John E. Zeber

Risk of Coronary Artery Disease in Type 2 Diabetes and the Delivery of Care Consistent With the Chronic Care Model in Primary Care Settings : A STARNet Study

Background:Modifiable risks for coronary heart disease (CHD) in type 2 diabetes include glucose, blood pressure, lipid control, and smoking. The chronic care model (CCM) provides an organizational framework for improving these outcomes. Objective:To examine the relationship between CHD risk attributable to modifiable risk factors among patients with type 2 diabetes and whether care delivered in primary care settings is consistent with the CCM. Subjects/Methods:Approximately 30 patients in each of 20 primary care clinics. CHD risk factors were assessed by patient survey and chart abstraction. Absolute 10-year CHD risk was calculated using the UK Prospective Diabetes Study risk engine. Attributable risk was calculated by setting all 4 modifiable risk factors to guideline indicated values, recalculating the risk, and subtracting it from the absolute risk. In each clinic, the consistency of care with the CCM was evaluated using the Assessment of Chronic Illness Care (ACIC) survey. Results:Only 15.4% had guideline-recommended control of A1c, blood pressure, and lipids. The absolute 10-year risk CHD was 16.2% (SD 16.6). One-third of this risk, 5.0% (SD 7.4), was attributable to poor risk factor control. After controlling for patient and clinic characteristics, the ACIC score was inversely associated with attributable risk: a 1 point increase in the ACIC score was associated with a 16% (95% CI, 5–26%) relative decrease in attributable risk. Discussion:The degree to which care delivered in a primary care clinic conforms to the CCM is an important predictor of the 10-year risk of CHD among patients with type 2 diabetes.

Evaluation of a pulsed-xenon ultraviolet room disinfection device for impact on contamination levels of methicillin-resistant Staphylococcus aureus.

BackgroundHealthcare-acquired infections with methicillin-resistant Staphylococcus aureus (MRSA) are a significant cause of increased mortality, morbidity and additional health care costs in United States. Surface decontamination technologies that utilize pulsed xenon ultraviolet light (PPX-UV) may be effective at reducing microbial burden. The purpose of this study was to compare standard manual room-cleaning to PPX-UV disinfection technology for MRSA and bacterial heterotrophic plate counts (HPC) on high-touch surfaces in patient rooms.MethodsRooms vacated by patients that had a MRSA-positive polymerase chain reaction or culture during the current hospitalization and at least a 2-day stay were studied. 20 rooms were then treated according to one of two protocols: standard manual cleaning or PPX-UV. This study evaluated the reduction of MRSA and HPC taken from five high-touch surfaces in rooms vacated by MRSA-positive patients, as a function of cleaning by standard manual methods vs a PPX-UV area disinfection device.ResultsColony counts in 20 rooms (10 per arm) prior to cleaning varied by cleaning protocol: for HPC, manual (meanu2009=u2009255, medianu2009=u2009278, q1-q3 132–304) vs PPX-UV (meanu2009=u2009449, medianu2009=u2009365, q1-q3 332–530), and for MRSA, manual (meanu2009=u2009127; medianu2009=u200928.5; q1-q3 8–143) vs PPX-UV (meanu2009=u2009108; medianu2009=u2009123; q1-q3 14–183). PPX-UV was superior to manual cleaning for MRSA (adjusted incident rate ratio [IRR]u2009=u20097; 95% CI <1-41) and for HPC (IRRu2009=u200913; 95% CI 4–48).ConclusionPPX-UV technology appears to be superior to manual cleaning alone for MRSA and HPC. Incorporating 15xa0minutes of PPX-UV exposure time to current hospital room cleaning practice can improve the overall cleanliness of patient rooms with respect to selected micro-organisms.

A systematic literature review of psychosocial and behavioral factors associated with initial medication adherence: a report of the ISPOR medication adherence & persistence special interest group.

