J. Elizabeth Jackson

Trends in Professional Advice to Lose Weight Among Obese Adults, 1994 to 2000

AbstractCONTEXT: Obesity is a fast-growing threat to public health in the U.S., but information on trends in professional advice to lose weight is limited. OBJECTIVE: We studied whether rising obesity prevalence in the U.S. was accompanied by an increasing trend in professional advice to lose weight among obese adults. DESIGN AND PARTICIPANTS: We used the Behavioral Risk Factor Surveillance System, a cross-sectional prevalence study, from 1994 (n= 10,705), 1996 (n=13,800), 1998 (n=18,816), and 2000 (n=26,454) to examine changes in advice reported by obese adults seen for primary care. MEASUREMENTS: Self-reported advice from a health care professional to lose weight. RESULTS: From 1994 to 2000, the proportion of obese persons receiving advice to lose weight fell from 44.0% to 40.0%. Among obese persons not graduating from high school, advice declined from 41.4% to 31.8%; and for those with annual household incomes below

Trends in cervical and breast cancer screening practices among women in rural and urban areas of the United States.

25,000, advice dropped from 44.3% to 38.1%. In contrast, the prevalence of advice among obese persons with a college degree or in the highest income group remained relatively stable and high (>45%) over the study period. CONCLUSIONS: Disparities in professional advice to lose weight associated with income and educational attainment increased from 1994 to 2000. There is a need for mechanisms that allow health care professionals to devote sufficient attention to weight control and to link with evidence-based weight loss interventions, especially those that target groups most at risk for obesity.

Age-Related Disparities in Cancer Screening: Analysis of 2001 Behavioral Risk Factor Surveillance System Data

OBJECTIVE The objective of this study was to assess rural-urban differences in mammography and Papanicolaou (Pap) smear screening. METHODS Data from the Behavioral Risk Factor Surveillance System (1994-2000, 2002, 2004) were used to examine trends in these two tests by rural-urban residence location. RESULTS In 2004, 70.8 percent of rural and 75.7 percent of urban respondents had received timely mammography; this difference remained significant in adjusted analyses and was greatest for women in remote rural locations. Although overall participation in mammography increased over time, a persistent rural-urban gap was identified. In contrast, in 2004, while 83.1 percent of rural and 86.1 percent of urban respondents had received a timely Pap test, the adjusted difference was not significant and Pap testing did not improve over time. Advanced age and low socioeconomic status were associated with a lack of screening. CONCLUSIONS Over an 11-year interval, mammography screening improved nationally, but women living in rural locations remained less likely than their urban counterparts to receive this test. However, no secular improvement in Pap testing was found, and no significant rural-urban differences were observed. POLICY IMPLICATIONS Interventions to improve breast cancer screening are needed for rural women. Such efforts should target older women and those with low socioeconomic status.

Prescription drug coverage, health, and medication acquisition among seniors with one or more chronic conditions

PURPOSE Although few studies have explored age-related health care disparities, some researchers have asserted such disparities uniformly disfavor the elderly and are largely attributable to ageism in the health care system. We compared age-related patterns of screening for colorectal cancer with those for breast and prostate cancer in persons aged 50 years and older. METHODS We analyzed data for all adults aged 50 years and older (N = 88,213) in the 2001 Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative, telephone-administered survey of personal health behaviors. Main outcome measures were adjusted prevalence by 5-year age-groups of colorectal cancer screening using fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy for men and women; rates of mammography screening for women; and rates of prostate-specific antigen (PSA) screening for men. RESULTS After adjustment for race/ethnicity, education level, income, health insurance, and self-rated health, predicted reported colorectal cancer screening (all modalities) increased significantly from when patients reached age 50 years until 70 to 74 years (66.0%, standard error [SE] 0.8%), remained constant until age 80 years, and then declined. The age-related gain in colorectal cancer screening was confined to whites among patients older than 60 years. Reported PSA screening increased until age 75 to 79 years (79.3%, SE 1.1%) and then declined, whereas reported mammography screening peaked at age 55 to 59 years (83.3%, SE 1.2%) and then declined. CONCLUSIONS Significant age-related disparities appear to exist for both evidence-based and non–evidence-based cancer-screening interventions. The issue of age-related disparities in cancer screening is complex, with the direction of disparity favoring the elderly for some services yet disfavoring them for others.

