rates of death or myocardial infarction (MI) of the early invasive management strategy in each stratum. RESULTS The final multivariate model included older age, ST segment depression on presentation, history of complicated angina before presentation, and elevation in baseline creatine kinase-MB fraction. Although patients with a higher risk score had an increased rate of death or MI within 42 days and 365 days (p < 0.001) in both management strategies, early invasive management for patients in the high and very high risk categories was associated with a lower rate of death or MI within 42 days compared with conservative management. No such benefit was seen in patients in the larger group of patients in the very low, low or moderate risk categories (p = 0.03 for the interaction between risk category and management assignment). CONCLUSIONS Risk stratification may be an effective method for identifying those patients with unstable angina or NQMI most likely to benefit from early invasive management. Selective use of early invasive management can have a substantial impact in reducing morbidity and mortality in higher risk patients, but may not be warranted in lower risk patients.

Quality Indicators for Falls and Mobility Problems in Vulnerable Elders

Falls and mobility problems are common and serious problems facing older adults. Accidents are the fifth leading cause of death in older adults.

Clozapine use and risk of diabetes mellitus.

Recent reports have raised the concern that clozapine increases the risk for diabetes mellitus. Accurate pharmacoepidemiologic data on whether such a hazard exists and its magnitude are needed to enable clinicians and patients to make proper treatment decisions about clozapine. The authors performed a case-control study involving 7,227 cases of newly treated diabetes and 6,780 controls, all with psychiatric disorders. Cases and controls were older than 20 years and enrolled in government-sponsored drug benefit programs in New Jersey. The authors measured the use of clozapine or other antipsychotic medications and additional covariates. They developed logistic regression models adjusted for demographic, clinical, and health care use characteristics to identify whether clozapine users were at increased risk to begin treatment for diabetes. Clozapine use was not significantly associated with developing diabetes (adjusted odds ratio [OR], 0.98; 95% confidence interval [CI], 0.74–1.31). There was no suggestion of relationships between larger dosages or longer durations of clozapine use and increasing risks of diabetes. On the other hand, nonclozapine antipsychotic medication use was associated with a modest but significantly increased risk of developing diabetes (adjusted OR, 1.13; 95% CI, 1.05–1.22). Among individual nonclozapine antipsychotics, significantly elevated risks were observed for two phenothiazine agents: chlorpromazine (adjusted OR, 1.31; 95% CI, 1.09–1.56) and perphenazine (adjusted OR, 1.34; 95% CI, 1.11– 1.62). In contrast to earlier reports, these results provide some reassurance that clozapine does not increase the risk of developing diabetes. Additional data from pharmacoepidemiologic studies and randomized controlled trials are needed to exclude the possibility of residual confounding and ensure the appropriate use of this agent.

The effect of a quality improvement initiative on the quality of other aspects of health care : The law of unintended consequences?

Problem:Policymakers and clinicians are concerned that initiatives to improve the quality of care for some conditions may have unintended negative consequences for quality in other conditions. Objective:We sought to determine whether a practice redesign intervention that improved care for falls, incontinence, and cognitive impairment by an absolute 15% change also affected quality of care for masked conditions (conditions not targeted by the intervention). Design, Setting, and Participants:Controlled trial in 2 community medical groups, with 357 intervention and 287 control patients age 75 years or older who had difficulty with falls, incontinence, or cognitive impairment. Intervention:Both intervention and control practices implemented case-finding for target conditions, but only intervention practices received a multicomponent practice-change intervention. Quality of care in the intervention practices improved for 2 of the target conditions (falls and incontinence). Main Outcome Measures:Percent of quality indicators satisfied for a set of 9 masked conditions measured by abstraction of medical records. Results:Before the intervention, the overall percent of masked indicators satisfied was 69% in the intervention group and 67% in the control group. During the intervention period, these percentages did not change, and there was no difference between intervention and control groups for the change in quality between the 2 periods (P = 0.86). The intervention minus control difference-in-change for the percent of masked indicators satisfied was 0.2% (bootstrapped 95% confidence interval, −2.7% to 2.9%). Subgroup analyses by clinical condition and by type of care process performed by the clinician did not show consistent results favoring either the intervention or the control group. Conclusion:A practice-based intervention that improved quality of care for targeted conditions by an absolute 15% change did not affect measurable aspects of care on a broad set of masked quality measures encompassing 9 other conditions.

Pharmacogenetic testing in the clinical management of schizophrenia: a decision-analytic model.

Abstract: Clinical application of pharmacogenetic testing has been proposed as a means of improving treatment outcomes in psychiatry. The identification of a putative genetic test for better clozapine response in schizophrenia offers an opportunity to evaluate the cost-effectiveness of such testing. The authors performed a cost-effectiveness analysis of a genetic test that may identify individuals with greater likelihood of responding to clozapine treatment. We modeled a target population of schizophrenia patients in an acute psychotic episode, using a lifetime time horizon and societal perspective. Outcome measures included life expectancy, quality-adjusted life expectancy, costs, and incremental cost-effectiveness. Effects of variations in testing parameters were also examined. For a 30-year-old with schizophrenia, applying the pharmacogenetic test and treating those predicted to respond to clozapine with clozapine-first cost US

Effect of Nurse Practitioner Comanagement on the Care of Geriatric Conditions

47,705 per additional quality-adjusted life-year, compared with treating all patients with conventional agents and reserving clozapine for treatment-resistant patients. In 1-way sensitivity analyses, test sensitivity and cost had the greatest impact on the incremental cost-effectiveness. We conclude that pharmacogenetic tests may achieve utility in clinical psychiatry, although their cost-effectiveness depends on several clinical parameters. More consistent reporting of test parameters such as sensitivity and specificity would greatly facilitate assessment of future pharmacogenetic studies.