Jennifer L. Kuntz

Patient-centered interventions to improve medication management and adherence: A qualitative review of research findings

OBJECTIVE Patient-centered approaches to improving medication adherence hold promise, but evidence of their effectiveness is unclear. This review reports the current state of scientific research around interventions to improve medication management through four patient-centered domains: shared decision-making, methods to enhance effective prescribing, systems for eliciting and acting on patient feedback about medication use and treatment goals, and medication-taking behavior. METHODS We reviewed literature on interventions that fell into these domains and were published between January 2007 and May 2013. Two reviewers abstracted information and categorized studies by intervention type. RESULTS We identified 60 studies, of which 40% focused on patient education. Other intervention types included augmented pharmacy services, decision aids, shared decision-making, and clinical review of patient adherence. Medication adherence was an outcome in most (70%) of the studies, although 50% also examined patient-centered outcomes. CONCLUSIONS We identified a large number of medication management interventions that incorporated patient-centered care and improved patient outcomes. We were unable to determine whether these interventions are more effective than traditional medication adherence interventions. PRACTICE IMPLICATIONS Additional research is needed to identify effective and feasible approaches to incorporate patient-centeredness into the medication management processes of the current health care system, if appropriate.

Identification of Stevens-Johnson syndrome and toxic epidermal necrolysis in electronic health record databases.

Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) carry a high mortality risk. While identifying clinical and genetic risk factors for these conditions has been hindered by their rarity, large electronic health databases hold promise for identifying large numbers of cases for study, especially with the introduction in 2008 of ICD‐9 codes more specific for these conditions.

The Importance of Considering Different Healthcare Settings When Estimating the Burden of Clostridium difficile

BACKGROUND Traditional surveillance methods may underestimate the true burden of Clostridium difficile infection (CDI) because they fail to capture cases brought to medical attention in outpatient settings or diagnosed during non-face-to-face patient-provider interactions. METHODS We identified CDIs diagnosed among Kaiser Permanente Northwest patients between 1 June 2005 and 30 December 2012. We categorized infections by whether they were diagnosed during an inpatient or outpatient encounter and whether they were diagnosed during a face-to-face (eg, hospitalization, outpatient visit) or non-face-to-face encounter (eg, phone, e-mail). We constructed a baseline surveillance estimate that included CDIs identified during hospitalization, representing burden captured through traditional surveillance approaches. We then constructed 2 additional estimates: 1 that included CDIs identified during outpatient face-to-face encounters and 1 that also included CDIs identified during non-face-to-face encounters. RESULTS We identified 8024 CDIs. Twenty-four percent occurred during a hospitalization, while the remaining CDIs were recognized in the outpatient setting. Surveillance focused on hospitalized patients would have captured less than one-quarter of total burden. The addition of cases identified during outpatient face-to-face encounters would account for 80% of CDIs. An additional 1702 CDIs would not be captured without inclusion of non-face-to-face encounters; thus, surveillance approaches that do not include telephone or e-mail encounters would miss 21% of CDIs. CONCLUSIONS Surveillance approaches that do not include outpatient or nontraditional encounters miss a substantial proportion of CDIs. Failure to capture these cases leads to underestimation of disease burden and difficulty in measuring interventions to control CDI.

Recommendations for Providers on Person-Centered Approaches to Assess and Improve Medication Adherence

Medication non-adherence is a significant clinical challenge that adversely affects psychosocial factors, costs, and outcomes that are shared by patients, family members, providers, healthcare systems, payers, and society. Patient-centered care (i.e., involving patients and their families in planning their health care) is increasingly emphasized as a promising approach for improving medication adherence, but clinician education around what this might look like in a busy primary care environment is lacking. We use a case study to demonstrate key skills such as motivational interviewing, counseling, and shared decision-making for clinicians interested in providing patient-centered care in efforts to improve medication adherence. Such patient-centered approaches hold considerable promise for addressing the high rates of non-adherence to medications for chronic conditions.

Clostridium difficile infection among veterans health administration patients

OBJECTIVE To report on the prevalence and incidence of Clostridium difficile infection (CDI) from 2009 to 2013 among Veterans Healthcare Administration patients DESIGN A retrospective descriptive analysis of data extracted from a large electronic medical record (EMR) database SETTING Data were acquired from VHA healthcare records from 2009 to 2013 that included outpatient clinical visits, long-term care, and hospitalized care as well as pharmacy and laboratory information. RESULTS In 2009, there were 10,207 CDI episodes, and in 2013, there were 12,143 CDI episodes, an increase of 19.0%. The overall CDI rate increased by 8.4% from 193 episodes per 100,000 patient years in 2009 to 209 episodes per 100,000 patient years in 2013. Of the CDI episodes identified in 2009, 58% were identified during a hospitalization, and 42% were identified in an outpatient setting. In 2013, 44% of the CDI episodes were identified in an outpatient setting. CONCLUSION This is one of the largest studies that has utilized timely EMR data to describe the current CDI epidemiology at the VHA. Despite an aging population with greater burden of comorbidity than the general US population, our data show that VHA CDI rates stabilized between 2011 and 2013 following increases likely attributable to the introduction of the more sensitive nucleic acid amplification tests (NAATs). The findings in this report will help establish an accurate benchmark against which both current and future VA CDI prevention initiatives can be measured.

Clostridium difficile infection, Colorado and the northwestern United States, 2007.