OBJECTIVESnNumerous factors influencing medication adherence in chronically ill patients are well documented, but the paucity of studies concerning initial treatment course experiences represents a significant knowledge gap. As interventions targeting this crucial first phase can affect long-term adherence and outcomes, an international panel conducted a systematic literature review targeting behavioral or psychosocial risk factors.nnnMETHODSnEligible published articles presenting primary data from 1966 to 2011 were abstracted by independent reviewers through a validated quality instrument, documenting terminology, methodological approaches, and factors associated with initial adherence problems.nnnRESULTSnWe identified 865 potentially relevant publications; on full review, 24 met eligibility criteria. The mean Nichol quality score was 47.2 (range 19-74), with excellent reviewer concordance (0.966, P < 0.01). The most prevalent pharmacotherapy terminology was initial, primary, or first-fill adherence. Articles described the following factors commonly associated with initial nonadherence: patient characteristics (n = 16), medication class (n = 12), physical comorbidities (n = 12), pharmacy co-payments or medication costs (n = 12), health beliefs and provider communication (n = 5), and other issues. Few studies reported health system factors, such as pharmacy information, prescribing provider licensure, or nonpatient dynamics.nnnCONCLUSIONSnSeveral methodological challenges synthesizing the findings were observed. Despite implications for continued medication adherence and clinical outcomes, relatively few articles directly examined issues associated with initial adherence. Notwithstanding this lack of information, many observed factors associated with nonadherence are amenable to potential interventions, establishing a solid foundation for appropriate ongoing behaviors. Besides clarifying definitions and methodology, future research should continue investigating initial prescriptions, treatment barriers, and organizational efforts to promote better long-term adherence.

Use of antipsychotic medications in pediatric populations: what do the data say?

Recent reports of antipsychotic medication use in pediatric populations describe large increases in rates of use. Much interest in the increasing use has focused on potentially inappropriate prescribing for non-Food and Drug Administration-approved uses and use amongst youth with no mental health diagnosis. Different studies of antipsychotic use have used different time periods, geographic and insurance populations of youth, and aggregations of diagnoses. We review recent estimates of use and comment on the similarities and dissimilarities in rates of use. We also report new data obtained on 11 health maintenance organizations that are members of the Mental Health Research Network in order to update and extend the knowledge base on use by diagnostic indication. Results indicate that most use in pediatric populations is for disruptive behaviors and not psychotic disorders. Differences in estimates are likely a function of differences in methodology; however, there is remarkable consistency in estimates of use by diagnosis.

Impact of the Chronic Care Model on medication adherence when patients perceive cost as a barrier

AIMSnCost burdens represent a significant barrier to medication adherence among chronically ill patients, yet financial pressures may be mitigated by clinical or organizational factors, such as treatment aligned with the Chronic Care Model (CCM). This study examines how perceptions of chronic illness care attenuate the relationship between adherence and cost burden.nnnMETHODSnSurveys were administered to patients at 40 small community-based primary care practices. Medication adherence was assessed using the 4-item Morisky scale, while five cost-related items documented recent pharmacy restrictions. CCM experiences were assessed via the 20-item Patient Assessment of Chronic Illness Care (PACIC). Nested random effects models determined if chronic care perceptions modified the association between medication adherence and cost-related burden.nnnRESULTSnOf 1823 respondents reporting diabetes and other chronic diseases, one-quarter endorsed intrapersonal adherence barriers, while 23% restricted medication due of cost. Controlling for age and health status, the relationship between medication cost and CCM with adherence was significant; including PACIC scores attenuated cost-related problems patients with adequate or problematic adherence behavior.nnnCONCLUSIONSnPatients experiencing treatment more consistent with the CCM reported better adherence and lower cost-related burden. Fostering highly activated patients and shared clinical decision making may help alleviate medication cost pressures and improve adherence.