Impact of Healthcare Delivery System on Where HMO-Enrolled Seniors Purchase Medications:

Background:The unabated rise in medication costs particularly affects older persons with chronic conditions that require long-term medication use, but how prescription benefits affect medication adherence for such persons has received limited study. Objective:We sought to study the relationship among prescription benefit status, health, and medication acquisition in a sample of elderly HMO enrollees with 1 or more common, chronic conditions. Research Design:We implemented a cross-sectional cohort study using primary survey data collected in 2000 and administrative data from the previous 2 years. Subjects:Subjects were aged 67 years of age and older, continuously enrolled in a Medicare + Choice program for at least 2 years, and diagnosed with 1 or more of hypertension, diabetes, congestive heart failure, and coronary artery disease (n = 3073). Measures:Outcomes were the mean daily number of essential therapeutic drug classes and refill adherence. Results:In multivariate models, persons without a prescription benefit acquired medications in 0.15 fewer therapeutic classes daily and experienced lower refill adherence (approximately 7 fewer days of necessary medications during the course of 2 years) than those with a prescription benefit. A significant interaction revealed that, among those without a benefit, persons in poor health acquired medications in 0.73 more therapeutic classes daily than persons in excellent health; health status did not significantly influence medication acquisition for those with a benefit. Conclusions:Coverage of prescription drugs is important for improving access to essential medications for persons with the studied chronic conditions. A Medicare drug benefit that provides unimpeded access to medications needed to treat such conditions may improve medication acquisition and, ultimately, health.

A National Study of Obesity Prevalence and Trends by Type of Rural County.

TO THE EDITOR: With the recent intensified focus on medication errors, the play on words in this letter is intended to highlight the importance of accurate transcription of drug regimen details. Two inadvertent overdoses of levothyroxine in elderly patients are described, one a tenfold overdose as a result of a misplaced decimal point (P) and the other a twofold overdose as a result of a mis-transcribed interval, qd instead of qod (Q). Case Reports. The first scenario involves an 82-year-old male nursing facility resident with Alzheimer’s disease and hypothyroidism. While receiving 25 mcg levothyroxine daily, his thyroid-stimulating hormone (TSH) level was 0.25 μU/mL (thyroxine not reported) and an order was handwritten to “decrease levothyroxine to 20 mg daily.” Due to a poorly legible designation of mg vs μg, this was transcribed as .20 mg and subsequently supplied as 200 mcg, resulting in a tenfold increase in the intended dose. The patient received the new dose for 6 days. No overt symptoms of hyperthyroidism were observed, although a repeat TSH test revealed an undetectable level. The TSH normalized after discontinuation of the medication. The second scenario involves a 96-year-old female resident of a skilled nursing facility. Although hypothyroidism was not among her admission diagnoses, levothyroxine 0.175 mg qd was among the admission medications. Review of hospital discharge records revealed a previous dose of 0.175 mg qod (every other day). Laboratory work revealed a TSH level of 0.14 μU/mL. Facility staff described the patient as anxious and agitated with a poor appetite, for which olanzapine and cyproheptadine were also prescribed. The levothyroxine dose was reduced, and the TSH normalized one month later. As the woman’s mood and appetite improved, recommendations to reduce the olanzapine and cyproheptadine doses resulted in discontinuation of cyproheptadine. Discussion. These cases illustrate the need for vigilance when transcribing medication orders, particularly when transferring patients between healthcare environments, when old records may be required to provide baseline information about drug therapy. Interdisciplinary review can identify inaccuracies and potentially prevent or resolve medication errors and related adverse effects. Such reviews may also help to eliminate a “prescribing cascade,” based on which new medication is prescribed to alleviate the adverse effects of an existing medication. Several published reports and guidelines describe strategies healthcare systems can implement to prevent or reduce errors.1-3 However, it remains relevant to report individual cases that highlight specific medications that may be particularly error prone. Levothyroxine may be associated with several commonly cited problematic aspects of prescription writing.3 In the first case, 20 mcg was transcribed as 20 mg, and subsequently transcribed again as .20 mg without a leading zero. In the second case, the Latin abbreviation qod was transcribed as qd. Levothyroxine is not included in the Institute for Safe Medication Practices’ list of high-alert medications.3 It is not among the medications commonly cited in list criteria as potentially problematic in elderly patients,4 and hormone and hormone antagonists represent only 2.5% of adult toxic exposures and 0.062% of fatalities.5 However, it nonetheless has the potential to be harmful if administered incorrectly. Elderly patients are particularly vulnerable to adverse drug events, and even medications generally considered benign may be problematic when erroneously transcribed. Rebecca B Sleeper PharmD FASCP BCPS Assistant Professor, Geriatrics Department of Pharmacy Practice School of Pharmacy Health Science Center Texas Tech University 3601 4th Street, Suite 1C162, Mail Stop 8162 Lubbock, Texas 79430-8162 fax 806/743-4209 rebecca.sleeper@ttuhsc.edu