To determine the incidence of Clostridium difficile infection during 2007, we examined infection in adult inpatient and outpatient members of a managed-care organization. Incidence was 14.9 C. difficile infections per 10,000 patient-years. Extrapolating this rate to US adults, we estimate that 284,875 C. difficile infections occurred during 2007.

Trimethoprim–sulfonamide use during the first trimester of pregnancy and the risk of congenital anomalies

Sulfonamide antibacterials are widely used in pregnancy, but evidence about their safety is mixed. The objective of this study was to assess the association between first‐trimester sulfonamide exposure and risk of specific congenital malformations.

Predicting the risk of Clostridium difficile infection following an outpatient visit: development and external validation of a pragmatic, prognostic risk score

Increasing morbidity related to Clostridium difficile infection (CDI) has heightened interest in the identification of patients who would most benefit from recognition of risk and intervention. We sought to develop and validate a prognostic risk score to predict CDI risk for individual patients following an outpatient healthcare visit. We assembled a cohort of Kaiser Permanente Northwest (KPNW) patients with an index outpatient visit between 2005 and 2008, and identified CDI in the year following that visit. Applying Cox regression, we synthesized a priori predictors into a CDI risk score, which we validated among a Kaiser Permanente Colorado (KPCO) cohort. We calculated and plotted the observed 1-year CDI risk for each decile of predicted risk for both cohorts. Among 356 920 KPNW patients, 608 experienced CDI, giving a 1-year incidence of 2.2 CDIs per 1000 patients. The Cox model differentiated between patients who do and do not develop CDI: there was a C-statistic of 0.83 for KPNW. The simpler points-based risk score, derived from the Cox model, was validated successfully among 296 550 KPCO patients, with no decline in the area under the receiver operating characteristic curve: 0.785 (KPNW) vs. 0.790 (KPCO). The predicted risk for CDI agreed closely with the observed risk. Our CDI risk score utilized data collected during usual care to successfully identify patients who developed CDI, discriminating them from patients at the lowest risk for CDI. Our prognostic CDI risk score provides a decision-making tool for clinicians in the outpatient setting.

PS1-23: The Incidence and Epidemiology of Inpatient and Outpatient Clostridium difficile Infections at Kaiser Permanente.

Background/Aims Clostridium difficile is the most common cause of healthcare-associated infectious diarrhea in the United States. However, few population-based epidemiologic studies of C. difficile infection (CDI) exist. Our aims were to: describe the epidemiology of CDI among HMO members from two geographical regions; extrapolate the incidence of CDI from these health plans to the U.S. population; and, identify patient characteristics that predict inpatient versus outpatient identification of CDIs. Methods We conducted a population-based, dynamic, retrospective cohort study among Kaiser Permanente Colorado (KPCO) and Northwest (KPNW) enrollees between June 1, 2005 and September 30, 2008. We identified incident CDIs and categorized infections based on identification in the inpatient or outpatient setting. We calculated incidence rates and extrapolated our estimates to the 2007 U.S. population. KPNW and KPCO regional electronic databases provided data on membership, pharmacy dispensings, demographics, clinical measures, and healthcare utilization. Logistic regression determined how strongly patient characteristics predicted inpatient versus outpatient identification of CDIs. Results We identified 2,879 incident CDIs; 55% were identified in the outpatient setting. In 2007, our total population incidence rate was 13.5 CDI cases per 10,000 person-years; incidence increased with age. Extrapolated to the U.S. white-only population, we estimate that 220,000 cases of CDI occurred among persons 20 years or older in 2007. Baseline characteristics and healthcare utilization prior to identification of CDI in both settings were similar, although individuals with CDI identified in the inpatient setting were older and had greater comorbidity than individuals with outpatient-identified CDI. We identified few strong and independent predictors of setting, although risk for CDI identification in the inpatient setting was associated with an estimated glomerular filtration rate <15 (OR: 4.96; 95% CI: 2.73, 9.02), inflammatory bowel disease (OR: 2.41; 95% CI: 1.45, 4.02), an outpatient antimicrobial dispensing in the previous 180 days (OR: 2.67; 95% CI: 2.13, 3.35), and malignancy (OR: 2.08; 95% CI: 1.60, 2.72). Conclusion The incidence of CDI among this population is substantial (13.5/10,000 person-years). Because the incidence of and risk for CDIs increases with age, the U.S. burden of CDIs will continue to rise as the proportion of older individuals in the U.S. population rises.

Myocarditis and pericarditis are rare following live viral vaccinations in adults

Reports of myocarditis and pericarditis following smallpox vaccination in adults suggested a need to assess inflammatory cardiac disease risk among adults who receive live viral vaccinations. From 1996 through 2007, among 416,629 vaccinated adults in the Vaccine Safety Datalink, we identified one probable pericarditis case and no cases of myocarditis in the 42 days following a live viral vaccination. Our self-controlled risk interval analysis found that, based on one case identified during the risk interval and 10 cases during the control interval, there is no increased risk of myopericarditis in the 42 days following vaccination (IRR, 0.57; 95% CI, 0.07, 4.51). Our study suggests that the occurrence of myopericarditis following live viral vaccination is rare with an estimated incidence of 0.24 per 100,000 vaccinated, which is not higher than the background rate and is much lower than the incidence rates reported following smallpox vaccination.