Psychiatric and medical admissions observed among elderly patients with new-onset epilepsy

BackgroundInpatient utilization associated with incidence of geriatric new-onset epilepsy has not been characterized in any large study, despite recognized high levels of risk factors (comorbidity).MethodsRetrospective study using administrative data (Oct 01-Sep 05) from the Veterans Health Administration from a nationwide sample of 824,483 patients over age 66 in the retrospective observational Treatment In Geriatric Epilepsy Research (TIGER) study. Psychiatric and medical hospital admissions were analyzed as a function of patient demographics, comorbid psychiatric, neurological, and other medical conditions, and new-onset epilepsy.ResultsElderly patients experienced a 15% hospitalization rate in FY00 overall, but the subset of new-onset epilepsy patients (n = 1,610) had a 52% hospitalization rate. New-onset epilepsy was associated with three-fold increased relative odds of psychiatric admission and nearly five-fold increased relative odds of medical admission. Among new-onset epilepsy patients, alcohol dependence was most strongly associated with psychiatric admission during the first year after epilepsy onset (odds ratio = 5.2; 95% confidence interval 2.6-10.0), while for medical admissions the strongest factor was myocardial infarction (odds ratio = 4.7; 95% confidence interval 2.7-8.3).ConclusionFrom the patient point of view, new-onset epilepsy was associated with an increased risk of medical admission as well as of psychiatric admission. From an analytic perspective, omitting epilepsy and other neurological conditions may lead to overestimation of the risk of admission attributable solely to psychiatric conditions. Finally, from a health systems perspective, the emerging picture of the epilepsy patient with considerable comorbidity and demand for healthcare resources may merit development of practice guidelines to improve coordinated delivery of care.

Factors in Second-Generation Antipsychotic Switching Patterns in a National Sample of Older Veterans With Schizophrenia

OBJECTIVEnA 2004 consensus statement by the American Psychiatric Association and other groups noted that metabolic side effects of second-generation antipsychotics require monitoring. To reduce risk, prescribers may consider factors differentially associated with development of metabolic abnormalities, such as age, gender, and race-ethnicity. As part of a study of older patients with schizophrenia (50-102 years), this study evaluated factors associated with antipsychotic switches and switches that incurred a greater or lesser metabolic risk.nnnMETHODSnAdministrative data were analyzed for a national cohort of 16,103 Veterans Health Administration patients with schizophrenia receiving second-generation antipsychotics. Multinomial logistic regression predicted the likelihood of switches from 2002 to 2003 and again from 2004 to 2005.nnnRESULTSnAt baseline nearly half the patients (45%) had a diagnosis of hypertension, a third (34%) had dyslipidemia, and 15% had a diagnosis of obesity. In both periods diabetes was associated with switches to lower-risk antipsychotics, and older patients were likely to experience neutral or no switches. Women were more likely to experience switches to higher-risk antipsychotics in 2004-2005.nnnCONCLUSIONSnGeneral medical conditions potentially associated with antipsychotic-related metabolic concerns were common; however, half of these patients were prescribed medication that made them liable to developing metabolic problems. Modest evidence suggests that metabolic considerations became a higher priority during the study. Future research should investigate the differential impact of antipsychotics on metabolic dysregulation for women and elderly patients. Findings underscore the need to monitor metabolic parameters of older patients taking antipsychotics.

Initial Medication Adherence-Review and Recommendations for Good Practices in Outcomes Research: An ISPOR Medication Adherence and Persistence Special Interest Group Report.

BACKGROUNDnPositive associations between medication adherence and beneficial outcomes primarily come from studying filling/consumption behaviors after therapy initiation. Few studies have focused on what happens before initiation, the point from prescribing to dispensing of an initial prescription.nnnOBJECTIVEnOur objective was to provide guidance and encourage high-quality research on the relationship between beneficial outcomes and initial medication adherence (IMA), the rate initially prescribed medication is dispensed.nnnMETHODSnUsing generic adherence terms, an international research panel identified IMA publications from 1966 to 2014. Their data sources were classified as to whether the primary source reflected the perspective of a prescriber, patient, or pharmacist or a combined perspective. Terminology and methodological differences were documented among core (essential elements of presented and unpresented prescribing events and claimed and unclaimed dispensing events regardless of setting), supplemental (refined for accuracy), and contextual (setting-specific) design parameters. Recommendations were made to encourage and guide future research.nnnRESULTSnThe 45 IMA studies identified used multiple terms for IMA and operationalized measurements differently. Primary data sources reflecting a prescribers and pharmacists perspective potentially misclassified core parameters more often with shorter/nonexistent pre- and postperiods (1-14 days) than did a combined perspective. Only a few studies addressed supplemental issues, and minimal contextual information was provided.nnnCONCLUSIONSnGeneral recommendations are to use IMA as the standard nomenclature, rigorously identify all data sources, and delineate all design parameters. Specific methodological recommendations include providing convincing evidence that initial prescribing and dispensing events are identified, supplemental parameters incorporating perspective and substitution biases are addressed, and contextual parameters are included.

Transition from military to VHA care: Psychiatric health services for Iraq/Afghanistan combat-wounded

OBJECTIVEnVeterans from the wars in Afghanistan and Iraq (OEF/OIF) report high rates of mental distress especially affective disorders. Ensuring continuity of care across institutions is a priority for both the Department of Defense (DoD) and the Veterans Health Administration (VHA), yet this process is not monitored nor are medical records integrated. This study assessed transition from DoD to VHA and subsequent psychiatric care of service members traumatically injured in OEF/OIF.nnnMETHODSnInpatients at a DoD trauma treatment facility discharged in FY02-FY06 (n=994) were tracked into the VHA via archival data (n=216 OEF/OIF veterans). Mental health utilization in both systems was analyzed.nnnRESULTSnVHA users were 9% female, 15% Hispanic; mean age 32 (SD=10; range 19-59). No DoD inpatients received diagnoses of post-traumatic stress disorder (PTSD); 21% had other mental health diagnoses, primarily drug abuse. In the VHA, 38% sought care within 6 months of DoD discharge; 75% within 1 year. VHA utilization increased over time, with 88-89% of the transition cohort seeking care in FY07-FY09. Most accessed VHA mental health services (81%) and had VHA psychiatric diagnoses (71%); half met criteria for depression (27%) or PTSD (38%). Treatment retention through FY09 was significantly greater for those receiving psychiatric care: 98% vs 62% of those not receiving psychiatric care (x(2)=53.3; p<.001).nnnLIMITATIONSnDoD outpatient data were not available. The study relied on administrative data.nnnCONCLUSIONSnAlthough physical trauma led to hospitalization in the DoD, high rates of psychiatric disorders were identified in subsequent VHA care, suggesting delay in development or recognition of psychiatric problems.

Mortality after cardiac or vascular operations by preexisting serious mental illness status in the Veterans Health Administration

OBJECTIVEnTo estimate 1-year mortality risk associated with preoperative serious mental illness (SMI) as defined by the Veterans Health Administration (schizophrenia, bipolar disorder, posttraumatic stress disorder [PTSD], major depression) following nonambulatory cardiac or vascular surgical procedures compared to patients without SMI. Cardiac/vascular operations were selected because patients with SMI are known to be at elevated risk of cardiovascular disease.nnnMETHODnRetrospective analysis of system-wide data from electronic medical records of patients undergoing nonambulatory surgery (inpatient or day-of-surgery admission) October 2005-September 2009 with 1-year follow-up (N=55,864; 99% male; <30 days of postoperative hospitalization). Death was hypothesized to be more common among patients with preoperative SMI.nnnRESULTSnOne in nine patients had SMI, mostly PTSD (6%). One-year mortality varied by procedure type and SMI status. Patients had vascular operations (64%; 23% died), coronary artery bypass graft (26%; 10% died) or other cardiac operations (11%; 15%-18% died). Fourteen percent of patients with PTSD died, 20% without SMI and 24% with schizophrenia, with other groups intermediate. In multivariable stratified models, SMI was associated with increased mortality only for patients with bipolar disorder following cardiac operations. Bipolar disorder and PTSD were negatively associated with death following vascular operations.nnnCONCLUSIONSnSMI is not consistently associated with postoperative mortality in covariate-adjusted analyses.